The value of simulation-based training in acquiring endoscopic skills is increasingly recognized. The use of isolated animal gut allows endoscopic procedural training with sufficient realism and difficulty to promote operator competence and confidence.1–3 Modification of this model by creating simulated pathology such as ulcers, varices, and arterial bleeding widens its applications and its value in learning complex hemostatic techniques by repeated supervised practice. However, procedural skill is not the only determinant of a successful clinical outcome, as many endoscopists have learnt, often to the patient's peril, when faced with controlling massive ulcer bleeding in a high-risk patient with unskilled support in the early hours of the morning. The proceduralist also needs to be skilled in resuscitation and sedation and must have the communication and leadership abilities to manage the endoscopy support team effectively. However, current simulator training in endoscopic hemostasis is primarily concentrated on endoscopic skills. Such training significantly improves the procedural skills,1–3 but it does not address other important in a clinical setting goals.
Kneebone et al4 has highlighted the significant deterioration of simulator acquired sigmoidoscopy skills when the operator is required to carry out the procedure in a simulated clinical setting. The distracting effects of anxiety, the need to make complex logistical decisions, and identify and treat intraprocedure complications while attempting endoscopic treatment are likely to be much more significant in the management of a patient with gastrointestinal (GI) bleeding.
To be beneficial, the experimental simulator-based teaching should focus on acquisition of both multiple skills and knowledge needed to solve complex problems and ability to perform promptly and efficiently during critical clinical events. The likelihood of personnel making mistakes increases as critical events evolve indicating the need for team training.5–7 It has been documented that individuals' thought processes, attention spans, and proficiency are compromised when stress levels increase and error reduction could be achieved through team training and team leadership. From a cognitive perspective, emergency situations involve a starting condition (eg, GI bleed but unknown precise diagnosis), a goal condition (in our case arrest of the bleeding to avoid surgery and/or fatal outcome), a possible and unpredictable condition (eg, development of complications and unstable patient at any stage of the procedure requiring prompt intervention), and available (may be limited) resources to achieve the goal.
Therefore, the ability to practice the acquisition of critical thinking to create an appropriate strategy, error management, and team work in a simulated critical care environment simultaneously with improving the procedural skills seems to be a unique learning opportunity. According to cognitive theory, as students gain experience in problem-solving paths of strategy development emerge, and improvement in performance is usually accompanied by increase in speed and reduction in the data processing.8–10
In an effort to enhance the scope of simulator-based training in the endoscopic treatment of GI bleeding, we have designed a course to improve clinical decision making and acquire principles of crisis resource management in a realistic clinical context.
MATERIALS AND METHODS
The participants were doctors, majority in the 1st or 2nd year of GI or surgical training programs, and included a number of endoscopy nurses. All participants had at least 6 months prior experience in upper GI endoscopy and had done cardiopulmonary resuscitation courses prior. All doctors had at least 4 years postgraduate experience and some previous clinical exposure to managing acutely sick and bleeding patients. The level of endoscopic training ranged from just 6 months of GI fellowship to 3 years of endoscopic experience. Although all had some exposure as above, none were dedicated anesthetic or intensive care trained. Overall, 23 doctors took part in the training. Eleven trainees took part in the first course and 12 in the second.
Experts who conducted the training were volunteers; each had at least 5 years experience in therapeutic endoscopy. They met before training to standardize teaching methods and review the scenarios and evaluation criteria. These included each particular hemostasis technique and the main components of the scenario-related performances such as correct diagnosis, proper management strategy, correct instructions to the assistants, recognition of complications, application of proper hemostasis, and successful leadership behavior. Each of three experts expressed their opinion judged on the afore-mentioned steps of trainees' performance.
The management of GI bleeding course was conducted at the Clinical Training and Education Centre (CTEC), The University of Western Australia, Perth, Australia twice during 2004–2005 and annually since. CTEC is a purpose-built, simulation-based medical skills teaching facility with three suites each comprising a training room with simulator, a control room, and an adjacent viewing/debriefing room.11 The simulator room incorporates two-pan tilt zoom video cameras and a scan converter connected to the simulator's vital signs monitor; the adjoining control room, separated from the training room by a one-way mirror, allows the trainers to observe the participants, control the scenario, and communicate to the trainee supervisor through wireless headset. The patient's voice was simulated by the controller talking through a speaker in the mannequin. The pump used to simulate ulcer bleeding was controlled by the supervisor. For the scenario-based teaching exercise, the training room was furnished with standard endoscopic equipment (gastroscope, processor, diathermy, and hemostatic accessories), and vital signs monitoring (including oximeter and electrocardiogram).
All courses were conducted and approved by the University of Western Australia. An approval for this project and the report were obtained from the local institutional ethics committee. Videotaping was used for provision of feedback and with written participants' permission only.
The Erlangen Endo-Trainer simulator (Erlangen, Germany) was used to simulate upper GI bleeding. This model and its role in teaching techniques of endoscopic hemostasis are well described.2,3,12 Frozen preparations of adult pig esophagus, stomach, and duodenum were thawed and opened along the greater gastric curve; simulated pathology (gastric and duodenal ulcers, esophageal mucosal tears, and Dieulafoy lesions) were created by incising appropriately shaped discs of mucosa over submucosal saline “cushions.” The lesions were placed at random sites, including the high lesser curve and posterior duodenal wall. Both “visible” and “nonvisible” arteries were simulated by positioning 1 and 2 mm diameter Silastic tubes in the base or edge of “ulcers” using a transmural hypodermic needle and secured with a serosal stitch; the individual tubes were marked to identify their position in the preparation and connected to a roller pump to simulate pulsatile, arterial bleeding of a “look-alike” blood substitute.
The porcine specimens of esophagus, stomach, and duodenum were mounted in an anatomic position within the plastic torso of the model. A wide-bore duodenal tube was inserted to drain or flood the preparation with “blood” during the procedure to improve endoscopic visibility or mimic massive hemorrhage; the duodenal stump and greater gastric curve were closed with continuous sutures and tested for air leaks.
Additionally, a full arm and hand model (Multi-Venous IV Training Arm, Laerdal Medical (AS, Norway) with injectable veins to enable simulated intravenous injection and blood transfusion was arranged on a standard endoscopy trolley adjacent to the Endo-Trainer and both were draped, leaving the head, forearm, and hand exposed (Fig. 1).
A SimMan (Laerdal Medical AS, Norway) monitor and software package were used to reproduce simulated pulse oximeter data, blood pressure, pulse and respiratory rates, and an electrocardiogram trace for the “patient.” SimMan is a sophisticated patient-simulator mannequin designed for training in advanced life-support skills; its software allows multiple physiological trends to be run simultaneously with additive effect. Preprogrammed clinical scenarios are available or as in this training exercise, can be custom designed for a particular clinical situation and progressively rolled out by a teaching faculty observer in the control room.
All equipment used was either disposable or for dedicated animal use only. The following equipment and accessories were used.
- Real Olympus GIF-140 video endoscopes.
- Erbe (Erbe Elektromedizin, Ltd., Tubingen, Germany) and Valleylab (Valleylab, Inc., Boulder, CO) electrosurgical generators.
- Argon plasma coagulation probe (Erbe Elektromedizin, Ltd., Tubingen, Germany), Gold Probe (Boston Scientific Corporation, Natick, MA), Hemoclip applicator (Olympus Corporation, Japan), Six-Shooter ligator (Wilson-Cook Medical, Inc., Winston-Salem, NC).
- Intravenous catheters and connection lines.
Evaluation of the Course by Participants
To assess participants' satisfaction with the course, a standardized structural questionnaire regarding the course outcome and organization was used. Each participant was asked to answer anonymously 12 questions on a 5-point scale (from “strongly disagree” to “strongly agree”). Each question also included four to eight reasons to explain the rating. Suggestions for further improvement of the course and any other comments were also asked to be expressed.
Conduct of the Course
The course consisted of 2 days of theoretical and practical sessions. The first day of the course covered both the basic theoretical background and practical approach to endoscopic hemostasis using epinephrine injections, endoclips, coagulation probes, and variceal banding devices. Participants were shown the techniques (initial didactic demonstration) and then practiced their skills under expert supervision on the Erlangen EASIE model, plastic models, and GI-Mentor II computer simulator (Simbionix Corp, Cleveland, Ohio) for approximately 4 hours. One tutor trained two to three doctors and evaluated all steps of their performance of the procedure, including manual skills in setting up the device, testing the equipment, localizing the bleeding site and application of specific hemostatic techniques—injection, electrocoagulation, hemoclip application, and variceal ligation. This training endoscopic hemostatic skill station was organized following previously published recommendations,3 but the trainees were not exposed to the full resuscitation and endoscopic simulator until day 2.
On the second day, the class was divided into four “endoscopy teams” each consisting of three people for simulated clinical setting exercises. Each team consisted of three doctors or two doctors and a nurse (because the majority of participants were doctors). The team decided on the endoscopist before the beginning of exercise, whereas the other two were responsible for support. In each session, the endoscopy teams were given a brief clinical scenario (Appendix) and were required to assume full management of the simulated patient. Four different clinical scenarios were used simulating ulcer hemorrhage and Diulefoy lesion. Trainees had to explain the procedure to the “patient,” assess their hemodynamic status, initiate resuscitation if indicated, administer sedation, perform an endoscopy, and identify and treat the bleeding lesion. The choice of hemostatic method, the preparation of the equipment (endoscopes, generators, and power settings), and the appropriate accessories (injection needles, Gold Probe, Hemoclip, or argon plasma coagulation probe) were entirely the responsibility of the trainees. Thirty minutes maximum was allowed to complete the exercise. Trainees were aware of the time limit, and they knew that they had to resuscitate the patient and apply endoscopic treatment. The details of clinical history and other parameters were only revealed once the exercise started. Each exercise was observed by at least three faculty members—one was in the room in control of the “bleeding pump,” and two were in the control room and could adjust the hemodynamic parameters. The faculty members adjusted the rate of bleeding and hemodynamic parameters depending on whether the treatment was appropriate. The exercise was video recorded, and all steps of the performance were timed. The rest of the faculty and trainees who finished their exercise could observe on the video monitor from the conference room. Each team was judged by three faculty members and was given detailed feedback of their overall performance and of the individual components of each strategic decision and each technique, endoscopic, and resuscitation. Diagnostic errors such as condition present but not detected, delayed diagnosis or misdiagnosis, and errors and incompetence in management strategies were addressed. Feedback was provided by the faculty conducting the course immediately after all groups finished the exercise with all participants present. Debriefing focused on reinforcing team approach to management of an unstable patient with GI bleeding.
At the end of the first day of simulator training, an improvement in endoscopic techniques with decrease in performance time was reported by all trainees. The tutors confirmed that at this stage, all trainees achieved successful hemostasis using injection and coagulation, and about ¾ were successful with clip application and variceal ligation. This objective evaluation by the experts indicates that trainees' self-assessment reflects real improvement. The main results of the self-administered questionnaire used to assess participants' satisfaction with the course are shown in Table 1. The response rate to the questionnaire was 100%. All 23 doctor-trainees found the course worthwhile and reported that their practical ability to manage GI bleeding improved as a result of the course. All of them also found the scenarios with hands-on practice useful. Ninety-five percentage of participants reported that their understanding of principles of endoscopic management of GI bleeding improved. Increased awareness of managing an acutely ill patient in relationship to the resuscitation was reported by 82.6% of trainees and in relationship to effective leadership and communication by 83.3%. The trainees also reported a high level of anxiety when performing procedures in this high-fidelity simulated setting. However, they recognized the usefulness of such experience to adapt to unpredictable changes in dynamic and complex situations.
Simulator training in endoscopic hemostasis, an important gastroenterological procedure possessing the main skills needed for most urgent endoscopic operations, represents a new paradigm in postgraduate interventional education.
Although an earlier review of the published literature by Gerson and Van Dam13 concluded that there was insufficient evidence to recommend that endoscopy simulators replace traditional teaching, there is growing evidence that simulator- based courses can accelerate training particularly at an early stage.2,3,13,14 Di Giulio et al15 used the GI mentor to teach basic manual skills of upper endoscopy and demonstrated that computer-based training is an efficient and effective teaching tool. Using the same simulator, Ferlitsch et al16 have shown a significant improvement in endoscopic skills after only 3 weeks of training. Hochberger et al17 have used the Erlangen EASIE animal-based model extensively in training and in a recent prospective study have shown objective clinical improvement in the trainees' performance after intensive hands on experience with this model. There is also emerging evidence that even 1-day intensive courses in endoscopic hemostasis using Erlangen EASIE simulator can have a positive impact on trainees' performance.2
For endoscopic hemostasis as for other complex interventional procedures equally important are technical skills and knowledge of the procedure and the ability to process, integrate, and respond correctly and quickly to complex information in a dynamic team setting. Experience in clinical judgment, leadership, teamwork, and communication are becoming recognized as key determinants of outcome and patient safety, especially in emergency situations and when dealing with unexpected.18–20 However, currently, the nontechnical skills in simulator training are taught to a limited degree only if at all.
Kneebone et al4,18 pioneered the use of medical simulators in a realistic environment by positioning a surrogate patient adjacent to the computer generated endoscopic image. Integrating skills training in sigmoidoscopy within a clinical context improved the perceived realism of the procedure and enhanced the learning experience by allowing interaction with the patient but increased the anxiety of the participants with a corresponding reduction in dexterity.4,18,21
Successful management of acute GI bleeding requires a team approach and the endoscopist because team leader must not only be competent in resuscitation but must also possess strong communication and leadership skills. The value of teaching the team approach to managing life support and multiple trauma has been recognized for over a decade but has so far received little attention in endoscopy teaching programs. Experience of medical emergency team training shows that despite appropriate levels of individual skill, the team often functions poorly because of lack of organization and leadership.22 Moreover, it has been demonstrated that performance can be improved significantly by training on simulated patients using realistic clinical scenarios and providing extensive feedback and analysis.22,23
To provide simulator training and practice in both psychomotor and cognitive skills in emergency situations (under pressure), we used a two-stage approach. To our knowledge, this is the first course in endoscopic management of GI bleeding to incorporate the acquisition of technical skills with a team approach to the resuscitation and overall management of a bleeding patient.
On the first stage, the trainees practice mainly procedural skills, whereas the second stage integrates technical procedures with unexpected changes in “patient's” status requiring immediate responses from the trainee as the team leader. Such training not only improves the endoscopic hemostatic skills of the trainees but also gives them an opportunity to experience the complexity and danger in a dynamic environment and to practice in problem solving, leadership, and teamwork. Such realistic (but safe) setting should increase their knowledge of the procedure and its potential pitfalls.
The 2-day CTEC course in the endoscopic control of GI bleeding provides realistic clinical scenario-based simulation which the trainee is likely to encounter in daily practice. The training and debriefing sessions were focused on a structured team approach to a patient with GI bleeding, highlighting the importance of monitoring, early and adequate resuscitation, effective endoscopic treatment, and the recognition of the limitations of both the treatment modality and personal skills. Importantly, the majority of participants expressed high satisfaction with the training course. They noticed that it was helpful in adapting to and overcoming the difficulties in managing unexpected complications and performing complex problem-solving tasks in a dynamic environment.
Issenberg et al24 have conducted an extensive review of the published literature concerning the use of high-fidelity medical stimulators. This study emphasized the key importance of feedback, repetitive practice, curriculum integration, variation in task difficulty, and clinical setting in facilitating learning; it stressed the value of providing a controlled environment where trainees can learn from mistakes without risk to patients.24
The CTEC course satisfies all these criteria, particularly feedback based on faculty and peer review of video recorded performance, and is an important addition to our GI Fellowship teaching program. Once setup, the training model outlined can be used many times and provides an opportunity for repetitive practice to reinforce newly acquired skills. It is anticipated that in future courses, the number of simulated scenarios will be increased with the degree of difficulty tailored to the training and experience of endoscopists and support staff. Communication skills training is an essential part of the course, and the scenarios could be expanded to include clinical history taking, obtaining informed consent, consulting colleagues, and informing patient or kin of treatment outcomes.
Although the presented pilot 2-day intensive simulator endoscopic training was enthusiastically accepted by trainees and can potentially improve patients' safety, only further long-term assessment and prospective randomized controlled trials will determine whether the skills learned in the course translate into the ability to perform such procedures safely in clinical practice.
There is growing evidence that endoscopic training can be improved by the use of simulation. A number of publications have reported a positive training effect when using simulators in the early phase of endoscopic training. Management of GI bleeding is arguably one of the most challenging and stressful endoscopic procedures. It requires a high degree of technical and cognitive skills and knowledge and is also one of the most difficult techniques to teach trainees because of limited exposure, time constraints, stress of the situation, and high risk to the patient. In this article, we report on the application of a biomechanical GI bleeding model in a close to reality simulated clinical setting to teach principles of endoscopic management of GI bleeding. The 2-day intensive course allows trainees not only to improve their endoscopic hemostatic skills but also to gain practical experience in clinical judgment and to develop better leadership and teamwork abilities in emergency situations. Future randomized trials are needed to evaluate the patient-relevant effectiveness of the model objectively.
1. Maiss J, Prat F, Wiesnet J, et al. The complementary Erlangen active simulator for interventional endoscopy
training is superior to solely clinical education in endoscopic hemostasis—the French training project: a prospective trial. Eur J Gastroenterol Hepatol
2. Maiss J, Wiesnet J, Proeschel A, et al. Objective benefit of a 1-day training course in endoscopic hemostasis using the “compactEASIE” endoscopy
3. Matthes K, Cohen J, Kochman ML, Cerulli MA, Vora KC, Hochberger J. Efficacy and costs of a one-day hands-on EASIE endoscopy
simulator train-the-trainer workshop. Gastrointest Endosc
4. Kneebone RL, Nestel D, Moorthy K, et al. Learning the skills of flexible sigmoidoscopy—the wider perspective. Med Educ
5. Barker J. Error reduction through team leadership: what surgeons can learn from the airline industry. Clin Neurosurg
6. Helmreich RL. On error management: lessons from aviation. Bmj
7. Schwid HA, O'Donnell D. Anesthesiologists' management of simulated critical incidents. Anesthesiology
8. VanLehn K. Cognitive skill acquisition. Annu Rev Psychol
9. Haider H, Frensch PA. Why aggregated learning follows the power law of practice when individual learning does not: comment on Rickard (1997, 1999), Delaney et al. (1998), and Palmeri (1999). J Exp Psychol Learn Mem Cogn
10. Schunn CD, Lovett MC, Reder LM. Awareness and working memory in strategy adaptivity. Mem Cogn
11. Riley RH, Grauze AM, Chinnery C, Horley RA, Trewhella NH. Three years of “CASMS”: the world's busiest medical simulation centre. Med J Aust
12. Hochberger J, Euler K, Naegel A, Hahn EG, Maiss J. The compact Erlangen Active Simulator for Interventional Endoscopy
: a prospective comparison in structured team-training courses on “endoscopic hemostasis” for doctors and nurses to the “Endo-Trainer” model. Scand J Gastroenterol
13. Gerson LB, Van Dam J. Technology review: the use of simulators for training in GI endoscopy
. Gastrointest Endosc
14. Hochberger J, Maiss J, Hahn EG. The use of simulators for training in GI endoscopy
15. Di Giulio E, Fregonese D, Casetti T, et al. Training with a computer-based simulator achieves basic manual skills required for upper endoscopy
: a randomized controlled trial. Gastrointest Endosc
16. Ferlitsch A, Glauninger P, Gupper A, et al. Evaluation of a virtual endoscopy
simulator for training in gastrointestinal endoscopy
17. Hochberger J, Matthes K, Maiss J, Koebnick C, Hahn EG, Cohen J. Training with the compactEASIE biologic endoscopy
simulator significantly improves hemostatic technical skill of gastroenterology fellows: a randomized controlled comparison with clinical endoscopy
training alone. Gastrointest Endosc
18. Kneebone RL, Scott W, Darzi A, Horrocks M. Simulation and clinical practice: strengthening the relationship. Med Educ
19. Yule S, Flin R, Paterson-Brown S, Maran N. Non-technical skills for surgeons in the operating room: a review of the literature. Surgery
20. Kneebone RL. Practice, rehearsal, and performance: an approach for simulation-based surgical and procedure training. JAMA
21. Kneebone R. Evaluating clinical simulations for learning procedural skills: a theory-based approach. Acad Med
22. Cooper S, Wakelam A. Leadership of resuscitation teams: “Lighthouse Leadership.” Resuscitation
23. DeVita MA, Schaefer J, Lutz J, Wang H, Dongilli T. Improving medical emergency team (MET) performance using a novel curriculum and a computerized human patient simulator. Qual Saf Health Care
24. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach
APPENDIX: TWO SAMPLE SCENARIOS USED IN THE MANAGEMENT OF GI BLEEDING COURSE
Sample Scenario 1
Background information given to trainees:
- An 85-year-old female patient is admitted via the emergency department with a 3-day history of melena. She has a history of noninsulin-dependant diabetes and ischemic heart disease and had a previous myocardial infarct. She takes Aspirin, Celecoxib and Ramipril. While in emergency department, she has an episode of hypotension. Her admission blood count shows hemoglobin of 105 g/L, and her coagulation profile is normal.
- The patient has been transferred to the endoscopy unit for urgent gastroscopy. She is awake on a trolley and consented for the procedure. Her heart rate is 108 beats/minute, blood pressure 105/48 mm Hg supine, and oxygen saturation 94% on room air.
- Once sedated, the patient becomes rapidly hypoxic, oxygen saturation falling to 78%.
- Increase oxygen, attempt to rouse the patient, reverse sedation, check oxymeter probe, insert airway, bag, and mask.
Sample Scenario 2
Background information given to trainees:
- A 27-year-old fit male admitted via emergency department with hematemesis and melena. His history is remarkable only for a recent leg injury, and he has been taking high-dose non-steroidal anti-inflammatory drug for pain control in the last 2 weeks. On admission, his hemoglobin is 89 g/L. He is transferred to the endoscopy unit for urgent gastroscopy.
- The patient is awake on a trolley and consented for the procedure. He has a small intravenous cannula in his left arm. His pulse rate is 110 beats per minute, his supine blood pressure is 105/60 mm Hg, and his oxygen saturation is 99% on room air.
- After sedation, patient's blood pressure begins to fall. As the scope is inserted, his blood pressure falls to 88/52 and then to 74/40 mm Hg.
- Insert a large-bore intravenous cannula, increase intravenous fluids, administer blood products, and treat the bleeding lesion.