Simulation-based education is being more widely adopted1,2 because well-designed simulations can provide opportunities for “scheduled” medical crises,3 enhance trainees’ competence without unnecessary patient risk, and may be able to improve patient outcomes. Excellent medical expertise and effective team dynamics are necessary for successful resuscitation,4–6 but traditional resuscitation courses may not be sufficient to prepare learners to provide quality of care during actual patient resuscitations.7–9 The implementation of simulation-based resuscitation courses10 or regular routine team training using full-scale patient simulators has been shown to improve resuscitation performance in the clinical environment.11 This often occurs at major academic institutions with fully developed and staffed simulation centers.
On the other hand, there seems to be a gap between institutions with well-established simulation programs and those where simulation programs have just started. Simulation training is not available at many institutions and there is often a lack of trained facilitators who serve as barriers for the development of this training modality. It is recognized that the quality of simulation facilitators is one of the most valuable factors for successful simulation training,12 and trainees and facilitators may need to travel to more experienced centers to participate in high-quality training. However, travel takes time and incurs additional effort and financial costs, thus limiting opportunities to disseminate simulation training to less-equipped centers.
Technology has made remote-facilitated simulation learning possible.13–15 In one study, von Lubitz et al15 demonstrated that they could control all their simulators from three different manufacturers using proprietary program developed by a company during the training of more than 35,000 health professionals. We have not identified such technology and one reason could be that many clinicians do not have free access to custom programs such as this or available system can be applied to only specific products.
In this context, we developed a remote-facilitated simulation system with low-cost, preexisting, and easy-access resources that can be applied to any simulators driven by personal computer (PC). Using this system, a remote facilitator can control a simulator and provide simulation training and debriefing to trainees. The objective of this study was to examine the technical feasibility of remote-facilitated simulation and to describe its characteristics compared with on-site-facilitated simulation.
This study was exempt from approval, per our institutional review board.
We connected the National Center for Child Health and Development (NCCHD) in Tokyo and the hospital affiliated with Kanazawa University (Kanazawa) across the Internet. The training sessions were held over 4 months between November 2007 and March 2008. The distance between the two centers was approximately 560 km. The Department of Anesthesia and Intensive Care Unit (ICU) at NCCHD has a simulation center that provided a physical facsimile of an ICU environment. Kanazawa also has a simulation center that also provided a physical facsimile of a general ward environment.
Equipment and Technical Requirements
Table 1 and Figure 1 show overviews of the system. Two PCs at NCCHD and Kanazawa were used for sessions controlled by a facilitator at Kanazawa. One of the two PCs at NCCHD and Kanazawa were used to control an infant highfidelity simulator, SimBaby (Laerdal Medical Corp., Wappingers Fall, NY), while the other PC at each institution was used to control long-distance communication. All PCs were connected to the Internet. UltraVNC (Free Software Foundation, Inc., Boston, MA) is free remote control software that can display the screen of a remote computer via the Internet or local area network on the screen of the host. This means that it is possible to work on a remote computer from another location as if one were sitting in front of it and operating the simulator and its application software. The simulator system contained a default webcam, but the remote facilitator and the trainees could not monitor the situations through the camera of the simulator system in real time during the scenarios. Therefore, we added another camera and employed long-distance communication software, Skype (Skype Technologies S.A., Rives de Clausen, Luxembourg), so that the facilitators could view the action at the remote site and facilitate real-time communication with the trainees. We employed fiber-optic network to connect between two sites, at a connection speed of 20 megabits per second (Mbps) (upload and download). Table 2 shows additional cost to develop the remote-facilitated system in addition to the patient simulator system and PC.
Two facilitators (T.I. and K.O.), who were also Pediatric Advanced Life Support instructors, controlled the system from each of the stations during the first two pilot sessions. This enabled the investigators to determine whether they could technically control the simulator and provide simulation training from each side. In three subsequent sessions, the facilitator from Kanazawa (K.O.) controlled the system during training sessions for the participants at NCCHD. The other facilitator (N.S.) was experienced in performing remotefacilitated simulation sessions.
The first two sessions addressed technical issues and for these we recruited seven healthcare providers who had no prior experience with simulation. During three subsequent sessions, 16 fellows of the Department of Anesthesia and ICU were recruited from NCCHD. They were considered eligible to assess the feasibility and characteristics of remote-facilitated simulation compared with on-site-facilitated simulation because they had previously received simulation-based training regularly at NCCHD.
Each remote-facilitated simulation session consisted of briefing, simulation scenarios, and debriefing. Each simulation scenario lasted for ≤15 minutes and involved a case of either ventricular fibrillation or desaturation in an intubated patient. Simulation sessions were video-recorded at the training site and the video files could be transferred to the remote facilitator site through the system. The remote facilitator debriefed the participants through the system, and the recorded videos were used as required during the debriefing sessions. The communication software allowed the participants and the facilitators to communicate interactively throughout all sessions.
Data Collection and Outcome Measures
Each participant completed an online survey within 24 hours after each session. The survey questionnaire (Fig. 2) consisted of questions using a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree). The surveys asked participants to rate the overall effectiveness, quality of sound, whether they could understand the facilitators, and whether they would like this type of training in the future. Feedback from the facilitators was collected verbally after each session, and its summary was recorded using a spreadsheet by the primary author. Facilitators were also asked to rate the operability of the remote simulation compared with the on-site simulation system using a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree).
We hypothesized that every participant rates each question neutral (score 3) and analyzed the survey data if the scores differ from the hypothesized value using Wilcoxon signed-rank test. We considered P < 0.05 as statistically significant. Stata 11.1 (Stata Corporation, College Station, TX) was used. The feedback from the facilitators was content analyzed to assess the quality of the remote-facilitated simulation system and to identify its technical issues.
All survey questions were rated statistically significantly greater than a score of 3: P < 0.05 for Q2 and P < 0.01 for all except Q2. Survey results of three sessions indicated that 93.8% (15/16) of the participants rated remote-facilitated simulation to be effective (Fig. 2, Q1), and 87.5% (14/16) rated it to be as effective as or more effective than the on-sitefacilitated simulation system (Fig. 2, Q2). All participants perceived that the quality of the sound of the system was at least as good as the on-site one (Fig. 2, Q3) and thought they could understand what the facilitator said at least as well as the on-site one (Fig. 2, Q4). Nearly 88% (14/16) of the participants rated that they would like to receive simulation training through the system again. We experienced some technical problems during the remote-facilitated sessions, such as sound quality, screen size, and abrupt interruption of the PC with communication software due to unintended activation of the PC’s sleep mode. These problems were identified through content analysis of the facilitators’ feedback. The solutions listed in Table 3 were applied successfully to each problem. All three facilitators reported operability of the remote system with a score of 5 and agreed that it was as effective as the on-site simulation system.
To our knowledge, this is the first report of remote-facilitated simulation using low-cost, preexisting, and easy-access resources. The system was feasible as most of the participants rated it as effective as or more effective than the on-site-facilitated simulation system and felt that they would like to take the remote-facilitated training again. With the exception of minor problems that were quickly addressed (Table 3), we experienced no major problems that would have prevented the operation and reproducibility of the remote-facilitated system.
It can be challenging to develop simulation-based team training in remote areas with few simulation facilitators.16 It may be more practical for trainees and facilitators to schedule simulation training with remote-facilitated systems as they can save travel time. Remote-facilitated systems may also enable institutions to schedule simulation sessions more frequently.
There are several possible additional applications of remote-facilitated simulation: (1) to train facilitators, (2) to control high stakes assessment, and (3) to use in standardized training programs. This type of system can enable facilitators in training to learn how experienced facilitators run sessions and debrief remotely. A simulation-based objective structured clinical examination has been incorporated into Israeli board examination in anesthesiology.17 Reproducibility of the scenarios and reliability of the raters are important areas in high-stake assessment, and modified version of this system may be able to support it. There are some examples of standardized training, such as Pediatric Critical Care Boot Camp18 and the international training program of intensive care medicine developed by European Society of Intensive Care Medicine.19 Remote-facilitated systems could be applied to these standardized training programs, and these applications might enhance dissemination of simulation-based education and globalization of training efficiently, leading to standardization of patient care and eventually help improved patient outcomes.
Our remote-facilitated simulation system was low cost, easy to setup, and rated equivalent to an on-site simulation but did have some technical limitations. The small number of fixed webcams may make it difficult for facilitators to recognize subtle movement and nonverbal communications. It would be ideal to deploy multiple cameras that would allow the facilitators to see from a greater number of viewpoints and move the cameras as necessary. There was concern from facilitators that they needed to pay more attention to how participants felt during debriefing as it was hard to recognize their facial expressions. Another technology-related issue is the Internet connection speed. While we were able to run the remote-facilitated system with minimally 1 Mbps for upload and 800 kilobits per second for download, its connection rate requirements may not be possible in some developing countries. The software and simulators may be exchanged for alternatives, thus widening the possible applicability of the remote-facilitated simulation system.
This study has some important design limitations. We conducted a survey with only a small number of physicians. While we described characteristics of the remote-facilitated simulation system and examined its feasibility, we did not address its reliability and effectiveness. Also, we did not examine whether this system had an impact on educational efficacy with limited number of the faculty and whether this system could be really applicable to other situations such as training facilitators, high-stake assessment, and standardized training programs. Moreover, our measurements were subjective; objective parameters should be assessed in the near future, including operability.
Our experience indicated that remote-facilitated simulation with low-cost, preexisting, and easy-access resources is technically feasible, and the operability was adequate to the point the facilitators felt the same as an on-site-facilitated simulation system. Further investigations should examine its reproducibility and produce more objective data that can be used to assess the validity and reproducibility to other applications and settings.
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