1. Epstein, R. M. (2007). Assessment in medical education (4). The New England Journal of Medicine, 356, 387-96.
2. Harden, R. M. (2006). Trends and the future of postgraduate medical education (10). Emergency Medical Journal, 23, 798-802.
3. Hogan, M.H. et al. (2006) Use of Human Patient Simulation and the Situation Awareness Global Assessment Technique in Practical Trauma Skills Assessment (61) The Journal of Trauma Injury, Infection and Critical Care (5), 1047-1052.
4. Issenberg, S. B. et al. (2010) Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review (4) BEME Guide No. 4, 27-37.
5. Hogan, M.H. et al. (2006) Use of Human Patient Simulation and the Situation Awareness Global Assessment Technique in Practical Trauma Skills Assessment (61) The Journal of Trauma Injury, Infection and Critical Care (5), 1047-1052.
6. Janssen-Noordman, A.M.B. et al. (2006) Design of Integrated practice for learning professional competences (28) Medical Teacher (5), 447-452.
7. Kurahashi, Med, et al. et al. (2010) Technical skill training improves the ability to learn (61) Surgery (5), Article in Press 1-6 .
8. Levinson, A. J. (2010) Where is evidence-based instructional design in medical education curriculum development? Medical Education (44), 536-537.
9. Kahol, K. et al. (2011). Initial experiences in embedding core competency education in entry-level surgery residents through a non-clinical rotation (3). Journal of Graduate Medical Education (5) 95-99.
10. McKinley, et al. (2008) Development of a tool to support holistic generic assessment of clinical procedure skills (42) Medical Education, 619-627.
11. Murin, S. (2010) Simulation in procedural training (137) Chest (5), college of Chest Physicians www.chestpubs.org/site/misc/reprints.xhtml.
12. Okuda, et al. (2009) The utility of simulation in medical education: what is the evidence? (76) Mount Sinai Journal of Medicine, 330-343.
13. Waters, R and McCracken, M (2011Assessment and evaluation in problem-based learning Georgia Institute of Technology.
525 Interdisciplinary Collaboration Enhances Learner Experience During Acute Care Simulation Team Training
Tracey Robilotto, MSN,2 Frank Jacono, MD1
1PULMONARY, CRITICAL CARE AND SLEEP MEDICINE, VETERANS AFFAIRS MEDICAL CENTER CLEVELAND, CLEVELAND, OH, USA and 2SIMLEARN NATIONAL CENTER, VETERANS HEALTH ADMINISTRATION, ORLANDO, FL, USA
Introduction/Background: “Interdisciplinary learning in health care education is a core educational requirement cited by the Institute of Medicine (IOM)”2 and is increasingly being identified as essential to ensure safe, effective and patient-centered care.1 The IOM also recommends that training to improve patient safety include simulation team training.3 In the fast paced and often high acuity environment of acute care, providing team training and/or simulation presents an especially challenging situation. Too often this training occurs within disciplines rather than between them. Mock cardiopulmonary codes are not a new concept; however, the American Heart Association placed a new emphasis on team training and debriefing with the 2005 ECC (emergency cardiopulmonary care) practice guidelines. In a response to the AHA practice changes, our facility set out to improve team collaboration in cardiac arrest situations by providing bi-weekly mock codes for staff. Nursing education was tasked with providing the mock codes. An evaluation form was developed to score staff on the key AHA resuscitation strategies. This feedback was then reported to the hospital Code Committee and the care area manager. Over the first three months it was found that staff was compliant with the key strategies on average 69% of the time. Nursing also experienced difficulty with medical team participation. It was experienced on most occasions that the medical team would respond and leave after finding it was a mock code; frequently stating that they were too busy or had “real” patients to care for. This lack of medical team participation sparked this author to request assistance from the intensive care director who also serves as the code committee chair. With this new approach, nursing and medicine would collaborate in running the mock codes.
Description: A mock code schedule was developed by the authors including one in-patient situation and one out-patient situation each month. This schedule was kept strictly confidential between the authors. An available location was located prior to the mock code and an ALS trainer was brought to the location. A code was called by either using the wall code button or by calling the operator. This collaborative approach showed an immediate improvement of participation and improved evaluation scores to an 88% average. This collaborative approach provided an optimum environment for learning and debriefing and eventually led to expanded programs.
Conclusion: The following discussion summarizes the lessons learned from this activity. There were several results from this collaborative approach. Not only were resuscitative efforts improved, but potential patient safety issues were uncovered. On one occasion a mock code found that the emergency cart used for out-patient emergencies could not fit in the parking garage elevator and could not be carried up multiple flights of stairs. Because of this issue identification an alternate equipment case was implemented. On another occasion it was found that construction had closed stairwell exits creating a 12 minute emergency team response time and the inability to access an oxygen source. This area is now equipped with a crash cart and portable oxygen tank. After attending a collaborative mock code the chief medical resident requested collaboration with nursing education to develop a “boot camp” experience for new medicine residents that would provide a safe environment to practice resuscitative methods. Each week the residents spent four hours in the collaborative environment to practice ACLS algorithms. The mock codes were videotaped and utilized for a team debrief. This program is still being used in this facility and has received a great deal of positive feedback.
1. Baker, C., Pulling, C., McGraw, R., Dagnone, J, Hopkins-Rosseel, D., & Medves, J. (2008). Simulation in interprofessional education for patient-centred collaborative care. Journal of Advanced Nursing 64(4), 372-379. Doi: 10.1111/j.1365-2648.2008.04798.x.
2. Reese, C., Jefferies, P., & Engum, S. (2010). Learning together: Using simulation to develop nursing and medical student collaboration. Nursing Education Perspectives 31(1), 33-37.
3. Webbe-Janek, H., Lenzmeier, C., Ogden, P., Lambden, M., Sanford, P., Herrick, J., Song, J., Pliego, J. & Colbert, C. (2012). Nurses’ perceptions of simulation-based interprofessional training program for rapid response and code blue events. Journal of Nursing Care Quality 27(1), 43-50. Doi: 10.1097/NCQ.0b013e3182303c95.
557 Simulation as an Effective Instructional Framework for Clinical Competencies: MPA Student Evaluation of Transition from Problem Based Learning Format to Simulation
Lorraine Petti, MPA, PA-C1
1PHYSICIAN ASSISTANT EDUCATION, SAMUEL MERRITT UNIVERSITY, OAKLAND, CA, USA
Introduction/Background: The hypothesis for this research is as follows: evolving from PBL (problem based learning) format to simulation based teaching for clinical case instruction will result in improved educational effectiveness in areas of clinical reasoning, critical thinking, communication, and professionalism.1,2 Since 2000, Samuel Merritt University Physician Assistant Program has utilized the PBL format for the contextual framework of our three semester Integrating Seminar course with group discussion of patient cases. There is growing evidence to support immersive learning environments and increasing utilization of simulation based instruction in medical education.3,4 In fall 2011, SMU piloted a major course modification which utilized simulation in place of PBL as the contextual framework for case presentations with similar course modifications in spring and summer semesters of 2012. The primary objective of the three semester MPA Integrating Seminar course is to facilitate our students’ abilities to integrate knowledge obtained in didactic program coursework into clinical application: medical decision making, clinical problem solving, assessment and management of commonly encountered disorders in primary care. With the transition to a simulation instructional format we had three primary objectives: (1) To enhance our students’ instructional experience by creating an active learning environment; (2) Increase students self confidence in clinical decision making; (3) Demonstrate student competence in areas of Professionalism/Communication and Clinical Reasoning/Critical Thinking.
Description: The method included the following process. Research participants included 108 PA students at Samuel Merritt University comprised of two cohorts. All students attended a weekly 3 hour Integrating Seminar course over 2 consecutive semesters. Student cohort #1 was limited to PBL format x 3 semesters (33 students). Student cohort #2 were in semesters 1 and 2 with PBL format and the 3rd semester with simulation (37 students). Student cohort #3 were in semesters 1, 2 and 3 with progressively increasing participation in simulation scenarios (38 students). Students assumed the role of primary care provider or patient in simulated scenarios addressing clinical content which was relevant to their current didactic curriculum. Simulations were immediately followed by debriefing with clinical faculty in small cohort groups of 8-10 students. This curricular format replaced the standard PBL format which was characterized by small group case discussion. Participants completed two student self assessment surveys: PBL Effectiveness Assessment and Simulation Effectiveness Assessment. The following results were found. PBL Effectiveness Assessment: Data from our PBL effectiveness survey was collected from student cohort #1 limited to PBL format for three semesters, indicated an overwhelming agreement (98%) that simulation would have added valuable learning experience to this course. Student cohort #2 with two semesters PBL, and one semester of simulation unanimously favored the simulation course format over PBL. Simulation Effectiveness Assessment: Simulation effectiveness was mapped to three of our core learning competencies: critical thinking, communication, and clinical reasoning. Simulation Effectiveness Survey data from the second and third cohorts indicated a strongly positive assessment of instructional effectiveness in areas of clinical reasoning, communication, critical thinking and improved clinical application of medical knowledge.
Conclusion: Requiring our students to be active learners in patient encounter simulation exercises enabled us to test a clinical learning format based on immersion learning theory. We chose an Integrating Seminar course which was most conducive to this application. The primary course objective is to facilitate our students’ abilities to integrate knowledge obtained in didactic program coursework into clinical application. The following information discusses the conclusions of this research activity: (1) Survey results confirmed that students perceived simulation as an effective teaching format to achieve course objectives; (2) Specifically, our students favorably scored their educational experience in this course as improved over time across core learning competencies: critical thinking, communication, and clinical reasoning; and (3) Our next research project will develop an objective assessment rubric for each student to assess progression of minimum core competency criteria over time with increased exposure to simulation.5
1. Steadman RH, Coates WC, Huang YM, Matevosian R, Larmon BR, McCullough L, Ariel D: Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills. Critical Care Medicine 2006; 34: 151-157.
2. Doucet MD, Purdy RA, Kaufman DM, Langille DB: Comparison of problem-based learning and lecture format in continuing medical education on headache diagnosis and management. Medical Education 1998; 32: 590-596.
3. Schroedl CJ, Corbridge T, Cohen ER, Fakhran SS, Schimmel D, McGaghie WC, Wayne DB : Use of simulation-based education to improve resident learning and patient care in the medical intensive care unit: A randomized trial. Journal of Critical Care 2012; 27: 219.e7-13.
4. Okuda Y, Bryson EO, DeMaria S, Jacobson L, Quinones J, She B, Levine Al: The utility of simulation in medical education: what is the evidence? Mt Sinai Journal of Medicine 2009; 76: 330-343.
5. Issenberg B, Ringsted C, Ostergaard D, Dieckmann, P: Setting a Research Agenda for Simulation-Based Healthcare Education: A Synthesis of the Outcome From an Utstein Style Meeting. The Journal of the Society for Simulation in Health Care 2011; 6: 155-167.
565 Simulation Scenarios Created by Students for Students
Janice McMillan, BA,1 Alexander Bitzer, BS,1 Elisabeth Wright, MS,2 Keith Littlewood, MD2
1UNIVERSITY OF VIRGINIA SCHOOL OF MEDICINE, CHARLOTTESVILLE, VA, USA and 2MEDICAL SIMULATION CENTER, UNIVERSITY OF VIRGINIA SCHOOL OF MEDICINE, CHARLOTTESVILLE, VA, USA
Introduction/Background: Curriculum is usually created and proscribed by experts. Students often have representation at the level of curriculum committees, but rarely have direct input into particular educational encounters. We have taken a first step in creating a model in which students are the mentored creators of simulation scenarios. Importantly, these scenarios address topics that the students themselves have only recently experienced. The processes, challenges, future steps, and educational theory related to this model will be discussed.
Description: Curriculum in healthcare education and training is typically created and implemented by faculty experts. The content of the formal curriculum is usually dictated by a curriculum committee that must consider institutional standards for its learners, as well as external expectations such as those stated by regulatory agencies or implied by standardized examinations. This presupposes that experts best understand what learners should come to know, a logical assumption. Recent advances in educational and psychological theory, however, challenge the assumption that most experts understand how learners come to know. This deficit can be partially addressed with faculty development and the implementation of active learning modalities. However, the difference between expert and novice cannot be completely bridged. Whether viewed through the lens of threshold concepts and transformation or cognitive theory’s working memory and schema, the expert can not fully appreciate obstacles as experienced by the learner. Recent novices (students who have just completed a portion of the curriculum), can offer important insights and understanding of the knowledge and practices that were difficult in their own recent transition. Importantly, this depends upon the recent novice actually having moved past the common adaptive behaviors such as mimicry to authentic development. The obvious challenge to recent novices in developing simulation scenarios is a lack of experience in application and refinement. In our estimation, this requires that experienced faculty be available for scheduled and ad-lib check-ins to provide contextual perspective. These sessions are intended to offer broad options and areas for exploration rather than a strict script of any sort. This allows the recent novice to retain the overall vision and strategy of development with the benefit of expert guidance. The University of Virginia’s School of Medicine has a long-standing Medical Student Summer Research Program (MSSRP) in which students can spend the summer between their first and second years in research labs or educational organizations. The Medical Simulation Center has previously sponsored students who were incorporated into active projects and participated in introductory tutorials on educational theory and practice. Most recently, we have changed this experience so that a team of two students is charged with creating a simulation scenario to be integrated into the medical school curriculum. Critically, the content of the experience would be based in the Mind, Brain, and Behavior (MBB) system of the NxGen curriculum. This system had just been completed by the MSSRP students before the summer break. The students were specifically asked to create a list of particularly challenging topics that they felt should be reinforced through voluntary immersive experiences. The primary faculty member then asked these candidates to look for characteristics of threshold concepts. On this basis, the team selected the recognition and initial management of increased intracranial pressure and early seizure following subarachnoid hemorrhage as a paired simulation scenario experience.
Conclusion: We describe a new model for simulation curriculum development in which recent novices are the mentored developers. This is intended to address the failings of expert-developed curricula in terms of threshold concepts and cognitive theory. Our intention is to implement these scenarios and assess their effectiveness based upon the following criteria: (1). Student Likert-scale evaluations of this experience will be compared to our evaluation database of traditionally developed scenarios; (2). Student responses of what they have gained from the session and what questions remain will be compared to the goals and objectives of the sessions; and (3). Randomly selected students will participate in encounter groups to discuss the challenges of the MBB system and whether these recent-novice developed scenarios addressed these challenges.
1. Meyer JHF, Land R. Threshold concepts and troublesome knowledge 1 - Linkages to ways of thinking and practising. In: Rust C, editor. Improving Student Learning - Ten Years On. Oxford: Oxford Centre for Staff and Learning Development; 2003.
2. Van Merrienboer JJG, Sweller J. Cognitive load theory in health professional education: design principles and strategies. Med Educ. [Review]. 2010 Jan;44(1):85-93.
3. Kneebone RL, Scott W, Darzi A, Horrocks M. Simulation and clinical practice: strengthening the relationship. Medical Education. 2004 Oct;38(10):1095-102.
4. The UVa NxGen Curriculum (Accessed July 20, 2012): http://www.medicine.virginia.edu/education/medical-students/UMEd/nxgen/AdvancingCurriculum-page.
Disclosures: Elisabeth Wright, MS, receives grant support from the Josiah Macy, Jr. Foundation. Keith Littlewood, MD, receives Research funding from Pfizer Pharmaceutical and Josiah Macy Foundation.
568 Simulating On-Call Pages as an Assessment Tools of Senior Pediatric Residents
Karen Mangold, MD,1 Mark Adler, MD1
1PEDIATRICS, NORTHWESTERN UNIVERSITY, FEINBERG SCHOOL OF MEDICINE, CHICAGO, IL, USA
Introduction/Background: Residents spend a large amount of time answering pages. There are very few published descriptions of educational sessions that included the answering pages. Published studies have shown that residents feel more confident after this type of training. No published work describes the assessment of resident performance in answering pages. Simulations involving a resident answering pages offers a unique way to assess resident skills, such as decision-making, resource management and communication skills. Paging simulations also offer a convenient assessment method, as they only require a phone and a pager, which are readily available in the health care environment.
Description: Second-year residents in pediatrics participated in a formative assessment. As part of a larger assessment event, residents received sign-out on a series of patients and then rotated through six OSCE-style stations that used different simulation modalities. One of the stations involved them answering a series of pages about patients from their sign-out. Conversations were recorded and analyzed later for their responses to the nurse and intern’s inquiries. Residents were allowed to call any consults to gather information or mobilize resources to evaluate patients. We evaluated each resident on their clinical management of each scenario, as well as their communication skills and decision-making abilities. We used anchored rating scales to assess the resident’s response to each page.
Conclusion: This is a new method for assessing resident skills using simulated pages. The simulation involved minimal technology, making it easy to use in a variety of training settings.
1. Patel SP, Lee JS, Ranney DN, Al-Holou SN, Frost CM, Harris ME, et al. Resident Workload, Pager Communications, and Quality of Care. World J Surg. 2010 Aug. 12;34(11):2524–9.
2. Marshall RL, Gorman PJ, Verne D, Culina-Gula S, Murray WB, Haluck RS, et al. Practical training for postgraduate year 1 surgery residents. Am. J. Surg. 2000 Mar.;179(3):194–6.
3. Boehler ML, Rogers DA, Schwind CJ, Fortune J, Ketchum J, Dunnington G. A senior elective designed to prepare medical students for surgical residency. The American Journal of Surgery. 2004 Jun.;187(6):695–7.
586 Continuous Renal Replacement Therapy: Using Simulation to Educate and Train Nurses
Christine Lawlor, BSN, RN,3 Ried Mary, RN, CCRN,3 Pamela Aitchison, RN,1 Morris Kharasch, MD,2 Ernest Wang, MD2
1CENTER FOR SIMULATION AND INNOVATION, NORTHSHORE UNIVERSITY HEALTHSYSTEM, EVANSTON, IL, USA and 2EMERGENCY MEDICINE, NORTHSHORE UNIVERSITY HEALTHSYSTEM, EVANSTON, IL, USA and 3INTENSIVE CARE, NORTHSHORE UNIVERSITY HEALTHSYSTEM, EVANSTON, IL, USA
Introduction/Background: The Intensive Care Unit initiated continuous renal replacement therapy (CRRT) four years ago. The staff’s experience with CRRT is limited due to an average of 10 cases per year. The annual bedside nurse’s needs assessment identified CRRT as the number one educational deficit for staff. The literature states that there are “no universal competencies for care of the CRRT Patient.” Additionally, there are three different models of care delivery for the CRRT patient in a critical care unit with varied level of costs and manpower requirements.1,2 This leads to inconsistency. The potential for error and risk to patient safety is paramount. Furthermore, the unit recognized that all of the nurses should be competent in basic training and responsiveness to urgent patient care conditions. The purpose and development of this pilot education program was to first meet the educational needs of the bedside nurse and demonstrate didactic training coupled with simulation experience is sustainable by nurses. This was measured by an anonymous survey and timing to assess education objectives.
Description: In the first phase (1A) of the design a small sample group of nurses was selected. Education was provided via a power point presentation followed by a simulated case scenario with the goal to have the nurse perform critical actions. The three critical care actions were as follows: (1). Identifying Alarms (high pressure) troubleshoot/intervene; (2). Treating hypotension by decreasing UF, increasing vasoactive medications; and (3). Disconnect from CRRT within 5 minutes to avoid clotting catheter. Additionally, the appropriate documentation of the above actions into the electronic medical record was demonstrated. The evaluations and feedback of the pilot group reported an increase in level of comfort after simulation but requested to have more hands on time with the simulation and more alarms to troubleshoot. We gathered the same nurses back to simulation for an updated scenario based on these requests (Phase 1B). At the completion of phase 1B, 68 nurses were brought to the simulation lab for annual competency training. Every nurse had didactic training via a power point presentation in a classroom setting. Immediately afterwards, the nurses engaged in the simulation case. Each nurse was given a pre and post simulation questionnaire regarding comfort level with CRRT. A debriefing of the simulation experience occurred. To ascertain if our education was sustainable, we set up portable simulation in the ICU two months after phase 1 B. The same questionnaire was administered and the same simulation case was presented. The only change was related to alarm origin. Of the staff, 65% completed the portable simulation case. Although the nurses level of comfort dropped after the initial education, their timing did not significantly change.
Conclusion: An evaluation of participant’s comfort level utilizing a pre and post simulation questionnaire explored level of comfort caring for patients receiving CRRT and nurses understanding of machine function. Additionally the ability to intervene and perform emergency disconnect from the CRRT machine was in included in the questionnaire. Before training greater than 50% of nurses rated their comfort as slight or not at all for 3 out of 4 objectives. After training, this level dropped to <10%. Finally the time elapsed to meeting objectives was measured. Repeated practical education with hands on experience is a key to a successful education program.3 The findings of this pilot illustrate the benefit of didactic education with the addition of simulation training. The key measure showed improvement with nurses being better equipped to respond to urgent patient care conditions and intervene appropriately. Furthermore, during observation it was noted that despite a decrease in stated confidence level, nursing troubleshooting appeared seamless and staff required less cues.
1. Nursing Issues in Renal replacement therapy: organization, manpower assessment, competency evaluation and quality improvement processes. Patricia Graham and Eileen Lischer. Seminars in dialysis vol 24, no 2 2011 pp 183-186.
2. Starting up a continuous renal replacement therapy program on ICU. Wilfried DeBecker Department of Intensive Care University Hospital Gasthuisberg, Leuven, Belgium.
3. Continuous Renal Replacement Therapy. Edited by: John A Kellum, Rinaldo Bellomo, Claudio Ronco. Oxford university press 2010.
601 Description of a Successful Multiple Patient Encounter Simulation Model for Emergency Medicine Resident Education
Joseph Turner, MD,2 Lee Wilbur, MD,2 Jonathan Kirschner, MD,1 Roderick Morrison, MD,1 Dylan Cooper, MD2
1EMERGENCY MEDICINE, INDIANA UNIVERSITY, INDIANAPOLIS, IN, USA and 2EMERGENCY MEDICINE, INDIANA UNIVERSITY SCHOOL OF MEDICINE, INDIANAPOLIS, IN, USA
Introduction/Background: Emergency medicine (EM) residency programs make widespread use of simulation as an educational tool, with 85 percent of programs incorporating mannequin simulation into their training.1 While the clinical practice of EM involves managing multiple patients of variable acuity simultaneously, most simulation experiences involve single patient encounters. There are very few reports of multiple patient high-fidelity simulation encounters in emergency medicine resident training. Kobayashi et al. have described a process for the development of multiple patient encounters.2 Several other authors have described multiple patient scenarios focused on improving teamwork, with teams of multiple physicians and nurses managing patients simultaneously.3,4,5 To our knowledge, there are no studies describing programs with a single resident managing multiple patients simultaneously. We developed and successfully piloted an efficient model for multiple patient high-fidelity simulation scenarios for single physician learners. This model has great potential to improve emergency medicine resident education and advance patient care, and it could be adopted for other fields and professions.
Description: Our Simulation Management and Oversight Committee of EM faculty and residents, in collaboration with simulation technicians, developed two multiple patient scenarios for senior EM residents. Each scenario incorporated three patients: two critically ill patients and one lower acuity patient and was set up in three adjacent simulation rooms. One technician and two EM faculty (one confederate, one observer) managed each scenario. A single third-year resident participated in each scenario, managing all three patients simultaneously with the help of only the confederate nurse. Each scenario lasted approximately 30 minutes with an additional 25-30 minutes of comprehensive, structured debriefing and self-assessment. All participants and trainers completed a written survey immediately following the session. The survey included questions with a 5-point Likert scale (strongly disagree to strongly agree) and open-ended questions regarding specific strengths and weaknesses of the session.
Conclusion: In this pilot, four resident volunteers each led a scenario and were fully debriefed in less than two hours using five faculty and two technicians. On post-session surveys the residents all agreed or strongly agreed that the session was a good learning experience, could be a useful evaluation tool, and should be incorporated into the EM simulation curriculum. Residents specifically commented that the experience was more realistic than traditional simulation cases. All faculty trainers felt the program was an effective learning tool and should be continued. Multiple patient simulation scenarios are powerful learning tools that more realistically reproduce actual conditions than single patient encounters. Previous authors have demonstrated the feasibility of such programs in EM training and their value in improving teamwork skills. Our pilot differs by limiting active management of cases to a single learner. We chose this model for several reasons. First, it closely resembles the oral board style cases required for board certification in EM, and the future of EM board certification is likely to be simulation-based. Second, it offers simple logistics for large programs with multiple learners. Finally, it concentrates decision making on a single learner, improving their learning experience and effectively modeling community emergency departments where many graduates will work. Feedback following the session was overwhelmingly positive, and we have since incorporated multiple patient scenarios into our EM simulation curriculum. The efficiency of the model is an additional strength, allowing multiple learners to participate in a short time period. This model is flexible and could be adapted for other medical fields and professions which require management of multiple patients simultaneously.
1. Yasuharu O, Bond W, Bonfante G, McLaughlin S, Spillane L, Wang E, Vozenilek J, Gordon J: National growth in simulation training within emergency medicine residency programs, 2003-2008. Acad Emerg Med. 2008; 15(11):1113-1116.
2. Kobayashi L, Shapiro M, Gutman D, Jay G: Multiple encounter simulation for high-acuity multipatient environment training. Acad Emerg Med. 2007; 14(12):1141-1148.
3. Reznek M, Smith-Coggins R, Howard S, Kiran K, Harter P, Sowb Y, Gaba D, Krummel T: Emergency medicine crisis resource management (EMCRM): pilot study of a simulation-based crisis management course for emergency medicine. Acad Emerg Med. 2003;10(4):386-389.
4. Shapiro M, Morey J, Small S, Langford V, Kaylor C, Jagminas L, Suner S, Salisbury M, Simon R, Jay G: Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? Qual Saf Health Care. 2004; 13(6):417–421.
5. Small S, Wuerz R, Simon R, Shapiro N, Conn A, Setnik G: Demonstration of high-fidelity simulation team training for emergency medicine. Acad Emerg Med. 1999; 6(4):312-323.
643 Pediatric Anesthesia Simulation Program
Bistra Vlassakova, MD,2 Carlos Munoz, MD,3 Linda Bulich, MD,3 Julianne Bacsik, MD,3 Andres Navedo, MD,3 Richard Blum, MD, MSE, FAAP3
1 and 2ANESTHESIA, BOSTON CHILDREN’S HOSPITAL, BOSTON, MA, USA and 3ANESTHESIA, PERIOPERATIVE AND PAIN MEDICINE, BOSTON CHILDREN’S HOSPITAL, BOSTON, MA, USA
Introduction/Background: ACGME accredited pediatric anesthesia fellowship programs must ensure trainees manage a minimum number of complex high intensity/index cases during fellowship training. The random nature of the apprenticeship training model is capable of providing the mandated ACGME requirements but cannot ensure trainees receive adequate exposure to high intensity/index cases and the associated skills and knowledge to be a proficient pediatric anesthesia consultant. Simulation provides a versatile, supervised platform for systematic supplemental training, providing safe and reproducible conditions where trainees can practice the essential technical and behavioral skills without putting actual patients at risk.
Description: A simulation program was created to meet the training needs of the pediatric fellowship program at Boston Children’s Hospital (BCH). This simulation course attempted to increase a pediatric anesthesia fellow’s technical skills and increase exposure to a wide range of clinical cases. The two-day program consists of full day modules that provide a graded increased case complexity designed for formative feedback, not individual assessment. Scenarios were created by an anesthesia simulation team with diverse expertise. Clinical scenarios involved the entire spectrum of perioperative care, preoperative assessment, intra-operative and post-operative management. The emphasis of this program is the knowledge and technical skills required to care for complex pediatric anesthesia cases. Scenarios were also designed such that critical behavioral skills including communication, leadership and task delegation were often required for optimal management. Each scenario had a primary anesthesiologist and a first responder; other roles including surgeon and circulating nurse were confederate actors. Modules start with a short didactic session that included overview of the course, brief review of adult learning theory, introduction to the simulated environment, hands-on review of the Laerdal SimBaby, and reviewing Crisis Research Management principles (fellows receive CRM training in a course at the Center for Medical Simulation). Scenarios were approximately 30 minutes long followed by a 30 minute debriefing. Fellows completed an eight question survey to reflect on their experience with the simulation program for future program improvement (four-point Likert scale; strongly agree, agree, disagree and strongly disagree). Each module had three to four trainees and three faculty facilitators. Fifteen fellows participated in the first module and 13 completed the second module. Module one had 5 clinical scenarios and module two- four cases. Survey results include: 100% strongly agree or agree for both modules that the scenarios met their expectations; scenarios were clinically relevant; they had a high degree of realism; they had high quality of debriefing; and they provided a supportive environment.
Conclusion: The rigorous curriculum design made the program successful in meeting educational goals. The fellows felt the anesthesia simulation faculty and their abilities to facilitate and teach difficult and complex cases in a safe, supportive environment were the strength of the program; they rated it extremely well. This program will enthusiastically continue with plans to introduce a third module on difficult pediatric airway management. Formal options for studying clinical outcomes are being reviewed. The development of this program is an important step toward organizing a pediatric Maintenance of Certification in Anesthesia (MOCA) course and the BCH Simulation Program is the first pediatric hospital-based program endorsed by American Society of Anesthesiologists to provide this MOCA requirement. Pediatric Anesthesia has recently been recognized by American Board of Medical Specialties in 2012 (initial certification examination planned in 2013). Simulation will likely play an increasing role in performance assessment in certification and recertification and our program will aid trainees in preparation for such assessments.
697 Simulation-Based Orientation Program for New Nurses Entering Work in a Large Hospital: Communication and Decision-Making Skills Needed to Survive in the New Work Environment
Orna Divon-Ophir, MA, CCRN, CNM, IBCLC,1 Shoshana Goldberg, PhD,2 Amitai Ziv, MD, MHA1
1ISRAEL CENTER FOR MEDICAL SIMULATION (MSR), TEL HASHOMER, ISR and 2NURSING AND PARA-MEDICAL PROFESSIONS, SHEBA MEDICAL CENTER, TEL HASHOMER, ISR
Introduction/Background: Simulation based workshops were developed for new, typically young, registered nurses starting their work in the various departments at Sheba Medical Center, the largest hospital in Israel. The need for the workshop grew out of the realization that young nurses entering the workforce face multiple challenges, which often lead to early dropout during the first year, after much investment has already been made in their orientation program. A simulation based workshop was developed enabling the participants to improve their communication skills and decision making process in encounters with SPs portraying challenging patients, family members and other staff members. The encounters were developed in correlation with challenges stated by nurses in focus groups. The objectives included the following: (1). To improve the nurses communication and decision making process in various subject matters; (2). To strengthen the new nurses’ self-confidence and sense of capabilities in the clinical field where they cope with challenging staff members, families and patients.
Description: The work shop was designed for 2 groups of 12 nurses trained in an 8 hour workshop. The participants encountered 6 scenarios as a trainee or as an observer and received oral and written feedback from the actors. They then participated in group debriefing with an emphasis on behaviors to preserve and behaviors to improve. The scenarios in the workshop include coping with a family refusing to discharge a patient, patient’s low compliance in medication therapy, dealing with an uncooperative, over-worked doctor, learning to communicate with senior staff members about medication errors, dealing with delivering bad news and treating multiple patients while deciding on treatment priority. At the end of the day, the trainees filled out an evaluation form.
Conclusion: In general, the nurses’ feedback showed high satisfaction and felt that the workshops were an important addition to their orientation process.
Disclosures: Amitai Ziv, MD, MHA, receives grant support from the BIRD Foundation, is a consultant for Simbionix USA and the Michener Institute for Applied Health Professions, Canada, and is a stockholder of Semantic Medical Simulation (SMS) Ltd.
698 Resuscitating Newborn Conjoined Twins: Simulation Sets the Stage
Anne Ades, MD,5 David Munson, MD,3 Nancy Dixon, BSN, RN,4 Roberta Hales, MHA, RRT-NPS, RN,1 David Rodgers, EdD, NREMT-P2
1CENTER FOR SIMULATION, ADVANCED EDUCATION AND INNOVATION, CHILDREN’S HOSPITAL OF PHILADELPHIA, PHILADELPHIA, PA, USA and 2CENTER FOR SIMULATION, ADVANCED EDUCATION, AND INNOVATION, CHILDREN’S HOSPITAL OF PHILADELPHIA, PHILADELPHIA, PA, USA and 3NEONATOLOGY, CHILDREN’S HOSPITAL OF PHILADELPHIA, PHILADELPHIA, PA, USA and 4NEWBORN AND INFANT INTENSIVE CARE UNIT CHILDREN’S HOSPITAL OF PHILADELPHIA, PHILADELPHIA, PA, USA and 5PEDIATRICS, CHILDREN’S HOSPITAL OF PHILADELPHIA, PHILADELPHIA, PA, USA
Introduction/Background: Conjoined twin delivery is very rare (1.47 per 100,000 births)1 thus limiting clinicians’ abilities to gain experience in managing emergencies. Delivery room resuscitation of conjoined twins can be extremely challenging especially if airway management is needed. Given the extreme rarity of conjoined twins, most practitioners have had no training or exposure to help them anticipate, prepare or conduct a delivery room resuscitation. Simulation was identified as the best means to prepare the resuscitation team.
Description: One week prior to the planned delivery of thoracopagus conjoined twins, the neonatal resuscitation team conducted a simulation session with the entire newborn resuscitation team present. The session was conducted in situ in the newborn resuscitation room. A low fidelity simulated model of the twins was made, which allowed for positioning and handling of the patients. The simulation was conducted in two parts. First the team walked through the expected resuscitation sequence, stopping frequently to discuss each aspect of team member roles and responsibilities, equipment and patient positioning, and resource allocation. As issues were identified, the team experimented with different solutions and identified the best option before moving on to the next phase of the resuscitation. Among the issues identified and resolved with the walk through simulation included the following: (1). Equipment positioning; (2). Personnel positioning; (3). Establishing priority sequences for assessment and management for each patient; (4). Clarifying team dynamics and roles; (5). Procedures established for providers to identify the patients when calling out orders and physiologic findings; and (6). Positioning the patients for procedures including endotracheal intubation. After the walk through was complete, the resuscitation team and room were reset and a real time simulation of the resuscitation starting with the entry of the twins into the room from the maternal operating room was conducted. This simulation allowed for final testing of the previously identified issues and confirmed the results were satisfactory. A final debriefing session was conducted at the conclusion of the real time simulation to fine tune any changes and confirm that the whole team was clear on their roles and responsibilities.
Conclusion: The orchestration of complex situations to allow safe and efficient care can be achieved through the use of simulation. The invaluable lessons the team learned from the simulations were implemented during the resuscitation of the twins a week after the simulations. Comparing video of the simulation and the resuscitation, the actions of the resuscitation team greatly mirrored the steps developed in the simulations.
1. Mutchinick OM, Luna-Muñoz L, Amar E, Bakker MK, Clementi M, Cocchi G, da Graça Dutra M, Feldkamp ML, Landau D, Leoncini E, Li Z, Lowry B, Marengo LK, Martínez-Frías ML, Mastroiacovo P, Métneki J, Morgan M, Pierini A, Rissman A, Ritvanen A, Scarano G, Siffel C, Szabova E, Arteaga-Vázquez J. Conjoined twins: a worldwide collaborative epidemiological study of the International Clearinghouse for Birth Defects Surveillance and Research. Am J Med Genet C Semin Med Genet. 2011 Nov 15;157C(4):274-87. PMID: 22002822.
701 Simulation Debriefing the Army Way: The Application of the U.S. Army’s After-Action Review (AAR) Format to Medical Simulation Debriefing
Taylor Sawyer, DO, MEd,1 Shad Deering, MD2
1MEDICAL SIMULATION CENTER, TRIPLER ARMY MEDICAL CENTER, HONOLULU, HI, USA and 2OBSTETRICS AND GYNECOLOGY, UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES, BETHESDA, MD, USA
Introduction/Background: Post-simulation debriefing is a critical component of effective learning in simulation-based medical education (SBME).1-3 When done correctly, post-simulation debriefing facilitates learning through active reflection on performance during the simulation, aids in the identification of mental models that lead to behavioral changes, and provides an opportunity to revise flawed mental models for application in future experiences.4-11 The process of reflective observation, facilitated during post-simulation debriefing, is a key component of the experiential learning cycle.9,12 Facilitating the post-simulation debriefing session in a constructive manner in an effort to close identified performance gaps is at the foundation of post-simulation debriefing as a type of formative assessment.11 Given the importance of post-simulation debriefing in SBME it is not surprising that multiple formats for conducting the exercise have been proposed.11,13-20 Most of these formats are founded on learning theory, with input from behavioral science, and were adapted from earlier models of facilitated debriefing in simulation-based education and/or aviation.6,13 21,22 Prior reviews have noted a lack of empiric evidence to suggest an optimal format for post-simulation debriefing in SBME, and there is a clear need for further investigation and research in this area.3,13 The U.S. Army’s After-Action Review (AAR) format is a method of post-simulation debriefing that has been used within the U.S. Army for almost four decades. According to military experts, the application of the AAR format to post-simulation debriefings has been a key element to the U.S. Army’s success, and the AAR format has been widely adopted outside the military by multiple commercial organizations.23-25 The debriefing format presented here was adapted from the Army AAR format to specifically address key items important in medical simulation and eliminate the military specific components.26 Applying the AAR format to SBME provides a well defined structure to the debriefing and supports the learning process through reliance on pre-identified performance standards.
Description: When conducting a medical simulation debriefing using the AAR format the facilitator should use a high to intermediate level of facilitation to guide the participants through the stages of the debriefing.22 The initial steps for conducting the debriefing include a brief introduction during which the facilitator defines the rules of the debriefing, explains the learning objectives, shares with the participants any relevant benchmarks for performance that were evaluated, and reviews with the groups what was supposed to happen during the simulation. Next, the facilitator leads the participants in an investigation into what actually happened, and a discussion of why things happened the way they did. To conclude the debriefing, after all the important learning objectives have been discussed, the facilitator should lead the participants into a summary and formalization of the learning points, focusing on what went well, what did not go well and what the participants would do differently if confronted with a similar situation in the future. The steps of a medical simulation debriefing using the AAR format are summarized in Table 1. These stages typically occur in sequential order, which provides a standardized, structured and supported nature to the debriefing. This structured format avoids missing or jumping over important steps in the debriefing process.
Conclusion: The use of the AAR format provides a structured and supported method to conduct an effective post-simulation debriefing. Further research is needed to objectively determine the advantage of using the AAR format in SBME.
1. Issenberg SB, McGaghie WC, Petrusa ER, et al: Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Med Teach 27:10–28, 2005.
2. McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research: 2003–2009. Med Educ 2010;44:50–63.
3. Raemer D, Anderson M, Cheng A, Fanning R, Nadkarni V, Salvoldelli G. Research Regarding Debriefing as Part of the Learning Process Sim Healthcare 6:S52–S57, 2011.
4. Crookall D: Debriefing. Simul Games 1992;23:141-142.
5. Thatcher D: Promoting learning through games and simulations. Simul/Games Learn.1986;16:144-154.
6. Lederman L: Debriefing: Toward a systematic assessment of theory and practice. Simul Gaming 1992;23:145-160.
7. Dewey J: Experience and Education. New York, Macmillan, 1929.
8. Argyris C, Schon D: Theory in Practice: Increasing Professional Effectiveness. London, Jossey-Bass, 1974.
9. Kolb DA: Experiential Learning. Upper Saddle River, NJ, Prentice Hall, 1984.
10. Seel NM: Mental models and complex problem solving: Instructional effects, in Elen J, Clark RE (eds): Handling Complexity in Learning Environments: Theory and Research. New York, Elsevier, 2006.
11. Rudolph J, Simon R, Ramer D, Eppich W. Debriefing as formative assessment: Closing performance gaps in medical education. Acad Emerg Med. 2008;15:1010-1016.
12. Pearson M, Smith D. Debriefing in experienced-based learning. Simulation/Games for Learning.1986;16(4):155-172.
13. Fanning R, Gaba D. The role of debriefing in simulation-based learning. Simulat in Healthc. 2007;2(2):115-125.
14. Dismukes R, Gaba D, Howard S. So many roads: Facilitated debriefing in healthcare. Simulat in Healthc. 2006;1:23-25.
15. Zigmont JJ, Kappus LJ, Sudikoff SN. The 3D Model of Debriefing: Defusing, Discovering, and Deepening. Semin Perinatol. 2011;35:52-58.
16. Rudolph J, Simon R, Dufresne R, Raemer D. There’s no such thing as “nonjudgmental” debriefing: A theory and method for debriefing with good judgment. Simulat in Healthc. 2006;1(1):49-55.
17. Phrampus, P. Debriefing in Simulation Education. Accessed 2/11/2012 at: www.wiser.pitt.edu/sites/wiser/.../day1_PP_JOD_DebriefingInSimEdu.pdf.
18. Van Heukelom J, Begaz T, Treat R. Comparison of postsimulation debriefing versus in-simulation debriefing in medical education. Simul Healthc. 2010;5(2):91-97.
19. Kuiper RA, Heinrich C, Matthias A, Graham M, Bell-Kotwall. Debriefing with the OPT model of clinical reasoning during high fidelity patient simulation. Int J of Nurse Ed Scholar. 2008;5(1):1-14.
20. Wallin CJ, Meurligh I, Hedren L, et al. Target-focused medical emergency team training using a human patient simulator: effects on behavior and attitude. Med Educ.
21. Steinwachs B. How to facilitate a debriefing. Simul Gaming. 1992;23(2):186-195.
22. Dismukes R, Smith F: Facilitation and debriefing on aviation training and operations. Aldershot; UK: Ashgate, 2000.
23. Morrison J, Meliza L. Foundation of the After-Action Review Process. Special report #42. 1999. U.S. Army Research Institute for the Behavioral and Social Sciences.
24. Garvin D. A Guide to Putting Learning Organization to Work: The U.S. Army’s After-Action Reviews: Seizing the Chance to Learn, p. 106-116. Harvard Business School Press. Boston, MA, 2000.
25. Darling M, Parry C, Moore J. Learning in the thick of it. Cambridge: Harvard Business Review, 2005. 84-92.
26. Training Circular 25-20, A Leaders’ Guide to the After-Action Review, Headquarters, Department of the Army, Washington DC. 30 September 1993. www.au.af.mil/au/awc/awcgate/army/tc_25-20/tc25-20.pdf.
Disclosures: Shad Deering, MD, assisted in the development of the Mobile Obstetric Emergencies Simulator for the US Army, that has been patented and licensed to Gaumard Scientific.
726 Integration of Screen-Based Simulation with Physiological Modeling in Medical Curricula
Anna Lerant, MD,3 Jeffrey Orledge, MD, MS,4 Kristi Wilson, RN, MSN,2 Joyce Shelby, BS, MBA,2 Robert Hester, PhD,5 W Bosseau Murray, MD1
1CLINICAL SIMULATION CENTER, PENNSYLVANIA STATE UNIVERSITY COLLEGE OF MEDICINE, HERSHEY, PA, USA and 2ACADEMIC AFFAIRS, UNIVERSITY OF MISSISSIPPI MEDICAL CENTER, JACKSON, MS, USA and 3ANESTHESIOLOGY, UNIVERSITY OF MISSISSIPPI MEDICAL CENTER, JACKSON, MS, USA and 4EMERGENCY MEDICINE, UNIVERSITY OF MISSISSIPPI MEDICAL CENTER, JACKSON, MS, USA and 5PHYSIOLOGY AND BIOPHYSICS, UNIVERSITY OF MISSISSIPPI MEDICAL CENTER, JACKSON, MS, USA
Introduction/Background: Screen-based simulation is a versatile and inexpensive mode of simulation, which is especially well-suited for self-directed, problem-based, and/or team-based learning. Screen-based simulation has also been shown to increase retention of concepts learned from textbooks1 as well as in high fidelity simulation sessions.2
Description: Our first year medical students (M1s) have been using physiology simulators3,4 for more than 20 years. We use these screen-based simulators to increase the understanding of physiological concepts through experiential and self-directed learning. These simulators incorporate most body systems (cardiovascular, endocrine, urinary, etc.) and allow modeling for both short-term and long-term changes in physiological parameters. Displays of results include numerical values and trend charts. Examples of scenarios include exercise, breath holding, hemorrhage, congestive heart failure, or the effects of renal artery stenosis.4 The students are evaluated in small group discussions or during formal lectures using audience response systems. Our third year (M3) and fourth year (M4) medical students, as well as our post-graduate year 1 (PGY1) anesthesiology and emergency medicine residents, have access to multiple “flat screen” simulators, such as an EKG rhythm generator, an ACLS simulator, a sedation simulator, and an anesthesia simulator2 through institutional licenses. The ACLS simulator is also available as a mobile application for both Macintosh and Windows operating systems. These simulators provide learning objectives, 20-30 emergency scenarios, real-time scoring, and debriefing. Most provide context-sensitive help menus (i.e. advice on the best treatment pathway at this specific stage of the crisis), while some also provide “artificial intelligence” as an evaluation tool after the trainee has completed the crisis session. We use these screen-based simulators as part of a graduated series of simulation modalities designed to prepare trainees for the care of critically ill patients. Step1 is psychomotor learning of invasive procedural skills on low-fidelity simulators (airway management, vascular access, etc.). Students prepare for these sessions using on-line, self-directed learning modules that contain videos, checklists and brief tests. In Step 2 we introduce screen-based simulation to reinforce the cognitive concepts and algorithmic management of medical crises. Once the trainees have grasped the management principles of the crisis event as it pertains to each of their disciplines, in Step 3 we introduce the trainees to manage medical crisis events as multi-disciplinary groups or interprofessional teams using high fidelity simulators. These sessions also serve as opportunities to learn the principles of crisis resource management (CRM) in inter-disciplinary and interprofessional groups. We introduce our students to the screen-based simulation software as groups, in team-based learning (TBL) setting. We then distribute case assignments for self-directed learning for each participant to be completed in their own time, as home work. Learning outcomes are measured with checklists during the subsequent high fidelity simulation sessions, as part of algorithmic knowledge in medical crisis management. We also use perceived student value and satisfaction with the usefulness and quality of learning with these simulators.
Conclusion: Our results confirm previous reports1,2 that screen-based simulation is an effective way to improve performance in high fidelity simulation sessions. Using screen-based learning as a part of a graduated series of simulation modalities, we are able to reach a larger number of learners with greater effectiveness and participant satisfaction - at a lower cost.
1. Schwid HA, Rooke GA, Michalowski P, Ross BK: Screen-based anesthesia simulation with debriefing improves performance in a mannequin-based anesthesia simulator. Teach. Learn. Med. 2001; 13: 92-6 PM:11302037.
2. Schwid HA, Rooke GA, Ross BK, Sivarajan M: Use of a computerized advanced cardiac life support simulator improves retention of advanced cardiac life support guidelines better than a textbook review. Crit. Care Med. 1999; 27: 821-4 PM:10321676.
3. Abram SR, Hodnett BL, Summers RL, Coleman TG, Hester RL Quantitative Circulatory Physiology: an integrative mathematical model of human physiology for medical education. Adv Physiol Educ. 2007;31(2):202-10. PM:17562912.
4. Hester RL, Brown AJ, Husband L, Iliescu R, Pruett D, Summers R, Coleman TG: HumMod: A Modeling Environment for the Simulation of Integrative Human Physiology. Front Physiol 2011; 2: 12 PM:21647209.
Disclosures: Robert Hester, PhD, receives grant support from the National Science Foundation (NSF), EPSCoR funding, and is a stockholder/partner/owner in HC Simulation, LLC.
764 Delivering In Situ Simulation in a Clinical Environment: A Technical Perspective
Christopher Gay, BSc,2 Donna Oldfield,1 Makani Purva3
1HULL INSTITUTE FOR LEARNING AND SIMULATION, HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST, HULL, GBR and 2MEDICAL EDUCATION, HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST, HULL, GBR and 3MEDICAL EDUCATION, ANAESTHETICS, HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST, HULL, GBR
Introduction/Background: In June 2011 the Hull Clinical Skills Facility opened, featuring six manikin style high fidelity simulators and a video feedback system. Learning is achieved by taking part in a scenario with simulation manikins, then replaying their session via a video feedback system, (known as SMOTS1) where debriefing and discussion takes place. It became necessary to transplant this functionality into a clinical environment to broaden the scope of involved learners. There were multiple challenges and we would like to describe how we addressed them.
Description: Core to the scenario was the neonatal simulator system which needed to be lightweight to enable transportation to a clinical environment. More difficult were the challenges posed by the video feedback process. During the first session we used flash memory video cameras, with the footage being played back via a TV in feedback sessions. This proved unsatisfactory due to the inability to bookmark discussion worthy events in the footage, and the lack of real time viewing of the scenario from the nearby room. The latter necessitated the audience being sat in the same room as the scenario reducing the realism of the environment for the learners. We used a Newborn HAL S3010 model which is wireless and relatively lightweight allowing easy transportation. After discussions with the IT department and SMOTS manufacturer, the mobile video feedback system was reprogrammed to work within a specific IP address range of the new location. Coupled with a portable mini projector, laptop and speakers, we had all the functionality of the normal facility but over in the Labour Ward. The resulting two in-situ simulation sessions has delivered training to 22 learners, at a similar functionality to what they would experience in the dedicated facility. Learners were able to take part in the high fidelity simulation scenario in a real clinical environment, whilst other learners were able to watch live and have directed discussion about the events unfolding on screen. Due to IT limitations the actual playback of recorded video was not possible, but the skill of the facilitators ensured in depth discussion and learning was still achieved.
Conclusion: Delivering in-situ simulation enables access to those staff who would otherwise not be able to attend sessions away from their department, with the bonus of using an actual rather than replicated clinical environments. Good relationships with the IT department and SMOTs manufacturer were vital to the success for the project. Whilst this setup of the technical side is challenging, the end result was that learning was delivered to 22 people who would otherwise have missed this experience.
792 Using Human Factors and Cognitive Psychology as Drivers of Patient Safety in the Simulated Environment
Frank Mazza, MD,1 Judy Kitchens, MHA1
1CLINICAL QUALITY AND PATIENT SAFETY, SETON HEALTHCARE FAMILY, AUSTIN, TX, USA
Introduction/Background: There is now wide acknowledgement that human performance in healthcare settings is suboptimal, leading to harm and even preventable death due to medical errors. The cause of this harm, to a large extent, lies in the lack of human and system reliability, which is largely based on human factors. The human factors, in turn, reflect known human cognitive limits. This presentation is aimed at introducing the concept of the human as a variable when evaluating team performance in a simulated environment, recognizing that the human is a system unto himself, as well as a system within a system. A major focus will be to demonstrate to healthcare practitioners and researchers how cognitive limitations, such as inattentional blindness and errant assumptions and conclusions, lead to medical errors. The intent is not to highlight simulation as a training tool, but rather to demonstrate how the human component functions, so that providers can understand the limits of cognition, anticipate downstream effects on performance and adjust their behaviors accordingly to prevent and mitigate medical errors. The presentation will make the case that simulation can be a practical adjunct to didactic teaching about how to make systems in healthcare more reliable. The model can also be used to advance research into strategies that can make a meaningful impact on the undesirable influence of human factors on patient safety.
Description: The Seton Healthcare Family has received national and international recognition for its work in the area of Perinatal Safety that led to a staggering and sustainable reduction in birth trauma and iatrogenic prematurity. One component of this work has been Seton’s use of simulation to promote reliable team performance during perinatal crises. Though the latter occur rarely, the potential adverse consequences for patient outcomes are great for a labor and delivery team not highly practiced in attending to emergencies. Our work in a simulated environment has determined that the real value of simulation lies in demonstrating firsthand how team performance in a crisis setting is almost always suboptimal, if not outright error-prone, even when the team believes that performance has been outstanding. We believe that when this realization emerges, the result is a highly motivating affirmation to providers that they must change their behavior and incorporate principles of high reliability (previously taught to them in didactic format) into their day to day work as clinicians. This workshop will begin with a discussion of how cognitive psychology offers important lessons for human performance, the types of errors that humans make, and the profound decrement in human performance that accompanies high levels of stress. Selected known strategies that mitigate the effects of human factors will be discussed, and video vignettes will be played that illustrate how performance during medical crises is suboptimal. Proposed process and outcomes measures for improving performance will be highlighted. Audience participation will be actively solicited to establish whether the model represents a feasible approach to drive research that establishes simulation as a useful adjunct for enhancing patient safety. A reactor panel of experts will consider whether this or a similar model might be used to partly shift the construct for healthcare simulation from classic training/debriefing to a tool that can be used for cognitive research. The panel and audience will also be asked to explore the question of whether SSIH should create/sponsor a human factors interest group.
Conclusion: We propose a model for establishing simulation as an important tool in driving clinical performance, patient safety outcomes, and cognitive research. The instructional design involves introducing healthcare providers to the relevance of human factors and cognitive psychology to the work that they perform.
800 Examining Inter-Specialty Dynamics in Crisis Resource Management through the Creation and Implementation of a Simulation-Based Workshop
Ilana Bank, MDCM, FRCPC, FAAP,3 Rachel Fisher, MDCM, FRCPC,1 Lily HP Nguyen, MDCM, MSc, FRCPC2
1ANESTHESIA, MCGILL UNIVERSITY, MONTREAL, QC, CAN and 2OTOLARYNGOLOGY, HEAD AND NECK SURGERY, MCGILL UNIVERSITY, MONTREAL, QC, CAN and 3PEDIATRIC EMERGENCY MEDICINE, MCGILL UNIVERSITY, MONTREAL, QC, CAN
Introduction/Background: Crisis Resource Management (CRM) is the management of complex and dynamic situations requiring high cognitive demand and teamwork.1 The aim of CRM training is to reduce human errors by emphasizing training in effective teamwork and systematic responses to medical crises.2 Traditionally, CRM training has been primarily focused on the ability of a physician to be an effective and efficient team leader. Recently, team training amongst multidisciplinary health care professionals (doctors, nurses, respiratory therapists)3-6 has been found to improve team functioning in medical crisis situations. In clinical practice, teams managing crisis situations often involve physicians from multiple specialties,7 yet there exists very little published research on inter-specialty training – doctors from different specialties training together to manage crisis situations.8-11 Traditionally the medical specialist is trained to be, and assumes the role of the leader of the team. However, when multiple specialists are involved, there is a potential for unclear leadership and potentially differing approaches to the medical situation at hand, opening the door for communication errors and delays in effective and safe patient care. This may ultimately lead to medical errors and poor patient outcomes.12 Potential challenges encountered in interspecialty CRM include: the multiplicity of possible leaders, potential differences in management strategies, ineffective communication, poor collaboration, delays in decision making and potential delays in the institution of appropriate care.13
Description: We created a half-day simulation based inter-specialty team training program in CRM for senior residents from Anesthesia, Otolaryngology-Head and Neck Surgery (OTL-HNS), and Pediatric Emergency Medicine (PEM) to address the potential challenges faced by these specialties in crisis situations. The team training included a 1-hour plenary where concepts of CRM skills were explained. The residents participated in four simulation scenarios (12 minutes each), followed by an inter-specialty debriefing. Scenarios were designed to require inter-specialty and multidisciplinary collaboration in order to have a positive patient outcome. Residents completed a self-evaluation of individual and team CRM skills using a 5-point likert scale. Residents reported self-perceived improvement in their personal CRM skills, such as communication, delegation and resource utilization. For items relating to perceptions of individual performance, there was a significant increase in self-assessed ability from pre to post-course participation (mean (SE) pre = 3.4 (.14), post = 4.0 (.17), F(1,80) = 27.7 p<.0001).Team CRM skills such as, situational awareness and ability to recognize limitations within an inter-specialty team, collaboration in developing and implementing a management plan, also showed a significant difference in the pre to post assessment. For items relating to perceptions of team based skills, there was a significant increase in self-assessed ability from pre to post-course participation (mean (SE) pre = 3.5 (.26), post = 4.2 (.19), F(1,20) = 17.9 p<.005). No significant differences were found across the three specialties. Residents agreed that the course allowed them to be better equipped to function in an inter-specialty team (100%), was relevant to their clinical practice (85%), and should be implemented in their residency curriculum (93%). Sample comments include: “We were able to discover the expertise and perspective of other specialties” and “We have to work in teams to know the limitations / use of other experts.”
Conclusion: In conclusion, the inter-specialty CRM course that was created was well received and participants reported a significant improvement in CRM skills, as evaluated by a self-assessment tool administered pre and post course participation. We plan to continue providing this course to future residents and future research and analysis will focus on the objective measures of performance and fluency of this kind of inter specialty team training on team functioning and patient care in the clinical environment.
1. Eppich W, Brannen M, Hunt EA. Team training: implications for emergency and critical care pediatrics. Current Opinion in Pediatrics, 2008. 20:255-260.
2. Risser DT, Rice MM, Salisbury ML, Simon R, Jay GD, Berns SD. The potential for improved teamwork to reduce medical errors in the emergency department. Annals of Emergency Medicine, 1999. 34:373-383.
3. Nishisaki A, Nguyen J, Colborn S, Watson C, Niles D, Hales R, et al. Evaluation of multidisciplinary simulation training on clinical performance and team behavior during tracheal intubation procedures in a pediatric intensive care unit. Pediatr Crit Care Med. 2011;12(4):406-14.
4. Capella J, Smith S, Philp A, Putnam T, Gilbert C, Fry W, et al. Teamwork training improves the clinical care of trauma patients. J Surg Educ. 2010;67(6):439-43.
5. 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. 2005;14(5):326-31.
6. Hunt EA, Heine M, Hohenhaus SM, Luo X, Frush KS. Simulated pediatric trauma team management: assessment of an educational intervention. Pediatr Emerg Care. 2007;23(11):796-804.
7. Eppich WJ, Brannen M, Hunt EA. Team training: implications for emergency and critical care pediatrics. Curr Opin Pediatr. 2008;20(3):255-60.
8. Freeth D, Ayida G, Berridge EJ, Mackintosh N, Norris B, Sadler C, et al. Multidisciplinary obstetric simulated emergency scenarios (MOSES): promoting patient safety in obstetrics with teamwork-focused interprofessional simulations. J Contin Educ Health Prof. 2009;29(2):98-104.
9. Jankouskas T, Bush MC, Murray B, Rudy S, Henry J, Dyer AM, et al. Crisis resource management: evaluating outcomes of a multidisciplinary team. Simul. 2007;2(2):96-101.
10. Volk MS, Ward J, Irias N, Navedo A, Pollart J, Weinstock PH. Using medical simulation to teach crisis resource management and decision-making skills to otolaryngology housestaff. Otolaryngol Head Neck Surg. 2011;145(1):35-42.
11. Undre S, Koutantji M, Sevdalis N, Gautama S, Selvapatt N, Williams S, et al. Multidisciplinary crisis simulations: The way forward for training surgical teams. World J Surg. 2007;31(9):1843-53.
12. Bion JF, Abrusci T, Hibbert P. Human factors in the management of the critically ill patient. Br J Anaesth. 2010;105(1):26-33.
13. Daniels K, Lipman S, Harney K, Arafeh J, Druzin M. Use of simulation based team training for obstetric crises in resident education. Simul. 2008;3(3):154-60.
811 Using Simulation to Enhance Pediatric Resident Communication Skills with End-of-Life Discussion
Kristen Glass, MD,3 Gary Ceneviva, MD,1 George Blackall, PsyD,3 Robert Shotto, LPN, BA,2 Melanie Comito, MD,3 Robert Tamburro, MD3
1PEDIATRICS, HERSHEY, PA, USA and 2MEDICAL EDUCATION, PENNSYLVANIA STATE UNIVERSITY COLLEGE OF MEDICINE, HERSHEY, PA, USA and 3PEDIATRICS, PENNSYLVANIA STATE UNIVERSITY, HERSHEY CHILDREN’S HOSPITAL, HERSHEY, PA, USA
Introduction/Background: Most pediatric residents are not comfortable with their training in palliative care medicine.1,2 Recent literature suggests that experiential, cased-based curricula are associated with enhanced resident confidence regarding end-of-life discussions.3,4 However, given the relative infrequency of pediatric deaths, in conjunction with resident duty hour restrictions, it is difficult to assure that residents receive adequate clinical exposure to these scenarios. Consequently, we developed a program in which pediatric residents and fellows are mentored through a palliative care scenario with a simulated patient (high-fidelity mannequin) and a standardized parent. Here, we describe the development, implementation and early experiences of this program.
Description: In preparation for this simulation, we crafted the following situations. The following two scenarios were developed by members of the pediatric oncology and critical care divisions: one was an adolescent with a terminal brain tumor and respiratory failure while the other was an infant with Trisomy 18 and multiple medical problems. Mannequins and vital sign profiles were prepared to closely mimic those of an actual patient with those conditions. Trained actresses were hired to play the mothers of these children. These actresses reviewed the script, researched the diagnoses, and underwent a training session with a pediatric intensivist and clinical psychologist to develop a realistic understanding of their roles. A multidisciplinary team consisting of at least one physician, one nurse, and one behavioral health specialist was assembled to mentor each trainee through the simulation experience. The session began with the mentoring team meeting with the trainee for 15-30 minutes to discuss the case and to provide insight into the approach to the scenario. The trainee was also provided with the goals of the encounter which included the following: 1) determining what the mother knows about the clinical condition, 2) delivering difficult news clearly and compassionately, 3) and developing goals of care with the mother. The trainee then entered the simulated patient room in the Simulation Center while the mentoring team remained in a nearby conference room observing the encounter via a live streaming h.264 codec video feed through a commercial viewing software. The patient room contained the patient mannequin attached to the appropriate medical equipment (e.g. ventilator, intravenous pumps, cardiopulmonary monitor, etc) with the patient’s mother sitting at the bedside. The encounter was limited to 60 minutes during which the trainee was expected to meet with the mother and attend to any patient needs that arose. Following the encounter, the trainee returned to the conference room where a debriefing occured. The debriefing included the trainee, the mentors, and the actress. The goal of the debriefing was to provide the trainee an opportunity to reflect on their experience, what they think they did well, and where they struggled. The mentors and actress provided constructive feedback. The tone of the debriefing was collaborative with the goal being to help the trainee gain insight into his/her strengths and weaknesses. The members of the mentoring team also provided written feedback to the trainee. The session was videotaped such that the mentoring team may review a segment of the encounter with the trainee as part of the post-encounter critique. The trainee completed an evaluation of the program. The preliminary results are discussed as follows. To date, thirteen trainees have participated in the program. Three-quarters of the trainees reported they had NOT received strong training in end-of-life care during medical school. Following this experience, the majority of trainees now reported that they felt comfortable in their ability to have meaningful end-of-life care discussions with families.
Conclusion: This simulation program holds promise as a meaningful experience to improve trainee confidence with end-of-life discussions as clinical opportunities may be sparse. Further implementation with continued and detailed trainee feedback is needed to assess its utility.
1. McCabe ME, Hunt EA, Serwint JR. Pediatric residents’ clinical and educational experiences with end-of-life care. Pediatrics. 2008 Apr;121(4):e731-7. PubMed PMID: 18346988.
2. Kolarik RC, Walker G, Arnold RM. Pediatric resident education in palliative care: a needs assessment. Pediatrics.2006 Jun;117(6):1949-54. PubMed PMID: 16740835.
3. Fischer SM, Gozansky WS, Kutner JS, Chomiak A, Kramer A. Palliative care education: an intervention to improve medical residents’ knowledge and attitudes. J Palliat Med. 2003 Jun;6(3):391-9. PubMed PMID: 14509484.
4. Stevens L, Cook D, Guyatt G, Griffith L, Walter S, McMullin J. Education, ethics, and end-of-life decisions in the intensive care unit. Crit Care Med. 2002 Feb;30(2):290-6. PubMed PMID: 11889295.
815 Assessment of Second Year Medical Student Knowledge of Basic Obstetrical Skills Coupled with Bilingual Communication in a Simulated Remote Field Situation
Rebecca Bowden, PhD,1 Camille Bentley, DO,2 Jill Pitcher, DO,3 Kylie Kanze, DO,3 Tina Underwood, MA,1 Thomas Told, DO4
1CLINICAL ASSESSMENT AND SIMULATION, ROCKY VISTA UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE, PARKER, CO, USA and 2GLOBAL MEDICINE, ROCKY VISTA UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE, PARKER, CO, USA and 3PRIMARY CARE, ROCKY VISTA UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE, PARKER, CO, USA and 4RURAL AND WILDERNESS MEDICINE, ROCKY VISTA UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE, PARKER, CO, USA
Introduction/Background: To address the shortage of doctors practicing rural medicine in the state of Colorado, Rocky Vista University College of Osteopathic Medicine (RVUCOM) developed an eighteen-month Rural and Wilderness Medicine (R&WM) honors track for first and second year osteopathic students. The track is designed to introduce the students to situations and patients they will encounter as the sole health care provider in their area of practice. A 2011 survey of rural clinicians in Colorado asked them to rate how well they felt their undergraduate and graduate medical training prepared them for rural practice.1 Forty-eight percent of respondents felt their training in maternity care and working with interdisciplinary teams (58%) was inadequate during their undergraduate years. These percentages were reduced to 25% and 31%, respectively, during their residency training. To address some of these inadequacies in undergraduate education for rural clinicians, a pilot program in basic obstetrics was developed for the second year R&WM track students in the 2011-2012 academic year. The program was designed as a combination of didactic and simulation experiences. The capstone event of the program was a team-based simulated hybrid emergency delivery with a non-English speaking standardized patient.
Description: Students in the R&WM track (n=13) participated in several didactic sessions focusing on fetal monitoring and caring for obstetric patients. Birthing simulations using NOELLE (Gaumard) designed to reinforce the objectives of the preceding didactics followed each session. Topics included normal labor and delivery, post partum care of mother and baby, post partum hemorrhage, shoulder dystocia and newborn resuscitation. The capstone event was a hybrid simulated emergency delivery in a field with Spanish-speaking standarized patients (SP). One SP portrayed the role of the mom-to-be and gave birth via MamaNatalie (Laerdal). The other SP portrayed the mom-to-be’s mother. Both were instructed to speak only in Spanish. The interpreters for the scenario were second year students in our Global Medicine honors track (n=10). All Global students have participated in medical missions to Spanish-speaking countries. Their fluency in Spanish ranged from basic medical Spanish to complete fluency. The students were randomly assigned to care teams of 4 students consisting of 2 or 3 R&WM students and 1 or 2 Global track students. The field setting had very limited resources for the students to use during the delivery. This required the teams to assess the setting carefully for resources available for use for the birth. Faculty members evaluated the students on teamwork (modified TeamSTEPPS), communication and basic clinical decision-making skills. After each scenario, the students and the standardized patients participated in a faculty-led debriefing. After the debriefing, the students were asked to evaluate the capstone event by survey. All participants (n=22) completed the questionnaires.
Conclusion: Analysis of survey responses from the R&WM participants revealed the pilot program improved their clinical confidence in handling normal and emergency deliveries (25%). They also reported increased confidence in communication skills with non-English speaking patients (86.4%). All participants (Global and R&WM) rated the emergency delivery as a valuable experience to very valuable for developing teamwork. Based on faculty evaluation of the 6 teams, only 1 team met the TeamSTEPPS criteria of teamwork. Based on the feedback received from students and faculty, this project will be expanded to develop a more comprehensive longitudinal team-training obstetrics program for the R&WM track students.
1. Colorado Health Institute: Colorado Rural Physician Survey 2012 http://coloradohealthinstitute.org/uploads/downloads/Rural_Physician_Chartpack_Revised_5June2012.pdf.
816 Simulation Training to Educate Residents About Managing Commonly Encountered Oncology Scenarios
Gayle Murray, MD,3 Donna Jeffe, PhD,2 Robert Hayashi, MD,3 James Fehr, MD1
1ANESTHESIOLOGY, WASHINGTON UNIVERSITY, SAINT LOUIS, MO, USA and 2MEDICINE, WASHINGTON UNIVERSITY, SAINT LOUIS, MO, USA and 3PEDIATRICS, WASHINGTON UNIVERSITY, SAINT LOUIS, MO, USA
Introduction/Background: Work hour restrictions in graduate medical education and shrinking exposure to pediatric emergencies created concerns that residents are ill equipped to manage acute situations. Innovative methods of education must be developed to meet these challenges. Simulation training, which has been used successfully in medical education, immerses the trainee in situations that mimic real-life scenarios and educates trainees to competently manage complex medical situations. We developed a simulation program to train pediatric residents on the management of acute oncology emergencies and evaluated the impact of the program on residents’ skills and coping with this acutely ill population. Training in the management of acute pediatric oncology topics is a novel approach to educating pediatric residents. We hypothesized that residents will gain knowledge and skills to help them care for these patients and will gain confidence in their abilities to manage these patients following simulation training.
Description: Pediatric residents training at St. Louis Children’s Hospital were recruited to participate in a pilot study during their hematology/oncology rotation. The intervention included five clinical-case scenarios commonly encountered oncologic problems (Table 1). Three of these scenarios were used to test residents in both the intervention and control arms; two of these cases simulated a dying patient and a new diagnosed patient, and included interaction with a standardized parent actor. A quasi-experimental pre-post design was used. The order of resident rotations was scheduled without regard for particular educational studies that might take place. Participants in both arms independently completed pre-rotation survey measures; surveys and three simulation tests were completed several weeks later toward the end of the rotation. Skill sets were measured using a skills checklist for each of the standardized scenarios and a global performance score; all simulations were videotaped for scoring. All data from controls (n = 9) were completed in the first three rotations, prior to simulation training to residents in the intervention arm (target accrual n = 30). Participants receiving the intervention managed the five cases as a team with assistance of a faculty member; all five cases were discussed and reviewed for 15-20 minutes. For testing, all participants independently interacted with the parent actor during the dying-patient and new-cancer-diagnosis scenarios, and in managing a medical case. After testing, participants completed an evaluation survey. Participants rated the educational program favorably; 88.9% of all participants agreed or strongly agreed that the program was helpful in caring for oncology patients. No participants rated the program unfavorably. All participants agreed or strongly agreed that the topics covered were ones they would encounter during their residency training and that they would recommend this training to other residents.
Conclusion: Simulation-based education for residents provides promise as a teaching strategy within residents’ work-hour constraints. This strategy may enhance the educational experience of modern day trainees. Follow-up assessment of residents’ retention of skills and knowledge as well as impact on patient care is needed.
Disclosures: Gayle Murray, MD, receives grant support from the United States Department of Health and Human Services and the National Institutes of Health (NIH) T32.
818 Implementation of an Interprofessional Simulation Instructor Course
Caren Gellin, MD,1 Christine Arnold, RN, MS,3 Sarah Peyre, EdD2
1PEDIATRICS, GOLISANO CHILDREN’S HOSPITAL, UNIVERSITY OF ROCHESTER, ROCHESTER, NY, USA and 2UNIVERSITY OF ROCHESTER MEDICAL CENTER, ROCHESTER, NY, USA and 3OBSTETRICS AND GYNECOLOGY, UNIVERSITY OF ROCHESTER MEDICAL CENTER, ROCHESTER, NY, USA
Introduction/Background: Trained instructors are a limited resource in the effort to expand simulation in medical centers. Many medical centers do not offer faculty development courses on simulation instruction and for those who want training, often they are forced to travel and incur expenses. Additionally, there are challenges with developing an interprofessional and multidisciplinary course that will meet the needs of attendees. At the University of Rochester Medical Center (URMC), we developed and implemented an Interprofessional Simulation Instructor Course (ISIC) for our faculty, staff, and senior trainees.
Description: To create an ISIC that would meet the varied needs within our complex medical center (URMC is a 739-bed adult hospital, a 124-bed children’s hospital, and has schools of medicine, nursing, and dentistry), a needs assessment was conducted on the interest and demand for faculty development on simulation education. To differentiate our potential stakeholders, separate needs assessment surveys were conducted for leadership and simulation personnel using SurveyMonkey©. The primary objective for the leadership survey was to assess the level of support and utilization of simulation. Recipients included department chairs, division chiefs, center directors, fellowship and residency program directors, deans, nursing education and practice council members, and nurse managers. The primary objective for the simulation staff survey included an assessment of their experience, training, and simulation needs as well as identification of content and logistic needs for an instructor course. The survey results indicated support for an instructor course and helped shape its content and structure. The emergent course objectives were as follows: (1). Apply adult learning principles in simulation-based education (SBE); (2). Develop learning objectives and design objective-based simulation scenarios; (3). Explain and demonstrate the role of the facilitator in SBE; (4). Demonstrate different techniques of debriefing; (5). Integrate teamwork and communication skills in scenario design and facilitation; and (6). Identify various methods of evaluating SBE. The 2-day, interactive course was designed for 8-10 participants, located within the medical center, and included small group work, simulations, role-playing, games, lectures, and discussion. CME (15 AMA PRA Category 1 Credits) was offered. Institutional tools including a debriefing model, a scenario design worksheet, a tracking tool, and a facilitator evaluation were developed in conjunction with the course. Each member of the interprofessional team of instructors previously attended, observed, and/or taught in at least two established simulation instructor courses. Acceptance into the course was monitored to ensure an interprofessional cohort. There was a reasonable graded tuition, which could be paid through budget transfer, to minimize attendee cost while allowing for sustainability. The pilot course in April 2012 included 6 interprofessional participants with 100% rating the course as “Excellent” overall on a 5-point Likert scale. Participants also indicated that the course met the stated learning objectives, used effective teaching methods, led to knowledge improvement, and could be applied to clinical, simulation, and personal interactions. There are additional courses in August and December of 2012 with an evaluation planned for 6 months after course completion to assess the course goals of increasing the utilization and quality of simulation in our institution.
Conclusion: An institutional ISIC was successfully implemented by addressing barriers through an assessment of local needs, integration of local feedback into the course design, minimization of attendee expense, elimination of travel, and focus on interprofessional challenges.
836 Innovative Model Used to Fill Gap in Medical Simulation Training
Van Wall, MS III,1 Bonnie Hunt, MS IV (medical student),1 John Hawkins, MS III,1 Vanessa Rodriguez, MS III,1 Rebecca Bowden, PhD,2 Anthony LaPorta, MD3
1ROCKY VISTA UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE, PARKER, CO, USA and 2CLINICAL ASSESSMENT AND SIMULATION, ROCKY VISTA UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE, PARKER, CO, USA and 3SURGERY, ROCKY VISTA UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE, PARKER, CO, USA
Introduction/Background: A limitation in current surgical simulation is the lack of simultaneous training of technical and non-technical skills.1 The Human-Worn Partial Task Surgical Simulator (Cut Suit), developed by Strategic Operations, is an innovative simulation model that fills this void. The typical medical curriculum focuses on two years of didactic basic science education, thus early exposure to both efficient and effective clinical training is essential to student preparedness prior to third-year rotations. The Cut Suit offers the ability to practice and evaluate clinically relevant non-technical and technical skills in one hyper-realistic simulator without risk to live patients. The anatomically accurate Cut Suit suspends reality with remote-activated bleeding and interchangeable pathology, allowing trainees to practice a variety of surgical and emergency procedures while simultaneously improving non-technical aspects of patient care. Incorporating the Cut Suit into skills training early in medical education will enhance student competence and confidence in technical and non-technical proficiencies prior to clinical rotations.
Description: Second-year students (n=22) at Rocky Vista University College of Osteopathic Medicine participated in a weeklong procedural skills course augmented by the Cut Suit, focused on concurrent instruction and assessment of technical and non-technical skills. Technical skills included suturing, surgical knot tying, peripheral IV access, tube thoracostomy, and surgical cricothyroidotomy. Non-technical skills included teamwork, effective and respectful communication, leadership, and performance under stress. Students first stabilized acute patients in an emergency department setting which facilitated training in triage assessment, placement of IVs, chest tubes, and surgical airways, as well as leadership and communication. Patients requiring surgical interventions were transferred to an operating room (OR) where procedures performed directly on the Cut Suit provided more technical surgical training while developing appropriate OR team dynamics and collaboration. A 360° evaluation assessed ACGME core competencies, and faculty assessed participants’ technical proficiencies.2 All student participants demonstrated significant improvement in each evaluated area.
Conclusion: The Cut Suit was an essential part of the week as it allowed for various technical training scenarios - from acute cholecystitis to femoral hemorrhage control - in emergency and OR settings while simultaneously developing non-technical core competencies. Additionally, the hands-on procedure simulations proctored by attending surgeons allowed students to become more competent and confident as they approached clinical rotations. The data collected in this pilot study supports further use of the Cut Suit for early training in medical education. We will follow the participants’ objective and subjective evaluations from third-year surgical rotations to further validate the training program. Applications for the Cut Suit simulator exist beyond clinical education. Military medical personnel have trained extensively with this model and believe the Cut Suit creates a hyper-realistic experience when worn during training simulations3. Furthermore, this model was proposed at the Spring 2012 Coalition for Physician Enhancement, Denver, CO, for use in the re-education of surgeons who have lost credentialing.4 The ability to train on a single simulator that combines technical and non-technical core competencies provides the most efficient method of education and training without placing patients at risk, thus filling the current void in medical-surgical simulator education.
1. Journal: Palter, V., Grantcharov T. (2010) Simulation in Surgical Education, CMAJ, August 10, 2010, 182(11).
2. ACGME Competencies: Suggested Best Methods for Evaluation Swing S, Bashook P. (2000) ACGME/ABMS Joint Initiative Assessment/Toolbox of Assessment Methods. ACGME Outcomes Project Version 1.1:1-9.
3. USMC Field Medical Training Battalion West, 1st Marine Division, Naval Expeditionary Medical Training Institute, USMC 1st Medical Battalion, 3rd Marine Division, Army Brigade Modernization Command at Ft. Bliss and a NATO nation special force have all integrated the Cut Suit into their training program.
4. Coalition for Physician Enhancement (CPE), Advances in Simulation Technology for Use in Physical Assessment, June 7-8, 2012, Denver, CO.
857 Assessing Handoff Effectiveness Using Standardized Residents
Rebecca Britt, MD,3 Dana Ramirez, MD,1 Gayle Gliva McConvey,2 Lorraine Lyman,2 Mark Scerbo, PhD,4 Brittany Anderson-Montoya, MS4
1PEDIATRIC EMERGENCY MEDICINE, CHILDREN’S HOSPITAL OF THE KING’S DAUGHTERS, NORFOLK, VA, USA and 2CENTER FOR SIMULATION AND IMMERSIVE LEARNING, EASTERN VIRGINIA MEDICAL SCHOOL, NORFOLK, VA, USA and 3SURGERY, EASTERN VIRGINIA MEDICAL SCHOOL, NORFOLK, VA, USA and 4PSYCHOLOGY, OLD DOMINION UNIVERSITY, NORFOLK, VA, USA
Introduction/Background: The Accreditation Council for General Medical Education (ACGME) restricted resident work hours to 80 per week in 2003,1 resulting in an increase in the number of transitions in patient care among healthcare providers.2 The increased number of hand-offs has been associated with errors in patient care.3 To mitigate the associated risks, the ACGME required residency programs to have a standardized process for transitioning care of patients by July 1, 2012. Consequently, a method for training and assessing the effectiveness of handoffs was developed.
Description: There are a number of mnemonics for handoffs; however, there is little empirical evidence supporting their effectiveness3. We surveyed a number of practicing physicians from a variety of specialties to determine what was needed in an effective handoff. We then created a transition of care checklist that could be varied slightly based on specialty needs. The resident training involved a presentation of the handoff checklist for both new and follow-up patients. The residents were then given practice patient scenarios to handoff under the direction of the faculty. Scenarios were developed to enable residents to evaluate patients, process information, and then handoff the patients. The residents encountered three standardized patients in an emergency department (ED) setting and were given 10 minutes to prepare to handoff the patients to the oncoming resident. The oncoming resident was portrayed and assessed by a standardized patient using two different instruments developed for this task. The first was a checklist for evaluating the completeness of the handoff and addressed patient demographics, diagnosis, current condition, medical history, events in the preceding 12 hours, physical exam, lab work, medications, interventions, plans for the next shift, and relevant miscellaneous information. The second instrument was a rating scale used to evaluate the overall quality of the handoff session and addressed organization, communication, confidence, clinical judgment, and professionalism. Standardized patients (SPs) were used as standardized residents (SRs) because of their extensive experience at observing and documenting behaviors and performance. The SRs were initially trained on the ED case scenarios, affect for portrayal, the assessment instruments, and a glossary of terms to familiarize SPs with the relevant medical terminology to ensure their understanding of case objectives and the salient points for effective handoffs. This allowed for realistic, repeatable, standardized, and controllable assessments of handoff skills. Initial training was followed with a dry run using faculty to refine the assessment scoring and proper affect for portrayal. After the formal assessment sessions, the SRs were encouraged to view videos of each encounter for quality assurance. Subsequent inter-rater reliability for multiple standardized residents was determined by appealing to G-theory.4
Conclusion: We designed and implemented a standardized training protocol for resident transition of care using a combination of traditional lecture with practice cases. Standardized patients were utilized in a novel manner by training them to portray residents. We also designed an innovative checklist for handoffs, based on interviews with a variety of specialists, which could easily be used across specialties. The curriculum includes formal assessment of the resident ability to adequately provide necessary content as well as overall handoff quality. The needed resources are the standardized patients specifically trained to serve as residents. However,this is a cost effective approach because many residents can be assessed with minimal impact on faculty time. The residents felt the experience was useful in organizing the handoff. The SRs found the experience challenging and rewarding and enjoyed playing a role different from the usual patient. We are in the process of training our incoming interns and completing a study to assess the effectiveness of this intervention.
1. Accreditation Council for Graduate Medical Education (2002). Report of the ACGME work group on resident duty hours. Chicago. June 11. http://www.acgme.org/DutyHours/wkgroupreport611.pdf(January 23, 2012).
2. Patterson, E. S., & Wears, R. L. (2010). Patient handoffs: Standardized and reliable measurement tools remain elusive. The Joint Commission Journal on Quality and Patient Safety, 36, 52-61.
3. Riesenberg, L. A., Leitzsch, J., & Little, B. W. (2009). Systematic review of handoff mnemonic literature. American Journal of Medical Quality, 24, 196-204. doi: 10.1177/1062860609332512.
4. Cronbach LJ, Gleser GC, Nanda H, Rajaratnam N. The Dependability of behavioral measurements: theory of generalizability for scores and profiles. New York: Wiley; 1972.
Disclosures: Mark Scerbo, PhD receives grant support from SimQuest, LLC.
859 Student Observation Versus Participation in Simulation Exercises: A Novel Approach for Reducing Logistical Challenges
Barbara Kaplan, MSN,1 Rebecca Gary, PhD,1 Melinda Higgins, PhD1
1NURSING, EMORY UNIVERSITY, ATLANTA, GA, USA
Introduction/Background: The simulation program within our nursing curriculum is rapidly expanding, and provides a wide range of topics that complements didactic content for both undergraduate and graduate students. Accommodating up to 120 students in a 3 to 4 hour time frame in limited space is logistically challenging. To overcome these logistical constraints, an alternative plan was devised where half of the students actively participate in the simulation while their cohort observes the simulation. Various measures have been employed to determine effectiveness in knowledge acquisition, clinical care, confidence and student satisfaction in simulation;1-3 yet, limited studies have evaluated whether students in an observation only group perform as well on examinations or perceive learning was effective compared to active participants. The primary aim of this study was to evaluate students’ test scores on questions related to content in a simulation experience, and whether being a participant or observer had any significant influence on the test scores. A secondary aim was to evaluate group differences on the METI Simulation Effectiveness Tool. We hypothesized there would be no group differences on test scores or on the METI Simulation Effectiveness Tool.
Description: Baccalaureate nursing students (N=103) were randomly assigned to the observation (N=50) or to the participation (N=53) group according to the schedule below (Table 1). In each group, 3 students observed and 3 participated.
There were no significant differences were noted on test items, the active participation group had a mean score of 9.3, while those in the observation group scored a mean of 9.4 (p=0.93). The majority of the questions on the METI Simulation Tool revealed no significant differences between groups (Table 2), indicating our hypothesis was partially supported. Students completed the METI Simulation Effectiveness tool via the course Blackboard site. Descriptive statistics and t-tests were used to analyze differences between groups.
Conclusion: Incorporating an observation group in clinical simulations is an effective strategy that does not appear to reduce learning or student satisfaction. Using a similar schedule as presented, the logistical challenges of conducting simulations in large student groups may be reduced in less time and with fewer resources.
1. Brannon, J., White, A., & Bezanson, J. Simulator effects on cognition and confidence levels. J Nurs Educ. 2008 Nov; 47(11), 495-500. PubMed PMID: 19010047.
2. Jeffries, P., & Rizzolo, M. NLN/Laerdal project summary report, designing and implementing models for the innovative use of simulation to teach nursing care of ill adults and children: A national multi-site study. 2006. New York: National League for Nursing.
3. Lapkin, S., Levett-Jones, T., Bellchambers, H., & Fernandez, R. Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: A systemic review. Clinical Simulation in Nursing. 2010; 6(6), e207-e222, doi:10.1016/j.ecns.2010.05.005.
861 Simulation for Interventional Pain Procedures Using Multiple Modalities to Enhance Realism
David Seamans, MD,2 Rebecca Wilson, RN, PhD1
1ADMINISTRATIVE SERVICES EDUCATION, MAYO CLINIC ARIZONA, PHOENIX, AZ, USA and 2ANESTHESIOLOGY, MAYO CLINIC HOSPITAL, PHOENIX, AZ, USA
Introduction/Background: Residents and fellows in the pain medicine program (an ACGME accredited subspecialty in anesthesiology) must develop the skills to provide comprehensive care to patients who require interventional pain procedures as well as managing rare complications. There are several challenges to optimizing realism in scenarios that comprehensively address competencies in patient care, interpersonal and communication skills, professionalism and medical knowledge. An additional challenge for simulation in pain medicine includes the requirement to use specialized equipment such as fluoroscopy which cannot be used within most simulation centers. Currently there are few published simulation activities for this discipline. We report a solution to some of these issues in describing a hybrid pain medicine simulation for residency and fellowship training. The scenario included several innovative elements; incorporating a variety of patient simulators (task trainers, high-fidelity mannequins, and standardized patients) and environments matched to the objectives of each phase of care to maximize realism for participants. Additionally, a web-based video system allowed observers to view the scenario seamlessly regardless of location.
Description: This hybrid simulation was done in four phases, staged in two environments: the multidisciplinary simulation center and the pain clinic. Multiple residents were involved in the four-part scenario, with four residents having primary patient care responsibility, one resident during each part of the scenario. The four parts to the scenario included: 1) obtaining informed consent using a standardized patient and family member, 2) fluoroscopically guided (C-arm) stellate ganglion injection done in the pain clinic using an injection mannequin (Khorman injection phantom) with participants assisted by pain clinic staff, 3) management of a serious complication (inadvertent intrathecal injection) in a PACU setting utilizing a high-fidelity patient simulator, and 4) post procedure discussion with the standardized patient and family member regarding the complication, potential sequelae and ongoing patient care. Parts 1, 3 and 4 were conducted in the simulation center. All phases were captured using a web-based video capture system, including an integrated mobile unit used in the pain clinic. Debriefing of the entire scenario was conducted at the end of the fourth phase utilizing video playback.
Conclusion: Participants expressed high satisfaction with the scenario. The use of multiple modalities and locations contributed to the overall positive perception of realism. To our knowledge, this integration of multiple locations and multiple modalities in a single simulation scenario has not been previously reported. Although hybrid simulations are potentially more challenging to implement; they can provide an enhanced sense of realism particularly for specialty specific techniques.1,2 In this case, a simple injection mannequin was used for the actual procedure which was done in the live environment of the pain clinic. This design feature contributed to realism by using the actual clinical environment and involved pain clinic staff members. The advantages of integrating standardized patients in anesthesia simulations have been previously described with numerous advantages proposed for the learners.3 These benefits were evident in our scenario as the use of a standardized patient and family member enhanced the portions of the scenario directed at improving communication and assessing professionalism. This scenario could be used as a template for many other interventional pain procedures. Although logistically more difficult, this design was well worth the effort.
1. Girzadas D, Antonis M, Zerth H, Lambert M, Clay L, Bose S, and Harwood R: Hybrid Simulation Combining a High Fidelity Scenario with a Pelvic Ultrasound Task trainer enhances the Training and Evaluation of Endovaginal Ultrasound Skills. Academic Emergency Medicine 2009; 16:429-435.
2. Siassakos D, Draycott T, O’Brien K, Kenyon C, Bartlett C, and Fox R: Exploratory Randomized Controlled Trial of Hybrid Obstetric Simulation Training for Undergraduate Students. Simulation in Healthcare 2010; 5(4): 193 – 198.
3. Cantrell MJ and Deloney LE: Integration of Standardized Patients into Simulation. Anesthesiology Clinics 2007; 25: 377-383.
878 Standardisation of Bronchoscopy Training Across Yorkshire and Humber Deanery
Faiza Chowdhury, MbChB, MRCP (UK),3 Anjali Gondker, MBChB MRCP (UK),1 Nanu Acharya, MbChB, MRCP,7 Rehan Naseer, MbChb, MRCP,5 Joseph Hogg, MbChB MRCP,4 Jack Kastelik, BSc, MBChB, MD, FRCP,2 Stephen Bianchi, BSc(Hons), MBChB, PhD, FRCP(Lon), FRCP(Glas)6
1RESPIRATORY MEDICINE, HULL ROYAL INFIRMARY, HULL, GBR and 2RESPIRATORY MEDICINE AND SIMULATION, HULL ROYAL INFIRMARY, HULL, GBR and 3SIMULATION FELLOW, HULL ROYAL INFIRMARY, HUL, GBR and 4RESPIRATORY AND ACUTE MEDICINE, PINDERFIELDS GENERAL HOSPITAL, WAKEFILED, GBR and 5RESPIRATORY MEDICINE, PINDERFIELDS GENERAL HOSPITAL, WAKEFIELD, UK, GBR and 6PULMONOLOGY, SHEFFIELD TEACHING HOSPITALS, SHEFFIELD, SOUTH YORKSHIRE, GBR and 7RESPIRATORY MEDICINE, SHEFFIELD TEACHING HOSPITALS, SHEFFIELD, SOUTH YORKSHIRE, GBR
Introduction/Background: Reduced exposure to bronchoscopy is a key issue for respiratory trainees with effect on their confidence in undertaking the procedure and thus patient safety.1 Studies have shown that simulation improves confidence in bronchoscopy2 skills but do not explore the most optimal teaching methods. The aim of this study was to assess two different methods of delivering bronchoscopy simulation training (*Authors 1 and 2 are first authors).
Description: Two half day simulation bronchoscopy courses were designed independently within the Yorkshire and Humber Deanery. Course 1 concentrated on providing knowledge based training consisting of a didactic lecture followed by equal time spent on a Symbionix simulator and on the BTS e-learning hub website. Course 2 provided pre-course material in the form of BTS guidelines and bronchoscopy procedure pocketbook. The course focused on hands-on simulation training using a bronchoscopy manikin and the Symbionix simulator. All candidates completed pre and post course Likert scale questionnaires in six areas relating to participant knowledge and confidence in using a bronchoscope. Overall 30 trainees (15 in each course) were evaluated. Candidates had performed between 0 to >300 previous bronchoscopies and were from across the SpR years. Both courses delivered significant improvement in confidence scores in all of the six areas assessed. The greatest improvement was found in confidence levels in technical ability (see table 1). Course 1 candidates showed a greater confidence improvement in factual skills (such as knowledge of contra-indications of the procedure and anatomy). Course 2 demonstrated that 93% of candidates agreed that the simulator helped to improve technical ability in contrast to 100% with manikin exposure. 100% of candidates found the pocketbook was a useful adjuvant to the course with 93% agreeing that they would find this useful to complement their training.
Conclusion: A combined and standardized bronchoscopy simulation course incorporating lectures and pre-course materials but focusing on hands on experience on both a manikin and a simulator is therefore considered to provide greatest educational benefit. This course is now active in Yorkshire and the Humber, and it is to be mandated for all new trainees to the programme3. Each SpR will also be re-assessed after a 3-month period incorporating a competency-based assessment approach.
1. Kenneth G. Torrington. Bronchoscopy Training and Competency: How Many Are Enough? Chest 2000; 118; 572-573.
2. A R C Patel, S Mandal, J J P Goldring. Simulated bronchoscopy training delivered by experienced peers improves confidence of new trainees. Thorax 2010;65:A116 doi:10.1136/thx.2010.150979.41.
3. William C. McGaghie, Viva J. Siddall, Paul E. Mazmanian and Janet Myers. Lessons for Continuing Medical Education From Simulation Research in Undergraduateand Graduate Medical Education: Effectiveness of Continuing Medical Education: American College of Chest Physicians Evidence-Based Educational Guidelines. Chest 2009; 135; 62S-68S.
885 On the Road to Improving Pediatric Disaster Management: A Simulation Workshop for Pediatric Emergency Medicine Physicians and Fellows
Ilana Bank, MDCM, FRCPC, FAAP,1 Elene Khalil, MD, CM, FRCPC, Diplomate of the American Board of Pediatrics1
1PEDIATRIC EMERGENCY MEDICINE, MCGILL UNIVERSITY, MONTREAL, QC, CAN
Introduction/Background: Children are a population segment especially vulnerable to disasters because of their unique anatomical, physiological, psychological and developmental particularities.1,2 Thus, pediatric hospital disaster responders must be well trained and prepared to receive and manage children in a mass casualty incident. Such training is a difficult task. Simulations of various types have been the traditional way of testing hospital disaster plans and training hospital staff in skills that are used in rare circumstances. Simulation offers a superior and longer-lasting learning experience than traditional didactic methods when training medical staff for pediatric disaster victims.3
Description: We created a simulation workshop for practicing Pediatric Emergency Medicine (PEM) physicians and other critical care fellows to learn to manage a disaster response. This experiential learning experience included a combination of high, medium and low fidelity simulators as well as standardized patients to achieve the following learning objectives: (1). Recognize the need for different triage method in a code orange versus conventional triage;(2). Recognize limitations of disaster triage /re-triage every patient arriving in a treatment area; (3). Recognize that disaster triage is a dynamic process, responsive to changes in available information; (4). Manage unstable patients given limited resources; (5). Apply principles of limited treatment and intervention in the ER: stabilize and dispose; and (6). Manage resources to maximize survival: best outcome for the most patients versus best individual outcome (paradigm shift). The workshop ran as part of the PEM CME program. An opening plenary session reviewed principles of disaster management and details of the hospital disaster plan. Participants were divided and participated in 3 stations each involving two or more patient encounters: Triage, Yellow, and Red areas. Debriefing took place immediately following each station. Objective abilities were assessed and debriefed by evaluators with experience in disaster preparedness. Subjective abilities were assessed using a post-workshop survey (with a retrospective pre-component to assess perceived change). Objective data was derived from the evaluation grids filled out by evaluators during the simulation. Results provided information on aspects done well and areas needing improvement that will be used for future training and simulation for this particular group of learners. See table 1.
Analysis of subjective data demonstrated that there were significant perceived improvements in the participants’ subjective abilities in all areas of disaster management. In addition, participants felt that the pediatric disaster simulation day was valuable to their learning (5.63 on 6 point likert scale).
Conclusion: Advanced learners who may be directly implicated in a disaster response believed that the simulation workshop improved their ability to manage patients in a code orange situation and felt that this CME activity was valuable to their learning.
1. Cichon, M.E., Fuchs, S., et al. (2009). A statewide model program to improve emergency department readiness for pediatric care.
2. Weiner, D.L. (2009). “ Lessons learned from disasters affecting children.” Elsevier Inc. Vol.10, NO.3.
3. Behar, S., J. S. Upperman, et al. (2008). “Training medical staff for pediatric disaster victims: a comparison of different teaching methods.” American Journal of Disaster Medicine 3(4): 189-199.
906 Development of a Resident-Originated Simulation Curriculum in a Pediatrics Residency: Needs Assessment Data and Process
Christie Glau, MD,3 Megan Gray, MD,4 Tuan Nguyen, MD,3 Eyal Ben-Isaac, MD,3 Todd Chang, MD,2 Alyssa Rake, MD,1 Anna Ganster, MD,3 Theodora Stavroudis, MD3
1ANESTHESIOLOGY AND CRITICAL CARE MEDICINE, CHILDREN’S HOSPITAL LOS ANGELES, LOS ANGELES, CA, USA and 2EMERGENCY MEDICINE, CHILDREN’S HOSPITAL LOS ANGELES, LOS ANGELES, CA, USA and 3PEDIATRICS, CHILDREN’S HOSPITAL LOS ANGELES, LOS ANGELES, CA, USA and 4NEONATOLOGY, CHILDREN’S HOSPITAL OF PHILADELPHIA, PHILADELPHIA, PA, USA
Introduction/Background: Rapid Response Teams (RRTs) and duty hour restrictions have limited the exposure of pediatric residents to acute and resuscitative pediatric care. Although many institutions have a simulation-based curriculum for pediatric residents, there are no such curricula designed specifically by the residents. In planning for a simulation curriculum developed by residents beginning in the 2012-2013 academic year, a needs assessment was performed with a sample of residents and recent graduates. We present the needs assessment and the process of incorporating all PGY-3 residents in the authorship and development of each curricular component.
Description: A needs assessment survey was conducted online among 36 participants within a single tertiary children’s hospital residency program among PGY-1 to PGY-3 residents and recent graduates. Questions within the survey contained demographic information and personal experiences within residency, including their participation as an RRT participant, a code blue participant, and a code blue leader. In addition, we queried the participants on several scenarios. These high risk or low volume scenarios were chosen based on consensus among the authors and modified by simulation experts within the hospital. A 5-point Likert scale measured the respondents’ experience, confidence, and the perceived need for simulation on the following: opiate overdose, supraventricular tachycardia (SVT), increased intracranial pressure (ICP), anaphylaxis, hyperkalemia, septic shock, status epilepticus, diabetic ketoacidosis, hypoglycemia, upper airway obstruction, neonatal serious bacterial infection, and status asthmaticus. A post hoc Shapiro-Wilk analysis verified the use of non-parametric tests. Data analyses were performed using Kruskal-Wallis, Chi-square, and Spearman Rank tests. The development process and recommended scenarios were modified based on the needs assessment results.Thirty-six responses were recorded with a 31% completion rate. An increase in median confidence levels and experience for all scenarios were seen with increasing post-graduate year (p < 0.001), as was the amount of experience as an RRT member (p < 0.001), a code blue member (p = 0.015), and as a code leader (p < 0.001). Among the scenarios presented, there was a significantly lower level of confidence and experience in the management of 3 scenarios: SVT, opiate overdose, and increased ICP (p = 0.001). This lack of confidence and experience were significantly correlated (rho = 0.686, p < 0.001). Although other scenarios were rated as higher in perceived need for simulation, perceived need did not correlate with experience nor confidence (p = 0.9). Third-year pediatric residents will be authoring and developing 1 to 2 simulation-based scenarios of their choice as a small group, to be administered to all PGY-1 to PGY-3 pediatric residents at the hospital for the 2012-2013 year. Each resident will be mentored by a simulation expert and content expert based on the scenario facilitated by the resident. These scenarios will be run quarterly by the PGY-3 resident for his/her colleagues, with appropriate debriefing using debriefing scripts and facilitation from expert faculty. Evaluation of this program will include repeating these scenarios every 6-months to document improvements in procedural, clinical, and communication skills, as well as a review of RRTs and code blues within the hospital. We developed a scenario handbook for the residents to assist with writing objectives, outlines, and scenarios.
Conclusion: A needs assessment survey confirmed that this institution provides opportunities for code leadership and is effective at experience in managing many scenarios but also identified three scenarios which participants identified as the least common and least confident in management: SVT, opiate overdose, and increased ICP. Careful facilitation from simulation and pediatric experts is required to guide residents in developing scenarios that reflect rarity within a single residency program based on our needs assessment.
1. Mickelsen S, McNeil R, Prikh P, Persoff J. Reduced resident “code blue” experience in the era of quality improvement: new challenges in physician training. Acad Med 2011; 86(6): 726-30.
2. Yang J, Howell MD. Commentary: Is the glass half empty? Code blue training in the modern era. Acad Med 2011; 86(6): 680-3.
909 The Implementation of a Patient Safety Simulation Curriculum for Pre-Clinical Medical Students at Ross University School of Medicine
Diana Callender, MBBS, DM,2 Nancy Selfridge, MD,2 Jenifer Cannon, MD, FACOG,2 Lisa Buckley, MS, PA-C,2 David Pederson, MEd1
1INTEGRATED MEDICAL EDUCATION, ROSS UNIVERSITY SCHOOL OF MEDICINE, NORTH BRUNSWICK, NJ, USA and 2INTEGRATED MEDICAL EDUCATION, ROSS UNIVERSITY SCHOOL OF MEDICINE, PICARD, PORTSMOUTH, DMA
Introduction/Background: The Institute of Medicine released its landmark study in 1999 in which it documented that approximately 98,000 deaths occur in the USA every year due to medical errors.1 The ACGME is addressing this in the competencies that residents learn during their training. Ross University School of Medicine has developed a curriculum to introduce pre-clinical students to the ACGME competencies, including improvement in practice and aspects of patient safety, as part of its organ-system based curriculum launched in September 2010. In addition to lectures and small group cases on systems, based practice and quality improvement, these concepts are woven into the simulation curriculum. Students are thus introduced to medical errors and error detection from their first semester of medical school.
Description: A Semester One scenario includes a Fentanyl overdose causing a cardiopulmonary arrest. This error is complicated both by a poor handover, which did not make the patient’s status clear, as well as an inability to find the patient’s chart. This resulted in cardiopulmonary resuscitation being performed on a patient with a Do Not Resuscitate order. Students are asked to brainstorm ways in which the overdose could have been prevented and how resuscitating a patient with a DNR order could have been avoided. In Semester Two, students experience a scenario wherein a nursing home patient who has been neglected, becomes dehydrated and develops pre-renal failure. In a Semester Three scenario a resident physician does not elicit a history of penicillin allergy before prescribing penicillin for a dog-bite. The nurse then asks the patient if he is allergic to the drug but uses the brand name which the patient does not recognize. The patient is given the drug and develops anaphylactic shock. In Semester Four students encounter a scenario wherein a patient with esophageal varicies presents with a massive upper GI bleed. As students work through the differential diagnosis and a treatment plan, a cardiac arrest occurs due to hypovolemic shock. During CPR, previously ordered blood arrives. However it is incompatible with the patient’s blood type. The scenario ends when students hang the inappropriate blood, or, more often, identify the error by checking the patient’s ID, patient number, and blood group type. Errors in each case are addressed during debriefing; students discuss actual or possible consequences of the errors and brainstorm ways they could have been prevented.
Conclusion: We feel that exposing students to the errors that occur in health care and their prevention early in training could result in a decrease in errors as they take on patient care responsibilities. We plan to track these students as they enter clinical rotations and see if their preceptors feel that they are more aware of error prevention than previous cohorts of students.
1. Kohn, LT, Corrigan L, Donaldson, MS, Eds: To Err Is Human: Building a Safer Health System Washington DC.. National Academy Press, 2000.
984 Development of a Simulation-Based Patient Safety Initiative
Eleanor Parker, BA,2 Rebekah Molyneux, MbChB, BSc,1 Makani Purva3
1MEDICINE, CLINICAL SKILLS FACILITY, HULL AND EAST YORKSHIRE DEANERY, HULL, GBR and 2INTENSIVE CARE UNIT, HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST, HULL, GBR and 3MEDICAL EDUCATION, ANAESTHETICS, HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST, HULL, GBR
Introduction/Background: An audit by our hospital’s Critical Care Outreach team indicated that there was a failure by some nurses to recognise, record and escalate the care of deteriorating patients. The hospital recognised the need to improve the level of education and training available to ward nurses. Local demographics and the nature of procedures performed, as well as local non-acute health care provision, were noted to be a significant contributory factor. We developed a simulation training programme aimed at nursing staff to improve the recognition and care of the deteriorating patient.1
Description: Feedback from a sample group of hospital staff (n=28) prior to initiation of the simulation training project indicated that there were perceived gaps in training provision centered around leading the care of the deteriorating patient, communication and escalating patient care when needed.2 Two thirds of respondents felt that simulation training on a yearly basis would be helpful in addressing these needs.3 Five pilot simulation training programmes have been delivered to 27 hospital staff with assistance from appropriately competent Specialist Nursing staff. The course is a half day. Instructional content includes early warning scores (EWS), SBAR and the ABCDE approach. The scenario itself is run in a four bedded area with live patients in the other three beds. The participants therefore have the added distraction, as they would in real life, of prioritising patients and dealing with other distractions while attempting to manage the deteriorating sim-patient. The sessions were filmed in order for all participants to give and receive feedback. Feedback and evaluation was sought from each participant pre- and post- course to determine the efficacy of simulation training. Results indicated uniformly increased confidence levels and skills with regard to detection and management of the deteriorating patient. Refer to chart.
Conclusion: As a result of this programme, the hospital has agreed to deliver the simulation programme for all Registered Nurses. Attendance will be mandatory, with the potential to evaluate the programme with reference to hospital-wide statistics on incident reporting, serious untoward incidents and mortality. To enhance the quality of education, we have now designed an e-learning programme that delegates will have to complete prior to attending the course. Through the e-learning programme, delegates will be taught the theoreticalaspects of the ABCDE approach, the correct usage of early warning scoring system and the use of the SBAR tool.
1. Simulation-based learning: how simulators help nurses improve clinical skills and preserve patient safety. Broussard, L. Nursing for Women’s Health 2008, 12(6): 521-4.
2. Measuring competence, self-reported competence and self-efficacy in pre-registration students’ Lauder, W., Holland, K., Roxburgh, M., Topping, K., Watson, R., Johnson, M., and Porter, M. Nursing Standard, 2008; 22 (20): 35-43.
3. The perceptions of undergraduate student nurses of high-fidelity simulation-based learning: a case report from the University of Tasmania Reilly, A., and Spratt, C. Nurse Education Today. 2007; 27: 542-;50.
1013 Implementing an Interdisciplinary Simulation Program on a Liberal Arts Campus: A Pilot Program with Survey Results
Jennifer Hitt, RN, MSN. CNE,3 Matthew Strum, PharmD,2 Anastasia Ballas Jenkins, PharmD2
1 and 2SCHOOL OF PHARMACY, UNIVERSITY OF MISSISSIPPI, OXFORD, MS, USA and 3UNIVERSITY OF MISSISSIPPI MEDICAL CENTER, JACKSON, MS, USA
Introduction/Background: As the use of simulation increases, it is important to develop interdisciplinary simulation programs outside of traditional medical-center based universities. Interdisciplinary simulation occurring in universities based on medical-center campuses benefit from multiple departments focusing on healthcare education. As a result, these campuses can use multiple roles, such as nursing, medicine, and pharmacy, during simulation. When the simulation is on a liberal arts campus, and limited healthcare-focused departments exist, the challenge arises to develop comprehensive interdisciplinary simulation. Following a review of essential educational requirements by the Accreditation Council for Pharmacy Education and the American Association of Colleges of Nursing, faculty at the University of Mississippi, a liberal arts campus, adopted the task to develop an interdisciplinary simulation program for pharmacy (Doctor of Pharmacy) and nursing students (Baccalaureate of Science in Nursing) not located on the cohort medical-center campus. During the development of the program, the faculty identified the liberal arts campus setting as a disadvantage, when compared to the cohort schools located on the medical-center campus. As a result, the faculty developed a plan to incorporate interdisciplinary simulation using nursing and pharmacy students, with advanced practice nurses and pharmacy faculty participating in proxy roles, such as medicine that are not available on the campus.
Description: Nursing and pharmacy students were divided into teams of 2 nursing students and 2 pharmacy students. Prior to the simulation, students were given descriptions of 4 simulated clients. Students were asked to review these cases, although the students did not meet prior to the simulation. Nursing students were given the task of client care, including physical assessment and medication administration. Nursing students were also instructed to consult pharmacy for issues with the client, including warfarin/enoxaparin bridging, diabetes/insulin education, metered-dose inhaler education, and phenytoin kinetics. The students were required to communicate various assessments and lab results between departments. In addition, the pharmacy students were charged to create orders for nursing students to carry-out. Students were evaluated based on individual roles and their communication and interaction with the other discipline. Following the simulation, surveys were distributed to pharmacy and nursing students and results were collected via an anonymous electronic survey utilizing Qualtrics Survey Software. Of the 36 students who participated in the simulation, 31 (86%) completed the survey, 13 (41.9%) self-identified as pharmacy and 18 (56.3%) as nursing. Overall students had a positive experience with the simulation based on the results of the survey. Regarding the addition of interdisciplinary courses into their respected curriculum, 100% of respondents agreed that more interdisciplinary courses should be offered. The students were asked to rank in order their preference for how interdisciplinary education should be offered. Majority of students, 74%, indicated simulation was their primary choice for interdisciplinary education, when compared to seminars, traditional lectures, or laboratory activities.
Conclusion: Students identified the need for interdisciplinary education and indicated a strong preference for this education to be simulation based. Faculty noted that observations and survey results indicate students value the simulation experience, even when all of the roles in the simulation could not be filled by other health profession students due implementation on a liberal arts campus. We recommend pre-simulation briefings between the nursing and pharmacy students to better identify each role during the simulation. In addition, we recommend continued use of advanced practice nurses and pharmacy faculty for the roles unavailable on the liberal arts campus.
1024 iOSCE: Integrating Virtual Patient and Standardized Patient for Pharmacists Training
Che-Wei Lin, MD, MPPM1
1CLINIC SKILL CENTER, WAN-FANG MEDICAL CENTER, TAIPEI, TWN
Introduction/Background: Recently, performance-based competence education has been used in a variety of health care professions, including in the training of pharmacists. The concept of simulation is an excellent element in performance-based education as it has been applied with great success in medical and nursing education in Taiwan. Members of the pharmacy department have recently asked the Clinical Skills Center to develop a designated program for the training of pharmacists. Notably, the pharmacists are especially interested in an iOSCE course, which is a novel instrument integrating a virtual patient with a standardized patient (SP). The iOSCE is a training program for medical students. In this program, the students collect information and perform physical examination from the SP. The script is from DxR Clinician© cases. Then, the students are asked to develop a differential diagnosis, select lab and imaging studies, and to make a final diagnosis. Structured record data is obtained for debriefing. Therefore, the members of the pharmacy department and the faculty of the Clinical Skills Center cooperate to develop an iOSCE training program for pharmacists under the auspices of our Clinical Skills Center.
Description: The content of the program was based on the daily activity of pharmacists using virtual patient system technology, which is a tool to train critical diagnostic reasoning. We have modified the function to fit the pharmacists’ training. We presented the diagnosis in the chief complaint. We designed a four station course. The first station is for training the pharmacists’ data collection. The pharmacists collect patient information from the virtual patient system (DxR Clinician©). They collect the history and lab information to evaluate the patient. The second station is designed to review prescriptions from an attending physician. The incorrect prescription will be used to determine whether they agree with medical decision or not. If they disagree, they must state their reason. The third station is a standardized doctor station for communications. They must call the standardized doctor to modify the prescriptions and give them suggestions and the standardized doctor will assess the communications skill. The fourth station is also a training communications station. The trainees will interview an SP and educate him/her. The SP will also assess the communications skill. After the simulation, we can analyze the data from the first and second station and obtain the checklist assessment from the third and fourth stations.
Conclusion: This pilot run was successful, and the results are promising. We also conducted focus interviews with the pilot trainees and they statde this course is similar to the reality of daily work. From this assessment, we also noted some useful data and gave them helpful feedback. In conclusion, the pharmacist iOSCE is a new, exciting training program.
1028 Simulation Saves Lives: An Interprofessional Approach to Pediatric Code Training
Dory Collette, RN, CCRN,2 Buffy Allen, RN, MSN1
1CLINICAL EDUCATION CENTER, SETON HEALTHCARE FAMILY, AUSTIN, TX, USA and 2DELL CHILDREN’S MEDICAL CENTER, SETON HEALTHCARE FAMILY, AUSTIN, TX, USA
Introduction/Background: Cardiac and respiratory arrests are low frequency, high risk events that require highly qualified healthcare teams to ensure positive patient outcomes. Dell Children’s Medical Center (DCMC) is dedicated to providing the highest quality of care to the children of Central Texas; and therefore, it invests in the training of its healthcare practitioners. Simulation education was developed for training Interprofessional Healthcare Teams (IHT) in assessment, recognition and management of infant and child cardiac and respiratory arrest.
Description: In situ interprofessional mock codes for cardiac and respiratory arrests were initiated in 2005. The in situ approach posed many challenges for the staff, such as distraction from actual patients, limited education time, and lack of hands on skills, as well as improper or omitted debriefing. Although patient outcomes showed slight improvement, satisfaction among the healthcare team revealed a need for a different training methodology. In 2010 DCMC invested in dedicated educational time for off-site code training at Seton Healthcare Family’s Clinical Education Center at Brackenridge (CEC), a high fidelity simulation center (CEC). This allowed the IHT to focus on skills and communication, practice in a safe environment, review video playback, ask questions, and participate in quality debriefing. On a quarterly basis, two hour training sessions were scheduled for teams consisting of resident physicians, nurses, respiratory therapists, and clinical assistants from Critical Care, Intermediate Care, and Acute Care Units. The simulation day agenda included didactic to teach communication techniques and assessment findings that would prompt a Care Response Team (CRT), pre-brief to the simulation environment and patient, mock code scenarios for cardiac and respiratory arrests for infants and children, debriefing sessions with video playback, observation of the next simulation, and a second mock code scenario and debriefing session. Due to overwhelmingly positive feedback from the practitioners and improved patient outcomes, simulation training sessions were held at the CEC on a monthly basis instead of quarterly and expanded to the Emergency Department. In addition to simulation training, Seton Healthcare Family developed Rounding to Influence with the help of Healthcare Performance Improvements consultants and the book Managing the Unexpected. Rounding to Influence was used to increase awareness and the use of CRTs, as well as emphasize the use of communication tools. The mock codes simulation trainings offer the practitioners an opportunity to practice these techniques.
Conclusion: Dedicated education time for interprofessional healthcare teams on a frequent basis has lead to not only practitioner satisfaction but improved patient outcomes. Practitioners report enhanced confidence, show improved communication, as well as outstanding assessment and intervention skills. There has also been consistent feedback from practitioners valuing this methodology and requesting more simulation opportunities. Patient outcomes data have demonstrated the transfer of knowledge to practice, in that code survival to discharge rates for preventable codes has improved by 59%, from 63% in fiscal year 2009 to 100% in fiscal year 2011. These staggering statistics drive the continuation of this training, as its value to patient outcomes is immeasurable. Dell Children’s dedication to high quality healthcare shows in the patients they serve.
1. Jeffries, P., et al. (2007). Simulation in Nursing Education: From Conceptualization to Evaluation. New York, NY: The National League for Nursing.
2. McGaghie, W., Draycott, T., Dunn, W., Lopez, C., Stefanidis, D. (2011). Evaluating the Impact of Simulation on Translational Patient Outcomes. Society for Simulation in Healthcare, Vol. 6 (No. 7), pg. 42-47.
3. Weick, K., Sutcliffe, K. (2007). Managing the Unexpected. San Francisco, CA: Jossey-Bass.
1043 Innovations in Simulation Research Dissemination: International Journal Club
Hiroko Iwashita, MD,2 Benjamin Berg, MD,1 Sayaka Oikawa, MD,1 Young Joon Kang, MD, PhD,2 Yong Su Lim, MD and PhD,1 John Lutz, BS,2 Paul Phrampus, MD, FACEP2
1SIMTIKI SIMULATION CENTER, UNIVERSITY OF HAWAII, JOHN A BURNS SCHOOL OF MEDICINE, HONOLULU, HI, USA and 2PETER M WINTER INSTITUTE FOR SIMULATION, EDUCATION AND RESEARCH (WISER), UNIVERSITY OF PITTSBURGH, PITTSBURGH, PA, USA
Introduction/Background: The critique of educational research is crucial to the continued improvement of simulation pedagogy. The expansion of simulation and other innovative teaching methods to many countries has lead to the development of a unique international journal club at the Winter Institute for Simulation Education and Research (WISER). Participants for the journal club include faculty from the Pacific Rim and visiting fellows at WISER and SimTiki. The purposes of the journal club are as follows: 1). to have a greater understanding of best practices in simulation-based medical education (SBME); 2). to critique and discuss study design of current simulation research and propose potential research designs for future studies; and 3). to have an opportunity to present and discuss in English. This presentation will include discussion of logistical and technological issues in developing an international journal club.
Description: Logistics of the journal club include scheduling, article selection, video meetings and evaluation. The journal club is scheduled monthly at a time that is convenient for all participants. The meeting is scheduled for evenings in Pittsburgh (7:00pm or 8:00pm), mornings in Japan (9:00am) and Malaysia (8:00am) and afternoons in Hawaii (2:00pm). Once scheduled, it is placed on calendar within the SimTiki Simulation Information Management System (SIMS). SIMS is the online system created by WISER to assist with scheduling of courses, course management and data collection. Software used to facilitate the journal club is GoToMeeting (Citrix, Santa Barbara, CA). GoToMeeting allows participants to view video from each of the sites and to view PowerPoint presentations from the site leading the journal club. Two articles for journal club are selected by fellows at WISER and SimTiki. Ideally SBME articles are selected two weeks before the meeting, and shared with participants through SimTiki SIMS. Presenters provide a fifteen-minute slide presentation followed by thirty-minutes of discussion. One of the fellows leads each discussion with guidance from the faculty at WISER and SimTiki. Discussion is focused on population (participants), interventions (research design including setting and types of simulator used), comparison (if appropriate), and outcomes (measurements and analysis). After completing the journal club meeting, the PowerPoint presentations are posted on SimTiki SIMS. Participants complete an evaluation of the journal club effectiveness on SimTiki SIMS.
Conclusion: Simulation education continues to develop and provides a new set of challenges for those new to simulation teaching in different countries. The purpose of our fellowship training is to observe and learn effective simulation teaching methods and also evaluate simulation center management and operations. Our international journal club was started in November of 2011 and has met on a monthly basis since that time. Since the initiation of journal club, 18 articles have been reviewed from a wide variety of journals including Simulation in Healthcare, Pediatric Critical Care Medicine, Resuscitation, The Journal on Quality and Patient Safety and many others. Challenges with the journal club thus far have included technical problems with loss of audio during initial web transmissions but subsequent meetings have been without issues. Other issues have included participants speaking to quickly. Additionally, participants have asked for postings of the PowerPoints prior to the journal club meetings. Scheduling of transmissions requires considerable coordination and communication; scheduling of future journal club meetings will take advantage of the SIMS platform.
2. Lutz J, Mitchell K, Schaefer JJ: The use of a Simulation Information Management System (SIMS) for Data Mining of Simulation Sessions. Anesthesia and Analgesia.
Disclosures: Benjamin Berg, MD is on the CME/CNE Speaker’s Bureau for Laerdal Medical. John Lutz, BS, is a consultant for SimMedical Inc., (a Company of UPMC), and a stockholder/partner/owner of Pittsburgh Simulation Strategies. Paul Phrampus, MD, FACEP, is a consultant for Karl Storz Endoskopy, is a Principle for Pittsburgh Simulation Strategies, Inc, and is the Chief Medical Officer of SimMedical Inc. (a Company of UPMC).
1058 Transfusion Safety: An Interprofessional Opportunity
Teresa Britt, MSN, RN,2 Wyenona Hicks, MS, MT (ASCP), SBB1
1ONEBLOOD, INC, OCALA, FL, USA and 2INTERPROFESSIONAL EDUCATION AND CLINICAL SIMULATION, UNIVERSITY OF TENNESSEE HEALTH SCIENCE CENTER, MEMPHIS, TN, USA
Introduction/Background: Blood transfusion is a procedure with many safety implications. Both The Joint Commission (TJC) and the Centers for Disease Control and Prevention (CDC) have recently addressed the need for improved blood transfusion safety. Accrediting agencies [e.g., AABB (American Association of Blood Banks), the College of American Pathologists (CAP), and the Food and Drug Administration (FDA)] have mandated guidelines regarding this complex procedure. Healthcare education has traditionally included transfusion therapy in all professional programs. Most recently, healthcare education standards have identified the importance of collaboration with other professions during educational experiences.1 From the synthesis of all these directives, it seems appropriate that transfusion safety should be taught collaboratively to all the providers that actually implement this highly-skilled process.
Description: The faculty from three colleges collaborated to make the logistics of this complex simulation occur in January and February, 2012. Unfolding case scenarios for seven patients who required different blood products were written and peer-reviewed. Simulated clinical environments were created for the pediatric, adult and geriatric patients. A simulated Transfusion Services Center for blood distribution was also created on another floor within the facility. A Transfusion Safety course was developed and placed on Blackboard where all participating students were enrolled. This course site provided all the pre-brief materials and a pre-assessment quiz. After the interprofessional simulation, this course site was used for post-assessment and post-survey of participants. On the selected dates, Medical students (M4), senior Nursing students and senior Clinical Lab Science students all met in the Nursing Simulation Lab. The interprofessional teams introduced themselves and then reviewed their assigned patient’s case information. All students functioned within their scope of practice; with the MD student obtaining informed consent, the student nurse performing the initial pre-transfusion assessment and the clinical lab sciences student responsible for type and cross-match completion. The nurse was notified when the blood was ready and then went to the Transfusion Services area to obtain. Realistic safety checks were performed in this distribution area. Some errors were placed on the blood units to see if student participants would detect if all errors were actually caught prior to patient transfusion. The blood was administered after the appropriate safety checks at the bedside and each patient (as the cases continued to unfold) developed a different type of blood transfusion reaction. Each team completed the process of proper communication when this blood transfusion reaction occurred; the communication was initiated via telephone by the student nurse, followed by the student MD, and then the student nurse, and finally by the Transfusion Services(clinical lab sciences) student. After the scenarios were completed, a lengthy debrief occurred with all participating students and faculty. Transfusion safety, pathophysiology of transfusion reactions and proper communication were reviewed and discussed.
Conclusion: This was truly a wonderful experience for the students and faculty. The interprofessional educational activity emphasized collaboration, communication, respect and the importance of each healthcare member’s role. The students got to participate with future colleagues and learn about their scope of practice and educational preparation. The faculty all benefited from working with faculty, staff and students that were not from their traditional colleges. The very complex process of blood transfusion and transfusion reactions was presented in an experiential way to facilitate student learning. The post-survey results were encouraging and this interprofessional educational experience is to be repeated in early 2013.
1. Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.
1061 Neurological Emergency Simulation for Medical Students not Neurologists: Developing a Simulation to Link Classroom Theory to Emergency Interventions
Alexander Bitzer, BS,1 Janice McMillan, BA,1 Elisabeth Wright, MS,2 Keith Littlewood, MD2
1UNIVERSITY OF VIRGINIA SCHOOL OF MEDICINE, CHARLOTTESVILLE, VA, USA and 2MEDICAL SIMULATION CENTER, UNIVERSITY OF VIRGINIA SCHOOL OF MEDICINE, CHARLOTTESVILLE, VA, USA
Introduction/Background: The Mind, Brain, and Behavior (MBB) system is a 10-week block in the University of Virginia’s innovative “Next Generation” Cells to Society Curriculum and integrates psychiatry, neuroanatomy, and behavioral science. The system thus emphasizes neuroscience theory and places less emphasis on disease management. Therapeutic interventions addressed in the MBB system are often complex, sensitive, and require advanced training. However, all future physicians should be able to recognize neurological emergencies due to time sensitivity and the potential for negative sequelae. Feedback from medical students at UVa suggests a push by students to increase their exposure to low stress clinical experiences via simulation. The simulation team has therefore begun offering additional simulation-based educational sessions in which students opt to participate in outside of the formal curriculum. These “extracurricular” sessions provide the opportunity to combine and review difficult concepts presented in previous organ systems in an optimal learning environment.
Description: The extracurricular simulation experience designed for the MBB system reinforces emergency interventions for strokes, seizures, and elevated intracranial pressure concepts previously presented in class. Students receive preparatory articles and participate in instrumentation tutorials and debriefing discussions as described below. The goal of this simulation is to educate students in the recognition and management of neurological emergencies in a simulation setting so that they can more quickly and effectively treat future patients when such events occur. The sessions were designed to address several primary goals: 1). Recognize and treat increased intracranial pressure in an emergency setting; 2). Attend to patient concerns and emotional well-being in emergent scenarios; 3). Identify potential etiologies and treatments of seizures in an emergency/post-operative setting; and 4). Begin to navigate healthcare system by communicating with appropriate consult services. Prior to the simulation sessions, students are given on-line review material on neurological emergencies and instructed in the use of an extraventricular drainage device, manometer, and management of IV fluid lines. The 90 minute educational experience allows for six students to participate in two scenarios and associated debriefings. The group is divided into teams of three; each team participating in one scenario while the second team observes in real-time. In the first scenario, students are presented with a lethargic 41 year old in the ER complaining of a severe headache, photophobia, nausea and blurry vision. Following the assessment, the team is expected to administer emergency treatments for increased ICP secondary to a subarachnoid hemorrhage. Next, the entire group debriefs and case materials for the second case are provided including a head CT and CBC/CMP values. The second team of students next evaluates the patient admitted to the ICU by the first team. During this scenario, students are expected to use a Becker EDMS II EVD device to therapeutically drain CSF and administer anti-epileptic therapy when the patient suffered a post-SAH seizure. The scenario is conducted on a wireless adult simulator equipped with a ventriculostomy port in a simulated ICU. Following this case, the teams again participate in a group debriefing and are asked to evaluate the educational experience via a web-based survey.
Conclusion: Recognition and management of medical emergencies during the simulation experience continues to challenge pre-clerkship medical students due to gaps in theory and disorientation in the unfamiliar hospital setting. The combination of preparatory materials, instrumentation tutorials, and debriefing discussions aims to address these obstacles to improve student confidence and overall performance regarding neurological emergencies. Student perceptions, as reported by a post-simulation survey, have been universally positive regarding the level of value provided by these experiences. For example, 100% of the participating students agreed that the simulation experience built understanding of related clinical concepts. Additionally, 100% of students “strongly agree” that these experiences challenged their critical thinking and decision-making skills. Students also provided feedback such as, “These sessions are improving our ability to think on the spot”; a sentiment that was reflected in many students comments. Participants were also asked to reflect on self-identified improvements in performance via a post-simulation survey. The students reported a desire to improve teamwork skills in the following domains: 54.5% Communication; 36.4% Situation Awareness; 36.4% Appropriate Assertiveness; 27.3% Team Leadership; and 18.2% Mutual Trust/Back-up Behavior. This innovative educational experience will help shape future efforts to evaluate learners’ performance in the simulation before and after tutorials to determine when this learning is most beneficial.
Elisabeth Wright, MS, receives grant support from the Josiah Macy, Jr. Foundation. Keith Littlewood, MD, receives Research funding from Pfizer Pharmaceutical and Josiah Macy Foundation.
1063 A Brief Pediatric Internship Bootcamp for 4th Year Medical Students
Rebekah Burns, MD,3 Mark Adler, MD,5 Walter Eppich, MD, MEd,1 William McGaghie, PhD,4 Jennifer Trainor, MD2
1EMERGENCY MEDICINE, NORTHWESTERN UNIVERSITY, ANN AND ROBERT H LURIE CHILDREN’S HOSPITAL, CHICAGO, IL, USA and 2PEDIATRIC EMERGENCY MEDICINE, NORTHWESTERN UNIVERSITY, ANN AND ROBERT H LURIE CHILDREN’S HOSPITAL, CHICAGO, IL, USA and 3PEDIATRICS, DIVISION OF EMERGENCY MEDICINE, NORTHWESTERN UNIVERSITY, ANN AND ROBERT H LURIE CHILDREN’S HOSPITAL, CHICAGO, IL, USA and 4CENTER FOR EDUCATION IN MEDICINE, NORTHWESTERN UNIVERSITY, FEINBERG SCHOOL OF MEDICINE, CHICAGO, IL, USA and 5PEDIATRICS, NORTHWESTERN UNIVERSITY, FEINBERG SCHOOL OF MEDICINE, CHICAGO, IL, USA
Introduction/Background: The transition from medical student to intern is a challenging process characterized by a steep learning curve. Increased clinical responsibilities require strong communication and organizational skills as well as the ability to apply medical knowledge.1 Focused courses targeting skills necessary for success as a resident have increased self-perceived preparedness, confidence and medical knowledge.2,3,4,5 Relatively little time is devoted to pediatrics in undergraduate medical education. Literature on pediatric-specific bootcamps is lacking. A simulation-based educational curriculum may help prepare students entering pediatric training.
Description: We developed a novel, 3½ day elective course entitled “Pediatric Internship Bootcamp” using input from education experts, feedback from recent graduates of Northwestern University Feinberg School of Medicine (FSOM) who matched in Pediatrics, Medicine/Pediatrics or Family Medicine, and the medical literature.6 The course was offered to 4th year FSOM students who matched into pediatric-related internships in May of 2012. We used a combination of longitudinal cases, simulation, didactics, videos, role-play, small group discussions and debriefings. Students worked in groups of four led by a course facilitator. Topics are delineated in Table 1. Feedback, self-reflection and discussion were encouraged throughout the course. At the end of the course, each participant completed a multi-station objective structured clinical exam utilizing a standardized parent and task-trainer. The scenario required the synthesis and application of multiple bootcamp elements. Assessment instruments to evaluate history taking and information sharing with a parent, data synthesis, assessment and plan formulation, informed consent, and performance of an infant lumbar puncture were piloted. A faculty member debriefed students individually. All participants completed a post-course evaluation form. Twelve students participated in the course. All agreed with the statements, “The facilitators presented the material in an effective manner,” “I took away ideas I plan to implement in internship,” and “I think all students should participate in a similar experience.” When asked about the most useful components of the course, one student responded, “The opportunities to practice were the best part we often don’t get time to practice tasks that residents consider mundane (i.e., calling consults, answering pages, etc.) and it was great to be able to do that and have some discussion/feedback around it.” Other comments included “Motivated learners with motivated teachers presenting deliberately high-yield, useful information is a recipe for some great learning; keep this going” and “So many skills I didn’t even know were learnable…being armed with these skills helps us.” Refer to Table 1.
Conclusion: A focused bootcamp addressing the key knowledge and skills required for pediatric-related residencies was valued by graduating medical students entering into Pediatric, Medicine/Pediatric and Family Medicine residencies. Future directions include validating assessment instruments and targeting both short and long-term outcome goals.
1. Lempp H, Cochrane M, Seabrook M and Rees J. Impact of educational preparation on medical students in transition from final year to PRHO year: A qualitative evaluation of final-year training following the introduction of final-year training following the introduction of a new Year 5 curriculum in a London Medical School. Med Teach. 2004;26:276-278.
2. Teo AR, Harleman E, O’Sullivan P and Maa J. The key role of a transition course in preparing medical students for internship. Acad Med. 2011;86:860-865.
3. Laack TA, Newman JS, Goyal DG and Torsher LC. A 1-week simulated internship course helps prepare medical students for transition to residency. Simul Healthc. 2010;5:127-132.
4. Esterl RM, Henzi DL and Cohn SM. Senior medical student “boot camp”: Can result in increased self-confidence before starting surgery internships? Current Surg. 2006;63:264-268.
5. Boehler ML, Rogers DA, Schwind CJ, Fortune J, Ketchum J and Dunnington G. A senior elective designed to prepare medical students for surgery residency. Am J Surg. 2003;187:695-697.
6. Lyss-Lerman P, Teherani A, et al. What training is needed in the fourth year of medical school? Views of residency program directors. Acad Med. 2008;84:823-;828.
1077 High Fidelity Simulation ACLS: Emphasizing Non-Technical Skill Training
Nur-Ain Nadir, MD,1 Brenda Natal, MD, MPH, RN,1 Ian DeSouza, MD1
1EMERGENCY MEDICINE, STATE UNIVERSITY OF NEW YORK, DOWNSTATE MEDICAL CENTER, BROOKLYN, NY, USA
Introduction/Background: Advanced Cardiac Life Support (ACLS) training has improved the quality of cardiac code delivery.1 Traditional table-top ACLS courses, however, do not focus on non-technical skills such as confidence and communication.2 As a result, novice trainees either resist adopting leadership roles or are non-proficient at it.3 We have observed similar behaviors amongst emergency medicine (EM) interns during weekly simulation exercises at our institution. To address this problem, we have designed an ACLS course based on prior studies,2,4 that utilizes high-fidelity simulation to teach a combination of both technical and non-technical skills integral to the efficient delivery of cardiac codes. Our approach is novel, in that it integrates both team dynamics training and ACLS didactics within the same course.
Description: Our course is taught by ACLS instructors in two eight hour blocks over two days. In keeping with the American Heart Association (AHA) guidelines,5 the initial 8 hours of the course are dedicated to lectures and skill stations that address various ACLS algorithms. On the second day, non-technical skills are introduced and practiced in a dedicated “Team Concepts” skill station. Subsequently, students are tested on both technical and non-technical skills in a high fidelity simulation mega-code. All students are required to pass a post-course written test. Our course combines the deliberate practice of leadership, teamwork and communication skills with the application of ACLS knowledge to simulated case scenarios in real time. A series of cases based on ACLS protocols6 have been created and programmed into our human patient simulator (METI). Groups of six students are tested together. For each case a different student is assigned team leader role. A checklist of critical behavioral actions based on prior studies (Table 1)2 is used in combination with ACLS algorithms to assess student knowledge. At the conclusion of each case a debriefing session is conducted.
Conclusion: At our institution, new EM interns are trained in ACLS, PALS and ATLS during orientation. PALS and ATLS are traditional table-top courses that serve as direct comparisons to our high-fidelity simulation ACLS course. We conducted a post-course survey comparing our course to traditional table top courses. In general, the high-fidelity simulation ACLS course received overwhelmingly positive feedback. Select results are summarized in Figure 1. 60% of surveyors found our course to be more realistic than alternative. With respect to the incorporation and deliberate practice of team-working/building skills, 95% found our course superior. In regards to the development and practice of leadership skills 80% found our course better. Ninety-five percent indicated future preference for a high fidelity simulation ACLS relative to traditional courses. Prior research supports the role of high fidelity simulation and deliberate practice in ACLS training.4 The results of our survey further support this finding. We plan to open this course to an interdisciplinary audience as well as introduce high-fidelity simulation based PALS course.
1. Hagyard-Wiebe T. Should critical care nurses be ACLS-trained? Dynamics. 2007 Winter; 18(4):28–31.
2. Stefan MS, Belforti RK, Langlois, G, Rothberg MB. A simulation-based program to train medical residents to lead and perform advanced cardiovascular life support. Hosp Pract (Minneap) 2011 Nov; 39(4):63–9.
3. Hayes CW, Rhee A, Detsky ME, Leblanc VR, Wax RS. Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents. Crit Care Med. 2007;35(7):1668–1672.
4. Wayne DB, Butter J, Siddall VJ, Fudala MJ, Wade LD, Feinglass J, McGaghie WC. Mastery Learning of Advanced Cardiac Life Support Skills by Internal Medicine Residents Using Simulation Technology and Deliberate Practice. J Gen Intern Med 2006; 21:251–256.
5. Bhani F, Manicini ME, Sinx E, Rodgers, DL, McNeil MA, Hoadley TA, Meeks TA, Hamilton MF, Meaney PA, Hunt EA, Nadkarni VM, Hazinski MF. Part 16: education, implementation, and teams: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 suppl 3):S920–S933.
6. Field JM, Hazinski MF, Sayre MR, Chameides L, Schexnayder, SM, Hemphill R, Samson RA, Kattwinkel J, Berg RA, Bhnaji F, Cave DM, Jauch EC, Kudenchuk PJ, Neumar RW, Peberdy MA, Perlman JM, Sinx E, Travers AH, Berg MD, Billi JE, Eigel B, Hickey RW, Kleinman ME, Links MS, Morrison LJ, O’Connor RE, Shuster M, Callaway CW, Cucchiara B. Ferguson JD, Rea TD, Vanden Hoek TL.
7. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010 Nov 2;122(18 Suppl 3):S640–56.
1096 Meeting Medical Student Demand for Simulation: Extracurricular Simulation Experiences
Phil Reynolds, BS,3 Andrea Fiumefreddo, MS,3 Mark Kirk, MD,2 Keith Littlewood, MD3
1 and 2EMERGENCY MEDICINE, UNIVERSITY OF VIRGINIA SCHOOL OF MEDICINE, CHARLOTTESVILLE, VA, USA and 3MEDICAL SIMULATION CENTER, UNIVERSITY OF VIRGINIA SCHOOL OF MEDICINE, CHARLOTTESVILLE, VA, USA
Introduction/Background: At the University of Virginia School of Medicine, the innovative “Next Generation” Cells to Society Curriculum is a systems-based curriculum that focuses on the integration of basic science and clinical practices early in the medical student education process. The curriculum has placed a larger emphasis on clinical skills education; and therefore, it relies heavily on the use of simulation-base education to supplement the didactic material. In the first two years of the medical education curriculum, each student participates in various clinical skills and procedural workshops, as well as several case-based simulation sessions linked to concurrent systems in the curriculum. In spite of this, there has been a strong demand from students for additional simulated clinical experiences during the beginning of their medical training. The Medical Simulation Center decided to develop optional simulation sessions to supplement the robust pre-clinical simulation experiences (Gordon, 2010). While providing additional simulation-based experiences accommodating an entire class of 156 medical students presented a logistical challenge, the development of extracurricular simulation experiences has proven to be a successful initiative to expand pre-clinical simulation while staying within resource constraints common to many simulation programs. This poster describes some of the considerations that must be made in order to implement an effective extracurricular simulation experience at other institutions.
Description: Optional extracurricular simulation experiences were developed to give interested students extra opportunities to develop clinical skills. The simulation scenarios themselves were selected to highlight particular subjects from a system in the curriculum. The 90 minute educational experience allows for six students to participate in two scenarios and associated debriefings. The two scenarios are unique, but have complementary learning objectives. The group is divided into teams of three; each team participating in one scenario while the second team observes in real-time. Following the first case, the group debriefs as a whole. The teams then switch roles so that the observing group can participate in the second scenario. After the second case, the teams again participate in a group debriefing and are asked to evaluate the educational experience via a web-based survey. There were several challenges associated with the implementation of these sessions. First, there was concern that the optional nature of these experiences would give the participating students an unfair advantage on the summative exam at the conclusion of the curricular system. To alleviate this concern, scenarios were designed to supplement the curriculum of the previous system. Session scheduling and student selection also proved to be a challenge. The dates for the afternoon blocks on which the sessions were held were chosen to fit the schedules of teaching faculty. To give the opportunity to all students that are interested, a lottery scheduling system was established. Each month, timeslots were released. Following the one week signup period, student names were randomly chosen to participate and were removed from future lottery pools until all interested students had the opportunity to participate.
Conclusion: The sessions for pilot project were comprised of two cases supporting learning objectives in the Gastrointestinal System. In the pilot project lasting only two months, 83 (53%) students participated in the extracurricular sessions. The student evaluations of the sessions were extremely positive, which included the following: (1). 99% reported that the simulation experience built understanding of related clinical concepts; (2). 98% believed the simulation session will make them more comfortable when faced with similar clinical situations; (3). 97% indicated their critical thinking and decision-making skills were challenged by the experience; and (4). 100% would recommend continued use of simulation in extracurricular sessions. Additional cases are currently in development for implementation in the fall. These cases will be for second year medical students and will support curricular concepts from the Mind, Brain, and Behavior system.
1. Gordon, J. A., Hayden, E. M., Ahmed, R. A., Pawlowski, J. B., Khoury, K. N., & Oriol, N. E. (2010). Early bedside care during preclinical medical education: Can technology-enhanced patient simulation advance the flexnerian ideal?. Academic Medicine, 85(2), 370-377.
Keith Littlewood, MD, receives Research funding from Pfizer Pharmaceutical and Josiah Macy Foundation.
1119 Measuring the Performance of a Medical Simulation Center: The Initial Step to Assessing the True Value of Medical Simulation
Yeongmin You, MBA(cand),3 Ernest Wang, MD,2 Morris Kharasch, MD,2 Pamela Aitchison, RN1
1CENTER FOR SIMULATION AND INNOVATION, NORTHSHORE UNIVERSITY HEALTHSYSTEM, EVANSTON, IL, USA and 2EMERGENCY MEDICINE, NORTHSHORE UNIVERSITY HEALTHSYSTEM, EVANSTON, IL, USA and 3HEALTH ENTERPRISE MANAGEMENT, NORTHWESTERN UNIVERSITY, KELLOGG SCHOOL OF MANAGEMENT, CHICAGO, IL, USA
Introduction/Background: Medical simulation has become an integral training component in a growing number of medical schools and independent health systems. We view this as part of strategic adaptations of health care organizations to the environmental changes in health care, increasing emphasis on safer health systems, enhancement of simulation technologies, and growing concerns about the potential malpractice in teaching hospitals. However, for many organizations, medical simulation is viewed as a cost center rather than a strategic asset or value generator. This is one of the major reasons that most medical simulation centers are not self-sustaining. It requires large capital investments to set up and operate a high-fidelity medical simulation center while revenue generated from training is very limited.1 Medical simulation centers offer health care systems many benefits. They can drive value based health care delivery by improving the quality of care through correct and timely diagnosis and treatments to the right patients.2 However, assessing the quantitative value of a center is extremely complicated, thus making its indispensable role difficult to recognize. The quantitative value of a medical simulation center is best measured by its performance. Kimberly and Zajac emphasized performance as the central constituent in the model of strategic adaptation for health care organizations.3 That is, performance as the key variable has interrelated impacts on other sets of variables (i.e., environment/strategy, strategy/structure, and structure/behavior) in the model. Furthermore, correct measurement of performance enables the pursuit of operational excellence for a medical simulation center.
Description: We believe our collaborative study with the Kellogg School of Management of Northwestern University to measure the performance of NorthShore Center for Simulation and Innovation (NCSI), a 13,000 square foot interprofessional and multidisciplinary medical simulation facility, provides useful suggestions on what to and how to measure to assess the performance of simulation centers. To measure the performance of NCSI, we examined factors in three categories we believe constitute the performance which include the following: 1). degree of alignment with the vision of NorthShore University Healthcare System, with which NCSI is affiliated; 2). utilization of NCSI; and 3). profit and loss. Aligned vision with NorthShore University Healthcare System will maximize the value that NCSI delivers to the parent company. To measure this, we tracked the portfolios of trainees and the ratio of internal / external training. We also considered the evaluations of trainees. We discovered the illusion of full utilization. Daily utilization of NCSI for the first quarter of 2012 reached 93%, but our findings indicated significant room for more activities that can add value to the center. These findings led to the list of low hanging fruits NCSI can take to increase operational excellence. With improved capacity, NCSI will have room for more research as one of the most innovative health systems in the community. Also, NCSI will be able to train more nursing staff, who play essential roles at the direct contact points with the patients for superior clinical care. We developed new revenue and cost structure to better track the profit and loss status of NCSI. This structure was especially meaningful as it allowed us to calculate the cost per hour per trainee. This calculation provided a quantifiable metric for determining whether our course fees and rental fees are correctly priced and helped us compare ourselves objectively with the competition.
Conclusion: The factors we measured to assess the performance of NCSI are objective, easy to replicate, and can be integrated in NorthShore University Healthcare System’s IT infrastructure. We are introducing metrics-based management to NCSI for more accurate and timely tracking of assessment data. Once implemented, this will enable us to transition to value-based pricing and move a step closer to being self-sustaining.
1. Medical Simulation in Medical Education: Results of an AAMC Survey. Passiment M, Sacks H, Huang G. AAMC. 2011.
2. Redefining Health Care: Creating Value-Based Competition on Results. Porter ME, Teisberg EO. HBS Press. 2006.
3. Strategic adaptation in health care organizations: implications for theory and research. Kimberly JR, Zajac EJ. Med Care Rev. 1985 Fall;42(2):267-302. PMID: 10274865 [PubMed - indexed for MEDLINE].
1120 Development of an Inter-Professional Disaster Preparedness Curriculum Utilizing a Combination of Didactic Training, High-Fidelity Simulation and Mass Casualty Exercise Participation
Edward Jasper, MD1
1EMERGENCY MEDICINE, THOMAS JEFFERSON UNIVERSITY, PHILADELPHIA, PA, USA
Introduction/Background: Disaster preparedness training is a critical component of health professional student education, as there have been numerous recent natural and man-made disasters around the world. In July, 2003, the AAMC in collaboration with the Centers for Disease Control and Prevention (CDC) released a report on medical school disaster preparedness training. This report, entitled “Training Future Physicians about Weapons of Mass Destruction: Report on the Expert Panel on Bioterrorism Education for Medical Students,” made a number of recommendations for a medical student disaster preparedness curriculum. The recommendations included that there should be training in various agents including biological, chemical, and nuclear/radiological, weapons of mass destruction and also that didactic plus experiential learning techniques should be utilized. Despite this report, there has been no national consensus on a disaster preparedness curriculum for medical students, nor has one been developed for nursing students or EMT/Paramedic students.
Description: A curriculum was developed and delivered to medical students, nursing students and EMT paramedic students that included the following components. First, it included a 1-2 hour didactic session primarily focusing on the current disaster possibilities, including natural and manmade events. This also included a discussion of hazard vulnerability assessment regarding the most likely threats and established the need to know more about this topic. Second, it included hands on training stations, which included intravenous insertion, use of personal protective equipment and a high fidelity manikin simulation scenario. There were four stations lasting 45 minutes each. Third, it included a mass casualty exercise conducted at Thomas Jefferson University Hospital utilizing all of the students trained, which totaled approximately 450. This was one of the largest single hospital full scale mass casualty exercise ever conducted. Student volunteers were trained in moulage application, and twenty stations were set up using forty students on the day of the exercise. All of the simulated victims had moulage application completed in less than two hours. A checklist to assist exercise development and delivery was also developed to assist in future years, as well as to help others who would like to duplicate an exercise of this magnitude. The students were not just simulated victims, which is typical of most hospital disaster exercises, but they were also trained observers who could provide useful input into the actual management of victims. Numerous valuable lessons were learned that could not be appreciated with smaller exercises, and students were able to observe, first-hand, the challenges hospitals face treating large numbers of mass casualty victims. The total time devoted to the disaster preparedness curriculum including exercise participation, was about eight hours. Evaluations of the program were generally positive, with the majority appreciating the opportunity to learn about disaster preparedness and have hands on experience in addition to the didactic material.
Conclusion: In order for the healthcare workforce to be able to respond to a real disaster, interprofessional training that includes the use of simulation ensures at least some familiarity with the many issues related to mass casualty response. Participation in a joint mass casualty exercise allows students to understand how they will have to work together as a team to meet the many challenges they will potentially have to face following a mass casualty event.
1121 Identification of Subject-Matter-Expert Effort Required for the Development and Validation of Healthcare Training-Based Virtual Environments
Ryan McMahan, PhD,5 Michael Steele, BS,4 Ryan Fink, MD,2 David Turner, MD,1 Jeffrey Taekman, MD3
1PEDIATRIC CRITICAL CARE, DUKE CHILDREN’S HOSPITAL, DURHAM, NC, USA and 2ANESTHESIOLOGY, DUKE UNIVERSITY MEDICAL CENTER, DURHAM, NC, USA and 3HUMAN SIMULATION AND PATIENT SAFETY CENTER, DUKE UNIVERSITY MEDICAL CENTER, DURHAM, NC, USA and 4SCHOOL OF MEDICINE, DUKE UNIVERSITY MEDICAL CENTER, DURHAM, NC, USA and 5COMPUTER SCIENCE, UNIVERSITY OF TEXAS AT DALLAS, DALLAS, TX, USA
Introduction/Background: Over the past several years, the Duke University Human Simulation and Patient Safety Center has worked collaboratively with a local vendor to develop and validate virtual environments for healthcare training. Developing virtual environments requires large development teams, including subject-matter experts (SMEs), researchers, artists, game designers, and software engineers. Understanding and managing interactions between healthcare workers and software developers is essential for success. To ensure the successful development and proper validation of these types of training tools, we have identified five phases of tasks that require considerable effort from the healthcare SMEs.
Description: The first phase of our process is scenario design. During this phase, the SMEs identify specific training objectives for each scenario to be developed. These objectives guide the SMEs’ design of patient profiles, case complications, and environmental settings. The SMEs also identify the correct and incorrect actions for each scenario, which become the basis for a within-virtual-environment assessment. During the second phase, the SMEs must collaborate with the software development team to ensure the scenario designs are properly represented in the software design document (SDD). This effort involves providing didactic materials, possibly in the form of mannequin-based walkthrough videos, giving feedback on stages of the document, and thoroughly reviewing the final version for approval. In the third phase, the SMEs oversee the design of a study meant to validate the effectiveness of the training tool being developed. To increase the likelihood of demonstrating positive educational outcomes, the study design phase should occur concurrently with the design document phase to ensure all training objectives are measured appropriately. SME effort during the study design phase involves identifying proper instruments for training assessment, building and validating those instruments if necessary, and filing the appropriate paperwork for the institutional review board. The fourth phase of the process is the software development cycle. During this cycle, SMEs must continue to collaborate with the software development team to review and approve art, animations, user interfaces, physiology, and other software aspects. To ensure adequate reviews, SMEs must allot sufficient time to walk through each developed virtual environment scenario multiple times. After the software development cycle, the fifth and final phase involves conducting the validation study approved during the study design phase. This effort includes recruiting subjects, assessing their virtual environment training with the instruments developed earlier, compiling and analyzing the results of the assessments, and finally reporting those findings.
Conclusion: Like mannequin-based simulation, developing a healthcare training-based virtual environment is time consuming, with potentially an even greater time commitment considering the large nature of the development team required. To promote the successful development and validation of such training tools, we have identified five phases of development that require SME effort: high level design of scenarios, design document development, designing a validation study, providing feedback during the software development cycle, and conducting the validation study of the completed software. Each of these phases requires considerable effort from the SMEs and should not be underestimated.
Disclosures: Jeffrey Taekman, MD, receives grant support from Pfizer and Abbott. Dr. Taekman also has proprietary interest in co-developed virtual environment projects (ILE@D, PDAATS, 3DiTeams).
1128 Using Tablet Computers to Facilitate Learner-Directed Group Debriefings in Neonatal Resuscitation Program (NRP) Simulations
Joe Livingston, MD,3 Hannes Prescher, BA,2 Lisa Grisham, MS, NNP1
1ARIZONA SIMULATION TECHNOLOGY AND EDUCATION CENTER, UNIVERSITY OF ARIZONA, TUCSON, AZ, USA and 2ARIZONA SIMULATION TECHNOLOGY AND EDUCATION CENTER (ASTEC), UNIVERSITY OF ARIZONA, TUCSON, AZ, USA and 3PEDIATRICS, UNIVERSITY OF ARIZONA, TUCSON, AZ, USA
Introduction/Background: Debriefing following simulation training is consistently identified as the most important aspect of the learning experience.1-3 Traditionally, debriefing is done in a group, lead by one or more instructors with the emphasis on group and individual reflection.2 However, group debriefings can often be plagued by the reluctance of trainees to participate. Moreover, trainees may have difficulty identifying the salient points of the simulation exercise or have a false sense of their performance. Studies have shown that providing video feedback during debriefing can provide learners with a more objective review of their performance and help them identify skills that were inadequately performed.4-6 Other studies have proposed using formative assessment as a guide to facilitate debriefing.7 A recent study showed that it can be effective in teaching nontechnical skills in medical simulation.8 Our innovation implements a unique approach that combines individual video feedback with a formative self-assessment instrument immediately after the simulation training and prior to group debriefing. The objective of this innovation is to increase trainee participation, and thereby to create a higher quality debriefing.
Description: As part of their training, pediatric residents participate in weekly in-situ neonatal simulation training along with staff members of University of Arizona Medical Center’s (UAMC) Neonatal Intensive Care Unit (NICU). Each simulation lasts 10 minutes and is video recorded with a Flip Video™ camera. Following the simulation, the video is downloaded and transferred to four iPad tablets. Learners are given 15 minutes to individually review the video recording and complete the written formative assessment. The formative assessment instrument consists of three parts: learners fill out a timeline of actions, answer several questions about the resuscitation, and rate a variety of technical and nontechnical skills on a 10-point likert scale. This scale is modified from the STORC OB Safety Initiative Clinical Teamwork Scale by adding specific neonatal resuscitation questions.9 Finally, learners select a short clip from the video recording that identifies a moment where something did not go as well as it could have and another clip where the team performed particularly well. These clips are then used anonymously in the ensuing group debriefing.
Conclusion: Implementation of the video-enhanced formative assessment instrument will increase participation in the group debriefing. It will improve the quality of the talking points and the ability of learners to identify the intended learning objectives of the simulation training. We believe this improvement will result from the ability of learners to view and reflect on what happened in the simulation before talking about it with other learners and instructors. Watching a video recording of their actions will provide learners with a more objective perspective of their performance. Completing a self-assessment will provide them with meaningful talking points for the ensuing group debriefing. This will effectively reduce the facilitator’s lecture time and will allow the debriefing to assume a peer discussion. Responses on the formative assessment instrument will prove useful in understanding the learning progress of the trainees and in guiding subsequent trainings. Future research work will need to assess the impact of this unique debriefing style on performance in subsequent simulations and also in clinical practice. We report this program innovation because we believe it stimulates discussion during simulation training and fosters the learning process.
1. 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 2005; 27:10–28.
2. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc 2007;2:115–125.
3. Savoldelli GL, Naik VN, Park J, Joo HS, Chow R, Hamstra SJ. Value of debriefing during simulated crisis management: oral versus video-assisted oral feedback. Anesthesiology 2006; 105(2):279-85.
4. Birnbach DJ, Santos AC, Bourlier RA, et al. The effectiveness of video technology as an adjunct to teach and evaluate epidural anesthesia performance skills. Anesthesiology 2002 Jan; 96(1):5-9.
5. Hamilton NA, Kieninger AN, Woodhouse J, Freeman BD, Murray D, Klingensmith ME. Video review using a reliable evaluation metric improves team function in high-fidelity simulated trauma resuscitation. J Surg Educ 2012 May-Jun; 69(3):428-31.
6. Lee MO, Brown LL, Bender J, Machan JT, Overly FL. (2012). A medical simulation-based educational intervention for emergency medicine residents in neonatal resuscitation. Society for Academic Emergency Medicine, 19(5):577-585.
7. Garrison C, Ehringhaus M. (2012). Formative and summative assessments in the classroom. Association for Middle Level Education. Retrieved from http://www.amle.org/Publications/WebExclusive/Assessment/tabid/1120/Default.aspx.
8. Boet S, Bould D, Bruppacher HR, Desjardins F, Chandra DB, Naik VN. (2011). Looking in the mirror: self-debriefing versus instructor debriefing for simulated crises. Crit Care Med, 39(6): 1377-1381.
9. Guise JM, Deering SH, Kanki BG, Osterweil P, Li H, Mori M, Lowe NK. (2008). Validation of a tool to measure and promote clinical teamwork. Society for Simulation in Healthcare, 3(4): 217-223.
1148 Utility of Failure in the Human Simulator on Long-Term Performance
Andrew Goldberg, MD,1 Eric Silverman, MD,1 Adam Levine, MD, Samuel DeMaria Jr MD1
1ANESTHESIOLOGY, MOUNT SINAI SCHOOL OF MEDICINE, NEW YORK, NY, USA
Introduction/Background: It has been observed that anesthesiologists have failed to recognize and promptly manage certain rare intra-operative events. Prior studies have suggested this gap can be bridged through simulation.1 This project aims to demonstrate that High-Fidelity Simulation is an effective educational tool that safely permits trainees to experience catastrophic events that could not be intentionally, ethically re-created in an operating room (OR). It has already been demonstrated that simulation can accelerate skill acquisition in multiple clinically relevant situations. However, these studies may underutilize the potential of human simulation. They are set up to teach specific objectives and are terminated once those objectives are met. Early termination of scenarios prior to irreversible patient harm/death may fail to elucidate certain knowledge gaps that participants only explore after injuring the patient. Trainees’ failures, resulting in simulated patient harm, may generate a sense of ownership and responsibility for their mistakes. Furthermore, failures may make participants feel inadequate or disappointed and lead to a desire to take corrective action to improve future practice.2,3 Even experienced anesthesiologists appear to have deficiencies in proper clinical management of specific rare events. Prior studies showed experienced anesthesiologists were ill prepared to manage a central oxygen supply failure.4 At our institution, we observed that this simulation, which has been a part of the curriculum for many years, is the most memorable according to the majority of the residents. It is hypothesized that the emotional response created by the failure of the learner, and subsequent simulated death of the patient, is the most educational part of the scenario. It creates such an impact that residents have long-term memory of the simulation and are quick to recognize, and react to similar future situations.
Description: Using a randomized, controlled, observer-blinded design, we compare future performance of anesthesiology residents causing simulated patient harm by not recognizing an oxygen pipeline failure, to trainees where an attending anesthesiologist intervenes and prevents that harm (actual OR replication). The study is performed using the METI high-fidelity simulator. The oxygen source to the anesthesia machine is cut and the simulator is allowed to desaturate. In the control scenario, the simulator desaturates until the patient dies from hypoxia (unless the residents appropriately intervene). In the experimental group, an attending enters the room and points out that the patient is desaturating because the oxygen supply is compromised, and illustrates the proper technique for saving the patient prior to simulated harm. The hypothesis is that patient demise secondary to resident underperformance is a more powerful learning tool versus experiencing the same scenario with early attending intervention and patient survival.
Conclusion: Demonstrating that it is the failure of the performer that causes long-term retention of material illustrates the importance of the simulated environment as this specific experience can never be ethically or successfully replicated in real-life.
1. Park CS, Rochlen LR, Yaghmour E, Higgins N, Bauchat JR, Wojciechowski KG, Sullivan JT, McCarthy RJ. Acquisition of critical intraoperative event management skills in novice anesthesiology residents by using high-fidelity simulation-based training. Anesthesiology. 2010;112(1):202-11.
2. Scott SD, Hirshinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The Natural History of Recovery for the Healthcare Provider “Second Victim” after Adverse Patient Events. Qual. Saf. Health Care. 2009; 18: 325-30.
3. Lander LI, Connor JA, Shah RK, Kentala E, Healy GB, Roberson DW. “Otolaryngologists’ Responses to Errors and Adverse Events.” Laryngoscope. 2006; 116:1114-20.
4. Weller J, Merryy A, Warman G, Robinson B. Anaesthetists’ management of oxygen pipeline failure: room for improvement. Anaesthesia. 2007;62:122-126.
1154 The Use of Standardized Patients and Confederates to Teach Communication Skills and Professionalism in Pediatric Residency
Helen Maliagros, MD,5 Jamilah Grant-Guimaraes, MD,3 Sandeep Gangadharan, MD,3 Barbara DeVoe, DNP, FNP-BC,4 M Isabel Friedman, RN, DNP, MPA,1 Robert Kerner, RN JD,1 Margaret (Peggy) Delaney, RN, MSN, CEN BC,4 Andrew Rotjan, RN, EMT-P,2 Ronald Ulrich, BA, EMT,1 Cesar Pastrana, BA,2 Andrew Drozd, EMT2
1CENTER FOR LEARNING AND INNOVATION, NORTH SHORE LONG ISLAND JEWISH HEALTH SYSTEM, LAKE SUCCESS, NY, USA and 2PATIENT SAFETY INSTITUTE, NORTH SHORE LONG ISLAND JEWISH HEALTH SYSTEM, LAKE SUCCESS, NY, USA and 3PEDIATRICS, NORTH SHORE LONG ISLAND JEWISH HEALTH SYSTEM, LAKE SUCCESS, NY, USA and 4CENTER FOR LEARNING AND INNOVATION, NORTH SHORE LONG ISLAND JEWISH HEALTH SYSTEM, COHEN CHILDREN’S MEDICAL CENTER OF NEW YORK, LAKE SUCCESS, NY, USA and 5PEDIATRICS, NORTH SHORE LONG ISLAND JEWISH HEALTH SYSTEM, COHEN CHILDREN’S MEDICAL CENTER OF NEW YORK, LAKE SUCCESS, NY, USA
Introduction/Background: The Accreditation Council for Graduate Medical Education (ACGME) identifies six core competencies required in residency training. Interpersonal and communication skills as well as professionalism are two of these six core competencies integral to physician development. The ACGME states that interpersonal and communication skills “result in the effective exchange of information and collaboration with patients, their families, and other health professionals” and that professionalism is “manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.”1 Professionalism and effective communication skills have been shown to successfully increase patient satisfaction, understanding, and compliance. Likewise, proficiency in these competencies, has been directly linked to improved clinical outcomes.2,4 Teaching these qualities during residency can be challenging. Simulated scenarios with standardized patients/ confederates are useful modalities in residency professionalism education. Implementation of such educational programs have been shown to increase resident confidence as well as performance in difficult situations such as breaking bad news, and admitting a mistake.2,3 The evaluative process for these skills has been somewhat debated. The 360-degree evaluation has been used for decades by business organizations and has now come into favor for resident assessment. This allows educators to gather evaluations from nurses, patients/ parents, and attending physicians. Such evaluations allow educators a closer look in the level of proficiency in these competencies as well as to further identify areas for improvement.1
Description: A communication and professionalism curriculum was developed to address the specific needs of pediatric residents in these core competencies. Pediatric specific scenarios highlighted situations such as sexual identity in adolescent patients, a variety of cultural specific norms of child rearing during illness, and communicating with parents in difficult situations. The educator conducted monthly interprofessional classes at a simulation facility for small group learning. Groups included four to six senior residents (PGY 2 and 3), as well as several pediatric nurses. Classes began with a short didactic session on communicating with a family in crisis as well as cultural competency. The didactic session was followed by simulated scenarios with the use of standardized patients and confederates as parents/ guardians. One resident performed each scenario, with or without the presence of a pediatric nurse depending on availability, while the rest of the group watched the scenario unfold in a debriefing room. After each scenario, a small group discussion and debriefing were conducted. This included the attending physician/educator, clinical education specialists, the standardized patients and/or confederates (staying in character), pediatric nurses, and residents. During the debriefing, feelings and previous experiences were shared among the group. Feedback was provided from all members of the group including the patient and/ or family members.
Conclusion: Each resident submitted an evaluation of the course upon completion. Residents were asked to score how effectively each of the goals of the course was met as well as their own confidence with communication skills and professionalism after the course. The results of these evaluations were overwhelmingly positive, demonstrating an increased confidence in dealing with such difficult situations in pediatrics after our intervention. In future studies, we plan to assess the validity of these evaluations by performing a 360-degree evaluation of the residents before and after our course. Competence in Interpersonal/ Communication skills and Professionalism will be evaluated using the new ACGME Pediatric Developmental Milestones.4 We anticipate that our intervention will improve resident interpersonal and communication skills as well as professionalism in the clinical setting.
1. Brinkman WB, Geraghty SR, Lanphear BP, Khoury JC, Gonzalez del Rey JA, DeWitt TG, Britto MT. Evaluation of resident communication skills and professionalism: a matter of perspective? Pediatrics. 2006 Oct; 118 (4): 1371-1379.
2. Issenberg SB, Chung HS, Devine LA. Patient safety training simulations based on competency criteria of the Accreditation Council for Graduate Medical Education. Mt Sinai J Med. 2011; 78: 842-853.
3. Greenberg LW, Ochsenschlager D, O’Donnell R, Mastruserio J, Cohen GJ. Communicating bad news: a pediatric department’s evaluation of a simulated intervention. Pediatrics. 1999 Jun; 103 (6): 1210-1217.
4. Accreditation Council for Graduate Medical Education. The Pediatric Milestone Project. Available at: http://www.acgme.org/acWebsite/RRC_320/320_PedsMilestonesProject.pdf. Accessed July 23, 2012.
1155 Sepsis and Technology: The Link to Improve Outcomes
Karrin Dunbar, BSN1
1CENTER FOR PROFESSIONAL PRACTICE OF NURSING, UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER, SACRAMENTO, CA, USA
Introduction/Background: Over 550 people died in in our institution from 2009 to 2011 from sepsis. Sepsis is the tenth most common cause of death and is the leading cause of death for critically ill patients in the U.Sat a cost of 16.7 billion annually1. Our strategic goal was to reduce sepsis mortality by 15% thru early identification and timely goal directed therapy. To affect this change we utilized our robust EMR system and engaged the nursing staff to initiate the initial sepsis screening process. The six-month evaluation of this process change exposed poor compliance and comprehension with resistance of nurses to act on the best practice alert. Face-to-face surveys revealed nurses felt the initial mandatory eLearning focused more on the click of the computer, and less on the nurse’s role with screening and intervention. Findings stimulated the creation of a scenario based, interactive, foundational curriculum to invest nurses of their role in sepsis survivability.
Description: The traditional format of lecture presentation needed transformation. For a practice change to occur nurses needed to be educated in situations in which they worked. This presented a challenge for a 580-bed hospital with 1800 nurses. An interactive, collaborative format was developed. Lectures describing fundamental concepts provided the opportunity improve the nurse’s knowledge of sepsis phases, expand EMR skills and modify attitudes. For nurses to be able to practice as they practice, vignettes of nurses caring for patients at all stages of sepsis were developed.This format created the opportunity for nurses to observe and document their assessments utilizing the EMR as they would at the patient’s bedside. Following each scenario, debriefing sessions focused on decision-making processes and role expectations. These dialogues provide the opportunity to build upon previously learned knowledge. Thru simulation, nurses are able to link accurate identification and consistent actions to positive patient outcomes thus generating an empowering realization of the nurse’s role in decreasing sepsis mortality.
Conclusion: Classes are not static, created once and repeated monthly. Incorporated into every class are up-to-date compliance measures and sepsis mortality statistics. Scenarios are modified, based on current compliance rates to ensure nurses understand how they are affecting patient care and where improvement is needed. Since the initiation of this program, our sepsis mortality rate has decreased by 12.4%. Nurse compliance and understanding of their role in screening at risk patients has increased by 28%. No longer are nurses questioning whether to act, they are acting, based on their knowledge of their role in the screening process. The role of the nurse is changing, and technology is a vital component of nursing practice. Innovative education focused on the use of technology to advance the practice of nursing, which is clearly essential. We have demonstrated when nurses use technology to enhance bedside care, positive patient outcomes are the result.
1. Surviving Sepsis Campaign: www.survivingsepsis.org.
1156 Thoracic Ultrasound Training Using Simulation: The Hull Experience
Sega Pathmanathan, BM, MRCP, MRCP(Respiratory),1 Jack Kastelik, BSc, MBChB, MD, FRCP2
1CLINICAL SKILLS FACILITY, HULL INSTITUTE OF LEARNING AND SIMULATION (HILS), HULL, GBR and 2RESPIRATORY MEDICINE AND SIMULATION, HULL ROYAL INFIRMARY, HULL, GBR
Introduction/Background: Thoracic ultrasound (USS) has become an invaluable skill amongst respiratory specialists. The current curriculum requirement for respiratory trainees is to achieve level 1 competency in thoracic USS. This involves acquiring specific knowledge and skills as well as performing a defined number of procedures on patients with normal and pathological findings under the supervision of an experienced, usually level 2 or above, USS certified practitioner. The need for USS training was heightened in 2008 by a National Patient Safety Agency (NPSA) report highlighted concerns with the complications of chest drain insertion.1 This subsequently led to the British Thoracic Society revising their guidelines on chest drain insertion to include USS. In Hull we have designed a thoracic USS course with the aim for trainees to acquire basic USS skills. It was also set up with a view to not only training respiratory trainees but other those of other specialities as well.
Description: The objective of this research was to review our experience in simulation training in thoracic USS and acquisition of knowledge regarding USS physics, USS machine function, image acquisition, anatomy and hands-on skills in operating thoracic USS on a simulated mannequin. The methods used included the following factors. Thoracic USS courses incorporated lectures on USS physics, USS machine function, image acquisition and anatomy. This was followed by a practical session that included simulation training on the Blue Phantom thoracic ultrasound training models as well as practice on patients with pleural disorders. The Blue Phantom models allowed participants to train in anatomy, pleural fluid identification and simulation of pleural procedures such as thoracocentesis and chest drain insertion. The Blue phantom model provides a realistic image of the thoracic cavity with pleural fluid. It has a self healing membrane to allow multiple attempts at aspiration without leaving a mark. Participants completed an assessment questionnaire. Their satisfaction was recorded with on a Likert scale with a range of (1 to 5). Overall 19 candidates were evaluated. There were 7 respiratory speciality trainees, 2 intensive care trainees and 10 consultants (5 Intensive care, 4 respiratory and 1 Thoracic Surgeon). Three of the trainees had previous experience in USS training. All but 2 of the delegates completed a feedback form. In the feedback, all 17 (100%) of delegates reported high training value of the theoretical aspects of the course with 8(47%) scoring 5. In addition all 17 delegates reported high benefits from thoracic USS skill acquisition during the practical and simulation sessions with 11(65%) scoring a 5. The overall self reported improvement in theoretical skills was at 89%. With regards to the practical skills, 79% of delegates showed improvement in their confidence of operating the USS machine and acquiring an image, while 68% of delegates felt confident in their technical skills on performing thoracic USS.
Conclusion: Our experience suggests that thoracic USS courses as part of regional respiratory specialist training can be delivered within the curriculum delivery budget. The courses provided a large proportion of theoretical and practical skills required from respiratory trainees. We have demonstrated improvements in both the theoretical knowledge and the practical skills in using the USS in a manner that all delegates felt was of a high training value. The Blue phantom model was well received and the general consensus was it provided a realistic replica of the pleural cavity. We aim to run further courses for respiratory trainees as well as other specialities like thoracic surgery, emergency medicine and intensive care. We would therefore suggest that similar format is adopted through other regions to enhance thoracic USS training.
1. Chest drains: risks associated with the insertion of chest drains, NPSA. Reference NPSA/2008/RRR003.
2. Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010, Tom Havelock, Richard Teoh, Diane Laws, Fergus Gleeson, on behalf of the BTS Pleural Disease Guideline Group, Thorax 2010;65 (Suppl 2) :ii61eii76.
1169 Training Simulation Faculty - How Are We Doing? A Telephone Survey
Sarah Didier, MBBS, MRCPCH,4 Claire Clarke,3 Helen Moore, MBChB, MRCPCH,2 Makani Purva1
1MEDICAL EDUCATION, ANAESTHETICS, HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST, HULL, GBR and 2PAEDIATRICS AND SIMULATION, HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST, HULL, GBR and 3CLINICAL SKILLS, HULL INSTITUTE OF LEARNING AND SIMULATION (HILS), HULL, GBR and 4PAEDIATRICS, HULL ROYAL INFIRMARY, HULL, GBR
Introduction/Background: Across the United Kingdom, there has been a massive expansion in simulation training and it has now become a recognised part of junior doctor training with hospitals expected to deliver this training to both junior medical and nursing staff. It is therefore critical that simulation trained faculty are well trained and able to deliver this essential teaching technology. As the newest simulation centre to open in the north Yorkshire region in 2011 in the United Kingdom, the Hull Clinical Skills and Simulation centre was built in a busy tertiary care hospital catering to the needs for over 180,000 people. We developed and delivered a simulation course to train simulation faculty. The aim was to train senior level staff, (consultants, senior residents and senior nursing staff) to set up multidisciplinary simulation training sessions of their own. Attendees were trained in the fundamentals of simulation based learning, effective debriefing skills, simulator programming, scenario development and design. As part of the interactive day course, participants concluded the training day by developing and producing their own scenario which is formally debriefed by participating team members. They were then given feedback on their performance from trained faculty. Our objective was to ensure an adequate cohort of trained faculty exist; and in so doing, we expect to advance the delivery of simulation based education in our region. As part of our on-going curricula development and assessment in simulation delivery, teaching and training, we conducted a telephone survey to evaluate the commitment to simulation and on-going interest in simulation.
Description: We conducted a telephone survey targeting participants who had attended the first 3 of our 5 courses, Train the Trainer in Simulation, between September 2011 and April 2012. A total of 20 respondents were interviewed over the telephone. Please refer to Table 1 which illustrates the background of respondents.
Since completing the training, 80% of respondents admitted to using the skills and simulation techniques learnt during their training. Forty-five percent of respondents had continued to be involved in simulation based projects in their own hospital, while 60% of respondents had gone on to run simulation courses in their own hospital. Forty percent of respondents had been involved in creating educational material for simulation; and of these, more than one third had been involved with debriefing and scenario scripting. Ninety-five percent were willing to teach on future simulation courses.
Conclusion: We aimed to determine whether skills attained by our delegates through our course training was being sustained through active participation in simulation based courses at their hospitals and whether our course results in participants remaining an active part of this critical technological learning technique. Immediate post course feedback is extremely useful for any course development; however, by questioning our participants again some months after they attended our course, we were able to gather further information. It is encouraging to note that the majority of participants have incorporated simulation into their training programmes. Our results show us more than 50% of participants continue to be trainers in simulation in a multidisciplinary fashion, satisfying our objective of promoting simulation based training in our region. Our results also show that we can target previous delegates to continue to deliver training as part of our own programme in our hospital. Most of the participants who had been involved in creating educational materials were involved in scenario scripting and debriefing. We have therefore extended our course to two days with more time devoted to teaching debriefing.
1170 Troubleshooting the Deterioration of a Ventilated Neonate: A Simulated Approach
Atul Malhotra, MD, FRACP,1 Alice Stewart, BSc, MBBS, GCHlthSc, FRACP,2 Stuart Marshall, MBBS, FANZCA3
1MELBOURNE, AUS and 2NEONATOLOGY, MONASH UNIVERSITY, MELBOURNE, VIC, AUS and 3SIMULATION CENTRE, SOUTHERN HEALTH, MELBOURNE, VIC, AUS
Introduction/Background: Sudden deterioration of a ventilated infant is a common and potentially life-threatening event in any neonatal intensive care unit. Neonatal resuscitation programs have been in widespread use across the world, teaching appropriate, standardized resuscitation algorithms to medical and nursing staff. Although potentially useful in any situation, these algorithms are primarily focused on resuscitation at birth. While individual neonatal intensive care units may have locally developed protocols for managing the sudden deterioration of a ventilated neonate, these have not received general acceptance, with only limited reporting in the literature.1 The aim of this current study was to evaluate the feasibility and efficacy of two algorithms for managing acute deterioration in the ventilated neonate using a high fidelity simulated environment.
Description: Two clinical algorithms were designed to provide medical and nursing staff with a systematic approach to trouble-shooting and managing acute deterioration in a mechanically ventilated neonate. They were developed by consensus of a group of neonatologists and senior neonatal nurses. One algorithm was developed for use in the delivery room/operating theatre environment, and the other for use in the neonatal intensive care unit setting. Each algorithm addressed the equipment, endotracheal tube, and patient-related issues that could lead to the sudden deterioration of a mechanically ventilated neonate. The two algorithms are shown below. The algorithms were disseminated to medical and nursing staff electronically followed by interactive tutorials and discussion. An in-situ simulation program was conducted to evaluate the algorithms. Multi-disciplinary sessions were delivered using the high-capability SimNewB® (Laerdal, Norway) infant simulator. On the day of each simulation session, an introductory briefing was followed by simulated scenarios which had been designed specifically for practice of the algorithms and which were set in either the neonatal intensive care unit or delivery suite environment. Debriefing was conducted after each scenario. At the end of the session, participants were invited to complete an evaluation form. Participant responses were used to evaluate the feasibility and efficacy of the algorithms. Neonatal medical and nursing staff (n=67) were exposed to between 3 to 6 scenarios based on deterioration of a ventilated infant in a simulated environment. Staff satisfaction with the use of the algorithms in these situations was very high. Participants felt more comfortable with dealing with the situation of a deteriorating ventilated infant and felt that the algorithms were systematic and practical in a stressful environment.
Conclusion: The algorithms designed to address issues related to the sudden deterioration of a ventilated neonate in the delivery room or ward setting were practical and feasible. They allowed for systematic assessment of equipment, endotracheal tube and patient related issues. Future studies could address whether the algorithms are effective when used as a cognitive aid.
1. Brion LP. Sudden deterioration of the newborn infant: II. Diagnosis-based approach in the intensive care unit. Journal of Perinatology 1999; 19(4):294-304.
1173 Evaluation of In-situ Simulation to Pilot a Systematic Approach to Acute Deterioration of the Ventilated Neonate
Atul Malhotra, MD, FRACP,1 Alice Stewart, BSc, MBBS, GCHlthSc, FRACP,2 Stuart Marshall, MBBS, FANZCA3
1MELBOURNE, AUS and 2NEONATOLOGY, MONASH UNIVERSITY, MELBOURNE, VIC, AUS and 3SIMULATION CENTRE, SOUTHERN HEALTH, MELBOURNE, VIC, AUS
Introduction/Background: The approach to resuscitation of the neonate at birth has been largely standardised through neonatal resuscitation programs, which are informed by international resuscitation guidelines and are algorithm-based. However, similar standardised approaches do not currently exist for management of sudden cardiorespiratory deterioration of a ventilated neonate.1 In response to this common management issue, we aimed to develop and pilot analgorithm-based approach to sudden deterioration in a ventilated neonate through in situ simulation in a single neonatal intensive care unit.
Description: A group of neonatologists and neonatal nurses developed two clinical algorithms (see abstract, Troubleshooting the deterioration of a ventilated neonate: A Simulated Approach, Malhotra et al) for managing acute deterioration in a mechanically ventilated neonate: one for the delivery suite setting, and another for the intensive care ward environment. The algorithms were designed for multidisciplinary use, and systematically addressed equipment, endotracheal tube and patient-related causes of deterioration. In particular, they emphasized the standardised assessment of adequacy of pressure delivery and interpretation of flow wave pattern generated by the ventilator. 2 The algorithms were electronically disseminated to medical and nursing staff, followed by in-service education sessions. An in-situ simulation program was chosen as a means to pilot the algorithms. The program was conducted daily over five days. An introductory briefing was followed by multidisciplinary simulated scenarios designed specifically for practice of the algorithms, and delivered using the high-capability SimNewB® (Laerdal, Norway) manikin. Debriefing was conducted after each scenario. At completion of the program, participants were invited to complete an evaluation form, consisting of a Likert scale and free text questionnaire. A total of 56 neonatal medical (n=16) and nursing (n=40) staff participated in the simulation program. The post-program evaluation response rate was 89% (50/56). On Likert scale ratings there was 96% agreement that the program was a valuable learning experience, and 98% agreement that in situ simulation was useful (Figure 1). Participants’ free text responses indicated a high level of engagement with the algorithms. Participants responded positively to having a structured approach to the sudden deterioration of a ventilated neonate, and many identified application of the algorithms to their practice as a clinical learning point. While the ability to undertake simulation in the clinical environment was highly regarded, some participants reported distraction by the clinical activities of the unit. Many of the free text responses related to enhanced awareness of crisis resource management skills, including leadership and followership, situational awareness, and calling for help early.
Conclusion: A systematic approach to the sudden deterioration of the ventilated neonate was addressed in a single neonatal intensive care unit through the development of algorithms. The algorithms were piloted in the safety of the simulated environment, and were well received by neonatal staff. It is planned to now further refine the algorithms ready for introduction into clinical practice. The success of the in-situ simulation pilot program has led to the development of an ongoing simulation program within the unit.
1. Brion LP. Sudden deterioration of the newborn infant: II. Diagnosis-based approach in the intensive care unit. Journal of Perinatology 1999; 19(4):294-304.
2. Schmolzer GM, Hooper SB, Crossley KJ, Allison BJ, Morley CJ, Davis PG. Assessment of gas flow waves for endotracheal tube placement in an ovine model of neonatal resuscitation. Resuscitation 2010; 81:737-41.
1174 A Low-Tech, Locally Sourced Laparoscopic Surgical Training Program for Sub-Saharan Africa
Pamela Andreatta, PhD,2 David Marzano, MD1
1OBSETRICS AND GYNECOLOGY, UNIVERSITY OF MICHIGAN, ANN ARBOR, MI, USA and 2OBSTETRICS AND GYNECOLOGY, UNIVERSITY OF MICHIGAN, ANN ARBOR, MI, USA
Introduction/Background: Compared with open surgical methods, patients who have procedures performed using laparoscopic methods experience lower post-operative pain, reduced morbidity, and shorter healing times.1-3 Laparoscopy has tremendous implications for the health outcomes and economies of low-resourced countries, stemming from decreased blood loss, lower infection risks, reduced need for analgesia, shorter hospital stays, and a faster return to work.4-5 As a result, initiatives for expanding the uses of laparoscopic surgery in resource-limited regions could have significant benefits.6-7 Simulation-based training programs are frequently used to facilitate the acquisition of laparoscopic skills, with ample evidence to support their effectiveness.8-12 However, these programs require substantial financial investment to establish and sustain, something few institutions can afford in resource-limited environments. The purpose of this pilot study was to evaluate the feasibility and baseline impact of a low-cost, low technology, locally sourced simulation-based training program for laparoscopic surgical training in a resource-limited environment.
Description: A comprehensive instructional program was developed by one of the authors (PA) to include training exercises, performance criteria, objective feedback, and proficiency targets for learning novice-level laparoscopic surgical skills. The program included hands-on familiarization with seven exercises, each designed with variable challenges from easiest to most difficult: 1) Instrument Control A, 2) Instrument Control B, 3) Cutting, 4) Laparoscopic Camera Navigation, 5) Translocation, 6) Dissection, and 7) Instrument Control C. We selected cost-sensitive materials and supplies available at local markets to encourage sustainability, and used them with donated laparoscopic equipment and instruments. We built box-trainers using wood, foam, heavy fabric, glue and hardware hinges to support the training models. Total per person cost for a box trainer and supplies to complete all of the training exercises was less than 30USD. Twenty residents and physicians from surgical specialties affiliated with a regional medical center in Ghana completed the program and evaluated its value for learning in each of seven training exercises. We used descriptive methods to evaluate the extent to which we were able to facilitate the program activities, the participants’ perceptions about the value of the training, the number of participants who were able to complete the program in its entirety, and acceptability of the program to participants for learning laparoscopic skills. We calculated means and standard deviations to analyze the variables of interest. We were able to facilitate all program activities using locally sourced materials. A total of 18 subjects (90%) completed the training in its entirety. Two were unable to complete the last exercises because of clinical duties. Mean ratings for each training exercise ranged from 3.27 +/- 1.49 (average) to 4.85 +/- .38 (very good). The most challenging exercises received the highest ratings.
Conclusion: The results of previous laparoscopic training programs in sub-Saharan Africa indicated challenges with sustainability and mixed levels of acceptance within local surgical communities.5, 13 Our pilot data suggest that a low-technology, low cost laparoscopic training program designed for sustainability using locally sourced materials is feasible to implement, and evaluated as beneficial by surgeons who will perform and teach these procedural techniques. Many institutions in limited-resource regions receive donations of laparoscopic equipment and supplies that remain unused due to the lack of accessible training.14 Increasing the availability of laparoscopic surgical training increases regionally-based opportunities for surgeons to acquire the requisite skills to perform minimally invasive procedures with greater efficacy and frequency. Reducing the number of open procedures has the potential to decrease the concomitant rates of morbidity and mortality that adversely burden families, communities and economies of low-resource regions.
1. Nguyen KT, Marsh JW, Tsung A, Steel JJ, Gamblin TC, Geller DA. Comparative benefits of laparoscopic vs open hepatic resection: a critical appraisal. Arch Surg. 2011 Mar;146(3):348-56. Epub 2010 Nov 15. Review. PMID: 21079109.
2. Wauschkuhn CA, Schwarz J, Boekeler U, Bittner R. Laparoscopic inguinal hernia repair: gold standard in bilateral hernia repair? Results of more than 2800 patients in comparison to literature. Surg Endosc. 2010 Dec;24(12):3026-30. Epub 2010 May 8. Review. PMID: 20454807.
3. Cirocchi R, Abraha I, Farinella E, Montedori A, Sciannameo F. Laparoscopic versus open surgery in small bowel obstruction. Cochrane Database Syst Rev. 2010 Feb 17;(2):CD007511. Review. PMID: 20166096.
4. Bendinelli C, Leal T, Moncade F, Dieng M, Toure CT, Miccoli P. Endoscopic surgery in Senegal. Benefits, costs and limits. Surg Endosc. 2002 Oct;16(10):1488-92. Epub 2002 May 7. PMID: 11988789.
5. Raiga J, Kasia JM, Bruhat MA. Laparoscopic surgery in the Cameroon. Int J Gynaecol Obstet. 1999 Apr;65(1):65-6. PMID: 10390103.
6. Udwadia TE, Udwadia RT, Menon K, Kaul P, Kukreja L, Jain R, Prasad S. Laparoscopic surgery in the developing world. An overview of the Indian scene. Int Surg. 1995 Oct-Dec;80(4):371-5.
7. Stevens PS, De Villiers M, Van Niekerk ML. A survey on the current status of laparoscopic training in paediatric surgery in South Africa. S Afr J Surg. 2011 Mar 14;49(1):36-8.
8. Crochet P, Aggarwal R, Dubb SS, Ziprin P, Rajaretnam N, Grantcharov T, Ericsson KA, Darzi A. Deliberate practice on a virtual reality laparoscopic simulator enhances the quality of surgical technical skills. Ann Surg. 2011 Jun;253(6):1216-22. PMID: 21516035.
9. Brar SS, Wright F, Okrainec A, Smith AJ. A structured strategy to combine education for advanced MIS training in surgical oncology training programs. Surg Oncol. 2011 Sep;20(3):129-33. Epub 2011 Apr 5.
10. Tavakol M, Mohagheghi MA, Dennick R. Assessing the skills of surgical residents using simulation. J Surg Educ. 2008 Mar-Apr;65(2):77-83.
11. Zendejas B, Cook DA, Bingener J, Huebner M, Dunn WF, Sarr MG, Farley DR. Simulation-based mastery learning improves patient outcomes in laparoscopic inguinal hernia repair: A randomized controlled trial. Ann Surg. 2011 Sep; 254(3):502-511.
12. Andreatta PB, Woodrum DT, Birkmeyer JD, et al. Laparoscopic skills are improved with LapMentor training; results of a randomized, double-blinded study. Ann Surg. 2006; 243: 854-863.
13. Okrainec A, Smith L, Azzie G. Surgical simulation in Africa: the feasibility and impact of a 3-day fundamentals of laparoscopic surgery course. Surg Endosc. 2009 Nov;23(11):2493-8. Epub 2009 Apr 3. PMID: 19343438.
14. Perry L, Malkin R. Effectiveness of medical equipment donations to improve health systems: how much medical equipment is broken in the developing world? Med Biol Eng Comput. 2011 Jul;49(7):719-22. Epub 2011 May 20. PMID: 21597999.
1175 Simulation in Paediatric Medicine: Development of the First Regional Paediatric Simulation Programme in Yorkshire, United Kingdom
Sarah Didier, MBBS, MRCPCH,3 Ranganath Ranganna, MBBS, MRCPCH(UK),3 Helen Moore, MBChB, MRCPCH,2 Makani Purva1
1MEDICAL EDUCATION, ANAESTHETICS, HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST, HULL, GBR and 2PAEDIATRICS AND SIMULATION, HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST, HULL, GBR and 3PAEDIATRICS, HULL ROYAL INFIRMARY, HULL, GBR
Introduction/Background: Junior doctor training in the United Kingdom (UK) has undergone significant recent changes. The restricted working hours following adaptation of the Working Time Directive and the major restructuring of training into run-through training may have combined to result in junior doctors having decreased opportunity to perform certain procedures and a limited exposure to less common medical conditions. There has also been a significant increase in the integration and commitment to simulation based learning programmes in the last 10 years.1 In 2011, the Yorkshire deanery appointed two senior paediatric trainees to clinical education and simulation. One of the main objectives of the appointment was to develop a fully immersive simulation training programme in paediatric simulation.
Description: A training needs analysis was performed on all paediatric trainees in the Yorkshire deanery during the first stage of the project. Perceived confidence in management of common paediatric and neonatal based scenarios, current exposure to simulation and feedback trainees received on their performance in the workplace were assessed. The pilot programme was structured on the results of the analysis. The standardised template of the programme included a communication scenario with topics such as bad news delivery and dealing with drug errors, testing knowledge of relatively rare paediatric events, a neonatal scenario, an acute intervention and a critical care scenario. The scenarios were all carefully mapped to the educational curricula for training paediatric doctors. All scenarios were run in a simulated paediatric ward and NICU or obstetric theatre and used high-fidelity paediatric, newborn and preterm patient simulators. Faculty included two senior grade simulation fellows in paediatrics providing debriefing, a paediatric nurse and midwife or advanced neonatal nurse practitioner for the fully immersive effect. In total 5 pilots of the programme were delivered to paediatric trainees across Yorkshire. The scenarios were aimed at Speciality Training year 3 (ST3) trainees who had at least 3 years experience, and who were about to commence more independent practice as registrars. Pre and post course feedback was analysed. Trainees were asked to rate their confidence in scenarios, rate the debriefing sessions and the venue. Performance in the scenarios was rated from not confident (1) to very confident (5). Refer to Table 1 for pre and post course feedback, mean, standard deviation and P values.
Conclusion: The feedback from the pilot programmes was overwhelmingly positive and had achieved all the objectives that it had set out to deliver. Especially encouraging was the significant improvement in confidence levels of our trainees’ abilities to provide a good handover and deliver bad news to patients. Delivery of a good handover2 in the current climate of frequent shifts where there may be up to 4 handovers in one 12 hour period is critical. Furthermore, good communication is an essential skill for doctors. Among the positive comments in free text feedback was the enjoyment of the realism of the scenarios and the preparation the scenarios gave to performing at a more senior level. Following the success of the pilots, the Yorkshire regional educational governing body has given the programme mandatory status and from September 2012, the programme will be assimilated into the training programme for ST3 trainees in Paediatrics in Yorkshire.
1. A Framework for Technology Enhanced Learning. DOH, Nov 2011 http://www.dh.gov.uk/publications.
2. Communication and Miscommunication: Handover between Junior Doctors. Hayes AJ, Pool R, Roughley C, Scholes S, Sharifi L, Woodside R, Reilly S, Roberts P, Salter T, Singleton LReinvention: A journal of research. 2012 Apr 5(1).
1190 Towards the Development of a Scientifically-Based Clinical Simulation Template
Lauren Benishek,1 Elizabeth Lazzara, MA,2 Eduardo Salas, PhD1
1INSTITUTE FOR SIMULATION AND TRAINING, UNIVERSITY OF CENTRAL FLORIDA, COLLEGE OF MEDICINE, ORLANDO, FL, USA and 2PSYCHOLOGY, UNIVERSITY OF CENTRAL FLORIDA, COLLEGE OF MEDICINE, ORLANDO, FL, USA
Introduction/Background: Anyone who has developed or used simulation-based training (SBT) within a clinical context realizes the utility of simulation templates. Simulation templates are models for structuring simulation scenario content. They have two important purposes. First, when designed appropriately, simulation templates can facilitate development of SBT scenarios. When referencing a well-organized simulation template, instructional designers may effectively create scenarios more quickly than when working unsystematically and without guidance. Second, templates provide a standardized mold for creating scenario records, enabling replication of the scenario at separate points in time and by different users. A number of clinical simulation templates already exist. Although some are more easily available than others, a comparison of templates accessible online reveals that content and organization vary across clinical simulation templates. This raises the question of what information a functional template for developing clinical simulation scenarios should include and what format best represents this requisite information. The answer would have widespread implications for how templates are used in clinical simulation scenario development. Good clinical simulation templates are complete, easy to understand, capable of facilitating scenario development to meet instructional objectives, and document the scenario. At their core is a meaningful organizational strategy for presenting scenario information. Currently lacking in most available clinical simulation templates, however, is a clear connection to the science supporting SBT. This may be a critical disadvantage in the process of designing instructionally sound clinical simulation scenarios. Therefore, we advance a new simulation template, the Template of Events for Applied and Critical Healthcare Simulation (TEACH Sim; see Attachment), founded on scientific principles of SBT scenario development.
Description: Simulation templates are tools with the potential to translate scientific knowledge to a practical context. Accomplishing this translation requires ensuring that a template itself originates in science, which can be as simple as creating a template to align with a scientifically accepted methodology. This is the premise upon which the TEACH Sim was developed. Effective and instructionally sound training is created by systematically linking training content (i.e., clinical competencies) to instructional objectives.1-3 The Simulation Module for Assessment of Resident Targeted Event Responses (SMARTER)4 is an event-based approach to training (EBAT)5-7 and measurement specifically designed for clinical contexts. SMARTER capitalizes on the unique advantages of SBT for clinical training through developing and maintaining links between instructional objectives, competencies, scenario events, and performance measures. Because of its scientific foundation and application to clinical SBT scenario design, the SMARTER methodology was adopted as the framework underlying the structure and organization of TEACH Sim. TEACH Sim supplies four major contributions beyond other existing templates. First, the structure of TEACH Sim has been carefully designed to reflect the current state of the science in regards to scenario and measurement development. Second, it emphasizes the linkages between instructional objectives, competencies, and event-response pairs, which the SMARTER methodology establishes as critical elements of scenario development.4 Third, it actively guides scenario and measurement development through the provision of tables designed to explicitly link event-response pairs with instructional objectives and competencies (see Section E of the Attachment). Fourth, TEACH Sim’s content is customizable to match the individualized needs and preferences of the user. Although the structure of the template is scientifically grounded, the content supported by this structure is flexible.
Conclusion: TEACH Sim is the next iteration in clinical simulation template technology. Current existing simulation templates lack clear foundations to clinical SBT science. Consequently, TEACH Sim is forwarded as a template that is connected to the science of training3 and founded on a widely accepted methodology for developing and archiving clinical SBT scenarios.4 The content of TEACH Sim is customizable and adaptable to specific needs of the user as well as future scientific trends.
1. Goldstein IL, and Ford JK: Training in organizations: Needs assessment, development, and evaluation, 4th edition. Belmont, Wadsworth/Thomson Learning, 2002, pp. 22-3.
2. Rosen M, Salas E, Wu TS, Silvestri S, Lazzara EH, Lyons R, Weaver SJ, and King HB: Promoting teamwork: An event-based approach to simulation-based teamwork training for emergency medicine residents. Acad Emerg Med 2008; 15: 1190-8.
3. Salas E, Tannenbaum SI, Kraiger K, and Smith-Jentsch K: The science of training and development in organizations: What matters in practice. Psychol Sci Public Interest 2012; 13: 74-101.
4. Rosen M, Salas E, Silvestri S, Wu TS, and Lazzara EH: A measurement tool for simulation-based training in emergency medicine: The simulation module for assessment of resident targeted event responses (SMARTER) approach. Simul Healthc 2008; 3: 170-9.
5. Fowlkes JE, Dwyer DJ, Oser RL, and Salas E: Event-based approach to training (EBAT). Int J Aviat Psychol 1998; 8: 209 –21.
6. Fowlkes JE, and Burke CS: Event-based approach to training (EBAT). Edited by Stanton N, Hedge A, Brookhuis K, Salas E, and Hendrick H. Boca Raton, CRC Press, 2005, pp 458-64.
7. Fowlkes JE, and Burke CS: Targeted acceptable responses to generated events or tasks (TARGETS). Edited by Stanton N, Hedge A, Brookhuis K, Salas E, and Hendrick H. Boca Raton, CRC Press, 2005, pp 502-8.
1191 Pediatric Emergencies: A Crisis Resource Management Curriculum Using High Fidelity Simulation for Medical Students
Ilana Harwayne-Gidansky, MD,1 Alexandra Leader, MD,3 Sheemon Zackai, MD,3 Christopher Strother, MD2
1PEDIATRICS, COLUMBIA UNIVERSITY MEDICAL CENTER, NEW YORK-PRESBYTERIAN HOSPITAL, NEW YORK, NY, USA and 2EMERGENCY MEDICINE, MOUNT SINAI SCHOOL OF MEDICINE, NEW YORK, NY, USA and 3PEDIATRICS, MOUNT SINAI SCHOOL OF MEDICINE, NEW YORK, NY, USA
Introduction/Background: Pediatric simulated crisis resource management (CRM) is an under-studied and important area of training. However, there are little to no published curriculum in CRM for pediatrics and no studies to date examine the effect of a crisis resource management curriculum utilizing high-fidelity simulators on medical student attitudes towards pediatric crises. Our objectives include the following: 1). to design a CRM curriculum for third year medical students, 2). to expose medical students to pediatric resuscitation using high-fidelity simulator, 3). to use simulator to practice both manual skills (effective bag valve mask ventilation), communication skills, and crisis resource management (CRM), and 4). to assess attitudes about pediatric resuscitation and specifically CRM both before and after session.
Description: This was a collaborative design between Pediatric ICU and Pediatric EM leadership to create a novel curriculum to train third-year medical students in basic resuscitation and CRM, including the following: 1). standardize lecture on CRM and roles in resuscitation, 2) simulated pediatric arrest scenario, performed twice with two different groups, 3) manual skills lab (effective BVM), 4) feedback by non-participating group, and 5) pre- and post-tests assessing attitudes about CRM and pediatric resuscitation.
Conclusion: There were 138 students who participated in this simulation-based curriculum during their pediatric clerkship. We analyzed data points using Excel, and GraphPad statistical calculators. Independent Z-tests (as unpooled proportions), all significant at 95% level, Student’s T-test showed statistical significance in all 4 questions asked. Subjective improvement was noted in 3 out of 4 of the following questions that were asked: 1). “I feel comfortable in a pediatric resuscitation” (p<0.001, 35% change in those who agree); 2). “I know how to communicate well in a pediatric resuscitation” (p<0.001, 41% change in those who agree); 3). “I know what my role is in a pediatric resuscitation” (p<0.001, 62% change in those who agree). Objective improvement was noted in airway, circulation, and behavioral microskills. There was also a statistically significant improvement in overall skills (Refer to Table 2). Demographics had no confounding effect on results. The use of a self-assessment tool is a limited and subjective measure of success. Our subjective and objective outcomes were measured immediately post-intervention; we do not yet have data on long-term subjective and objective measures. We plan to incorporate a longitudinal post-test during the coming year to be administered to this class of students. This curriculum was well-received by students and pediatric clerkship leadership. This is the first published curriculum of which we are aware that addresses pediatric CRM for medical students. Both subjective and objective improvement was noted after this workship. CRM curriculum teaching third-year medical students improves both confidence level and clinical skills needed in a pediatric arrest.
1192 Listening to Your Patient: Honing Student Physical Exam Skills Through Human Patient Simulation
Charles Murphy, MD,1 Christopher Strother, MD,1 Joanne Hojsak, MD2
1EMERGENCY MEDICINE, MOUNT SINAI SCHOOL OF MEDICINE, NEW YORK, NY, USA and 2PEDIATRICS, MOUNT SINAI SCHOOL OF MEDICINE, NEW YORK, NY, USA
Introduction/Background: At our School of Medicine, the process of clinical performance and development of the doctor-patient relationship begins in the 2-year clinical skills course, Art and Science of Medicine (ASM). Students often struggle to understand the relationship between information obtained from the medical history and physical exam (PE) and how this leads to the differential diagnosis. Human simulation is used extensively in medical education to facilitate clinical skills training, but has not been described in early medical school education. In 2011 simulation was integrated into the physical exam sessions in ASM1. The goal was to provide students with a better understanding of relationships between performance of PE techniques and the meaning of their associated findings. Additional goals included assisting in recognizing pathologic findings and enhancing interviewing skills.
Description: The Class of 2014 participated in a 90-minute clinical simulator session focusing on two cases: pneumonia/asthma and congestive heart failure. Students, working in teams, interviewed the simulator patient. The history was transcribed in a medical write-up format as it unfolded. Each student performed a focused PE based on the chief complaint, experiencing abnormal PE findings as opposed to practicing on healthy volunteers or standardized patient actors. CXR and EKG were displayed for clinical correlation. Students completed pre/post-session surveys of their confidence in their skills. We also compared the Class of 2014’s performance in the end-of-course standardized patient (SP) scenario to the performance of the prior Class of 2013 who did not receive the intervention. Correct PE element scores in the cardiac and pulmonary exams were obtained and compared between classes. These scores were compared with abdominal examination scores, which were not addressed in the simulation.
Conclusion: The surveys were obtained from 140 students. They reported that simulator sessions helped them: identify systolic/diastolic murmurs (94%), understand components of cardiac/pulmonary review of systems (88%), measure BP (61%) and pulse (57%). They rated their comfort level as improved for: listening to breath sounds (91%), identifying rales (89%), cardiac murmurs (89%), wheezing (88%), and distinguishing systolic from diastolic murmurs (78%). Students rated class size (94%) and session duration (85%) optimal for learning. Comparing Class of 2014 (n=133) and 2013 (n=128) in SP encounters revealed a greater number of correct PE elements on the cardiac exam (1,165 correct elements for 2014 vs. 1,096 for 2013, p=0.005) and pulmonary exam (767 for 2014 vs. 699 for 2013, p<0.001), while the correct abdominal exam score remained similar (758 vs. 727, p= 0.771). Simulator training in ASM1 improves students’ comfort levels in key aspects of the cardiac and pulmonary exams. It also exposes them to abnormal heart/lung sounds. These skills improvements are provided in a manner perceived optimal for student learning. Improvement in exam maneuvers secondary to the intervention is suggested by the improved post-course performance in the intervention class. A prospective study aimed at further assessing the clinical impact of the intervention is planned in 2012. An OSCE evaluation will be conducted at semester midpoint to assess performance improvement of PE techniques and to strengthen current data.
1201 A New Approach to Asthma Inhaler Education Using Simulation Technology
Gunjan Gupta,2 Rakesh Gupta, MD1
1PULMONARY, CRITICAL CARE, SLEEP MEDICINE, ROGER WILLIAMS MEDICAL CENTER, PROVIDENCE, RI, USA and 2TRINITY COLLEGE, HARTFORD, CT, USA
Introduction/Background: Approximately one in twelve people have asthma, one in two people with asthma had an asthma exacerbation in 2008, and cost the United States about $56 billion in medical costs, lost school/work days and early deaths in 2007.1 National asthma guidelines to improve asthma outcomes rely heavily on the use of inhaled medications, metered dose inhalers (MDI) being the most common device. However, as many as 86% of patients use MDI incorrectly2 and inhaler technique can deteriorate over time.3 Of the $25 billion/year spent on inhalers, $5-7 billion are squandered on incorrect use of inhalers.4 Incorrect technique results in more drug deposition in the mouth than delivered to lungs. Common problems include hand – breath coordination, failure to fully inhale or exhale, not tilting the head, and others that can be corrected with training.3 Commonly used tools for education on inhaler technique include verbal/written instructions or a demonstration by healthcare workers (who may not have received proper training). Unfortunately, some patients may receive no instruction. Online tools and videos have proliferated, but are mostly passive and lack important attributes such as ease of use, accessibility, and comprehensiveness. High rates of improper inhaler technique in recent studies demonstrate a need for more effective tools that can reduce time demands on busy practitioners. We believe that interactive software simulation can be a more effective educational tool. Our goals include developing a comprehensive asthma education portal that includes interactivity to engage patients and more importantly, teach correct inhaler technique leading to improved asthma outcomes. In this abstract, we focus on the inhaler training component.
Description: Our team of physicians, engineers, creative graphic designers, patients, and entrepreneurs brainstormed the learning process to create interactive components: “Learn to Breathe”, “Learn to Inhale”, “Inhaler Lessons” and “Assist Me”. The “Learn to Breathe” tool addresses errors that result from failure to take deep breaths or identify the points of full inhalation, full exhalation and the correct time to actuate MDI. A moving vertical “breath bar” is synchronized with an onscreen instructor’s depth and pace of breathing which identifies these points in breathing cycle using visual and audio cues. Then the patient practices deep breathing with the onscreen instructions and breath bar. The “Learn to Inhale” tool coordinates the steps involved in taking an inhaler with “Learn to Breathe” and provides interactive coaching for each step of using an MDI. The third tool “Inhaler Lessons” provides detailed reasoning associated with each step, visual interpretation of what happens inside the body when the inhaler is used correctly or incorrectly, and provides tips for improvement. An audio tool called “Assist Me”, only available on smart phones and tablets, ensures consistent reinforcement of the steps from “Learn to Breathe” and “Learn To Inhale” every time the patient uses the inhaler. These tools are complemented by using age appropriate games, incentives and interactive general education on asthma/inhaler devices on the website.
Conclusion: A simulation approach to inhaler training and asthma education is likely to be a more effective alternative to the conventional methods. We are leveraging the technology to improve patient participation in self-management of asthma. In addition, the platform design can be modified for use in various healthcare settings. We envision providers creating integrated treatment plans by setting up training tools, data inputs (symptoms, peak flow etc.) and asthma action plans customized to individual patients that patient can access on any of their own devices.
1. http://www.cdc.gov/VitalSigns/Asthma (accessed: 28 July 2012).
2. Press VG, Arora VM, Shah LM, et al. Misuse of respiratory inhalers in hospitalized patients with asthma or COPD. J Gen Intern Med. 2011 Jun;26(6):635-42.
3. Hagmolen of ten Have W, van de Berg NJ, Bindels PJ, et al. Assessment of inhalation technique in children in general practice: increased risk of incorrect performance with new device. J Asthma. 2008 Jan-Feb;45(1):67-71.
4. Fink JB, Rubin BK. Problems with inhaler use: a call for improved clinician and patient education. Respir Care. 2005 Oct;50(10):1360-74.
1202 Simulation in Obstetrics and Gynaecology: A Multidisciplinary Approach
Arunaz Kumar, MBBS, MD, MRCOG, FRANZCOG1
1OBSTETRICS AND GYNAECOLOGY, MONASH UNIVERSITY, MELBOURNE, VIC, AUS
Introduction/Background: Obstetrics and Gynaecology training can be a challenging experience for medical and midwifery students who have had no prior experience in the field. Introduction of simulation-based education at a student or a junior trainee level helps to promote learning in a clinical environment.1 Simulation not only helps to standardize teaching practice, but can also be utilized for certification of a competency-based skill. It is helpful if students attain confidence in learning a skill on mannequins prior to exposure to learning in a clinical setting. This confidence, in turn, translates into patients feeling confident about the students’ knowledge of the subject and is, hence, likely to facilitate the student attaining competence in performing that skill earlier. Introduction of third-year medical students to normal labor and delivery through simulation has been found to equip them with skills and confidence needed to perform deliveries early in their clerkship.2 Simulation is also a valuable tool for team based learning for both technical and non-technical skills.3 The experience of learning and working together as teams is ideally enforced in early years of medicine, nursing and midwifery training. This not only helps students in developing a multidisciplinary approach towards patient management but also develops an appreciation and respect for other health professionals, which improves teamwork and hence clinical outcome. Evidence also supports the use of inter-professional education to develop an understanding and respect for members working in a team, which is one of the key features of patient care.4 There is still a need for larger trials to assess the benefit of inter-professional education at an undergraduate level.4 The project vision was to assess the use of innovative methods of training medical and midwifery students. The innovations introduced included teaching multi-professional groups of students, procedural skills using part task trainers, and teaching communication strategies and management of clinical situations. The goals also focused around teaching a large number of students in a session yet maintaining one-to-one supervision of each student learning each skill at a gentle pace.
Description: Of the participants, 280 medical and 80 midwifery students were offered to attend a workshop in Women’s Health involving simulation based training over a 12 month period. The 3 training skill modules taught included the following: 1). Gynaecology - Speculum Examination, Bimanual Examination, Pap smear, 2). Obstetrics “A” - Vaginal Examination (Assessment of cervical dilatation, effacement, presentation and station), and 3). Obstetrics “B” - Conduct a normal vaginal birth, Estimation of blood loss. There were approximately 90 medical and midwifery students at each workshop that lasted 4 hours done quarterly. Students were provided with pre-workshop reading material and were expected to have read the documents prior to the workshop. Each group had 6-8 students and one facilitator (medical/ midwifery) who provided teaching, demonstration and supervision of one of the skills listed above using the designated models (see picture, Model-med International Pty Ltd, Australia). Students rotated through each lesson, which lasted one hour. All students completed a post session evaluation form with 30 items addressing various aspects of the lessons graded on a 5 point Likert scale.
Conclusion: Participant satisfaction with the training workshop was high. Evaluations assessed aspects of lesson content, knowledge, and time allocated for the session. Overall improvement of confidence in the skill involved and team work was also demonstrated. There was more than 95% agreement about the content, reproducibility, level and validity of the lessons as well as advantage of multidisciplinary teaching of the same skill. Besides learning the clinical skills, students were encouraged to relate to clinical case scenarios where these skills were applicable. The educational impact was high as it was an interactive hands-on workshop and achieved its goal to maintain students’ engagement.
1. Curran VR, Butler R, Duke P, Eaton WH, Moffatt SM, Sherman GP, Pottle M. Evaluation of the usefulness of simulated clinical examination in family-medicine residency program. Med Teach. 2007; 29(4): 406-7.
2. Jude DC, Gilbert GG, Magrane D. Simulation training in the obstetrics and gynecology clerkship. Am J Obstet Gynecol. 2006; 195(5): 1489-92.
3. Freeth D, Ayida G, Berridge EJ, Mackintosh N, Norris B, Sadler C, Strachan A. Multidisciplinary Obstetric Simulated Emergency Scenarios (MOSES): Promoting Patient Safety in Obstetrics with Teamwork-Focused Interprofessional Simulations: J Contin Educ Health Prof. 2009; 29(2): 98-104.
4. Siassakos D, Timmons C, Hogg F, Epee M, Marshall L, Draycott T. Evaluation of a strategy to improve undergraduate experience in obstetrics and gynaecology. Med Educ. 2009; 43(7): 669-73.
Oral Presentation 1204 Using Systems Integration Simulation to Re-Assess Emergency Response Teams
Bonnie Mobley, BSN,1 Mark Adler, MD2
1KIDSTAR MEDICAL EDUCATION, NORTHWESTERN UNIVERSITY, ANN AND ROBERT H LURIE CHILDREN’S HOSPITAL, CHICAGO, IL, USA and 2PEDIATRICS, NORTHWESTERN UNIVERSITY, FEINBERG SCHOOL OF MEDICINE, CHICAGO, IL, USA
Introduction/Background: As an exclusive pediatric facility, that expanded from a compact 9 story structure to a unique and new 24 story campus, we were faced with an increased number of emergency response calls for out patient and adult incidents. Upon review of code data from our previous facility, 42% of codes were for non-inpatients. In response to these concerns, the hospital developed a new Emergency Response model, the Non-Inpatient Emergency Assessment & Response (NEAR) Team, a smaller response team that can quickly and efficiently respond first to non-inpatient and adult code responses. The challenge was to efficiently and effectively educate two groups, a small group of responders and a larger and more diverse group encompassing all hospital staff, in order to successfully transition non-inpatient response from a CODE to a NEAR call. This was achieved efficiently, without an increased demand on resources, and effectively, housewide education with 100% understanding of the process on go live day.
Description: This project was structured using a formal process improvement methodology. The goal was to develop a systems integration project using simulation, that would implement a NEAR Team Response, in three pilot areas of the hospital, pre-identified as having high non-inpatient related calls. After testing the process, amending and re-evaluating it with further simulations, the process was implemented housewide with further simulation as a method to educate and reinforce the response change. When developing the learning objectives we used the NEAR process as our guide: ensure feasibility of a response time of < 5 minutes; ensure 100% compliance with Emergency Responders response of < 5 minutes, 100% availability of emergency equipment; ensure response team complied with EMTALA regulations; eliminate barriers to calling a NEAR response. Simulated code events and focused debriefing in the three pilot areas promptly identified process issues and departmental policies that created barriers to meeting the objectives and allowed for iterative revision and improvement of the process. During housewide implementation impromptu NEAR response simulations were held in high risk low incident areas (inpatient floors, main public areas and clinics) to reinforce the process implementation and prevent decay of education. Post-implementation review of activations of both the new and full codes were collected for 6 months and reviewed again at a year. Outcomes: (a) All NEAR Team calls are entered into a Safety Event Reporting System, (b) activation of the correct team 90% of the time, (c) 100% availability and response of team members, (d) 100% availability of emergency equipment, (e) All non-inpatients are offered additional ED assessment/screening, (f) 100% compliance with Refusal of Care processes. Advantages include the following suppositions: this was an effective way to introduce a new process, it facilitates testing of new processes prior to housewide implementation, it provides a safe learning environment for participants and debriefing allows for questions related to the process and, it effectively provided education on a new process in a manner that required fewer resources, while allowing for testing and reinforcement of implementation of the NEAR call.
Conclusion: Using simulation uncovered un-anticipated process and systems issues. In three piloted areas, using simulation, the structure of the education module was tested. We found additional educational needs, individual departmental polices that negated the NEAR response and the need for revisions to the educational module. Once the revised education module was launched for all hospital staff, simulation was used to test the response team in various areas of the hospital as well as effectiveness of the education provided. Process issues were identified and addressed prior to implementing the response team.
1. Performance of first responders in simulated cardiac arrests. Marsch SC, Tschan F, Semmer N, Spychiger M, Breuer M, Hunziker PR. Crit Care Med. 2005 May;33(5):963-7. PMID: 15891321 [PubMed - indexed for MEDLINE].
2. Portable Advanced Medical Simulation for New Emergency Department Testing and Orientation. Kobayashi L, Patterson MD, Overly FL, Shapiro MJ, Williams KA, Jay GD.Acad Emerg Med. 2008 Nov;15(11):1166-74. Epub 2008 Jul 14. PMID:18638036 [PubMed - indexed for MEDLINE].
3. Using simulation to orient code blue teams to a new hospital facility. Villamaria FJ, Pliego JF, Wehbe-Janek H, Coker N, Rajab MH, Sibbitt S, Ogden PE, Musick K, Browning JL, Hays-Grudo J. Simul Healthc. 2008 Winter;3(4):209-16. PMID:19088665 [PubMed - indexed for MEDLINE].
1237 Hybrid Simulation with Virtual Patients
Rachel Ellaway, PhD,2 Aislinn Joy, MB,3 David Topps, MB, ChB, MRCGP, FCFP,4 Kevin Lachapelle, MD1
1ARNOLD AND BLEMA STEINBERG MEDICAL SIMULATION CENTRE, MCGILL UNIVERSITY, MONTREAL, QC, CAN and 2INFORMATICS, NORTHERN ONTARIO SCHOOL OF MEDICINE, SUDBURY, ON, CAN and 3MEDICAL EDUCATION UNIT, UNIVERSITY COLLEGE CORK, CORK, IRL and 4FAMILY MEDICINE, UNIVERSITY OF CALGARY, CALGARY, AB, CAN
Introduction/Background: Simulation activities are typically based around brief, intense encounters. As such they are less effective at representing longitudinal and social aspects of care and the motives and identities of those involved in the care process. This significantly limits the applicability of simulation for training primary care providers, diagnosticians and others whose practice depends on working in these broader contexts. Dieckmann’s work1 provides us with an initial framework enhancing the conceptual clarity of simulation for goal oriented use (education, training or research). The single simulator focused activity design has been extended through the development of hybrid techniques,2 in particular those that involve standardized patients and part-task trainers. Dieckmann’s concepts deal mainly with the social reality of the simulated experience for individual candidates and help to guide and theoretically frame the design and conduct of scenarios. We can think about this as part of a broader continuum of simulation experience and simulation-based learning.3 This paper describes hybrid simulation activities using virtual patients. Virtual patients are online learning activities, usually requiring learners to respond to complex clinical situations by making critical decisions within a predefined scenario and dealing with the consequences; as such they combine aspects of educational narrative, computer games and simulation.4 This paper describes the use of virtual patients with other simulators to create new kinds of simulation activities that expand the range and utility of simulation-based education as a whole.
Description: The authors have been exploring different methods of combining simulators and creating hybrid simulation activities.5 A key component of this work has been the development and use of virtual patients to extend and enhance activities around mannequins. The virtual patient software used was the free and open-source OpenLabyrinth platform6 and the project team developed the virtual patients (VPs) and scenarios. Although there are no technical limits to the complexity of the scenario designs, the hybrid activities followed two main design patterns: 1). VP > mannequin > VP: this is what we have called a ‘bookend’ activity. An example is the “bridge too far” scenario where a VP follows the paramedics caring for a young adult with a spinal injury, the activity transfers to the mannequin for handling and resuscitation skills and back to the VP for follow up care and rehabilitation; 2). Presentation > VP > standardized patient: this is what we have called a ‘miller’ activity as it progresses from ‘knows’, through ‘knows how’ to ‘does’. An example is a session teaching triage skills where learners are first introduced to the basic concepts of triage, then applies their skills in a limited VP scenario and then again with live standardized patients. We will discuss how these patterns follow good educational practice and can be educationally effective by allowing for progressive development and autonomy and combining psychosocial and practical skills activities in the same scenario to create learning continua not possible using these modalities on their own.
Conclusion: We have found designing and creating hybrid simulation activities are both effective and relatively straightforward to accomplish. The required tools are simple to use, and the main challenge is engaging the creativity of the educators who are putting these scenarios together. These scenarios are rich and engaging and have been well rated by the learners who have participated in them. Nevertheless, there are limitations to this approach including greater logistical complexity and the need for more time to complete these extended activities than simple task-based, simulation-based educational scenarios. The implications for this work are significant in as much as the use of virtual patients in combination with more traditional simulation modalities extends the utility of both and opens up hitherto inaccessible forms of simulation-based education.
1. Dieckmann P, Gaba D, Rall M. Deepening the Theoretical Foundations of Patient Simulation as Social Practice. Simulation in Healthcare. 2007;2:183–193.
2. Kneebone R. Simulation in surgical training: educational issues and practical training. Medical Education. 2003; 37(3):267-277.
3. Ellaway R, Kneebone R, Lachapelle K and Topps D. Connecting and combining simulation modalities for integrated teaching, learning and assessment. Medical Teacher. 2009; 31(8):725-731.
4. Ellaway R, Poulton T, Smothers V and Greene P. Virtual Patients Come of Age. Medical Teacher. 2009; 31(8):683-684.
5. Ellaway R, Topps D, Lachapelle K, Joy A and Richards M. Exploring Simulation Integration. 11th Annual International Meeting on Simulation in Healthcare; 2011 Jan 22-26; New Orleans, LA: Society for Simulation in Healthcare.
6. Ellaway R. OpenLabyrinth: an Abstract Pathway-Based Serious Game Engine for Professional Education. Proceedings of the Fifth IEEE International Conference on Digital Information Management (ICDIM) 2010, Thunder Bay, ON: IEEE.
1249 Physical Therapy Clinical Instructor Assessment and Feedback Multi-Session Workshop Culminating in an Integrated Standardized Patient Examination
Carol Recker-Hughes, PT, PhD,1 Amber Hansel, BFA,2 Jill Dungey, PT, DPT, MS, GCS,1 Susan Miller, PT, DPT, MS1
1PHYSICAL THERAPY, STATE UNIVERSITY OF NEW YORK, UPSTATE MEDICAL UNIVERSITY, SYRACUSE, NY, USA and 2STANDARDIZED PATIENT PROGRAM, STATE UNIVERSITY OF NEW YORK, UPSTATE MEDICAL UNIVERSITY, SYRACUSE, NY, USA
Introduction/Background: Ongoing student assessment is a critical component of effective clinical instruction; however, Clinical Instructors (CIs) may lack competence and confidence in providing student feedback. Although these skills may be delivered as part of a professional development course, CIs rarely have the opportunity to implement them in an authentic experience. For this reason we developed a five-part continuing education program for CIs that included participation in an Integrated Standardized Patient Examination (ISPE) for Doctor of Physical Therapy (DPT) students. The ISPE is a comprehensive assessment of student competencies that takes place during a student-standardized patient (SP) examination.
Description: This course was designed to assist CIs in developing essential assessment and feedback skills. Training sessions included strategies for providing feedback, eliciting student reflection, and promoting clinical decision making. CIs viewed pre-recorded student-SP interactions, after which CIs role played providing feedback and questioning to facilitate student reflection and clinical decision making. CIs remotely observed the ISPE encounter, then engaged with the student in a clinical decision making question and answer session, completed a checklist, and provided the student with feedback. CI/student interactions were video recorded. Students completed a written questionnaire on the CIs’ performances and also self-assessed. Academic Faculty from the DPT program observed the student-SP encounter, completed an intricate assessment checklist, and conferred with the CI prior to the CI-student interaction. CIs reviewed the videos of their student interactions and, at the final training session, debriefed with the course instructors. CIs provided feedback on the experience in small groups and completed a course evaluation, including how they intend to modify future interactions with students in the clinic.
Conclusion: Feedback was overwhelmingly positive. CIs included comments on the course material quality and the meaningful interactions between faculty/students/CIs. All of the 23 CIs agreed or strongly agreed with the statement, “I feel better prepared to ask questions which will facilitate clinical decision making.” Likewise, 20 of 23 CIs agreed or strongly agreed with the statement, “I feel better prepared to provide feedback to students in the clinic.” Student feedback included comments on giving/accepting constructive criticism, appreciation of immediate feedback, and the opportunity to verbalize their rationale with the CIs. CIs facilitated students’ reflections and promoted problem solving in the interactions after the ISPE in a manner which is not possible in a traditional examination format. Feedback indicates this faculty development course, utilizing authentic learning experiences/simulation, provided opportunities to strengthen teaching skills of the CIs while simultaneously strengthening the students’ experience with the ISPE.
1. Panzarella K., Manyon A: Using the Integrated Standardized Patient Examination to Assess Clinical Competence in Physical Therapy Students. Journal of Physical Therapy Education. 2008; 22(3): 24-32.
2. Recker-Hughes C, Pivko S, Mowder JJ, Brooks G.: Clinical Instructors’ Self-Perception of Competence in Teaching Core Content Areas of Curriculum to Professional DPT Students: Implications for Academic Programs. Journal of Physical Therapy Education. 2008; 22(2): 51-59.
3. Trowbridge, Robert L., Laura K. Snydman, Jenna Skolfield, Janet Hafler, and Robert G. Bing-You: A Systematic Review of the Use and Effectiveness of the Objective Structured Teaching Encounter. Medical Teacher 2011.33 (2011): 893-903.
4. Gelula, Mark H., and Rachel Yudkowsky: Using Standardised Students in Faculty Development Workshops to Improve Clinical Teaching Skills. Medical Education 37.7 (2003): 621-29.
1266 Emergency Detection in Labor and Delivery: A Guide for Simulation Training
Ashley Hughes, BS,3 Shirley Sonesh, PhD,1 Eduardo Salas, PhD,2 Megan Gregory, BS3
1HUMAN SYSTEMS INTEGRATION RESEARCH, INSTITUTE FOR MEDICAL SIMULATION AND ADVANCED LEARNING, ORLANDO, FL, USA and 2INSTITUTE FOR SIMULATION AND TRAINING, UNIVERSITY OF CENTRAL FLORIDA, COLLEGE OF MEDICINE, ORLANDO, FL, USA and 3PSYCHOLOGY, UNIVERSITY OF CENTRAL FLORIDA, COLLEGE OF MEDICINE, ORLANDO, FL, USA
Introduction/Background: According to the Center for Risk Insurance report on errors in obstetrics, 77% of all major errors in the delivery room stem from delay of treatment, poor technical skills and improper management of emergencies.1 These preventable sources of error (i.e., human error) in the medical field result in increased hospital costs and can result in unnecessary complications or loss of life. Early recognition of an emergency situation has been identified as crucial to positive outcomes in patient care.2 Similarly, teamwork has been identified as critical in coordinating patient care to promote patient safety and quality of care in OB.3 The purpose of this paper is to describe our investigation of the roles of decision making and teamwork processes of a labor and delivery ward in order to promote the design of simulation based team training (SBTT). Through addressing technical (i.e., McRoberts maneuver) and nontechnical (i.e., teamwork, problem recognition) skills identified through our methods, we can promote simulation design for labor and delivery and contribute to healthcare simulation best practices.
Description: In order to determine critical knowledge, skills, and attitudes (KSAs) salient to obstetric emergencies, we conducted and systematically coded semi-structured interviews with 27 obstetric subject matter experts (SMEs) and coupled interview findings with over 24 hours of direct ward observation. Interviews were coded using HyperResearch software by three separate coders. Disagreements with coding were resolved via discussion. Themes extracted presented the barriers and facilitators to patient care, as well as signals of emergencies (see Table 1). Similarly, an observational protocol was utilized to collect patient status, cues, decisions, and patient outcomes to further uncover critical clinical decision making processes. Extracted themes included facilitators and barriers to patient care (see Table 1 referencing the interview and observation coding examples ). Codes were systematically extracted by two coders and differences were resolved via discussion. Disagreements between the two coders were resolved via third party consultation. See Table 1.
Findings reveal that collaboration with an expert physician as a decision making process resulted in positive patient outcome. Themes of teamwork were also identified as helping in an emergency and lacking in the organization (see Table 2 referencing Training Need Findings). See Table 2.
Conclusion: Needs identified in qualitative findings can begin fueling the SBTT content, equipment selection, and evaluation.4 Design of obstetric clinical scenarios should be designed to teach and assess cue recognition for situation awareness (SA) of patient status, communication between healthcare providers, coordination, and cooperation in working together. Using multiple human patient simulators (HPS; i.e., Noelle) to simulate emergency and nonemergency scenarios will allow for evaluation of SA and shared decision making initiation via teamwork. Simulation scenarios will be recorded for KSA evaluation. We anticipate SBTT designed according to these critical core competencies will improve team performance, situation awareness, decision making and subsequently, quality of patient care. Since clinical decision making is an intrinsic part of practice, it is essential to simulate and train for the aforementioned competencies while considering the context within which those decisions are embedded.
1. Ruoff G, Feng L. CRICO Strategies’ Report on Malpractice Errors in Obstetrical Care Provides Roadmap for Enhanced Patient Safety (Second Annual Benchmarking Report). 2011; Retrieved from CRICO website http://www.rmf.harvard.edu/~/media/Files/_Global/KC/News/OBRelease_Final.p.
2. Beckmann U, Gillies DM, Berenholtz SM, Wu AW, Provonost P. Incidents relating to the intra-hospital transfer of critically ill patients: An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care. Intensive care med. 2004; 30: 1579-1585.
3. Editorial: Quality Patient Care in Labor and Delivery: A Call to Action. JOGNN. 2011; 40: 1-3.
4. Rosen MA, Salas E, Wu, Silvestri, Lazzara EH, Lyons R, Weaver SJ, King H. Promoting Teamwork: An Event-based approach to simulation-based teamwork training for emergency medicine residents. Acad Emerg Med. 2008; 15: 1190-1198.
1271 Using an Appreciative Leadership Approach to Define Simulation in Paediatric Rehabilitation: The Holland Bloorview Story
Kathryn Parker, PhD,2 Golda Milo-Manson, MD1
1DEVELOPMENTAL PAEDIATRICS, HOLLAND BLOORVIEW KIDS REHABILITATION HOSPITAL, TORONTO, ON, CAN and 2PAEDIATRICS, HOLLAND BLOORVIEW KIDS REHABILITATION HOSPITAL, TORONTO, ON, CAN
Introduction/Background: Simulation programming in the field of paediatric rehabilitation has yet to be developed. Holland Bloorview Kids Rehabilitation Hospital, Canada’s largest paediatric rehabilitation facility, wanted to explore the use of simulation as an innovative educational tool for both staff and students. Moving forward, we needed to define simulation in a way that was relevant to Holland Bloorview’s context and to engage members of the Holland Bloorview community in the development and growth of this innovation. This work contributes to the field of simulation by highlighting two distinct leadership challenges. First, it is the first program to define simulation in paediatric rehabilitation. Second, how do we build this definition so staff can see the relevance and value of simulation to their work at a time of rapid transformational change in client care.
Description: We used an appreciative leadership approach1 to define simulation programming at Holland Bloorview and build organizational awareness and interest in simulation. Born from the fields of positivist psychology, sociology and neuroscience, this approach uses 5 core strategies to mobilize creative potential within an organization. We conducted 15 semi-structured interviews with leaders and clinical educators over a period of 4 months. Information from the interview notes was summarized and categorized into themes to define simulation. Based on this definition, we engaged members of the community to co-create the official launch of our simulation program. The five core strategies, their definition and how they were used is presented in the table below.
Members of the Holland Bloorview community defined communication, collaboration and ethical decision making as the 3 programmatic themes for simulation, all grounded in the relationship with clients and families. As co-creators of the program, staff are actively engaged in the building and delivery of simulation; and as a result, 8 new scenarios in communication have been built in the last 4 months in collaboration with clients and families. We surveyed staff following the official launch of our simulation program in March 2012 and found that 100% would recommend using simulation to others; 76% were very interested in developing their skills in simulation; and 100% saw their own work and the work of the hospital benefitting from the use of simulation.
Conclusion: The appreciative leadership approach has fostered collaboration across groups, built positive energy for simulation and has helped the system to co-create a simulation program reflective of organizational values and principles. We have also been able to identify current and future champions of simulation, which will aid in building capacity for simulation across the organization. For leaders who are charged with building simulation with limited resources, this approach can facilitate positive change and foster collaboration in the creation of a shared future in simulation programming within a unique organizational context.
1. Whitney D, Trosten-Bloom A, Rader K. Appreciative leadership: Focus on what works to drive winning performance and build a thriving organization. New York: Mc Graw Hill; 2010.
1291 Program Improvement Through Standardized Simulation Testing
Joanne Weinschreider, RN, MS1
1NURSING, SAINT JOHN FISHER COLLEGE, ROCHESTER, NY, USA
Introduction/Background: The complexity of medicine today requires that our newly hired novice nurses come with a solid foundation in knowledge, communication, organization and complex nursing skills. Although novice nursing graduates are exposed to a variety of clinical experiences, they are expected by new employers to proficiently work in fast paced high stress medical environments. Nursing schools have the responsibility of educating and evaluating nursing students for competency prior to graduation. With a large number of new graduates entering the healthcare field each year there is a need to ensure quality in our educational programs. Simulation testing is one option for ensuring quality and competency in nursing students prior to graduation. The outcomes of standardized simulation testing can be used in multiple ways. The traditional focus of standardized testing in nursing schools is to provide summative feedback to the learners regarding their actions during simulated events. However, the results of standardized simulation testing may also be helpful when used to evaluate programs. Information gathered about cohorts after standardized simulation testing can be used to identify weaknesses and opportunities in the program that prepared the students.
Description: To evaluate our students’ preparedness to move forward at critical times in their education, standardized simulation-based testing was instituted. Program faculty tested undergraduate nursing students using standardized simulation scenarios during the second semesters of their junior and senior years. Since implementing standardized simulation-based testing in spring 2011, over 300 students have been tested over three concurrent semesters. Simulations were developed to look at seven core areas of competencies: nurse-to-patient communication, complex nursing skills, patient safety, understanding of pathophysiology, organization and flow during patient encounters, efficiency and prioritization of care. Two facilitators scored the simulations in these seven areas using a tool developed by the college. The passing rate for the first semester (spring 2011) was 80% for juniors and 79% for seniors. From the results, program faculty identified opportunities for improvement related to nursing technical skills, patient safety and understanding of pathophysiology. In response to the information gathered from the first semester of testing the faculty instituted curriculum changes that included: 1) technical skill testing for second semester juniors and first semester seniors, and 2) a remediation plan for students that failed critical portions of simulation-based standardized testing. Remediation was instituted in fall 2011 for all senior students and spring 2012 for junior and senior students. After implementation of programmatic changes, the passing rate for fall 2011 dropped slightly to 77% for juniors however the senior passing rate continued to increase to 84%. The pass rate for spring 2012 increased to 90% for junior students and 94% for senior students.
Conclusion: Successfully preparing our learners for the complexity of medicine is vital to the medical profession. Evaluating programs using standardized simulation-based testing is one way to ensure that programs are meeting the needs of the learners. When students fail to pass simulation tests educational institutions have an opportunity to look critically at where cohorts of students struggled and develop programmatic changes to meet the needs of the learners. Standardized simulation-based testing is one way of evaluating a program’s success in preparing learners to transition into practice.
1. Gaba, D.M. (2004). The future vision of simulation in health care [Electronic version]. Qual Saf Health Care,13(Suppl. 1), i2-i10.
2. Lasater, K. (2007). High-fidelity simulation and the development of clinical judgment: Students’ experiences. Journal of Nursing Education, 46(6), 269-276.
Disclosures: Joanne Weinschreider, RN, MS, is a consultant forTheraSim, Inc.
1337 Emergency Medicine Simulation Training Program: Three Years Experience of Different Debriefing and Case Scenario Format
Joshua Hui, MD1
1EMERGENCY MEDICINE, UNIVERSITY OF CALIFORNIA LOS ANGELES MEDICAL CENTER, OLIVE VIEW, SYLMAR, CA, USA
Introduction/Background: Emergency Medicine is a unique specialty; physicians are expected to make rapid, life-and-death decisions with minimal patient information under dire circumstances. Controlled chaos is routinely part of the emergency department environment. By allowing trainees to encounter uncommon, high stakes clinical scenarios without real patient risk, simulation has naturally been incorporated into EM residency training. Between 2003 and 2008, the prevalence of simulation training in United States residency programs increased from 23% to 91%.1 The importance of simulation and its suitability for EM training was officially recognized in 2009 when the Society for Academic Emergency Medicine created the Simulation Academy. In 2009, a formal simulation curriculum for the UCLA-Olive View EM residency was implemented. Although the curriculum later became one of the most embraced resident educational endeavors, initial incompatibility issues with traditional debriefing methodologies, case write-up formats, and the nature of EM practice arose. While traditional debriefing styles include a relatively longer analysis phase followed by a relatively shorter didactic phase. The traditional case write-up format includes a fixed number of branching points.2 Through our experiences, a different debriefing style incorporating a shorter analysis phase and a longer didactic phase would result in more acceptance of the simulation curriculum by residents. In addition, switching to a case write-up format with flexible, on-the-fly branching points would better reflect the unique nature of the EM practice environment in where unpredictability of patients presentation is the norm.
Description: Between 2009 and 2012, our program ran over 150 simulation scenarios with over 240 physicians-in-training (i.e. residents) from the second to fourth year training levels. After each session, verbal and written surveys were requested from each resident. Each survey consisted of 3 parts: 1) opinions concerning the favorable aspects of the scenarios, 2) suggestions for areas of improvement, and 3) requests for certain topics and cases in the future. The chief residents and faculty also provided summaries of the verbal surveys from residents. We received approximately 170 written feedback components consisting of 8500 words and a significant amount of verbal feedback as well. There was overwhelming feedback in favor of changing the approach during debriefing sessions. We had initially used the traditional style, emphasizing the analysis phase, with a relatively short amount of time dedicated to the didactic phase. In response to feedback, an alternative approach with a longer didactic phase and a relatively shorter analysis phase was implemented. The didactic phase included focused teaching points pertinent to the scenario. Each debriefing session lasted approximately 15 to 20 minutes. After these changes, both verbal and written resident feedback unanimously supported the new style. Of note, the majority of residents enjoyed the realism of the simulation environment and scenarios. For the case write-up, we initially followed a traditional format including a fixed number of branching points. However, we realized that the traditional format is incompatible with the nature of EM practice. Trying to pre-program scenarios created logistical issues with the fluid characteristics of emergency situations. Thus, we created a new format allowing flexible branching points and “on-the-fly“ changes within the scenario, while maintaining pre-determined teaching objectives. This new format accommodates a wide range of unexpected responses from the scenario participants and a realism that is unique to real EM practice.
Conclusion: With respect to the traditional debriefing and case write-up formats, our internal survey of 8500 words and abundant verbal feedback provided foundations for creating two relatively different styles of writing scenarios and debriefing styles. Our format of case write-up allows maximum degrees of flexibility in making on-the-fly changes, while keeping the education objectivesconstantly in check. Our debriefing style also focuses less in the so-called psychoanalytic phase and more of the didactic phase, which focuses on exploring participants knowledge base deficit. We believe these two formats better reflect the unique nature of EM clinical practice. A limitation is that all participants came from a single residency. Future cooperation with other EM residency experiences or a national survey is warranted.
1. Okuda Y, Bond W, Bonfante G, McLaughlin S, Spillane L, Wang E, Vozenilek J, Gordon JA. National growth in simulation training within emergency medicine residency programs, 2003-2008. Acad Emerg Med. 2008 Nov;15(11):1113-6.
2. Rudolph JW, Simon R, Raemer DB, Eppich WJ. Debriefing as formative assessment: closing performance gaps in medical education. Acad Emerg Med. 2008 Nov;15(11):1010-6.
1346 From Novice to Virtual Surgeon: A Case Study of a Six Month Self-Directed Learning Programme in Laparoscopic Surgery Using Virtual Reality Simulation Technology
Neda Taghinejadi, iBSc, MBBS(cand),3 Rezan Abdul Kadir, MD,2 Pasquale Berlingieri, MD, PhD,1
1CENTRE FOR SCREEN-BASED SIMULATION, ROYAL FREE HOSPITAL, LONDON, UK, GBR and 2OBSTETRICS AND GYNAECOLOGY, ROYAL FREE HOSPITAL, LONDON, GBR and 3MEDICAL SCHOOL, UNIVERSITY COLLEGE LONDON, LONDON, GBR
Introduction/Background: The potential of simulation technology to advance the medical educational landscape is being increasingly recognised1. Within the field of laparoscopic surgery, in particular, virtual reality simulation technology is playing a central role in evolving educational strategies, having even been described as the backbone of training for surgeons2. However, the role of high fidelity virtual reality simulation technology within the undergraduate community is less clearly defined and medical students’ access remains extremely limited; the only studies available in the literature are those which focus on recruiting undergraduates for a limited period of time with the aim of determining the validity of the virtual reality simulators, as opposed to the real benefits for the learners. This descriptive case study details the insights gained from our experience of engaging a medical student in a six month, self-directed learning programme in laparoscopic gynaecological surgery at the Royal Free Hospital, centred on the use of virtual-reality simulation technology.
Description: A medical student, who was a complete novice in laparoscopic surgery, was offered the challenge of learning to perform four laparoscopic procedures on a high fidelity virtual reality laparoscopic simulator (LAPMentor, Simbionix Ltd., USA). The selected procedures included the following: tubal sterilisation, salpingectomy and salpingostomy for ectopic pregnancy, and bilateral salpingo-oophorectomy. In order to learn each laparoscopic surgery, the student embarked on a self-directed learning programme underpinned by open access to the LAPMentor. The student’s learning was reinforced via a stepwise progression through a blend of additional educational strategies, including the use of conventional medical textbooks and visualisation of surgical videos online via social media website like YouTube, for example. The final stage of the programme was comprised of observation of each procedure in theatre, where the student was able to address any lasting questions to the operating surgeon. The student was then invited to reflect upon the experience throughout the learning activities. By progressing through this self-directed learning programme, the student became able to perform each laparoscopic surgery on the LAPMentor by meeting the expert computer generated metrics. Furthermore, once this level of ability had been achieved, video capture software was used to record the student’s own performance of each procedure on the simulator. This resulted in the development of a unique academic collection of simulated surgical procedures, which is currently available to students at University College London via the local virtual learning environment platform, as well as to the wider scientific community through YouTube3.
Conclusion: The rapid advancement of the selected student’s surgical ability reflects the likely benefits of undergraduate exposure to virtual reality simulation technology. This case study confirmed our expectations that connecting students of the new digital generation with such resources and providing them with a stepwise structured approach may enable them to acquire and develop surgical skills from an early stage in their careers, turning novices into virtual surgeons. This could be achieved by implementing a rigorous self-directed stepwise programme characterised by intense repetition of laparoscopic surgical skills in a controlled setting4 with the support of experts’ feedback. In addition, we identified a further potential benefit of the student-simulation partnership: the production of innovative educational resources. Videos of simulated surgical procedures, like those created by the medical student undertaking this project, can be developed and made available online for the use of other undergraduates, as well as practicing clinicians. Thus, facilitating undergraduate access to VR simulation technology may not only benefit the students themselves, but can also contribute to the wider medical community through the creation of student-developed educational tools. The self-directed learning programme discussed here may represent an important starting-point in realising the unique opportunities that the student-simulation partnership has to offer to medical education.
1. Berlingieri P, Shaw B, Kadir RA, Potts HW. Training the digital generation – Perception of usefulness of virtual reality laparoscopic simulators among the fourth year medical student population [abstract]. In: Diversity in an age of standardisation. Abstracts of the ASME Annual Scientific Meeting; 2011 Jul 13–15; Edinburgh, UK. Edinburgh (UK): Association for the Study of Medical Education (ASME); 2011. p. 127.
2. Von Websky MW, Vitz M, Raptis DA, Rosenthal R, Clavien PA, Hahnloser D. Basic laparoscopic training using the Simbionix LAP Mentor: setting the standards in the novice group. J Surg Educ 2012; 69(4): 459-467.
3. Laparoscopic tubal sterilisation. YouTube [Internet]. San Bruno, California (USA): YouTube [Uploaded: 2011 Feb 27; Last accessed: 2012 may 9]. Available from: http://www.youtube.com/watch?v=zJXIho3GMaU.
4. Okuda Y, Bryson EO, DeMaria S Jr, Jacobson L, Quinones J, Shen B, Levine AI. The utility of simulation in medical education: what is the evidence. Mt Sinai J Med 2009; 76 (4): 330-43.
1348 Application of Simulation Methodology to Neonatal Resuscitation Program (NRP)
Elizabeth Radsliff, RN, MSN, PNP-BC,1 Polly Butler, DTR1
1CENTER FOR PROFESSIONAL PRACTICE OF NURSING, UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER, SACRAMENTO, CA, USA
Introduction/Background: The primary goal of this project is successful transition of the NRP program from a lecture driven instructional design to a multi-modal educational program, integrating simulation methodology. This change is significant, as most instructors and students are not familiar with simulation based education. Addressing this gap in knowledge requires a change in culture for the NRP program. The NRP program includes fundamental concepts and skills for neonatal resuscitation. It is a required competency for nurses working in Neonatal Intensive Care (NICU) and Labor and Delivery departments. Historically, the paradigm of the NRP program has been presentation of course content and demonstration of technical skills, using lectures and skill stations with low-tech mannequins and no formal debriefing process. The NRP curriculum for 2011 includes significant changes, including incorporation of a simulation based educational format. “This is a landmark edition and marks the most significant changes made to the teaching methodology since the inception of the NRP course in 1987,” Jeanette Zaichkin RN, MN, NNP-BC.1
Description: To meet the goal of implementing a simulation based NRP program, we started with stakeholder roundtables to establish new program goals and agree on implementation action plans. This was an important step to promote early stakeholder buy-in. The primary identified challenge, from the discussions, was to facilitate instructor acquisition of a new skill set (how to conduct and debrief simulation scenarios). To address this need, all NRP instructors were to be trained in a two day training program. Twenty NRP instructors participated in the two day training program, held two months before implementation of the new format. The first day of training covered curriculum changes and expectations. Participants’ comments during the training revealed apprehension about changes, especially facilitation of debriefing sessions. The second day focused on simulation methods. The format for day two was a dry-run class with participants in both student and instructor roles. Open dialogue was encouraged to clarify questions and address participant concerns. The first classes incorporating simulation based methodology were held February 2012. To facilitate a supportive training environment, two instructors were assigned to each station. The second instructors were experienced debriefers whose primary role was to help facilitate debriefing. After two months, instructors stated they no longer needed the second instructor.
Conclusion: Ninety six students have completed the new NRP program. Initial data has primarily been positive. A quote from one student evaluation stated the following: “New format made for a more amenable learning environment.” Instructors stated they had increasing comfort and confidence with the new curriculum. The course coordinator stated, ‘this instructor training program has been so successful that I am considering this model for future instructor training programs.’ We identified two key elements in making this a successful transition: 1). The most valuable component was early stakeholder involvement; instructors felt supported and valued as part of the team and were therefore more vested in the success of the program, and 2). ongoing post-course instructor debriefings are essential. Instructors feel respected when they see adjustments to the course based on their feedback. Evaluation and validation of methods and materials are ongoing. Written evaluations by all participants and post instructor debriefings are held after every class. Neonatal Intensive Care (NICU) and Labor and Delivery quality and safety dashboards are being monitored on relevant nurse sensitive indicators. Course materials and instructor aids have been developed or revised based on this feedback.
1. Zaichkin J, Weiner GM. Neonatal Resuscitation Program (NRP) 2011: new science, new strategies. Neonatal Netw. 2011 Jan-Feb 1;30(1):5-13. PMID: 21317092 [PubMed - indexed for MEDLINE].
2. Arnold J. The Neonatal Resuscitation Program comes of age. J Pediatr. 2011 Sep;159(3):357-358.e1. PMID: 21846521 [PubMed - indexed for MEDLINE].
1351 In Situ Training in Emergency and Advanced Response Skills (iSTEARS) During New Hire Nurse Orientation
Marie Padriga, RN, MSN,1 Yvonne Lin, RN, MN,1 Charmayne Anderson, RN, MN, CNL, VHA-CM1
1CLINICAL AND NURSING EDUCATION, VETERANS AFFAIRS PUGET SOUND HEALTH CARE SYSTEM, SEATTLE, WA, USA
Introduction/Background: The purpose of this training is to introduce VA Puget Sound Heath Care System (VAPSHCS) medical emergency response system (MERS) during the hospital’s new hire nurse orientation via simulated patient simulator and environment. MERS consists of Code Blue, Medical Emergency Team (MET) and Rapid Response Team (RRT). New hire nurses often encounter challenges such as getting to know the new environment while they are still being asked to deliver best practices in handling safe patient care. Unfamiliarity with equipment use and new systems, as well as lacking of exposure to hands-on experience during a medical emergency may influence the performance of healthcare providers when responding to a medical emergency.3 Information delivered during the traditional approach of hospital new hire nurse orientation is by a linear model approach, where the audience members are only receivers and have limited opportunity to reciprocate or question the information. The linear model approach found to be less effective for the adult learner. New hire nurses are identified as adult learners who learn better when they gain self-directed ability and share life experiences and knowledge.2 Furthermore, they learn better when the content material is relevant to their specialty area and when they can apply hands-on practice, particularly during a medical emergency.
Description: We simulated a deteriorating patient using a high-fidelity simulator used at a hospital public common ground and/or inside simulation laboratory. Participants used role play on different team members during the simulated scenario. By the end of the exercise, a debriefing process of the team performance was conducted. A post training evaluation with 7 questions was emailed to the participants three months after the simulation experience. The target audience was new hire nurses from all levels who had participated in the new hire nurse orientation between October 2010 and December 2011. In our sample size, out of 155 participants, 22 responded. Eight out of 22 participants (36.4%) were from outpatient/CBOC/primary care. Eight out of the 22 participants (36.4%) never had the patient simulation experience prior to this activity. Nine out of 22 participants (40.9%) moderately agreed that this simulation activity provided an overview of emergency and advance response skills (MET/RRT/Code Blue within VA Puget Sound Health Care System). Eight out of 22 participants (36.4%) felt confident in identifying the proper team to activate when there is a need. Ten out of 22 participants (45.5%) rated this learning activity as useful for them. Five out of 22 participants (22.7%) commented that hands-on practice is the most helpful part during this learning activity.
Conclusion: In general, this simulated learning activity was helpful to the new hire nurse group. This training exercise has the potential to be generalized to the entire hospital and to be conducted on a regular basis by working closely with code blue team, MET, and RRT. Due to limited staffing during this pilot study, training time was challenged to deliver equally to each new hire nurse group. A further proposal is recommended to design close-ended, open-ended, and probing questions to integrate with the debriefing process.
1. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Society for Simulation in Health Care. 2007;2(2):115-125.
2. Muraida L. Training basics: adult learning techniques & communicating effectively. 2009.
3. Villamaria FJ, Pliego JF, Wehbe-Janek H, Coker N, Rajab MH, Sibbitt S, Ogden PE, Musick K, Browning JL, Hays-Grudo J. Using simulation to orient code blue teams to a new hospital facility. Society for simulation in healthcare. 2008;3(4):209-216.
1357 In Situ Simulation: Practice of the Conjoined Twins Separation Surgical Procedure
Roberta Hales, MHA, RRT-NPS, RN,1 David Rodgers, EdD, NREMT-P,2 Susan Scully, RN, BSN, CNOR,3 Tiffany Snyder, RN, BSN4
1CENTER FOR SIMULATION, ADVANCED EDUCATION AND INNOVATION, CHILDREN’S HOSPITAL OF PHILADELPHIA, PHILADELPHIA, PA, USA and 2CENTER FOR SIMULATION, ADVANCED EDUCATION, AND INNOVATION, CHILDREN’S HOSPITAL OF PHILADELPHIA, PHILADELPHIA, PA, USA and 3OPERATING ROOM, CHILDREN’S HOSPITAL OF PHILADELPHIA, PHILADELPHIA, PA, USA and 4SURGERY, CHILDREN’S HOSPITAL OF PHILADELPHIA, PHILADELPHIA, PA, USA
Introduction/Background: Conjoined twins are a rare event occurring in one out of every 200,000 births,1 with only 5-25 percent surviving to surgical separation. Depending on the connection point and underlying organ involvement, conjoined twins separation surgery can be a dynamic, complex procedure requiring effective teamwork for the safe delivery of intraoperative patient care. The success rate of a conjoined twin separation varies depending on the point of connection and the internal organs shared. Approximately 75% of conjoined twins are joined at least partially at the chest and abdomen with varying degrees of organ sharing.2 In many cases, separation results in death of one or both of the twins; however, survival increases if they have separate organs. The surgical procedure necessitates coordination between numerous specialty teams (i.e., anesthesia, general surgery, plastic surgery, cardiothoracic surgery, and nursing) to prevent tangling of various lines, and movement of personnel and conjoined twins. Due to the intricacy of the procedure, a detailed, thought-out simulation was constructed to practice the generalized sequence of events and rectify the previous challenges of the last conjoined twin surgery in preparation for the upcoming conjoined twin surgery.
Description: A needs assessment was performed to identify the previous challenges of the last conjoined twin surgery. The two-part simulation was designed and implemented prior to the actual surgery to include operating room layout and patient/surgical flow. A realistic model of the conjoined twins was created. The two simulations were scheduled at the end of day to allow participation from all disciplines. The interdisciplinary team contributed input on the best layout and surgical/patient flow. The first simulation consisted of mapping out the operating room layout of the beds and equipment, and positions of personnel in the room; while, the second simulation covered the removal of tissue expanders, surgical and line set-up, draping, the operative procedure of separation, and the movement of separated twin to the adjacent bed. Each simulation contained ongoing, mini-debriefings during the simulation process. The first simulation identified several key issues that impacted the actual event. Included among these were the decision to move to a different room better suited for the case, layout of all equipment, position of the second operating table to receive the separated twin, and the feasibility of using IT with 2 anesthesia machines. The second simulation allowed the entire team to practice the case and make several key decisions including surgical case progression and personnel resource allocation, management of lines, tubes and drains, preparing the twin to be moved in sterile manner, and the physical act of moving the newly separated twin to her own operating table.
Conclusion: In-situ simulation is an educational tool that can be utilized to practice complex, rare surgical events that require unique equipment resources and involve teams that typically do not work together within the same surgical case.
1. Spitz L, Kiely EM. Experience in the management of conjoined twins. Br J Surg. 2002 Sep;89(9):1188-92. PMID: 12190687.
2. Brizot Mde L, Liao AW, Lopes LM, Silva MM, Krebs V, Schultz R, Zugaib M. [Conjoined twins: prenatal diagnosis, delivery and postnatal outcome]. Rev Bras Ginecol Obstet. 2011 May;33(5):211-8. PMID: 21860927.
1358 Design and Implementation of Standardised Obstetric Anaesthesia Simulation Course
Makani Purva,2 David Wright, BM BS, BMedSci1
1ANAESTHETICS, HULL, UK, GBR and 2MEDICAL EDUCATION, ANAESTHETICS, HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST, HULL, GBR
Introduction/Background: The objective was to establish a standardised obstetric anaesthesia simulation course for Yorkshire Deanery core anaesthetic trainees (CT1,2). The most recent CEMD report1 identified 7 direct deaths attributable to anaesthesia and 18 indirect deaths where anaesthesia contributed to the outcome. A key recommendation is to improve communication skills, which include team working, sharing of information, and interpersonal skills. The high stakes obstetric environment presents particular challenges for team working, decision making and plan execution. Obstetric anaesthetic emergencies are also infrequently encountered. Therefore simulation is ideal for learning both non-technical skills and targeted drills, and is recommended by the RCoA. The Yorkshire region has standardised protocols for the management of obstetric emergencies and high risk patients, designed to ensure consistency of practice throughout all regional hospitals. Standardising the delivery of simulation training using a current approach to learning theory, aims to improve skill acquisition and retention and ensure a minimum standard for clinical governance purposes. This work aims to illustrate the essential stages in course implementation and assess its delivery.
Description: A multidisciplinary committee was created. This identified learning outcomes from the RCoA CCT curriculum,2 including both technical and non-technical skills. These were mapped to scenarios, applying current best practice guidelines or consensus opinion. Principles of good simulation practice were agreed. A pre-course trainee manual included learning outcomes, to ensure awareness of the performance level required. Summaries of emergencies provided a knowledge base sufficient for adequate performance. It also evidenced the role of simulation within the current medical education context to facilitate value judgments and encourage participation. A faculty manual contained learning outcomes and recipes for resources, scenario content and key management interventions. A validated objective scoring tool3 for formative assessment and a debriefing guide were included. The pilot course was delivered using SimMan 3G®, in the operating theatre environment at the Clinical Skills Facility (Hull Royal Infirmary). Faculty included anaesthetists, obstetricians, midwives and operating department practitioners. The course was subsequently disseminated to two other hospitals. Faculty and trainee manuals ensured standardisation of course delivery. Participant feedback from the pilot course was good (See Table 1).
100% of (all course) participants scored the course as meeting the learning outcomes (ntotal=33). On the most recent course 85% strongly agreed; 15% agreed that the manual was useful and adequate; and 100% strongly agreed the course was good value (ntotal=7).
Conclusion: The formation of a multidisciplinary committee, with a systematic approach to course planning and delivery, produced a course with good participant feedback. Use of a multidisciplinary process to design and deliver simulation may more reliably reproduce the variation of the clinical environment and participant behavior, creating a more immersive and higher fidelity experience. This may aid skill acquisition and retention.4 The establishment of a standardised, CCT curriculum based regional course, through the development of faculty and trainee manuals, will allow future work to reliably examine skill retention and transfer to clinical practice. Based on feedback, the course has also produced a handbook of obstetric emergencies which will be distributed to all trainees.
1. Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer, 2006-2008. Lewis, G (ed.). BJOG. 2011 Mar; 118, (s1): 1-203.
2. CCT in Anaesthetics: Annex B – basic level training. The Royal College of Anaesthetists. 2010. [Online]. Available at http://www.rcoa.ac.uk/CCT/AnnexB.
3. Development of an objective scoring system for measurement of resident performance on the human patient simulator. Scavone, B., M., Sproviero, M., T., McCarthy, R., J., Pharm, R., Wong, C., A., Sullivan, J., T., Siddall, V., J., Wade, L., D. Anaesthesiol. 2006 Aug. 105: 260-6.
4. Features of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Issenberg, S. B., McGaghie, W.C., Petrusa, E. R., Gordon, D. L. And Scalese, R. Med Teach. 2005; 27 (1): 10-28.
1370 Use of High Fidelity Radiation Therapy Technology with Standardized Patients (SPs), in the Medical Radiation Sciences (MRS) Clinical Simulation Curriculum
Renate Bradley, MRTT, MMEd,1 Reshika Balakrishnan, BSc, BSc (Medical Radiation Sciences),1 Robert Case1
1RADIATION THERAPY, UNIVERSITY OF TORONTO, MICHENER INSTITUTE MEDICAL RADIATION SCIENCES, TORONTO, ON, CAN
Introduction/Background: Simulation experiences help students to learn the skills of problem solving from simple to complex situations away from the stressed environment of clinic.1 In the summer semester of 2009, The University of Toronto/Michener Institute joint program in radiation therapy delivered the very first pre-clinical simulation course. The purpose of the course is to allow the students to practice their skills in a safe environment prior to their clinical practicum, and also to allow the faculty the opportunity to support those students who may be facing challenges.
Description: Originally, the clinical simulation semester used technology that included conventional simulators to mimic radiation therapy linear accelerators (linacs). The records and activity were also all paper based. Our department acquired new, more current technology, which includes the world’s first “cold linacs”. These linacs are fully functional therapeutic radiation equipment with the exception that they only emulate the radiation treatment beam. Our records, including feedback and evaluations, are all now electronic using commonly used clinical software. A Virtual Environment Radiotherapy Training (VERT) system and our treatment planning system are also available for the students to use to practice their learned skills. Students were tasked to perform in the role of patients, which provided an opportunity for them to identify more closely with the patient experience. Standardized patients were also employed in the curriculum and provided feedback to the students.
Conclusion: Informal feedback from students and clinical faculty indicate that the curriculum now better correlates with the clinical environment in which the students will practise. The students are able to integrate into the clinical environment more quickly and at a higher level of performance due to their hands-on practise with the current technology.
1. Akaike M, Fukutomi M, Nagamune M, Fujimoto A, Tsuji A, Ishida K and Iwata T: Simulation-based Medical Education in clinical skills laboratory. J Med Invest 2012; 59:28-35.
Disclosures:Equipment discussed supplied by Elekta Oncology Systems as part of an established partnership between the Michener Institute and Elekta Oncology.
Oral Presentation 1371 Iron SIM Wars: Utilization of Mystery Cases and Team-Based Simulation
Carman Turkelson, MSN, RN, CCRN,2 Jill Stefaniak, MTD, CPLP,3 Noaman Ali, MD,1 Barbara Joyce, PhD3
1GENERAL SURGERY, BEAUMONT HEALTH SYSTEM, ROYAL OAK, MI, USA and 2NURSING RESEARCH AND EDUCATION, BEAUMONT HEALTH SYSTEM, ROYAL OAK, MI, USA and 3MEDICAL EDUCATION, OAKLAND UNIVERSITY WILLIAM BEAUMONT SCHOOL OF MEDICINE, ROCHESTER, MI, USA.
Introduction/Background: Education for healthcare professionals is rapidly transforming, with wide spread interest in preparing providers for deliberate collaborative practice with the goal of building a safer patient centered healthcare system.1-4 Now, more than ever, it is imperative for healthcare professionals to communicate, collaborate, coordinate and jointly problem solve with multiple professionals in order to meet the growing demands of the increasingly complex healthcare needs of society.3,5-8 In order to remain competitive in the healthcare market, improve quality and safety for the patient, and to address the multifaceted needs of a dynamic patient population, healthcare organizations must make interprofessional education and practice a priority initiative and expectation.9-12 Iron SIM Wars is an innovative simulation-based strategy offering a challenging, fast paced, entertaining approach for teaching and emphasizing critical teamwork concepts for an interprofessional healthcare team. By bringing the interprofessional healthcare team together in a competitive simulated environment, team members explored communication, decision-making, judgment and leadership skills while linking critical team concepts to practice in a safe environment.13-17
Description: Iron SIM Wars capitalized off of current pop culture, modeling a leading television show, Iron Chef, in which multiple chefs compete to make a winning dish using a mystery ingredient. In the Iron SIM Wars healthcare version, the team competition focused on solving varied etiology clinical scenarios using essential teamwork skills during a simulated patient event. The objective of the competition was for the teams to work together, correctly identify the problem and initiate appropriate care in a safe and efficient manner. Core concepts from the TeamSTEPPs evidence based team training curriculum were introduced at the beginning of the competition providing participants with an introduction to the foundational knowledge, skills and attitudes of an effective team member.10 During the competition, each team was presented with a mystery case prior to embarking on the simulation exercise. Team members worked together during the simulation event to solve the case using the teamwork concepts highlighted in the TeamSTEPPS overview. Teams were scored by an expert panel of 3 judges on their teamwork skills using the Mayo High Performance Teamwork Scale18 and by their ability to appropriately diagnose the priority problem and intervene in a timely manner. Teams participating in the program, but not actively engaged in the simulation exercise, viewed the opposing team scenario as audience members, following the case script and scoring their colleagues’ teamwork abilities. Each simulation concluded with a facilitated debriefing lead by the expert panel of judges where guided feedback on teamwork performance was provided. Twelve participants forming three teams competed in the pilot IRON SIM Wars competition. All participants completed a pre and post cognitive assessment as well as the NLN Simulation Design Scale, Educational Practices Questionnaire, and Student Satisfaction and Self Confidence in Learning Surveys to gauge their perceived level of self-efficacy and satisfaction with learning.
Conclusion: Interprofessional teams have limited opportunities to learn or practice critical communication and teamwork skills; yet are expected to perform effectively in highly dynamic and stressful crisis situations.9-10, 19 Initial results from this pilot project were overwhelmingly positive providing evidence to suggest that simulation-based interprofessional educational activities (such as Iron SIM Wars focusing on communication and teamwork) is a viable option for assisting healthcare professionals in attainment of critical teamwork competencies.10, 16, 20-21
1. Dillon, P. M., Noble, K. A., & Kaplan, L. (2009). Simulation as a means to foster collaborative interdisciplinary education.Nursing Education Perspectives, 30(2), 87-90.
2. Frenk, J., Chen, L., Bhutta, Z. A., Cohen, J., Crisp, N., Evans, T., . . . Zurayk, H. (2010). Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world.Lancet, 376(9756), 1923–1958. doi: 10.1016/S0140-6736(10)61854-5.
3. Grol, R., Berwick, D. M., & Wensing, M. (2008). On the trail of quality and safety in health care. BMJ: British Medical Journal (International Edition), 336(7635), 74-76. doi: 10.1136/bmj.39413.486944.AD.
4. World Health Organization (WHO). (2010). Framework for action on interprofessional education and collaborative practice. Geneva: World Health Organization. Retrieved March 11, 2012 from http://whqlibdoc.who.int/hq/2010/WHO_HRH_HPN_10.3_eng.pdf.
5. Chassin, M., R., & Loeb, J., M. (2011). The ongoing quality improvement journey: Next stop, high reliability.Health Affairs, 30(4), 559-568. doi: 10.1377/hlthaff.2011.0076.
6. Flin, R., O’Conner, P., & Crichton, M. (2008). Safety at the sharp end: A guide to non-technical skills. Surrey, England: Ashgate.
7. Kohn, L.T., Corrigan, J., & Donaldson, M.S. (2000). To err is human: Building a safer health system. Washington, D.C.: National Academy Press.
8. Joint Commission (JCAHO) Sentinel Event Statistics Data-Root Causes by Event Type (2004-2011) Http://www.jointcommission.org/assest/1118/Root_causes_event_type_2004-2011. March 2012.
9. Salas, E., DiazGranados, D., Klein, C., Burke, C. S., Stagl, K. C., Goodwin, G. F., & Halpin, S. M. (2008). Does team training improve team performance? A meta-analysis. Human Factors, 50(6), 903-933.
10. Salas, E., DiazGranados, D., Weaver, S. J., & King, H. (2008). Does team training work? Principles for health care.Academic Emergency Medicine, 15(11), 1002-1009.
11. Weaver, S. J., Lyons, R., DiazGranados, D., Rosen, M. A., Salas, E., Oglesby, J., . . . King, H. B. (2010). The anatomy of health care team training and the state of practice: A critical review. Academic Medicine : Journal of the Association of American Medical Colleges, 85(11), 1746-1760. doi: 10.1097/ACM.0b013e3181f2e907.
12. Wilson, K. A., Burke, C. S., Priest, H. A., & Salas, E. (2005). Promoting health care safety through training high reliability teams.Quality & Safety in Health Care, 14(4), 303-309. doi: 10.1136/qshc.2004.010090.
13. Aggarwal, R., & Darzi, A. (2011). Simulation to enhance patient safety: Why aren’t we there yet?Chest, 140(4), 854-858.
14. Buljac-Samardzic, M., Dekker-van Doorn, C., van Wijngaarden, J., & van Wijk, K. (2010). Interventions to improve team effectiveness: A systematic review.Health Policy, 94(3), 183-195. doi: 10.1016/j.healthpol.2009.09.015.
15. Fernandez, R., Vozenilek, J. A., Hegarty, C. B., Motola, I., Reznek, M., Phrampus, P. E., & Kozlowski, S. (2008). Developing expert medical teams: Toward an evidence-based approach.Academic Emergency Medicine, 15(11), 1025-1036.
16. Rosen, M. A., Salas, E., Wilson, K. A., King, H. B., Salisbury, M., Augenstein, J. S., . . . Birnbach, D. J. (2008). Measuring team performance in simulation-based training: Adopting best practices for healthcare. Simulation in Healthcare : Journal of the Society for Simulation in Healthcare, 3(1), 33-41. doi: 10.1097/SIH.0b013e3181626276.
17. Zhang, C., Thompson, S., & Miller, C. (2011). A review of simulation-based interprofessional education.Clinical Simulation in Nursing, 7(4), e117-e126. doi: 10.1016/j.ecns.2010.02.008.
18. Malec, J. F., Torsher, L. C., Dunn, W. F., Wiegmann, D. A., Arnold, J. J., Brown, D. A., & Phatak, V. (2007). The mayo high performance teamwork scale: Reliability and validity for evaluating key crew resource management skills.Simulation in Healthcare, 2(1), 4-10.
19. Shapiro, M. J., Gardner, R., Godwin, S. A., Jay, G. D., Lindquist, D. G., Salisbury, M. L., & Salas, E. (2008). Defining team performance for simulation-based training: Methodology, metrics, and opportunities for emergency medicine. Academic Emergency Medicine, 15(11), 1088-1097.
20. Weaver, S., J., Salas, E., & King, H., B. (2011). Twelve best practices for team training evaluation in health care.Joint Commission Journal on Quality & Patient Safety, 37(8), 341-349.
21. Zeltser, M. V., & Nash, D. B. (2010). Approaching the evidence basis for aviation-derived teamwork training in medicine.American Journal of Medical Quality : The Official Journal of the American College of Medical Quality, 25(1), 13-23. doi: 10.1177/1062860609345664.
1390 Neonatal Simulation Medicine and Resuscitation Team Training (nSMARTT): An Innovative Inter-Professional Neonatal Education and Training Model Using High-Fidelity Simulation and Checklists
Ron Heese, CS, RRT,3 Nicole Sneath, MScN NNP-BC,4 Barbara Wheeler, RN, BN, MN, IBCLC, RLC,1 Ceceile Porter, RN, BN, CEI,1 Fabiana Postolow, MD,2 Ganesh Srinivasan, MD,DM, FAAP2
1NEONATOLOGY, SAINT BONIFACE GENERAL HOSPITAL, WINNIPEG, MB, CAN and 2PEDIATRICS AND CHILD HEALTH (NEONATOLOGY), UNIVERSITY OF MANITOBA, WINNIPEG, MB, CAN and 3CHILD AND WOMEN’S HEALTH PROGRAM, UNIVERSITY OF MANITOBA, CHILDREN’S HOSPITAL OF WINNIPEG, WINNIPEG, MB, CAN and 4NEONATOLOGY, UNIVERSITY OF MANITOBA, CHILDREN’S HOSPITAL OF WINNIPEG, WINNIPEG, MB, CAN.
Introduction/Background: Neonatal resuscitation teams require the integrated acquisition of cognitive, technical, and behavioral skills and teamwork to support neonates during the critical period surrounding birth. In high stress situations, they need to provide optimal resuscitation care and minimize potential long-term morbidities. There is a paucity of models related to team training in neonatal resuscitation and immediate care of the very low birth weight newborn. The Neonatal Resuscitation Program1through the American Academy of Pediatrics (AAP), American Heart Association(AHA) and the Canadian Pediatric Society (CPS), provides some guidance, but does not focus on other high-risk neonatal populations, nor address adequately, training strategies focused on large inter-professional groups. We have created an innovative, inter-professional neonatal education and resuscitation training model using high-fidelity simulation and checklists. This model provides step-by-step guidance as to how to plan, set-up, achieve buy-in, implement and evaluate an inter-professional simulation based neonatal program that is structured, sustainable, cost-effective and can be reproduced in different settings.
Description: We have completed ten 8 hour sessions, training between 16-20 participants per session. Sessions were conducted at the Clinical Learning and Simulation facility at the University of Manitoba with live viewing, recording, re-playing capacity and high fidelity simulators based on the needs of our scenarios. Initial steps required putting together an inter-professional leadership team trained in neonatal simulation. This faculty consisted of physicians, nurses, nurse practitioners and respiratory therapists. The learning objectives were identified based on high-priority needs from clinical areas. Stakeholders and resources were identified next. The proposal was created describing the priorities to be addressed, highlighting project goals, objectives, resources, projected costs, cost-mitigation, timeline, evaluation and sustainability. This proposal was presented to the stakeholders using a one hour long, interactive and dynamic presentation, demonstrating the capabilities of high-fidelity simulation. Once approved, a project logo was created to distinguish the program brand, followed by identification of educational and program resources for participants and facilitators (i.e. USB drives with relevant literature, lanyards, pens, t-shirts etc.) to promote nSMARTT and obtain buy-in from participants. The program was carefully designed starting with identifying an integral support team (confederates, NRP scorers, administrative staff, technical support, and simulation faculty), and developing scenarios that met the educational objectives. NRP megacodes were adapted from the NRP™ 6th edition Instructor manual; other customized high-risk group scenarios and checklists were developed. Team-training scenarios included multi-patient, multi-room scenarios. Scenarios were pre-tested and refined to ensure they were aligned with the educational objectives. The nSMARTT faculty practiced and refined their de-briefing skills in preparation for the launch of the program. An integral part of this process was the creation and refining of pre and post evaluation forms completed by all the participants. This ensured the availability of objective information needed to evaluate the program. Pre-session learning packages were provided to all participants. Through out the program continual evaluation and pre and post-session debriefing among the nSMARTT faculty was scheduled. Appropriate health and nutritional breaks, which encouraged camaraderie and continuation of medical education certificates, were provided to all participants. Following completion of all the sessions, evaluation data was analyzed and summarized and results presented to the stakeholders demonstrating the magnitude of impact on the targeted educational objectives.
Conclusion: The nSMARTT model is an innovative, customizable and scalable educational strategy that facilitates inter-professional collaboration, practice and team training. nSMARTT can address a variety of identified clinical concerns including ongoing neonatal education, knowledge translation, quality improvement and critical event management in a structured, sustainable and reproducible manner.
1. Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Pediatrics Vol. 126 No. 5 November 1, 2010 pp. e1400 -e1413 .
1427 Patient Safety: Measuring Transfer of Training from Simulation to Clinical
Teresa Gore, DNP, CRNP, RN,3 Chetan Sankar, PhD,1 Bonnie Sanderson, PhD, MSN,3 Allison Jones-Farmer, PhD2
1COLLEGE OF BUSINESS, INFORMATION SYSTEMS MANAGEMENT, AUBURN UNIVERSITY, AUBURN, AL, USA and 2COLLEGE OF BUSINESS, STATISTICS AND BUSINESS ANALYTICS, AUBURN UNIVERSITY, AUBURN, AL, USA and 3NURSING, AUBURN UNIVERSITY, AUBURN, AL, USA.
Introduction/Background: High-fidelity manikins and standardized patients have been incorporated into nursing curricula for over a decade, allowing participants to practice nursing care in a safe, controlled environment in order to promote clinical decision making practice.1,2 However, current literature is sparse regarding the transfer of skills learned during simulation to improved clinical performance.3 There is a gap in empirical research that provides valid and reliable tools that evaluate the effectivenss in transitioning from simulation to clinical practice.4-7 Both Quality for Safe Education for Nurses (QSEN)6 and the Institute of Medicine (IOM)4,5,7 have called for transformation in nursing education to focus on quality and safety evidence-based nursing practice to improve patient care ultimately leading to improved patient outcomes.
Description: In response to this, a cross-disciplinary team of researchers with expertise in the following areas joined together to research this area further: 1). implementing simulation in nursing programs, 2). researching educational innovations and pedagogy, 3). developing research methods and testing them using statistics and business analytics, and 4). designing nursing clinical curricula. Identification of a model based on Social Learning Theory and Constructivism Theory9,10 was used to measure the effectiveness of dissemination of educational innovations10–13 as the basis of the proposed research. The model used the following constructs (and factors in parenthesis) to compute learning effectiveness measure the following: 1). learning experience (changes in skill, comprehension, application, attitude, and competencies), 2). facilitator or catalyst (learning objectives, modular presentation, local care setting, inspiration, and encouraging learners to explore and discover), 3). technology (interface design, content, interactivity, usability, and flexibility), 4). interaction and participation (ease of communication, response time, needs of multiple stakeholders, and encouragement of participation), 5). mentor’s inspiration (presentation methods, design, motivation techniques, timely feedback, and assistance rendered), and 6). hindrance and development (stress, boring content, dissatisfaction, dicontent, and lack of guidance). This model was adapted for simulation use in nursing curricula and a pilot study during Summer 2012. In the pilot study, we related Mashaw’s10 measure of perceived learning effectiveness to instructor/professional ratings of in-practice performance in a clinical setting. The application of knowledge in a clinical setting was measured on the key concepts of content knowledge (patient safety), communication, and critical thinking14. Figure 1 describes the model that was used to guide the research in the study.
Conclusion: A performance comparison was made between the simulation and clinical scores to evaluate students’ incorporation of key concepts into clinical practice of patient safety. At the completion of each segment (simulation and clinical rotation), students also completed the learning effectiveness questionnaire. The results of the study will be discussed at the conference. The results show that application of this model in nursing simulation programs has the potential to identify approaches that stand the best chance of demonstrating a convincing link between performance in the simulation and patient safety outcomes.
1. A Framework for Technology Enhanced Learning. DOH, Nov 2011 http://www.dh.gov.uk/publications.
2. Communication and Miscommunication: Handover between Junior Doctors. Hayes AJ, Pool R, Roughley C, Scholes S, Sharifi L, Woodside R, Reilly S, Roberts P, Salter T, Singleton LReinvention: A journal of research. 2012 Apr 5(1).
1. Gore T, Van Gele P, Ravert P, Mabire C. A 2010 survey of the INACSL membership about simulation use. Clinical Simulation in Nursing. 2012;8:125-33. DOI:10.1016/j.ecns.2012.01.002.
2. Nehring WM. High-fidelity patient simulation in nursing education. Sudbury: Jones and Bartlett Publishers; 2010.
4. Institute of Medicine (IOM). Crossing the quality chasm: A new health system for the 21stcentury. Washington: National Academies Press; 2001.
5. Institute of Medicine (IOM). Health professions education: A bridge to quality. Washington, DC: National Academies Press; 2003.
6. Cronenwett L, Sherwood G, Barnsteiner J, Disch J, Johnson J, MitchellP, Taylor Sullivan P,.Warren J. Quality and safety education for nurses. Nursing Outlook. 2007;55:3 122-31.
7. Wachter RM. The end of the beginning: Patient safety five years after “To err is human”. Health Affairs. 2004;W4:534-45.
8. Alessi SM, Trollip SR. Multimedia for learning: Methods and development (3rded.). Boston: Allyn & Bacon; 2001.
9. Bandura A. Social foundations of thought and action. Englewood Cliffs: Prentice-Hall; 1985.
10. Mashaw B. A model for measuring effectiveness of an online course. Decision Sciences Journal of Innovative Education. 2012;10:2 189-221.
11. Hazen B, Wu Y, Sankar CS, Farmer A. A proposed framework for educational innovation dissemination. Journal of Educational Technology Systems. 2012;40:3 301-21.
12. Sankar CS, Raju PK. Use of presage-pedagogy-process-product model to assess the effectiveness of case study methodology in achieving learning outcomes. Journal of STEM education: Innovations and research. 2011;12:7 45-56.
13. Sankar CS, Clayton H. An evaluation of use of multimedia case studies to improve an introduction to information technology course. International Journal of Information Communication and Technology Education. 2010; 6:3 25-37.
14. Bradley RV, Sankar CS, Clayton, HR, Mbarika V, Raju, PK. A study on the impact of GPA on perceived improvement of higher-order cognitive skills. Decision Sciences Journal of Innovative Education. 2007;5:1: 151-68.
15. Gore, T., Hunt, C.W., & Raines, K.H. Mock hospital unit simulation: A teaching strategy to promote safe patient care. Clinical Simulation in Nursing. 2008;4:5 57–64. DOI:10.1016/.
1428 Neonatal Simulation Medicine and Resuscitation Team Training (nSMARTT): An Innovative, Customizable and Scalable Inter-Professional Neonatal Education and Training Initiative Using High-Fidelity Simulation and Checklists
Barbara Wheeler, RN, BN, MN, IBCLC, RLC,1 Ceceile Porter, RN, BN, CEI, 1 Nicole Sneath, MScN NNP-BC,4 Ron Heese, CS, RRT,3 Fabiana Postolow, MD,2 Ganesh Srinivasan, MD,DM, FAAP2
1NEONATOLOGY, SAINT BONIFACE GENERAL HOSPITAL, WINNIPEG, MB, CAN and 2PEDIATRICS AND CHILD HEALTH (NEONATOLOGY), UNIVERSITY OF MANITOBA, WINNIPEG, MB, CAN and 3CHILD AND WOMEN’S HEALTH PROGRAM, UNIVERSITY OF MANITOBA, CHILDREN’S HOSPITAL OF WINNIPEG, WINNIPEG, MB, CAN and 4NEONATOLOGY, UNIVERSITY OF MANITOBA, CHILDREN’S HOSPITAL OF WINNIPEG, WINNIPEG, MB, CAN.
Introduction/Background: Neonatal resuscitation teams require the integrated acquisition of cognitive, technical, and behavioral skills and teamwork to support neonates during the critical period surrounding birth. The Joint Commission sentinel event reports describe how most errors and neonatal deaths occurred due to difficulties in team dynamics and communication. The American Academy of Pediatrics (AAP) and the Canadian Pediatric Society (CPS) have emphasized the role of Simulation and debriefing in the new Neonatal Resuscitation Program (NRP™ ) training curricula. Traditional educational methods and strategies such as didactic education days related to high-stakes neonatal intensive care at our institution were not effective in changing practitioner’s perceptions, attitudes and practice. There was also the need to train a large group of individuals in a relatively short period of time and no suitable models to address this need. We created a neonatal education and training model, nSMARTT, using high-fidelity simulation, the incorporation of checklists and facilitated debriefing, in order to address knowledge gaps, enhance team dynamics, and provide insight into high-stress neonatal clinical situations.
Description: The nSMARTT concept was designed by an inter-professional core group trained in medical simulation who obtained support from stake holders of the Child Health Program of the Winnipeg Regional Health Authority (WRHA). Ten one-day simulation workshops were conducted for 163 participants including nurses, respiratory therapists, nurse practitioners and physicians from the two tertiary neonatal care facilities in Winnipeg, Manitoba. The faculty included 6 facilitators, 4 confederates and 2 NRP Instructor scorers. The Sim Baby™, Sim NewB™, Noele™, Baby Hal™ and Lifeform™ Micro-Premie simulators were used. The multilayered format including interactive didactic sessions, simulation, and debriefing sessions including video were conducted at the Clinical Learning and Simulation facility, University of Manitoba. Four main educational objectives, introduction to simulation, team training, NRP and Golden hour, were identified for the initiative. Customized transitional checklists for “Golden hour” training were utilized. Informed consent for audio and video recording was obtained from all participants. Pre and post- participation evaluations using questionnaires and the Student DASH©-SV were used.
Conclusion: The nSMARTT educational initiative was well received by participants despite initial concerns about video debriefing and helped harness the collective experience of neonatal health care professionals working as teams. The nSMARTT inter-professional simulation-based team training model is an innovative customizable and scalable educational strategy, which facilitated inter-professional collaboration, knowledge translation and practice, while re-energizing and enhancing the culture of safety.
1. The Joint Commission. Preventing infant death and injury during delivery. Joint Commission Sentinel Event Alert, July21, 2004; Issue 30.
2. The Joint Commission. Preventing deaths during, after pregnancy.Joint Commission Sentinel Event Alert, January 26,2010; Issue 44.
3. Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Pediatrics Vol. 126 No. 5 November 1, 2010 pp. e1400 -e1413.
4. Simon R, Raemer DB, Rudolph JW. Debriefing Assessment for Simulation in Healthcare©– Student Version, Short Form. Cambridge, MA Center for Medical Simulation, 2010.
1448 Family and Community Medicine Post-Graduate Course Using Simulation as a Learning Method
Marco Marangoni, MD, PhD,3 Juliana Garcia, MD, MSc,1 Ana Iamassaki2
1PRESIDENTE PRUDENTE, SAO PAULO, BRA and 2ASSOCIATO LAR OF FRANCISCO, SAO PAULO, SP, BRA and 3MEDICAL SKILLS, UNOESTE WESTERN SAO PAULO UNIVERSITY, PRESIDENTE PRUDENTE, SP, BRA.
Introduction/Background: The use of simulation has largely been used in medical education specialties for urgency and emergency training. In Brazil, the primary care providers are known as family and community health providers (FCHP), and courses in this field usually adopt tradicional classes covering the most common diseases in primary care. Permanent education is the education based on needs identified by the professionals themselves during their process of work, which allows them to identify faults during their university courses.
Description: Considering the low availability of specialized professionals in primary care in Brazil, it’s common that the physicians and nurses that are working as FCHP do not have any specialization in this field. To improve the quality of assistance for the population, the government organizes courses of post-graduation in primary care to the professionals in a standard classical model, considering the most prevalent diseases treated in the basic health, and without consideration for the ability of the professional involved. This work shows a different strategy to a post-graduate course in family and community medicine for a specific group, composed of 19 nurses and 19 physicians, responsible for 19 basic heath units in the far west of the São Paulo state in Brazil. Half of the units were in a rural area, and the other half in an urban area of small cities. First the group discussed the difficulties that they experienced during their works. Visits to 19 basic health units were also made to understand the resourses/conditions that the professionals had; and based on the outcomes of the visits, different post- graduate courses were proposed, using simulation as the main teaching method. Initially, the simulation focused on communication and behavioral skills, considering that the relationship between the team and the community was acknowledged as a major problem. Ten different situations, all suggested by the professionals, were simulated and after received appropriate debriefing in groups of 9 or 10 professionals, mixing nurses and physicians, to emphasize the need of respect and teamwork. It was made with a personal camera and the debriefings were captured with the use of a simple image projector or a TV connected to the camera. Once reviewed, interpreted, and implemented, the cases were simulated in the same condition observed during the visits to the basic health units. This part of the simulation was conducted in the Skills and Simulation Laboratory in the University that was responsible for the course and certification, using a variety of low fidelity simulators of diferent brands and high fidelity simulators, such as SimMan 3G and Gaumard’s one year, five year and Noelle. The course lasted for 18 months and all the topics discussed were ultimately placed into permanent education, creating a new opportunity of formation and significant learning, considering that the needs of the professionals were implemented.
Conclusion: When we consider the psychological basis of adult education, we observe that health simulation is one of the most powerful instruments that promotes significant learning. This, combined with permanent education in the post graduate courses, can be used as a new strategy to prepare the professionals and may have a major role in the quality of assistance that the population receives (considering that it attempts to correct the faults showed during the graduation of these individuals).
1. Issenberg, S. B.; McGachie, W.C.; Petrusa, E.R.; Gordon, D.L.; Scalese, R.J. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher, vol. 27, n° 1, 2005 pp. 10-28.
2. Koponen J, Pyörälä E, Isotalus P. Comparing three experimental learning methods and their effect on medical students attitudes to learning comunication skills. Med Teach. 2012;34(3):e198-207.
3. da Silva LA, Ferraz F, Lino MM, Backes VM, Schmidt SM. Permanent education in health and nursing work: perspective os a transformative práxis.Rev Gaucha Enferm. 2010 Sep;31(3):557-61.
1454 A Grading Scale for Determining Lumbar Puncture Competency
Joshua Lenchus, DO, FACP, SFHM,2 Kaitlyn Ferreri, BS,1 Jesus Seda, BS,1 Israel Ugualde, BS1
1ANESTHESIOLOGY, UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE, MIAMI, FL, USA and 2MEDICINE, UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE, MIAMI, FL, USA.
Introduction/Background: A simulation-based procedural curriculum for house staff was developed in conjunction with the University of Miami, Jackson Memorial Hospital Center for Patient Safety. This project focuses on the safe performance of lumbar punctures by residents. As with other bedside procedures, patients who undergo a lumbar puncture can have complications; the specimen yield may be adversely affected, and/or the procedure may fail altogether. Competency is defined as the ability to perform the procedure independently, and without the need for supervision. It follows that those who achieve competency should have the highest completion rates, in the minimum number of tries (e.g. needle passes), with the least number of complications. We sought to create a systematic determination of each trainee’s readiness in performing lumbar punctures at the conclusion of the rotation. The validity of such an end-point competency rating may allow for further innovation in simulation-based training programs, namely, potential follow-up requirements for those not yet deemed competent.
Description: At the outset of a four-week immersive rotation on the Procedure Team, participants undergo expert training in a zero-risk, simulated session, using anatomically-correct, fluid-filled mannequins. Our simulation component provides demonstration, rehearsal and feedback on best-practice tenets for lumbar puncture. A comprehensive procedural checklist is used to assess a resident’s performance during this exercise and, subsequently, during the performance of the procedure on hospitalized patients. Each procedure is supervised by a dedicated attending; the checklist is scored, and rated subjectively by the supervisor and operator on a 1-5 grading scale (1, lowest; 5, highest). Every procedure provides a determination of resident competency as follows: (1). Not Competent: Less than 100% checklist score, and/or a subjective rating less than 4/5; (2).Borderline Competent:100% checklist score and all subjective ratings at least 4/5; (3).Competent: 100% checklist score; 5/5 faculty rating; 4/5 or 5/5 resident self-rating; (4). As a resident ascends the grading scale, the highest attained threshold is used to determine the final competency category. Competency determinations were linked to outcome measures in order to best gauge the applicability of the grading categories. When groups were compared, improving trends were noted through the following four outcome indicators: (1). Few passes: completed procedures that required no more than 2 needle passes; (2). Completed: attempted lumbar punctures that resulted in CSF sample; (3). Complication-free: completed procedures that did not result in a “traumatic tap” (e.g. CSF RBC ≥ 400); (4). Composite success: few passes, completed and complication-free. Refer to Table 1.
Conclusion: A simulation-based lumbar puncture curriculum, coupled with an experiential rotation, may assist in ultimate competency determination. Based on a step-wise increase of positive procedural outcomes, our grading system may prove useful in such assessment. Armed with this information, house staff would understand the need for further supervision until deemed competent. Our three-level, discrete grading scale is a practical and innovative approach to competency determination that may serve as a model for other training programs.
1457 Simulation-Based Assessment and Retraining for the Anesthesiologist: A Case Series of Twenty Participants
Stefan Samuelson, MD,1 Samuel DeMaria Jr, MD,1 Andrew Schwartz, MD,1 Alan Sim, MD,1 Adam Levine, MD
1ANESTHESIOLOGY, MOUNT SINAI SCHOOL OF MEDICINE, NEW YORK, NY, USA.
Introduction/Background: Anesthesiologists are a heterogeneous group, and current models of determining and maintaining competency in physicians may be inadequate for those with greater needs. We present a case series of 20 participants in which the simulated OR environment provides an effective means for assessing baseline competency in this specialized population, as well as a way to retrain physicians prior to return to clinical practice. Competency in anesthesia is a moving target throughout one’s career.1,2 The current model for assessment and maintenance, namely the ABA examination and MOCA programs, may not be adequate for all anesthesiologists; specifically, those whose needs are greater due to limited scope of practice, hiatuses from clinical duty, or medico-legal issues. While the use of simulation in anesthesia education has received increasing attention in recent years,3 at present few programs exist to address the needs of this specialized sub-population.4-6 This paper describes a program developed in our institution, using combined written and simulator-based education, to help determine competency in licensed and previously-licensed anesthesiologists prior to return to clinical practice.
Description: We have been using simulation as a tool for assessment and retraining at our institution since 2002. Physicians are referred or self-refer to our center with various needs: assessment, retraining, OR observation, or a combination of these. An initial needs assessment is followed by a feasibility assessment and finally an offer back to the participant or referring body regarding pricing, length, and a course of action specific to the participant’s needs. The participant then undergoes a four-hour simulator orientation, followed by an adaptable two-day formal simulation-based assessment. It is conducted with two board-certified anesthesiologists observing the cases in real time and two other support staff who portray other OR personnel as indicated. A minimum of three cases are presented on each day, with specific ACGME core competencies assessed. The assessment process is adjusted on an ongoing basis at the observers’ discretion to fully characterize areas of competency which need improvement. In addition, participants complete a standard CA-3 level Anesthesia Knowledge Test (AKT). After written and simulation-based assessment is completed, participants are debriefed extensively on their results. When indicated, a retraining regimen is designed, which is specific to their needs, but usually consists of a combination of simulation and observership with 3-4 simulated cases per day followed by 4 hours of OR time.
Conclusion: Anesthesiologists seeking to return to active clinical status are a heterogeneous group. The simulated environment provides an effective means by which to assess baseline competency and also a way to retrain physicians.
1. Gallagher CJ, Tan JM. The current status of simulation in the maintenance of certification in anesthesia. Int Anesthesiol Clin. 2010;48(3):83-99.
2. American Medical Association: Report 6 of the Council on Medical Education (A-08). Physician reentry Chicago; 2008 [http://www.ama-assn. org/ama1/pub/upload/mm/377/cmerpt_6a-08.pdf], accessed 7 April 2012.
3. Steadman RH. The American Society of Anesthesiologists’ national endorsement program for simulation centers. J Crit Care. 2008;23(2):203-6.
4. Varjavand N, Greco M, Novack DH, Schindler BA. Assessment of an innovative instructional program to return non-practicing physicians to the workforce. Med Teach. 2012; 34(4):285-291.
5. Larson CP Jr, Steadman RH. An advanced specialty training program in anesthesiology: a special educational fellowship designed to return community anesthesiologists to clinical practice. Anesth Analg. 2006;103(1):126-30.
6. DeMaria S Jr, Levine AI, Bryson EO. The use of multi-modality simulation in the retraining of the physician for medical licensure. J Clin Anesth. 2010;22(4):294-9.
1462 Implementation of A Training Program to Standardization of Facilitators for a Complex Undergraduate Medical Education Simulation Curriculum
Lisa Buckley, MS, PA-C,1 Diana Callender, MBBS, DM,1 Jenifer Cannon, MD, FACOG,1 Nancy Selfridge, MD1
1INTEGRATED MEDICAL EDUCATION, ROSS UNIVERSITY SCHOOL OF MEDICINE, PICARD, PORTSMOUTH, DMA.
Introduction/Background: Over the last three years a simulation curriculum has been developed and integrated into the systems-based preclinical curriculum for Semesters One through Four at Ross University School of Medicine. Each semester students participate in two different simulation sessions each lasting 50 minutes. The sessions contain a case that runs 15-20 minutes with a 30-minute debriefing. There are eight different simulation activities run for approximately 1,300 to1,350 students per semester and are repeated every four months giving approximately 7,800 to 8,000 hours of simulation per year. Each group contains eight students and one facilitator. There are 13 facilitators who have approximately 40% of their time allocated to simulation. Two simulations are collaborations with other departments. One focuses on Behavioral Science and medical ethics that is co-facilitated with a Simulation and Behavioral Science faculty member per group. There is also an airway management simulation, which gives clinical context and reinforces anatomy lab and lecture material. These sessions are also co-facilitated. Approximately fifteen behavioral Scientists and fifteen Anatomists are trained with the Simulation facilitators for these activities. During simulation formative assessment includes teamwork, professionalism, patient evaluation, formulation of differential diagnoses, and lab investigations. Knowledge transfer is assessed on post-tests. Summative assessment isby multiple-choice questions on written exams. Semesters Two, Three, and Four students have a simulation station in their OSCE where assessment includes a focused history and physical, interpreting vital signs, and discussing differential diagnoses, investigations and management. The requirements for each semester increase in difficulty from Semesters Two through Four.
Description: The training program has evolved as the curriculum was rolled out and refined. Currently, facilitator training begins with an initial two day introduction to simulation, which includes a tour of our facilities, multiple presentations, and interactive exercises on facilitating and debriefing simulations, including the use of the advocacy-Inquiry technique1 where relevant. A teaching algorithm has been developed for each case, based on the learning objectives, which all facilitators are required to follow. There is also a reading assignment for students, which helps ensure that all testable material is covered. Facilitators review the students’ reading assignments and the learning objectives of the upcoming case prior to a two hour training, which occurs eight times per semester. During the first hour of training feedback is elicited from the last case that was run and recommendations for case modifications are made. These are incorporated into the case in a meeting of senior faculty prior to the next semester’s training session. One or two randomly chosen video recordings of the case are also reviewed and the quality of facilitation in the videos is discussed and feedback is given to the facilitators. During the second hour of training, the documents used in the simulation are reviewed, including the learning objectives, debriefing checklists, laboratory values and imaging studies of the upcoming case are reviewed and questions are answered. The case is then run with facilitators as participants. This dress rehearsal helps troubleshoot any issues that may arise when the case is run with students.
Conclusion: When integrating simulation into a pre-clinical medical curriculum, the standardization of the simulation sessions by rigorous facilitator training is essential for student satisfaction and positive learning outcomes, especially when high stakes testing is involved.
1. Rudolph JW, Simon R, Dufresne RL, Raemer DB. There’s No Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment. Simulation in Healthcare. 2006;1:49-55.
1479 Acute Ischemic Stroke Simulation: A Pilot Module for Incoming Neurology Residents
Heidi Woessner1 Kevin Barrett, MD, MSc,3 William Cheshire, MD2
1MAYO CLINIC, ROCHESTER, MN, USA and 2NEUROLOGY, MAYO CLINIC, ROCHESTER, MN, USA and 3NEUROLOGY, MAYO CLINIC FLORIDA, JACKSONVILLE, FL, USA.
Introduction/Background: Acute ischemic stroke is a medical emergency that is frequently encountered by junior neurology residents early in training. Treatment is time-sensitive and depends upon rapid and accurate bedside evaluation and interpretation of neuroimaging studies. We designed a standardized acute ischemic stroke simulation to assess incoming neurology residents’ abilities to determine eligibility for intravenous thrombolysis for treatment of acute ischemic stroke.
Description: The training scenario was carried out in the Mayo Clinic Multidisciplinary Simulation Center. A simulated patient was used to provide history and examination findings suggestive of an acute stroke syndrome. Each trainee was instructed to obtain a focused history and perform a standardized 11-item neurological assessment (National Institutes of Health Stroke Scale) on the simulated patient. Real-time vital signs were displayed on dual monitors in the simulation room, and a non-contrast head CT was available for review. The scenario also included a nurse who reported laboratory values to the trainee and received the trainee’s verbal treatment orders. A staff member scored each trainee on the elements necessary to determine eligibility for intravenous thrombolysis, which included gathering of essential historical details, accurate neurologic examination, correct interpretation of the head CT, taking notice of increasing blood pressure values, timeliness of decision-making, and ability to communicate effectively and courteously with the patient and the medical team. The trainee was debriefed by the examiner at the conclusion of the simulation module.
Conclusion: Five incoming neurology and neurosurgery residents completed the acute ischemic stroke simulation. The time to complete the patient simulation scenario ranged from 12 to 18 minutes with a mean time of 15 minutes. All trainees accurately established the time of symptom onset, performed essential elements of the NIHSS, correctly interpreted the non-contrast head CT, identified and properly managed blood pressure, and discussed the rationale, risks, benefits, and alternatives to reperfusion therapy with the patient. All of the learners indicated that they found the exercise to be valuable toward developing their clinical skills of stroke assessment. In followup interviews, trainees indicated that the simulation exercise reduced their level of anxiety when evaluating their first hospital patient presenting with acute stroke symptoms. A standardized acute ischemic stroke simulation is feasible to perform at the outset of neurology residency. Simulation has the potential to identifyknowledge gaps early in training and prior to evaluating patients with acute stroke syndromes.
1480 OBGYN Residency Ambulatory FOSCE to Assess Interpersonal and Communication Skills Competency
Michele Manting, MD, MEd1
1OBSTETRICS AND GYNECOLOGY, TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER, PAUL L FOSTER SCHOOL OF MEDICINE, EL PASO, TX, USA.
Introduction/Background: A minimum of 50% of the average OBGYN generalist’s professional practice is spent providing ambulatory care. This setting provides the perfect laboratory for residents to hone communication skills. Bread and butter communication issues include various forms of counseling, obtaining informed consent and dealing with challenging patients. A clinician’s success at handling these issues is a marker of the ACGME’s Interpersonal and Communication Skills competency (ICS). This competency is important for practice building and has been linked to enhanced patient safety as well as limiting professional liability. But do we effectively evaluate our success in delivering residents with these important skills? Common assessment strategies include patient satisfaction surveys, rotational evaluations and 360 degree evaluations. These assessments infer generalized competence across a wide variety of possible clinical settings. A simulated clinic employing standardized patients (SP) allows for objective, standardized clinical examination (OSCE) of specific skills related to these encounter types. Our institution chose to use both global faculty assessment and standardized topic-specific checklists in a formative OSCE, which primarily provided feedback designed to stimulate professional growth through self reflection by identifying personal practice specific needs. In theory this should transfer to improved patient care and safety.
Description: Three 15-minute patient encounters were designed using a University of Washington ISIS case template in the following manner: ACGME ICS competency and program objectives were correlated with faculty input regarding potential ICS weaknesses; specific goals and objectives for each encounter were then linked to program objectives; and finally three cases were fleshed out. The cases developed were: 1). a 23 year old presenting for sterilization counseling; 2). a 45 year old woman requesting emergency contraception and 3). an angry patient frustrated by a series of office blunders. All actors and faculty underwent 2 hours of training to standardize presentations and evaluation. Standardized counseling checklists were identified and modified to meet the case objectives. Permission was obtained to use a global communication competency worksheet developed by the Indiana University OBGYN program. We partnered with the Paul L. Foster School of Medicine ATACS simulation center to host and video the FOSCE. Resident schedules were modified and Friday morning was chosen to accommodate night float rotators prior to going off for the weekend. For each video recorded encounter, two different faculty completed evaluations. One completed a global ICS assessment and the other scored the topic specific checklist. Residents received access to their videos and copies of all completed evaluation forms. They then set personal practice goals based on feedback and self-reflection.
Conclusion: An Ambulatory FOSCE is logistically feasible even in a clinically demanding OBGYN residency. What stood out was the difference between global assessment ratings (100% met expectations) compared to the checklist specific ratings for the counseling sessions (less than 50% of expected items consistently scored correctly by 100% of residents). There was not a similar discrepancy in the angry patient case. One difference between the two encounter types was the requirement to demonstrate application of clinical knowledge while otherwise communicating appropriately in the counseling sessions. This is an important distinction for the simulation community because it demonstrates the complexity of evaluating communication encounters-especially when improving patient collaboration, satisfaction and safety are intended outcomes of training. Reproduction of a similar discrepancy between global and checklist specific results at other programs or in different OSCE counseling and communication cases is an important next step. If similar results can be reproduced, it represents a significant gap in the current evaluation of ICS that can perhaps best be evaluated through similar simulations. We intend to have an annual Ambulatory FOSCE and subsequent offerings will be planned with research questions.
1. A core competency-based objective structured clinical examination (OSCE) can predict future resident performance. Wallenstein J, Heron S, Santen S, Shayne P, Ander D. Acad Emerg Med. 2010 Oct;17 Suppl 2:S67-71. doi: 10.1111/j.1553-2712.2010.00894.x. PMID:21199087[PubMed - indexed for MEDLINE].
2. Assessing competence in communication and interpersonal skills: the Kalamazoo II report. Duffy FD, Gordon GH, Whelan G, Cole-Kelly K, Frankel R, Buffone N, Lofton S, Wallace M, Goode L, Langdon L; Participants in the American Academy on Physician and Patient’s Conference on Education and Evaluation of Competence in Communication and Interpersonal Skills Acad Med. 2004 Jun;79(6):495-507 PMID: 15165967[PubMed - indexed for MEDLINE].
3. Assessing residents’ communication skills: disclosure of an adverse event to a standardized patient. Posner G, Nakajima A. J Obstet Gynaecol Can. 2011 Mar;33(3):262-8. PMID:21453567[PubMed - indexed for MEDLINE].
4. Beyond fulfilling the core competencies: an objective structured clinical examination to assess communication and interpersonal skills in a surgical residency. Yudkowsky R, Alseidi A, Cintron J. Curr Surg. 2004 Sep-Oct;61(5):499-503 PMID:15475105 [PubMed - indexed for MEDLINE].
5. Clinical skills assessment of procedural and advanced communication skills: performance expectations of residency program directors. Langenau EE, Zhang X, Roberts WL, Dechamplain AF, Boulet JR. Med Educ Online. 2012;17. doi: 10.3402/meo.v17i0.18812. Epub 2012 Jul 23. PMID:22833698 [PubMed - in process].
6. Comparison of faculty, peer, self, and nurse assessment of obstetrics and gynecology residents. Davis JD. Obstet Gynecol. 2002 Apr;99(4):647-51. PMID:12039128 [PubMed - indexed for MEDLINE].
1482 Increasing Rates of Evidence-Based PTSD Treatment Using Virtual Patient Simulations to Train Primary and Mental Health Care Practitioners
Glenn Albright, PhD1
1RESEARCH, KOGNITO INTERACTIVE, NEW YORK, NY, USA.
Introduction/Background: The prevalence of PTSD in the U.S. is increasing with almost 10% of women and 4% of men meeting criteria, including the high incidence among Iraq and Afghanistan veterans. The resulting toll on the individual often has devastating effects on the family and workplace, and, when factoring in healthcare costs, the economic loss is over 3 billion dollars annually. To effectively deal with this national mental health crisis, primary care physicians (PCPs) need to identify symptoms of PTSD and make appropriate referrals. Mental Healthcare Practitioners (MHPs) then must apply evidenced-based treatments. However, at each stage of the process - identification, referral and treatment – the current response from clinicians is inadequate. PCPs are in an ideal position to recognize trauma-related mental health conditions, such as PTSD, depression, alcohol or substance abuse, all of which can be masked by a host of physical ailments. According to a recent SAMHSA study, a significant proportion of adults with mental illness (62.1% or an estimated 27.9 million people) go untreated. Many patients with trauma-related mental health disorders go unidentified in PCP settings due to: 1) lack of training in symptom recognition and treatment options; 2) time constraints; 3) inadequate follow-up care with recognized at-risk patients; and 4) liability concerns. PTSD requires evidence-based treatment such as Prolonged Exposure (PE) therapy, a well-accepted but underutilized cognitive behavioral treatment that encourages patients to gradually but directly confront the memories of traumatizing events. Many MHP’s are reluctant to employ PE due to: 1) lack of adequate training; 2) contraindicated for PE evokes strong emotional reactions in patients; 3) concerns about symptom exacerbation; 4) high dropout rates; and 5) PE is too “manualized” and inflexible in its approach and practice.
Description: As a key element to its preparedness initiatives, the New York City Department of Health & Mental Hygiene (NYC-DOHMH) seeks to increase the early detection, referral and treatment of those individuals who have experienced traumatic events. Along with numerous nationally recognized subject matter experts (SMEs), NYC-DOHMH has collaborated with Kognito Interactive to develop the first virtual reality, avatar-based role-play simulations to: (1) train PCPs in identifying and making effective referrals of patients at-risk to MHPs and (2) train MHPs in conducting PE therapy. In both simulations, learners are placed in a virtual environment and interact with emotionally responsive virtual patients who possess memory and personality, thus react like real people who have experienced trauma and would benefit from PE. Simulation components address PCP and MHP barriers to detection, referral and treatment and employ role-plays coupled with real-time feedback from a virtual coach. As a result, learners become more proficient in internalizing best-practices and confident in managing the difficult conversations that often characterize working with this patient population. These simulations were built using Kognito’s Human Interaction Game Engine (HIGE), which integrates components drawn from cognitive neuroscience, social learning theory and motivational interviewing. HIGE’s has been used in creating dozens of simulations with several accepted for review by the National Registry of Evidenced-Based Programs and Practices. This presentation will demonstrate the simulations and explain the behavioral analytics tool, a part of the HIGE, which enables the capture and assessment of user conversation tactics that underlie changes in behavioral outcomes. Also, pilot data will be presented as well those factors contributing to a close cooperation between NYC-DOHMH, SMEs and Kognito to successfully develop the training.
Conclusion: Online, virtual patient role-play simulations have tremendous potential to engage large numbers of healthcare professionals in addressing significant needs. Such programs offer significant advantages by engaging users in hands-on, narrative-driven best-practice experiences that cost-effectively reach geographically dispersed populations to build knowledge and skills addressing health-driven behaviors in risk-free environments.
1. Albright, Glenn; Goldman, Ron; Shockley, Kristen M; McDevitt, Fiona; & Akabas, Sam. Using an Avatar-Based Simulation to Train Families to Motivate Veterans with Post-Deployment Stress to Seek Help at the VA. Games For Health: Research, Development, and Clinical Applications; 2011. 1(1), 9 p.
2. Becker, Carolyn; Zayfert, Claudia; and Anderson, Emily. A Survey of Psychologists’ Attitudes Towards and Utilization of Exposure Therapy for PTSD. Psychology Faculty Research. Paper 7; 2004. Retrieved from: http://digitalcommons.trinity.edu/psych_faculty/7.
3. Collins et al. Evolving Models of Behavioral Health Integration in Primary Care; 2008. Milbank Memorial Fund.
4. Dekel R, Monson C. Military-related post-traumatic stress disorder and family relations: Current knowledge and future directions. Aggress Violent Behav; 2010; 15:303 p.
5. Provider Training Content Draft. NYC Department of Health and Mental Hygiene in collaboration with the WTC Centers of Excellence and Weill-Cornell Medical Center; 2011.
6. US Department of Health and Human Services (2010). Mental Health United States, 2010. Substance Abuse and Mental Health Services Administration (www.samhsa.gov); 2010.
7. Powers, Mark B.; Halpern, Jacqueline M.; Ferenschak, Michael P.; Gillihan, Seth J.; Foa, Edna B. A Meta-Analytic Review of Prolonged Exposure for Posttraumatic Stress Disorder. Clinical Psychology Review; 2010. 30(6), 635 p.
8. Tanielian T, Jaycox LH, eds.Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences and Services to Assist Recovery; 2008. Santa Monica, CA; RAND Corporation.
Disclosures: Glenn Albright, PhD, is Co-Founder of Kognito Interactive.
1483 Comprehensive, Simulation-Based Clinical Care Orientation Informed Quality and Safety Mechanisms Prior to Moving to New Hospital Facilities
Pamela Andreatta, PhD,2 David Marzano, MD1
1OBSETRICS AND GYNECOLOGY, UNIVERSITY OF MICHIGAN, ANN ARBOR, MI, USA and 2OBSTETRICS AND GYNECOLOGY, UNIVERSITY OF MICHIGAN, ANN ARBOR, MI, USA.
Introduction/Background: The obstetrics and gynecology department of a tertiary care academic medical and level 3 trauma center moved its entire operations from a 25 bed, centrally oriented facility to a tangential location situated further from the main hospital and adult emergency medicine facilities. The new facilities included a fourfold increased footprint, 63 patient suites and 4 operating theatres arranged in logistically and physically distinct maze-like pods with few directly connecting corridors. Clinicians (physicians, nurses, allied health professionals, etc.) expressed concerns about their ability to seamlessly transfer patient care to the new environment, as well as to respond in a timely manner to consult requests from the main hospital or emergency department. The purpose of the program was to identify areas of concern for transferring patients within and between clinical units, manage patients within the new space, and respond to pages and consult requests, as well as collaboratively recommend solutions for optimizing patient care.
Description: An interdisciplinary team designed the program including: a medical educator, charge, surgical and floor nurses, physician directors from quality and safety, maternal fetal medicine, women’s health, gynecology, and clinicians from anesthesiology, neonatology, social work and midwifery. The resulting simulation-based program included separate and conjunctive uses of mannequin simulators and standardized patients in the actual clinical facilities to assure contextual fidelity. All simulated cases necessitated the use of resources for patient triage, low and high-risk antepartum care, normal and urgent intra-partum care, and normal and emergent postpartum care, including surgical interventions. The program began with an immersive orientation in the new facilities that included six concurrent simulated cases. The clinical teams managed their patients and responded to requests as they would normally during a shift. Additionally, participants were paged during their program session to consult at each of two institutional emergency departments (ED), pediatric and adult. We asked participants (N=180) to identify areas of concern, causes for delays, and issues they felt could adversely impact patient care. We analyzed these data using qualitative methods (theme generation, frequency distributions), identified two significant quality challenges, and derived recommendations for systems-level process improvements. See below:
Challenge 1. Communication, coordination, and responses to patient-related concerns within and between team members.
Passive communication system adds layers and delays to care.
Inability to prioritize patient events and clinical needs, leading to team inefficiencies.
Increased spatial scale and complexity minimizes direct connection between teams; reduces the knowledge of where personnel and clinical resources are situated or available at any given time.
Increased situational distribution of patients makes locating/tracking them difficult.
Challenge 2. Proximal location makes it much more difficult to respond to consultation requests from offsite services.
One-way travel times to the adult ED ranged between 10-20 minutes.
Increased patient volume without concomitant increases in staffing makes it difficult to coordinate and provide offsite consultation services (i.e. would leave Ob/Gyn understaffed).
Two emergency rooms (adult/pediatric) now require consultation services, further reducing the ability of Ob/Gyn personnel to respond quickly to requests.
The team proposed: a quality and safety team to continue the program on a routine basis; to establish a designated space for running routine simulation-based drills in the clinical space; adapting staffing policies to assure adequate clinical coverage; and a mobile device solution. We expect the program will continue to reveal quality challenges and facilitate their collaborative resolution.
Conclusion: We qualitatively evaluated system-level challenges associated with new hospital facilities using comprehensive, immersive simulation-based patient care. The outcomes provided recommendations for averting potential adverse impact on patient care that are in the process of being implemented.
1486 Out of the Lab and into Reality: Making Integration of Simulation a Reality in Undergraduate Nursing Education
Angela Iorianni-Cimbak, MSN, RN1
1SCHOOL OF NURSING, UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA, PA, USA.
Introduction/Background: Students commonly perceive simulation education as additional work that is disconnected from their primary educational experiences. In our institution, our undergraduate nursing students, as well as nursing faculty, expressed frustration regarding their perceptions of this disconnection between simulation and didactic elements of our curriculum. As a result, we developed a plan for integrative simulation across the curriculum. Our aim was to address, through culture change and operational pedagogical elements, perceived and real concerns on the part of both students and faculty about simulation standing apart from the curriculum.
Description: Our plan began with extensive communication that relied on discussion of the foundations of simulation and the various forms it can take in an undergraduate curriculum. Communication became the most essential component of this curricular integration plan. In parallel with communication to shift culture toward broad acceptance of simulation and its utility in varied elements of the undergraduate curriculum, we created a mechanism for collaboration between and among clinical course directors, clinical instructors, and simulation instructors. Analysis of the curriculum and educational settings suggested opportunity to enhance simulation integration in settings including the class room: to mitigate overemphasis on didactic learning while promoting integration, and in clinical post-conference and debriefing, to amplify practice-based learning. Simulation instructors met with clinical course directors and instructors to examine the patient populations, clinical phenomena, and practice settings in the larger perspective of curricular objectives. Clinical course directors and instructors were particularly encouraged to consider simulations relevant to their classroom and clinical settings as well as more specific novel opportunities they wished to explore. Simulations were then developed collaboratively. Importantly, national metrics including National Patient Safety Goals, Quality and Safety Education for Nursing competencies, and standards from The Joint Commission were incorporated into the simulations developed. Simulation instructors insured that all simulations employed our standardized approach to structure, content, and evaluation. Through the first year of this plan for integration, we developed 10 in class and clinical post-conference simulations addressing adult and older adult clinical populations in acute settings. Care of the delirious patient, the patient with advanced chronic obstructive lung disease, and the patient with pulmonary embolus are among the clinical topics explored in these simulations.
Conclusion: The results of our first year of focused simulation integration reveal high satisfaction among clinical course directors, clinical instructors, and students. This initiative has been adopted as the template for simulation integration across our undergraduate curriculum. We now find that course directors and clinical instructors are more able to consider simulation as an accessible and valuable educational strategy. Further they are requesting development of more in class and clinical post-conference simulations going forward. Notably, clinical instructors report students who have experienced simulation integration are generally more confident in clinical practice with patients and verbalize stronger synthesis of didactic information in the clinical setting. We have realized both cultural and operational gains in capitalizing simulation integration and in taking simulation out of the learning lab. We plan extended use of this template for integration throughout the undergraduate curriculum and exploration of its use in our graduate nursing programs.
1524 Emergency Course Using Simulation and Debriefing for Continuing Education in Health
Maria do Carmo Melo, MD,1 Nara Lucia Silva, RN2
1PEDIATRICIAN, FEDERAL UNIVERSITY OF MINAS GERAIS, BELO HORIZONTE, MINAS GERAIS, BRA and 2NURSING, UNIVERSIDADE FEDERAL DE MINAS GERAIS, BELO HORIZONTE, BRA.
Introduction/Background: The Simulation Laboratory of the Federal University of Minas Gerais School of Medicine has developed several activities with the objective of spreading healthcare knowledge and producing educational content. We have been using high-fidelity simulation-based learning and debriefing. In emergency situations, fast and structured management is crucial for a patient’s outcome.
Description: Teachers with experience in emergency cases prepared a course with simulated patient scenarios involving both children and adults. The selected content of the course included: basic life support, advanced life support, cardiopulmonary failure, shock, respiratory distress, cardiac failure and arrhythmia. The theoretical program was made available through digital media and participants were asked to read and familiarize themselves with the material prior to the course. In the practical part of the course we used manikins and simulation equipment, which was organized into 10 skill stations. The debriefing was used as a means to improve the acquisition of knowledge and the skills for advanced life support. To evaluate this approach we designed a brief, user-friendly, questionnaire that assessed the course. Twenty four professionals took the course, 87.5% of them were medical doctors and 12.5 % were nurses. As general quality was concerned, 100% of the participants evaluated the course as either good, very good or excellent. The content of the course was also evaluated as good/very good/excellent by 100% of the medical doctors and nurses; their instructors were evaluated as good/very good/excellent by a 100% of the participants. Additionally, the course was deemed useful by all the participants. This course was well evaluated and the system regarded it as good and easy to use. The incorporation of high-fidelity simulation-based learning has helped to enhance the realism of scenarios and cases, but it has also placed more emphasis on the importance of post scenario debriefing.1 Instructors could also request formal observation and feedback on their teaching styles, in collaboration with an existing faculty development program. The simulation offers a positively evaluated means to enhance students’ skills in recognizing and handling emergencies.2 Students were more satisfied with the simulation-based curriculum compared with group discussion in a randomized controlled study.3 It is therefore our belief, that the literature shows the importance of high-fidelity simulation and the use of debriefing on emergency training. The analysis presented here demonstrates the high rate of approval with the educational technique used in the course.
Conclusion: The emergency course has been improving the knowledge and has contributed to the continuous education of university professors and health professionals in the city of Belo Horizonte. The advanced simulation part allows participants to experience the situation as if it were real. Debriefing allows for reflection on one’s performance, and increases the efficacy of simulation training. Structured debriefings resulted in an improved accuracy of the educational intervention in emergency courses.
1. Cheng A, Rodgers DL, van der Jagt E, Eppich W, O’Donnell J. Evolution of the Pediatric Advanced Life Support course: Enhanced learning with a new debriefing tool and Web-based module for Pediatric Advanced Life Support instructors. Pediatr Crit Care Med.2012.May 16. [Epub ahead of print].
2. Ruesseler M, Weinlich M, Müller MP, Byhahn C, Marzi I, Walcher F. Republished: Simulation training improves ability to manage medical emergencies. Postgrad Med J. 2012 Jun;88(1040):312-6.
3. Ten Eyck RP, Tews M, Ballester JM. Improved medical student satisfaction and test performance with a simulation-based emergency medicine curriculum: a randomized controlled trial. Ann Emerg Med. 2009 Nov;54(5):684-91.
1536 Nursing Crew Resource Management: Innovation in Action
Michelle Aebersold, PhD, RN,1 Dana Tschannen, PhD1
1NURSING, UNIVERSITY OF MICHIGAN, ANN ARBOR, MI, USA.
Introduction/Background: Effective communication is a goal in virtually every report generated on how to improve patient outcomes and decrease errors. Under the area of teamwork and collaboration are two communication skills: assert one’s own position/perspective in discussions about patient care and choose communication styles that diminish the risks associated with authority gradients among team members.1 The recommendation for effective communication is clear; however, the best way to facilitate the development of that skill is still unknown. Crew Resource Management (CRM) is one training method developed that can be used to improve communication skills and has been shown to be effective in other areas.2
Description: The purpose of this project was to establish a training program for senior nursing students at a Midwestern university based on CRM and to integrate it into the senior level curriculum. To do that a partnership was established with the local Veterans Affair (VA) Patient Safety Center to provide a nursing based CRM program. The students attended a didactic workday to review the concepts of CRM including effective communication, human factors, situational awareness, leadership and followership. Students then participated in a series of two simulations in which they practiced their communication skills using the techniques learned in class.
Conclusion: Students (n=30) and faculty/staff (n=6) completed a survey after the CRM workday to evaluate their satisfaction and perceived learning experience. Overall students believed the program was very worthwhile (M=4.5, SD 0.56) and the teaching strategies were effective (M=4.6, SD=0.55). Ninety-seven percent of the participants (n=31) agreed or strongly agreed that they would recommend this training to other clinicians and 81% agreed or strongly agreed they would participate in more training like CRM. During the final simulation student groups (n=9 groups) were observed to determine if they attempted to use either of the communication strategies taught in CRM. Of the 9 groups, 5 attempted to use the strategies, 1 group moved right to going up the chain of command when the physician indicated he could not see the patient and 3 groups did not use any recognizable communication tool. After the success of the pilot, it was decided to implement NCRM into the senior year curriculum and evaluate it further with a pre and post simulation focused on communication skills. Preliminary analysis of that data shows a significant improvement (p<.05) in student performance.
1. Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., Sullivan, D.T., & Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122-131. doi:10.1016/j.outlook.2007.02.006.
2. Sculli, G. L. & Sine, D. M. (2011). Soaring to success: Taking crew resource management from the cockpit to the nursing unit. Danvers, MA: HCPro.
Disclosures: Michelle Aebersold, PhD, RN, is a Faculty Advocate for Pearson Education.
1542 Assessing Quality of Care to Adolescents Using Standardized Patients in Real Clinic Settings
Shoshanna Handel, MPH,1 Elet Howe Richard Zapata, 1 Angela Burgess,2 Colleen Gillespie, PhD,3 Sondra Zabar, MD,3 David Stevens, MD1
1HEALTHCARE DELIVERY IMPROVEMENT, NEW YORK CITY HEALTH AND HOSPITALS CORPORATION, NEW YORK, NY, USA and 2MEDICINE, NEW YORK UNIVERSITY, NEW YORK, NY, USA and 3MEDICINE, NEW YORK UNIVERSITY SCHOOL OF MEDICINE, NEW YORK, NY, USA.
Introduction/Background: Improving population health for adolescents requires reducing risk behaviors such as unsafe sexual practices and substance use. Challenges to high quality care for adolescents exist in terms of effectiveness (e.g. skill in eliciting an accurate sexual history) and patient centeredness (e.g. addressing concerns about confidentiality). Improving the quality of care delivered by health systems requires efficient, valid measurements of core clinical competencies. We created and piloted a novel program enlisting adolescent standardized patients (SPs) to evaluate provider performance in real pediatrics settings. This model, if effective in identifying needs for improvement, acceptable to participants, and fiscally sustainable, could be replicated for routine quality improvement use.
Description: We trained 12 young men to portray a 16-year-old with high risk sexual behavior who is seeking a pre-employment physical. Using a behaviorally-anchored checklist, these SPs evaluated 25 pediatricians at 7 public hospital primary care clinics (mean 3.8 visits/clinic, range 1 – 7). The pediatricians knew that they were being evaluated by an SP. SPs were trained to share information about risk behavior only if pediatricians took specific steps to put them at ease, including clarifying confidentiality protections and demonstrating non-judgmental behavior. They completed checklists evaluating providers’ communication skills (data gathering, relationship building, counseling; 13 items; Cronbach’s alpha for internal consistency=.88), risk assessment (16 items; alpha=.87); risk counseling (16 items; alpha=.87); treatment plan (3 items; alpha=.81); and patient-centeredness (3 items; alpha =.71). SPs also rated clinics in terms of patient-centeredness (3 items adapted from HCAPHS; alpha=.89). SPs were trained to give feedback to physicians about specific behaviors that helped them feel comfortable discussing behavioral risk. Data were analyzed to identify quality improvement needs, site differences, and correlations among assessed domains. Overall, pediatricians performed well in listening without interrupting, using understandable words, and discussing condom use (84%, 88%, 92% well done, respectively). SPs system-wide reported a need for more detailed information about confidentiality (44% well done), a more collaborative approach to developing a plan (32% well done), more detailed information about reducing risk (36% well done), and more screening for specific sexual risks (e.g. 8% screened for sex while high/drunk, 12% screened for intimate partner violence, 28% screened for male sex partners). SP satisfaction with pediatrician communication skills was mixed (24% excellent, 32% good, 36% okay, 8% poor). Strengths and weaknesses of individual pediatricians varied widely, suggesting need for targeted feedback and coaching in individual physicians. Scores in communication, screening, and counseling did not vary significantly between the 5 clinical sites. Participating pediatricians found the experience to be useful (46% very useful; 31% somewhat useful). All 25 agreed that this experience would help them improve the care they provide. Implementation cost was $34.50 per visit, including data collection and feedback to provider. Pediatricians participated during their non-patient (administrative) time. Costs not included are staff time for one-time developing program materials, as well as SP training, program coordination and data analysis.
Conclusion: This adolescent SP model effectively identified system-wide and individualized areas for improving pediatrician communication with adolescents about health risk, despite the fact that physicians knew this was an evaluated simulation. Inconsistencies in screening for specific sexual risk behaviors will guide provider education. These findings, along with participating pediatricians’ positive responses about the SP model’s usefulness, support the case for wider-spread implementation. After initial start-up costs, the per-physician cost is low enough to permit ongoing use of this model as part of a quality improvement program. Previous evidence suggests that participation enhances health outcomes among SPs themselves; further investigation will explore whether this effect will be observed among adolescent SPs. If so, the cost of the program would be additionally justified as a health promotion activity for SPs.
1544 Building Teamwork Through Simulation: Teaching “Out-of-Scope” Practices to Improve Team Knowledge and Confidence During Shoulder Dystocia Emergencies
Komal Bajaj, MD,2 Jessica Pohlman, MPA, NREMT-P,1 Benny Turner, MHSA,1 Katie Walker, RN, MBA1
1INSTITUTE FOR MEDICAL SIMULATION AND ADVANCED LEARNING (IMSAL), NEW YORK CITY HEALTH AND HOSPITALS CORPORATION, NEW YORK, NY, USA and 2OBSTETRICS AND GYNECOLOGY, NORTH BRONX HEALTHCARE NETWORK, BRONX, NY, USA.
Introduction/Background: Shoulder dystocia is an often unpredictable obstetric emergency that requires a team approach to achieve successful resolution in a timely manner to minimize risk of fetal and maternal injury. Obstetricians and midwives are routinely educated about maneuvers to resolve a shoulder dystocia as part of their training. Though delivering babies is outside the scope of practice for nurses, they play a critical supportive role during a shoulder dystocia emergency.1 Many nurses have not received any education about the maneuvers nor had opportunity to practice them. It is controversial whether to teach procedures which are out of health professionals’ standard scope of practice. Our simulation center serves the public hospital network of New York City. Over 400 Labor and Delivery nurses have participated in our 4 hour inter-professional Shoulder Dystocia Teamwork and Skills Course. After a short didactic session, each learner rotates as the team leader during which time they utilize a birthing simulator to organize team actions and perform a sequence of maneuvers to resolve the shoulder dystocia. It is reiterated to the learners that providers who don’t routinely deliver babies are not expected to be able to apply these skills in a clinical environment. Rather, performing the maneuvers during simulation serves as a learning tool to improve overall teamwork.
Description: Our hypothesis is that teaching nurses shoulder dystocia maneuvers, though it is out of their scope of practice, improves the individual’s acquisition of knowledge and confidence in addressing this emergent situation. This, in turn, likely improves the individual’s ability to respond to team needs and assist with the emergency. A paper-based assessment with ten multiple-choice questions was administered pre- and post-course. The questions focus upon the understanding of basic skills and protocols related to resolution of shoulder dystocia, topics for which nurses may not receive formal training. The pre- and post-course assessments were scored and a change in score (positive or negative) was determined for each learner. Narrative comments were obtained from post-course surveys as means of ascertaining self-perceived confidence levels.
Conclusion: A total of 416 learners who do not perform vaginal deliveries participated in our inter-professional shoulder dystocia course. Sixty-three percent of nurse learners improved their post-course score, with a median improvement of 15%. A third of post-course surveys included a comment regarding improved self-percieved confidence and preparedness in assisting with a delivery complicated by shoulder dystocia. Simulation-based training of shoulder dystocia maneuvers for healthcare providers who do not deliver babies improves understanding of shoulder dystocia and confidence to assist in the resolution of this obstetric emergency. These improvements may lead to better teamwork, which may reduce patient morbidity. This also raises questions for further research, including the dosage of simulation required to achieve retention of these skills and the overall improvement in clinical and medicolegal outcomes.
1. American College of Obstetrics and Gynecology Committee Opinion #487. Preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol. 2011 Apr; 117: 1032-4.
Disclosures: Katie Walker, RN, MBA is a consultant for Health Workforce Australia.
1559 Learning Management System (LMS) as a Simulation Education Research Engine
Alexander Libin, PhD, MS1
1SIMULATION AND TRAINING ENVIRONMENT LABORATORY, SITEL MEDSTAR HEALTH RESEARCH INSTITUTE, WASHINGTON, DC, USA.
Introduction/Background: The current learning paradigm in medical training of health care professionals, ranging from medical students to licensed allied health, relies predominantly on the apprenticeship model, and competency is established based on the number of performed procedures with little attention being paid to the evidence-based metrics centered on quality care including patient safety.1 Advanced learning technologies, including multimedia training, high fidelity simulations and serious health games, developed at at the Simulation and Training Laboratory (SiTEL) at the MedStar Health, and affiliated GHUCCTS/Clinical Translational Sciences Consortium infrastructure in Greater Washington DC area (USA) aim to establishcompetency metrics based on performance in simulated environments and enhanced learning with educational interventions while using an online Learning Management system (LMS 2.0) as a hub for de-identified performance data.
Description: Newly developed Embedded Assessment Architecture Algorithm (EMA) is implemented across MedSims, health games, LMS 2.0, and other online educational multimedia modules, and focuses on developing two types of scoring systems: application specific, or just-in-time, to provide scores immediately after the training (like in the S-BRONCH and EFM), and post-analysis data that would be transferred to the Common Elements System (COMMONS) as both raw and indexed data to be used for pilot data and cross-application analysis regardless of where exactly across MedStar and CTSA participating organizations, involving more than 30,000 allied health professionals and medical students, the pilot study was conducted and research data were generated.2 For assessments to be truly “authentic”, they must be linked to a specific instructional context and, ideally, occur as part of an ongoing learning process. The EMA works hand-in-glove with the Virtual Simulation Platform (VSP). The core of the VSP is developed around editable Simulation Object Templates (SOT). Each SOT provides numerous data points, directly addressing the problem of how to collect relevant data for assessment calculations. The SOT is linked to a) an embedded assessment “blueprint” that guide the focus and placement of the assessment tasks; b) the “variables”, which are the key concepts and skills that define the training and form the basis of the embedded assessment instrument; c) the assessment tasks and scoring guides, linked to specific variables; d) statistical and quality control procedures used to validate scoring procedures and produce measures of clinician performance on each of the variables; and e) feedback mechanisms, including variable maps that define clinician progress and performance.
Conclusion: Simulation in healthcare is on the cusp of a massive paradigm shift in healthcare training and education3,4. Driving this change is the rise of performance-based healthcare and evidence-based medicine; changing economic and regulatory environments; and the increasing need to effectively harness and apply new knowledge. In the near future, healthcare education will blend physical and virtual worlds, offering new ways for individuals and groups to learn. Embedded assessment instruments, designed from psychometric and statistical methods, will offer the quantitative analysis necessary to help clinicians and patients learn more efficiency; increase learning transfer and improve performance. Emerging technologies — artificial intelligence, natural language processing, cloud computing, cybernetics, digital humans, electronic patient records, gesture-based user interfaces, simulation, tablets and smartphones — will facilitate new levels of realism, authenticity and efficiency.
1. Libin A, Libin E. Cyber-Anthropology: A Merge of Human and Technological Worlds. In: Hybrid reality: Art, Technology, Human Factors. Montreal: IOS Press, 2003, 575-581.
2. Libin A, Lauderdale M, Millo Y, Shamloo C, Spencer R, Green B, Donnellan J, Wellesley C, Groah S. Role-Playing Simulation as an Educational Tool for Health Care Personnel: Developing an Embedded Assessment Framework. Cyberpsychol Behav. and Social Networking, 2010, 3.
3. Gawande A, Michael J. Zinner, David M. Studdert, Troyen A. Brennan, Analysis of errors reported by surgeons at three teaching hospitals. Surgery 2003;133:614-21.
4. Risser DT, Rice MM, Salisbury ML, Simon R, Jay G, Berns SD, The Potential for Improved Teamwork to Reduce Medical Errors in the Emergency Department. Annals of Emergency Medicine. Volume 34, Issue 3, Pages 373-383, September 1999.
1572 Integrated High-Fidelity Simulations Throughout an Adult-Gero ACNP Intensivist Sub-Specialty Program
Nathan Ashby, MD,1 Joshua Squiers, PhD, MSN, ACNP-BC,2 Joan King, PhD, ACNP-BC, ANP-BC, FAANP2
1ANESTHESIOLOGY AND CRITICAL CARE, VANDERBILT UNIVERSITY SCHOOL OF MEDICINE, NASHVILLE, TN, USA and 2VANDERBILT UNIVERSITY SCHOOL OF NURSING, NASHVILLE, TN, USA.
Introduction/Background: With an aging population, the United States faces an increasing demand for ICU care. Studies show improved length of stay and mortality metrics when patients are cared for by Critical Care trained providers.1 The physician workforce needed to meet this demand is projected to fall well short of future needs.2 Alternative staffing models utilizing Acute Care Nurse Practitioners in combination with physicians provide one solution to fill this void.3 Standard ACNP education programs utilize a combination of didactics covering a broad range of topics relevant to general acute and critical care with experiential learning through clinical rotations. This provides the foundation for caring for critically ill and acutely ill adult patients. However given the increase in the acuity of critically ill patients, additional didactic and clinical experiences are needed to assist new graduates to become active members of Intensivist teams. Proficiency in critical care requires additional knowledge of advanced pathophysiology and evidenced based clinical interventions. In particular, ICU care also requires an additional cognitive and manual skill set beyond that taught in most ACNP education curriculums. Perhaps most importantly, these critical care environments require students to learn to work at a faster pace and in a more stressful environment than that seen in most clinics and wards.
Description: Given these challenges, Vanderbilt University School of Nursing has developed a dedicated Intensivist training tract as part of its AG-ACNP program. This tract attempts to address these challenges by including an additional ICU focused didactic content and clinical rotations across a variety of specialty ICU’s. However, the centerpiece of this subspecialty is an integrated seven month long simulation curriculum. This integrated simulation curriculum meets biweekly for three hour sessions. Two to three simulations with group debriefings are accomplished at most biweekly sessions. The program is punctuated with intermittent procedural simulation based workshops to teach common ICU procedural skills. These simulations are designed to target one or two main educational content areas for each session. Content areas include a focus on clinical leadership, crisis management, dealing with common ICU problems, and breaking bad news to family members. Sessions are also designed to incorporate the pathology most commonly seen across a wide range of specialty ICUs and reflect lecture topics found in the critical care didactic course. Simulation sessions are set up to force critical thinking and decision making in stressful, high-paced environments. Pace and stress level can be modified to suit the level of the learners, producing a more consistent challenge. Debriefing allows for errors in knowledge, skills, and decision making to be discussed and recommendations made for managing future similar situations.
Conclusion: While many ACNP programs have begun integrating simulation into their programs, the Intensivist subspecialty at Vanderbilt has developed a formal simulation curriculum that builds on itself over two full semesters. By combining simulation scenarios that incorporate complex pathophysiology with environmental stressors, such as working with difficult team members or stressful family situations, the students learn new ways of adapting and managing complex critical care problems. By using simulation throughout the program, a number of special topics can be presented and timed to coordinate with didactic sessions and topics arising from student’s ICU rotations. This ultimately allows for specific adjustment of the educational curriculum to best suit the learners’ needs.
1. Pronovost, P. Angus, D. Dorman, T. Robinson, K. Dremsizov, T. & Young, T. Caring for the Critically Ill Patient Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients: A Systematic Review. JAMA. 2002;288(17):2151-2162.
2. Health Resources and Services Administration Report to Congress: The Critical Care Workforce: A Study of the Supply and Demand for Critical Care Physicians. Requested by: Senate Report 108-81.
3. Kleinpell, R., Ely, E., & Grabenkort, R. (2008). Nurse practitioners and physician assistants in the intensive care unit: An evidence-based review. Critical Care Medicine, 36(10), 2888.
Disclosures:Joshua Squiers, PhD, MSN, ACNP-BC, receives grant support from the United States Health Resource and Services Administration (HRSA) and the National Institutes of Health (NIH).
1582 Maximally Informed Purchase Decisions Using Human Factors and Simulation Scenarios
Richard Fidler, CRNA, CRNP, MSN, MBA,2 Victor Wei1 Meshell Johnson, MD3
1BIOMEDICAL ENGINEERING, SAN FRANCISCO VETERANS AFFAIRS MEDICAL CENTER, SAN FRANCISCO, CA, USA and 2HEALTHCARE SIMULATION PROGRAMS, SAN FRANCISCO VETERANS AFFAIRS MEDICAL CENTER, SAN FRANCISCO, CA, USA and 3PULMONARY CRITICAL CARE, SAN FRANCISCO VETERANS AFFAIRS MEDICAL CENTER, SAN FRANCISCO, CA, USA.
Introduction/Background: Medical equipment is expensive, with purchases costing millions of dollars for acquisition, followed by expensive and labor-intensive training to establish and maintain proficiency among end-user staff. Decisions are commonly made by local facilities by expert consensus, acquisition cost low-bid, or small group input, with little contribution from the end-users. As a result, end-users are often frustrated with new equipment, feeling voiceless and powerless in the decision-making process. Consumers frequently test-drive competing cars prior to making a purchase decision; however, this technique is not common for hospital equipment purchases. Simulation is growing as a technique to systematically evaluate equipment prior to purchase, while also affording institutions the ability to add user input through structured, systematic human factors evaluation and simulation based trials.
Description: Budgetary allocation for regional purchasing for new in-hospital defibrillators was obtained. A multidisciplinary expert group was formed including nurses, physicians, and biomedical engineers to determine maximum specifications achievable within budgetary constraints. An IRB approved 3-pronged approach to evaluating wants, needs, and minimum specifications was accomplished by combining results from electronic surveys to all nurses and physicians in the region; human factors evaluation of the intuitiveness of competing defibrillators, and lastly through standardized simulation scenarios involving end-user staff. These data were combined and summarized to make a maximally informed purchasing decision.
Conclusion: The noncompulsory regional electronic survey had a small return rate (n=78) considering the large number of clinicians available in the sample population. Information obtained from this survey suggests that many of our staff are poorly familiar with current research available regarding defibrillator technology and resuscitation techniques. Second, the human factors evaluation (n=74 subjects each using all three devices totally 222 usability tests) demonstrated statistically significant differences in the intuitive usability between devices tested. The results of the human factors evaluation also demonstrated that no single defibrillator was superior in all functions tested: AED shock, manual defibrillation of ventricular tachycardia, synchronized cardioversion of rapid atrial flutter, and transcutaneous pacing of complete heart block. Simulation scenario-based testing (n=16 scenarios with 8 multidisciplinary and interprofessional members) also produced valuable data suggesting significant usability differences and training requirements for each defibrillator, and the results of the simulation scenarios confirmed many of the findings from the human factors evaluations. As prior studies have shown, electronic survey data has a low response rate when compared to noncompulsory; however, the survey was a significant component of this study. Through the survey, when given the opportunity to request contact from study staff, the survey revealed champions at multiple hospitals that facilitated access to staff for human factors and simulation evaluation. Human factors evaluations, like ones in this study, are often conducted in a laboratory environment without clear correlation to clinical performance by actual end-users. This study demonstrates that human factors evaluations correlate strongly with simulation scenario assessed performance and are predictive of common errors and successes in usability. The use of simulation to confirm the human factors findings is novel and significant since it places human performance within the context of realistic situational stress. This combined strategy emphasizes the complementary roles of human factors evaluations and clinical simulation scenarios not just for educational value, but also for product evaluation. Although very labor intensive, this approach led this research team to make the most informed decision regarding a multi-million dollar purchase of critical, time-sensitive, life-saving equipment with plans to employ similar strategies in future major purchase decisions.
1606 Developing Inter-Professional Communication Skills with a High-Fidelity Human Patient Simulator
James Stevenson1 Clinton Chichester, PhD,2 Amanda Chichester, ScM, PhD (c)3
1BIOLOGY, PROVIDENCE COLLEGE, PROVIDENCE, RI, USA and 2BIOMEDICAL AND PHARMACEUTICAL SCIENCES, UNIVERSITY OF RHODE ISLAND, KINGSTON, RI, USA and 3PHARMACY PRACTICE, UNIVERSITY OF RHODE ISLAND, KINGSTON, RI, USA.
Introduction/Background: Miscommunication in healthcare settings can become a hindrance to providing safe and effective patient care and is a common cause of morbidity and mortality. Clinicians operate in an environment where a safe and effective outcome is directly related to the communication skills of people from multiple professions with differing responsibilities and levels of education. We have developed an educational scenario using a high-fidelity human patient simulator that focuses on inter-professional communication and teamwork that is adaptable for the educational level of the team members, from students in pre-clinical training to healthcare professionals in clinical practice.
Description: The scenario is modeled from a case of “serotonin syndrome”, a condition of serotonergic hyperactivity due to antidepressant drug interactions. Students or current healthcare professionals develop their skills in communication by conducting this role-playing simulation exercise. Along with improving communication skills, each discipline is also required to complete objectives specific to their area of expertise. For example, nursing must conduct an assessment of a patient presenting with altered mental status, neuromuscular hyperactivity and autonomic instability. Psychiatry is responsible for diagnosing serotonin syndrome as a result of serotonergic drug interactions while pharmacy must develop a treatment plan to attenuate the symptoms of serotonin syndrome. Throughout the scenario, all members of the inter-professional team must work together in a simulated hospital environment to diagnose and treat the simulated patient as the serotonin syndrome progresses in real time. To complete the scenario, the inter-professional team is required to develop a report using a standardized communication strategy called SBAR. With the aid of an actor playing the role of attending physician, the SBAR strategy is then put into practice.
Conclusion: By working together on a challenging case in a realistic clinical environment, either students or practicing healthcare professionals can develop inter-professional communication and teamwork skills using this novel high-fidelity human patient simulation-based exercise.
1. Leonard, M., Graham, S., & Bonacum, D. (2004). The human factor: The critical importance of teamwork and communication in providing safe care. Quality and Safety in Healthcare. 13(Suppl1),i85-i90.
2. Boyer, EW. and Shannon, M. (2005). Current Concepts: The Serotonin Syndrome. New England Journal of Medicine. 352: 1112-1120.
1622 Teaching Postpartum Hemorrhage: A Simulation Clinical Scenario Video
Shiree Nichols, MSN1
1PERINATAL NURSE EDUCATOR, FLORIDA HOSPITAL, ORLANDO, FL, USA.
Introduction/Background: One of the top three causes of maternal mortality in the United States and the most preventable is postpartum hemorrhage (PPH), but its incidence is increasing.6,9 Teaching Associate of Science in nursing (ASN) students how to recognize and act in this high risk, low frequency clinical situation can be challenging due to limited clinical time.3 As a staff development nurse educator in a central Florida hospital, I partnered with a local school of nursing to develop an active teaching strategy using simulation to teach students and new graduates about this life-threatening emergency4 Two years ago a live-action simulation clinical scenario, viewed over closed circuit from the simulation lab at the school of nursing was attempted, but technical difficulties caused the teaching strategy to take over 90 minutes to complete and was abandoned. This project involved production of a simulation clinical scenario video on PPH which could be used for each maternal newborn course, as well as in a nurse internship training program. Using videos in the classroom has been shown to be effective in teaching course content, especially something as visual as blood loss.1
Description: The Nursing Education Simulation Framework7 was used to design the simulation experience for the students. The educational practices incorporated active learning, feedback, collaboration, and realistic time on task. Simulation design included detailed objectives, use of low fidelity patient simulator, and adequate debriefing after viewing the video. The project included measurement of outcomes through test question analysis. Objectives were reviewed, with addition of an objective that students understand the need to quantify blood loss by weight.5 Scenario components were evaluated and revised based on current best practices and safety initiatives.6 The simulation clinical scenario was videotaped and then edited before being imbedded in the Turning Point classroom presentation program in order to include audience response questions at the end of each of two video segments to give formative evaluation.8 The video was presented in the classroom for Summer Term B students, and exam scores from Summer Term A were analyzed with scores from Summer Term B. Results of the classroom audience response system questions demonstrate the majority of students understood all but one of five questions. Debriefing discussions clarified the answer to this question. Following the classroom lecture portion on PPH, the students did not verbalize any questions about the content. Analysis of the exam scores on the three PPH questions for the two summer term classes revealed increased scores for the students who viewed the simulation clinical scenario video, evaluated the student nurse performance on the video using a skills checklist, audience response questions, and group development of I-SBAR report to the health care provider.2
Conclusion: Adding a simulation clinical scenario video on PPH may increase the ability of ASN students to identify PPH and perform appropriate nursing actions to prevent maternal morbidity and mortality. Additional outcome measures need to be conducted to determine whether the increased test scores for the PPH questions will be sustained. It is also suggested that the video be revised to include the addition of Foley catheter insertion due to bladder distention, as this was a difficult discussion point. In the future, other clinical scenarios could be developed using the NLN/Jeffries simulation framework and videotaped for classroom or new graduate education.
1. Grainger, C., & Griswold, A. (2011). The use of video in health profession education. In D. M. Billings, & J. A. Halstead, Innovative teaching strategies in nursing and related health professions (5th ed., pp. 281-292). Sudbury, MA: Jones and Bartlett.
2. Institute for Healthcare Improvement. (n. d.). SBAR technique for communication. Retrieved October 18, 2010, from http://www.ihi.org/IHI/Topics/PerinatalCare/PerinatalCareGeneral/EmergingContent/SBARTechniqueforCommunication.htm.
3. Jeffries, P. R. (2008). Getting in S.T.E.P. with simulations: Simulations take educator preparation. Nursing Education Perspectives, 29(2), 70-73.
4. Jeffries, P. R., Bambini, D., Hensel, D., Moorman, M., & Washburn, J. (2009). Contructing maternal-child learning experiences using clinical simulations. Journal of Obstetrics, Gynecology and Neonatal Nurses, 38, 613-623. doi:10.1111/j.1552-6909.2009.01060.x.
5. Lyndon, A., Lagrew, D., Shields, L., Melsop, K., Bingham, B., & Main, E. (2010). Improving health care response to obstetric hemorrhage: California Maternal Quality Care Collaborative toolkit to transform maternity care. California Department of Public Health, Maternal, Child and Adolescent Health Division. Sacramento, CA: California Maternal Quality Care Collaborative. http://www.cmqcc.org/.
6. Mahlmeister, L. R. (2010). Best practices in perinatal care: Strategies for reducing the maternal death rate in the United States. Journal of Perinatal & Neonatal Nursing, 297-301. http://journals.lww.com/jpnnjournal/pages/default.aspx.
7. National League for Nursing. (2007). Simulation in nursing education: From conceptualization to evaluation. (P. R. Jeffries, Ed.) New York, NY: National League for Nursing.
8. Rutledge, C. M., Barham, P., Wiles, L., Benjamin, R. S., Eaton, P., & Palmer, K. (2008). Integrative simulation: A novel approach to educating culturally competent nurses. Contemporary Nurse, 28, 119-128. http://www.contemporarynurse.com/.
9. The Joint Commission. (2010, January 26). Preventing Maternal Death. Retrieved September 20, 2010, from The Joint Commission: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_44.htm?print=yes.
1674 Introducing a Tablet-Based, Simulated Case Series to an Emergency Medicine Orthopedic Curriculum
Steven Warrington, MD, BS,1 Michael Beeson, MD, MBA1
1EMERGENCY MEDICINE, AKRON GENERAL MEDICAL CENTER, AKRON, OH, USA.
Introduction/Background: Simulation represents an advanced approach to medical education in that it provides an environment to make mistakes risk-free, practice, develop skills, schedule experiences, and test oneself. While these methods make simulation an ideal environment, there are multiple downfalls with simulation. One of the frequent problems with simulation-based residency education is the time required. For a simulation experience, a resident must schedule (or be given protected time) in advance. Time becomes a further issue in that it must be when the resources (location/mannequin/personnel etc.) are available, which may be during the resident’s typical clinical requirements or post-call hours. A second factor that detracts from simulation-based residency training is the cost. Cost is a factor in the high price of equipment, personnel, and time of residents away from clinical duties. Ever advancing technologies, such as smartphones and tablet computers, represent a unique medium for delivering simulation-based education for multiple reasons. Time becomes less of an issue when considering delivering an experience over a technology-based medium in that a trainee may have access at any time, from any location, without being dependent on another individual for running a simulation or debriefing. Another benefit to using technology is that many trainees already own one of these devices, which decreases some of the cost placed on a training program. Cost is also decreased in that other than the technology medium itself, materials do not need to be replaced. A further factor which decreases cost comes from the ability for a technology medium to supply any number of simulations, as well as to provide a medium for ongoing development of novel simulation experiences. At the authors’ institution the emergency medicine residency program was restructuring the orthopedic curriculum to decrease resident duty hours, increase resident exposure to emergency medicine-based orthopedics, and increase the desirability of the emergency medicine residency program. During this time the primary author as a resident developed a tablet-based application which was incorporated into the curriculum as a means of self-study on a focused topic using simulated cases with included debriefing. Residents are able to use this application at any time and location, which takes away multiple limitations of traditional simulation methods.
Description: A tablet-based application was developed to provide uniform unlimited access to residents for training on a focused topic using case-based simulation. Without significant prior programming knowledge the application was developed and released on a technology-based medium, which all residents at the training program own. Due to the application providing a focused educational experience, available to all residents regardless of time and location, through simulated cases with clinical and radiographic images, our residency program adopted this application as part of the new orthopedic curriculum, and is currently looking to further develop the use of common technology (i.e., smartphones, tablets) for educational purposes and implementation of simulation experiences.
Conclusion: The implementation of the application developed over the academic year of 2011 began July 1st, 2012. Anecdotally residents have enjoyed its use, as well as found it beneficial to be able to access at any time. The application was released globally to allow for usage by any trainee seeking focused simulated case-based education on emergency orthopedic care and has been downloaded by users across the world (including countries such as Canada, Greece, Turkey, Australia, and Brazil).
Steven Warrington, MD, BS, creates self guided case-based iPad applications for training purposes in emergency medicine.
1685 The Calm Before the Storm: Why In Situ Simulation Training is Critical, Before the Opening of New Facilities
Richard Latham, NREMT-P, CCEMT-P,2 Jason Zigmont, PhD,1 Gina Ruffner, EMT-P3
1OHIOHEALTH, COLUMBUS, OH, USA and 2DOCTORS HOSPITAL SIMULATION AND EDUCATION CENTER, OHIOHEALTH, COLUMBUS, OH, USA and 3CENTER FOR MEDICAL EDUCATION AND INNOVATION, RIVERSIDE METHODIST HOSPITAL, COLUMBUS, OH, USA.
Introduction/Background: A new free-standing Emergency Department was going to begin operations within the next month. The ED staff needed to become familiar with equipment, its location and usage, and policy and procedures prior to opening its doors to the public. Due to the creation of a completely new staff, the team needed to become familiar with both their own and others’ roles and responsibilities. The ED senior administration staff also wanted to use the training as a tool to help identify any potential issues of both the environment and of the staff. We used multiple high fidelity human patient simulators, in order to simulate, some of the more serious patients that can present to the ED. A total of 58 staff, from Registration all the way up to the ED attending physicians, participated in real time scenarios. The scenarios included both walk-in and EMS patients. Every new ED goes through some type of training or walk through prior to opening its doors. The ability to use high fidelity human patient simulators for this training clearly has major advantages. Our model used theories and concepts previously used on inpatient units and applied them to the free standing emergency department setting.
Description: We worked with the ED clinical nurse manager and clinical education coordinator to develop the scenarios, goals and objectives. We used the Laerdal SimMan3G and Gaumard Noelle high fidelity human patient simulators. We were able to simulate critically ill patients in real time, using the same space and equipment that would be used by the ED. Every scenario was run in real time, with real results based on patient management. After each scenario, a debriefing was preformed. This debrief did not solely focus on the patient care, but also on communication, teamwork, and environmental issues. Over 40 environmental/ equipment deficiencies found were noted and submitted to the clinical nurse manager and clinical education coordinator for follow up.
Conclusion: High fidelity in-situ training prior to the opening of the ED proved to be invaluable. The deficiencies found during the training led to corrective action before the doors opened, ensuring the safety of the patients and staff. Also as a result of the training, several policy and procedures were reviewed and changes were made. We succeeded in meeting and exceeding the goals and objectives and improved the overall operations of the ED prior to opening to the public. After conducting an overall internal review of the training, we found several lessons learned. These lessons included everything from how we can operate our simulators better in the in-situ environment, to placement of new signage for room locations so EMS knows where to go. The training methods used proved effective in execution of the ED opening. At the time of this submission, long-term follow up to determine the effectiveness of the training has yet to be conducted. Having only been open sixty days, the long term effects cannot be measured at this time. Short term (30 days) results have shown promise, in that the ED staff feels confident in the skills and knowledge, gained through the training. The simulation community at large will continue to have an increase of training requests as the need for healthcare grows. A growing number of those requests will be for new units, clinics, EDs and even whole hospitals. The ability to provide high fidelity in-situ simulation, before these facilities open, will allow for the identification of the need for potential operational changes, which would otherwise go unnoticed until the facility opened.
1. Bender J, Sheilds, R, Kennally, K. Testing With Simulation Before a Big Move at Women & Infants Hospital. Medicine & Health/Rhode Island. 2010 May;93(5):145-50.
1741 Intern Boot Camp: Setting the Standard with Simulation
Richard Latham, NREMT-P, CCEMT-P,2 Shawn Kerger, D.O., FAOASM,2 Ryan Warner, EMT-P, EMS CE-I,2 Jason Zigmont, PhD1
1OHIOHEALTH, COLUMBUS, OH, USA and 2DOCTORS HOSPITAL SIMULATION AND EDUCATION CENTER, OHIOHEALTH, COLUMBUS, OH, USA.
Introduction/Background: This year there were almost 23,000 applicants successfully matched to first-year residency positions. Of those who matched, nearly 16,000 were U.S. medical school graduates from the medical schools across the nation. Board scores only evaluate part of their knowledgebase; what about their basic clinical skills? In an effort to determine the level of clinical skill, and to establish a hospital-wide standard for knowledge and skill sets across the 18 specialties and sub-specialties at our hospital, we developed an “Intern Boot Camp” for our 40 new interns. While having a Boot Camp for new interns is hardly a new idea, most other camps are specialty-specific and don’t usually include multiple residency programs. Our Intern Boot Camp is required for all new interns, regardless of their program.
Description: When the new interns start our weeklong orientation process, they are put through the standard hospital new physician administrative training. On day three of orientation the Intern Boot Camp begins. The clinical skills that were evaluated during the Boot Camp included the following: 1). Urinary Catheter (UC) Placement, 2). Central Venous Catheter (CVC) Insertion, 3). Arterial Line Insertion, 4). Intravenous (IV) Line Start, 5). Airway Management, and 6). Code Management (ACLS). The Boot Camp day one consists of a full day of ACLS renewal training and airway management. The interns are put through a full ACLS renewal course, with an increased focus on leadership, communication and proper airway management in order to ensure competency of their code management skills. This also allowed us the opportunity to identify any intern who needs remediation, in advance of their first clinical shift. On day two, the interns are divided into groups and assigned a four-hour block on time for the remaining clinical skills evaluation. Interns were evaluated on UC placement; CVC insertion, arterial line insertion, and IV start. Each clinical skills station had a senior level resident or a subject matter expert on the skill (such as paramedics evaluating IV start skills). In addition to clinical skills, day two also included a one-hour instructional block on physician communication this year. This instruction dealt with how the intern can improve interactions with patients using the AIDET model, developed by the Studer Group. The course teaches the learners to interact with patients in a patient-centered communication model.
Conclusion: Though only two years old, the Intern Boot Camp has proven to be a very successful tool in the evaluation of the new interns. It has allowed us to refresh or train up clinical skills prior to the interns seeing real patients. It has also been proven to increase the confidence the interns have when they start their first clinical shift. We’ve also found that their being sim-ready allows for earlier procedure performance on the floors (with supervision), instead of receiving the “watch me do this one, you’ll get the next one” caveat from their seniors. The training has also allowed us to have each group of residents be on the same cycle of renewalfor ACLS/BLS, allowing for more flexibility to our training schedule, also reduced costs. The largest gain in having this Boot Camp was the ability to set a hospital-wide standard early in the careers of the interns. It is our goal is that this will have a lasting impact even after they graduate from their residency program, as well as improve patient outcomes.
1761 The Need for Needs Assessment: Tailoring Simulation Instructor Course Content for Clinical Nurse Educators and Clinical Nurse Specialists
Angela Blood, MPH, MBA,2 Cynthia LaFond, BSN1
1NURSING PROFESSIONAL PRACTICE AND RESEARCH, UNIVERSITY OF CHICAGO, CHICAGO, IL, USA and 2SIMULATION CENTER, UNIVERSITY OF CHICAGO, CHICAGO, IL, USA.
Introduction/Background: This poster will describe the development and results of a needs assessment for simulation instructor training for clinical nurse educators and clinical nurse specialists. Clinical nurse educators and clinical nurse specialists are often called upon to facilitate or help develop simulation learning experiences because of their expertise within the hospital setting. A need for additional simulation instructor training for these nurses within our institution was recognized, but with a centralized department of 20 clinical nurse educators and clinical nurse specialists, participation in an off-site, week-long simulation instructor course was not practical. Additionally, participation in exhaustive instructor training may not be the best use of time for individuals with prior simulation experience or with interest in only one facet of simulation or one particular project. In order to tailor education to the needs of members of the department, a simulation instructor needs assessment was desired. However, no needs assessments were identified within the literature.
Description: Fifteen of 20 potential participants completed the survey. Of these respondents, 63% reported 5 years or more of experience within his/her role. All of the respondents reported having some experience with simulation in the past; however, less than 25% had experience as a simulation instructor/project lead. Overall, respondents were most confident in designing nursing-specific patient-care scenarios (M = 2.53, SD = 0.83). Specific components of simulation facilitation were also rated highly, including fostering teamwork and collaboration (M = 2.80, SD = 0.78), collaborating with other facilitators (M = 2.71, SD = 0.99), and encouraging participant discussion during debriefing (M = 2.67, SD = 0.98). The nurses were least confident in choosing simulation resources and tools to meet learning objectives, specifically utilization of high-fidelity manikins (M = 1.87, SD = 0.83), standardized patients (M = 1.80, SD = 1.01), and computer programs (M = 1.79, SD = 0.80). The majority of respondents (80%) reported minimal to no confidence in developing assessment tools to evaluate trainee performance. For the open-ended questions, 13 of the 15 respondents identified areas within their work that could benefit from simulation. Chief concerns related to implementing a simulation project included time/other obligations, need for additional training in simulation, coordination of facilities/staff attendance, and need for additional educator support.
Conclusion: Surprisingly, no publications were identified in which an educational needs assessment was conducted for simulation instructors prior to training. As simulation training becomes more prevalent within hospitals, it is essential that clinical experts have training in the best methods of delivery; yet, institutions need to be cost effective and conscientious of staff members’ time. The results of this needs assessment helped to guide the development of a simulation instructor course, which was tailored to meet the immediate needs of the clinical nurse educators and clinical nurse specialists within the institution. Additionally, participant concerns were able to be addressed in the course design, building time into the course for participants to develop and practice implementing their own simulation scenarios.
1769 Integrated Curriculum for Central Venous Catheterization
Pin-Tarng Chen1 Chih-Yang Chen, MD,1 Hung-Wei Cheng, MD,1 Ho-Tien Lin, MD,3 Wei-Nung Teng, MD1
1ANESTHESIOLOGY, TAIPEI VETERANS GENERAL HOSPITAL, TAIPEI, TWN and 2ANESTHESIOLOGY, TAIPEI VETERANS GENERAL HOSPITAL, TAIPEI, TWN and 3ANESTHESIOLOGY, TAIPEI VETERANS GENERAL HOSPITAL, TAIPEI, TAIWAN, TWN.
Introduction/Background: Central venous catheter (CVC) insertion is necessary for aggressive fluid resuscitation, monitoring, and administration of parenteral nutrition and medication. To demonstrate the formal method of CVC insertion and decrease the failure and procedural complication rates, we set objectives for each phase of CVC insertion and conducted an integrated training curriculum using diverse materials related to the objectives.
Description: We solicited 4 anesthesiologists and 2 infection control specialists to serve as a panel of experts to establish objectives and develop teaching materials. We enrolled all PGY1 to PGY3 resident physicians from departments that have a high chance of performing CVC insertion (June–August, 2011), and PGY1 (May–September, 2012). The resident physicians were divided into groups, and the structured program was conducted as follows. Included was a 10-Minute Lecture that focused on indications, contraindications, complications of CVC insertion and basic anatomy. Also included was a Standardized patient (SP)-based hands-on demonstration. An interactive discussion was conducted to determine the optimal position for CVC insertion via the right internal jugular vein (RIJV). The SP then lay on a bed allowed regulation of height and position. The trainees were requested to demonstrate the correct positioning during CVC insertion, illustrate the anatomical landmarks, and outline the intended approach method. They then used a marking pen to locate the intended skin puncture site on the right neck and explained the needle direction and related maneuvers. The ultrasound application was included as follows: the instructor used ultrasound to survey the accuracy of the skin puncture site by locating the middle point of the probe on the marked points and identifying whether the RIJV was in the center of the ultrasound image. Afterwards, ultrasound was applied to observe the enlargement of the IJVs in the leg raise and Trendelenburg positions and the effect in terms of decreasing the overlap of the IJVs and common carotid artery (CCA) after turning the head to the contralateral site. The diameters of the IJVs in the cricoid and thyroid cartilage levels were also compared. Observation of visible respiratory jugular venodilation was demonstrated on the SP and rehearsed by ultrasound. Ultrasound was also used to observe the easy compression of IJVs during the checking of CCA pulsation and excessive skin traction or compression. Then, the trainees had the opportunity to use ultrasound to scan the bilateral IJVs, subclavian veins and femoral veins. The frog-leg position during femoral catheterization was also emphasized. Lastly there was a step-by-step demonstration and hands-on practice that included the following: 1). hand washing, disinfection, donning gloves, wearing a sterile gown, placing a skin towel and upper body drape, preparation of medication and related sterile techniques, 2). standard insertion technique using self-made manikin (the manikins were made of pediatric breathing circuits covered by Laerdal neck skins that could be thumbtacked on box. A rectangular hole was cut into the circuit (1×1.5cm) in order to be easily palpable to simulate the RIJV venipuncture site. The detailed techniques and tricks of CVC insertion were demonstrated and practiced on the manikins) and 3). CVC insertion on human anatomy CVC simulators (Laerdal IV Torsol and Simulab CentralLine Man): from preparation to fixation. We filmed the formal CVC insertion process on an ordinary ward for free e-learning.
Conclusion: This program demonstrated step-by-step standardization of CVC insertion using a structured curriculum of a lecture, interactive trainee-based discussion and ultrasound demonstration for knowledge accumulation, step-by-step technique training by hands-on practice of sterile techniques, and self-made manikins and torso simulators. The application of ultrasound is crucial in order to identify issues, such as an inappropriate skin puncture site and easy collapse of the RIJV by external compression. Self-made manikins are effective in Seldinger technique training. This program is a process of gradual development of the CVC insertion technique.
1783 Hull Institute of Learning and Simulation (HILS): A Year of Lessons Learnt
Donna Oldfield1 Christopher Gay, BSc,2 Makani Purva3
1HULL INSTITUTE FOR LEARNING AND SIMULATION, HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST, HULL, GBR and 2MEDICAL EDUCATION, HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST, HULL, GBR and 3MEDICAL EDUCATION, ANAESTHETICS, HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST, HULL, GBR.
Introduction/Background: Following a successful bid to the Strategic Health Authority and award of over three million pounds, the Hull Institute for Learning and Simulation at Hull Royal Infirmary officially opened in June 2011. The purpose built facility is equipped with high fidelity simulation manikins, mock wards, operating theatre, dental room and seminar rooms. The centres users have rated the services and facilities very highly and footfall is continually increasing. We would like to present two key activities that we felt were instrumental in setting up this facility successfully.
Description: In planning stages of the building, key people, who would potentially use the facility including departments within our trust, training providers in primary care, secondary, and in the community were approached and asked to complete a training needs analysis. This was a written survey developed by the Director of Medical Education. Individuals were sent a written survey and a majority of these were returned to us completed. Some questions included issues about the following: course title, target audience, room requirements, potential usage, equipment required, and faculty/Administration support required. The second activity, which we feel ensured our success, was the decision to apply for the ISO 9001 quality standard. This looks at management systems in place for customer service, record keeping and procedures to ensure that the centre is working most efficiently. The training needs analysis highlighted facilities needed to have to attract potential customers, these were then put in place. An example of this was our simulated operating theatre. This was required for anaesthetists to run medical emergency courses such as Obstetric Anaesthesia, Critical Incidents and Managing Emergencies in Paediatric Anaesthesia. Once the need was identified, anaesthetists were involved in designing the theatre to ensure the environment was appropriate and as realistic as possible for their training needs. We also identified potential courses we could run for our customers. One such opportunity arose when a training gap was noted by our team in the responses we received from education providers in the community and this concerned dealing with patients who suffer falls. Accordingly we set up a course addressing issues around falls, which was well attended and received very positive feedback from delegates. We achieved the ISO9001 standard and in the process made improvements in existing processes. Each process undertaken by the department was mapped onto individual flow charts, enabling staff to look at the tasks and see if they were being carried out in the most effective way. A suitable example was that of the room bookings procedure which was simplified. A single contact person was established ensuring information was not handled by multiple individuals resulting in duplication and confusion. A mock ward was required to run courses such as hand hygiene training and nursing simulation programmes. We involved nurses and doctors in planning stages to ensure our ward area is a true replica of the real world. Good pre-planning and maintenance of high standards in the day to day running of the centre has resulted in the following: 1) footfall continually increasing, reaching 5984 users by June 2012; 2) rising number of course/room bookings; and 3) 100% satisfaction rate from users for facilities and customer service.
Conclusion: Careful preplanning and involvement of all stakeholders is important, and we have shown how this is key to setting up a realistic and modern simulation centre. Continued well being of a centre requires that customers using the centre are happy. The process of achieving and maintaining the ISO9001 accreditation has ensured that we deliver high quality training, and we believe that this has been key to our continued success.
1. Hull Institute for Learning and Simulation website - www.hey.nhs.uk/clinicalskills.
2. ISO9001 Quality Standard - www.iso.org.
Disclosures: None© 2012 Society for Simulation in Healthcare