High-fidelity simulation is associated with good discriminability in emergency medicine residents' in-training examinations.

ABSTRACT: In-training examinations (ITEs), arranged during residency training, evaluate the residents' performances periodically. There is limited literature focusing on the effectiveness of resident ITEs in the format of simulation-based examinations, as compared to traditional oral or written tests. Our primary objective is to investigate the effectiveness and discriminative ability of high-fidelity simulation compared with other measurement formats in emergency medicine (EM) residency training program.This is a retrospective cohort study. During the 5-year study period, 8 ITEs were administered to 68 EM residents, and 253 ITE measurements were collected. Different ITE scores were calculated and presented as mean and standard deviation. The ITEs were categorized into written, oral, or high-fidelity simulation test forms. Discrimination of ITE scores between different training years of residency was examined using a one-way analysis of variance test.The high-fidelity simulation scores correlated to the progression of EM training, and residents in their fourth training year (R4) had the highest scores consistently, followed by R3, R2, and then R1. The oral test scores had similar results but not as consistent as the high-fidelity simulation tests. The written test scores distribution failed to discriminate the residents' seniority. The high-fidelity simulation test had the best discriminative ability and better correlation between different EM residency training years comparing to other forms.High-fidelity simulation tests had the good discriminative ability and were well correlated to the EM training year. We suggest high-fidelity simulation should be a part of ITE in training programs associated with critical or emergency patient cares.

Assessement of stress induced by high-fidelity simulation sessions among medical students.

INTRODUCTION: Simulation is a growing pedagogical method in training health professionals. The use of high-fidelity simulators may be associated with significant stress. OBJECTIVE: to measure self-assessed intensity of stress before and after a planned simulation training session of a third degree atrio-ventricular block  among  medical students. METHODS: A sample of 30 students participating in a high-fidelity simulation training course (10 playing the role of team leader and 20 in the role of medical intern) was studied. Stress was evaluated by self-assessment using a numerical scale before and after the session. The peri-traumatic distress inventory was used to measure the level of distress experienced by the participants. RESULTS: The median stress score was 3, 5±2, 4 before and 6, 2±2, 4 after the simulation session (p<0.001). Stress intensity increased significantly after the session in students playing the role of the team leader than those playing the role of medical intern (8, 4±0, 8 versus 5, 2±2, 3 p<0.001).The average score for peri-traumatic distress inventory was also significantly higher in the team leaders (18, 8±10, 4 Vs 9, 2±3, 7 p=0,022). CONCLUSION: Simulation-induced stress, as measured by self-assessment, increased significantly after the session and was influenced by the role to be played during the scenario.  Stress should be taken into account before debriefing.

Surgeons With Five or More Actual Cricothyrotomies Perform Significantly Better on a Virtual Reality Simulator.

BACKGROUND: Discriminating performance of learners with varying experience is essential to developing and validating a surgical simulator. For rare and emergent procedures such as cricothyrotomy (CCT), the criteria to establish such groups are unclear. This study is to investigate the impact of surgeons' actual CCT experience on their virtual reality simulator performance and to determine the minimum number of actual CCTs that significantly discriminates simulator scores. Our hypothesis is that surgeons who performed more actual CCT cases would perform better on a virtual reality CCT simulator. METHODS: 47 clinicians were recruited to participate in this study at the 2018 annual conference of the Society of American Gastrointestinal and Endoscopic Surgeons. We established groups based on three different experience thresholds, that is, the minimal number of CCT cases performed (1, 5, and 10), and compared simulator performance between these groups. RESULTS: Participants who had performed more clinical cases manifested higher mean scores in completing CCT simulation tasks, and those reporting at least 5 actual CCTs had significantly higher (P = 0.014) simulator scores than those who had performed fewer cases. Another interesting finding was that classifying participants based on experience level, that is, attendings, fellows, and residents, did not yield statistically significant differences in skills related to CCT. CONCLUSIONS: The simulator was sensitive to prior experience at a threshold of 5 actual CCTs performed.

Learning never stops: Evaluation of peer teachers in high fidelity simulation.

BACKGROUND: Nurse educators have used peer teaching as a means of providing effective learning to peer learners and enhancing peer teachers' comfort with teaching. There is a lack of evidence related to providing feedback to peer teachers. Receiving feedback may enhance peer teachers' knowledge synthesis and understanding of the teaching process. METHODS: We utilized a mixed methods approach to determine if an evaluation instrument was valid and helpful to peer teachers. Both peer learners and educators completed evaluations of peer teachers, which were then compared. After receiving summarized feedback, peer teachers completed a survey regarding their experience. RESULTS: There were no statistical differences between peer learner and educator ratings of peer teachers. Peer learners indicated they found peer teachers to be helpful in the high fidelity simulation setting. Peer teachers indicated satisfaction with the experience. Analysis of qualitative comments on peer-teacher surveys resulted in the identification of three themes: (a) validation of knowledge growth; (b) increased comfort with teaching; and (c) enhanced appreciation of teaching. CONCLUSIONS: Peer teaching may enhance knowledge gain and synthesis for both peer teachers and peer learners. Enhanced comfort with teaching may lead to enhanced comfort in teaching both patients and peers in future practice.

Standardized language systems for the design of high-fidelity simulation scenarios: A Delphi study.

PURPOSE: This study aimed to identify which of the standardised Nursing Interventions Classification (NIC) activities should be used in the design of clinical cases with high fidelity simulation for educational preparation of undergraduate nursing students in non-technical skills. DESIGN AND METHODS: A three-round Delphi study was carried out: the first round with taxonomy experts, the second round with academic and clinical lecturers with limited experience in the simulation-based learning methodology, and the third round with academic and clinical lecturers having at least two years of simulation experience. The NIC interventions were grouped into two levels of competence in accordance with the undergraduate nursing degree curriculum (1st- and 2nd-year students, the "novice" level; 3rd- and 4th-year students, the "advanced" level). The NIC allows the description of nurse student competencies in multiple clinical scenarios and throughout various contexts: theory, clinical practice and simulation. FINDINGS: The experts identified 163 interventions in 8 areas as relevant and feasible, selecting 42 for the "novice" students, in Nursing Fundamentals (13) and Adult Nursing Care 1 (29), and 97 for the "advanced" students: Maternity Care and Child Health Nursing (18), Mental Health (13), Nursing Care of Older People (12), Community Health Nursing (20) and Adult Nursing Care 2 (34). In addition, 24 interventions were identified as cross-cutting, with training to be provided across all four years of the degree. CONCLUSION: A total of 163 interventions of the NIC list were selected by experts as being both relevant and feasible to nursing undergraduate education. This creates the favourable framework to design high-fidelity scenarios for the training of non-technical skills according to the competences required and in line with the health care reality. Therefore, enabling an optimal combination of theoretical education by academic lecturers with practical training by clinical lecturers and staff nurses.

Experiences of Arab male nursing students during high fidelity maternity simulation training.

BACKGROUND: In Arab countries, many nursing schools rely heavily on simulation-based activities to provide experiential learning to male students with regard to maternal and child care; however, no study has been conducted to explore their experiences with such simulation training. AIM: To describe the experiences of male nursing students who were exposed to high-fidelity simulation training related to maternity and child care. METHODS: Husserl's approach to phenomenology guided this study, through the use of a structured interview with 15 Arab male nursing students. A thematic analysis technique served as a framework for the data analysis. FINDINGS: Thematic analysis revealed four essential themes: gained competency; compensation for missed clinical experience; overcoming of cultural or religious barriers; and challenges related to the use of simulation technologies. CONCLUSIONS: High-fidelity simulation can be a viable option to clinical training for enhancing Arab male nursing student competencies when providing maternal and child nursing care, which are often not available in the clinical area or are considered to be off limits due to cultural or religious reasons.

High-fidelity simulation increases pharmacy resident perceived competence during medical emergencies.

INTRODUCTION: Our objective was to assess postgraduate year one (PGY1) pharmacy resident perceived competence during medical emergencies before and after implementation of a longitudinal simulation training curriculum. METHODS: At the University of California San Francisco (UCSF) Medical Center, PGY1 pharmacy residents serve as primary code team responders for code blue, code sepsis, and code stroke, among other medical emergencies. In 2015, the UCSF Residency Training Program implemented a longitudinal simulation curriculum for PGY1 pharmacy residents. Throughout the residency year, residents participated in four simulation lab sessions that addressed various medical emergencies. To assess the impact that the simulation curriculum had on resident perceived competence during medical emergencies, a 19-question survey (13 clinical questions and six control questions) was distributed to the residents at the end of the residency year. Resident responses from the 2015 to 2016 and 2016 to 2017 surveys were compared to a control residency class from 2014 to 2015 who did not undergo the simulation curriculum. RESULTS: Simulation-trained PGY1 pharmacy residents reported significantly greater perceived competence in five of the twelve medical emergency scenarios (acute coronary syndromes, symptomatic bradycardia, supraventricular tachycardia, ventricular tachycardia, and cardiac arrest) as compared to non-simulation-trained controls. In addition, the PGY1 pharmacy residents felt that their performance as a clinical pharmacist would significantly improve as a result of the simulation curriculum. CONCLUSIONS: Incorporation of a longitudinal simulation curriculum into PGY1 pharmacy resident training can positively impact resident self-reported competence when performing essential pharmacist functions during medical emergencies.

Traditional clinical training combined with high-fidelity simulation-based activities improves clinical competency and knowledge among nursing students on a maternity nursing course.

BACKGROUND: Providing adequate and quality clinical training to student nurses is a major issue in nursing education. In the Middle East, this issue is more prominent because providing intimate healthcare to women in maternity nursing, especially by male nursing students, remains a challenge. PURPOSE: This study compared the effects of a combination of traditional clinical training with high-fidelity simulation (TCT+HFS) activities vs TCT alone on the clinical competency and knowledge among students enrolled in a maternity nursing course in a Middle Eastern public university. METHOD: A quasi-experimental research design was adopted in the study. The sample consisted of 74 students (40 in the TCT group and 34 in the TCT+HFS group) from a cohort of nursing students in a Middle Eastern university. The Creighton Competency Evaluation Instrument and a 29-item, researcher-designed knowledge scale was used to measure the relevant outcomes. RESULTS: No significant difference was observed in the knowledge (F = 1.064, P = 0.306) or clinical competency scores (F = 0.168, P = 0.683) between the TCT+HFS group and the TCT group. CONCLUSION: Substituting 25% of the clinical hours with HFS may yield similar learning outcomes (knowledge and clinical competency) as TCT.

Does the virtual refractor patient-simulator improve student competency when refracting in the consulting room?

BACKGROUND: The use of patient simulators in ophthalmic education appears limited. This study examines the effects of the addition of the 'Virtual Refractor' patient simulator learning activity into a short unit preparing students to determine the power of the spectacle lenses required by patients in a clinic. METHODS: Twenty-four year one optometry students were randomly assigned to either the simulator-intervention group (n = 12) or the non-intervention group. All students attended tutorials on refraction and the use of a refractor-head. Simulator-intervention students additionally attended a tutorial on the Virtual Refractor. All answered a questionnaire concerning time spent studying, perceived knowledge and confidence. Twenty-four short-sighted patients were recruited. Two refractions per student were timed and the accuracy compared with that of an experienced optometrist. RESULTS: Ten students from each group completed the study. Students who used the simulator were significantly (p < 0.05) more accurate at a clinical level (within 0.22 ± 0.22 DS, 95 per cent CI 0.12-0.32) than those who did not (within 0.60 ± 0.67 DS, 95 per cent CI 0.29-0.92) and 13 per cent quicker (4.7 minutes, p < 0.05). Students who used the simulator felt more knowledgeable (p < 0.05) and confident (p < 0.05), but had spent more time reading about refraction and practised on the Virtual Refractor at home for 5.7 ± 1.3 hours. CONCLUSION: The Virtual Refractor has many features of high-fidelity medical simulation known to lead to effective learning and it also offers flexible independent learning without a concomitant increase in the student time-burden. The improved accuracy and speed on first patient encounters found in this study validates the use of this patient simulator as a useful bridge for students early in training to successfully transfer theoretical knowledge prior to entering the consulting room. The translational benefits resulting from compulsory learning activities on a patient simulator can lead to reduced demands on infrastructure and clinical supervision.

Use of Emergency Manuals During Actual Critical Events in China: A Multi-Institutional Study.

INTRODUCTION: Emergency manuals (EMs) can help healthcare providers respond to crises more efficiently. Three anesthesia EMs have been translated into Chinese. These EMs have been made publicly available as a free document downloadable in China. A year after these Chinese versions of EMs were published, we conducted a multi-institutional survey in China to assess the progress of how well EM had been adapted and used in the setting of critical events. METHODS: Our study used a multi-institutional, anonymous electronic survey. We included hospitals that had conducted group studies of EMs as well as simulation trainings. The survey consisted of the five-point Likert scale, yes or no boxes, and multiple-choice questions with five possible choices. Statistical analysis included Pearson correlation coefficient and χ test. RESULTS: Nine hospitals were included in the study. The overall response rate was 56.4%. More than 70% of all respondents reported using an EM during at least one critical event within the past 6 months in China. A total of 87.7% of all respondents self-reviewed or group studied EMs. A total of 69% participated in multidisciplinary simulation training. Emergency manual use during a critical event showed a positive correlation with multidisciplinary simulation training (R = 0.896) and self-review/group study (R = 0.5234). The average self-reported use of EMs during clinical critical events is twice per anesthesiologist. CONCLUSIONS: This study demonstrated the nascent success of EM implementation in multiple Chinese institutions. Simulation training enhances the implementation and clinical usage of EM. Simulation training in an operating room was sufficient to learn how to use EM.

Pulse contour analysis of arterial waveform in a high fidelity human patient simulator.

The measurement of cardiac output (CO) may be useful to improve the assessment of hemodynamics during simulated scenarios. The purpose of this study was to evaluate the feasibility of introducing an uncalibrated pulse contour device (MostCare, Vytech, Vygon, Padova, Italy) into the simulation environment. MostCare device was plugged to a clinical monitor and connected to the METI human patient simulator (HPS) to obtain a continuous arterial waveform analysis and CO calculation. In six different simulated clinical scenarios (baseline, ventricular failure, vasoplegic shock, hypertensive crisis, hypovolemic shock and aortic stenosis), the HPS-CO and the MostCare-CO were simultaneously recorded. The level of concordance between the two methods was assessed by the Bland and Altman analysis. 150-paired CO values were obtained. The HPS-CO values ranged from 2.3 to 6.6 L min-1 and the MostCare-CO values from 2.8 to 6.4 L min-1. The mean difference between HPS-CO and MostCare-CO was - 0.3 L min-1 and the limits of agreement were - 1.5 and 0.9 L min-1. The percentage of error was 23%. A good correlation between HPS-CO and MostCare-CO was observed in each scenario of the study (r = 0.88). Although MostCare-CO tended to underestimate the CO over the study period, good agreements were found between the two methods. Therefore, a pulse contour device can be integrated into the simulation environment, offering the opportunity to create new simulated clinical settings.

Embryo transfer simulation improves pregnancy rates and decreases time to proficiency in Reproductive Endocrinology and Infertility fellow embryo transfers.

OBJECTIVE: To design and evaluate an ET simulator to train Reproductive Endocrinology and Infertility (REI) fellows' techniques of ET. DESIGN: Simulation model development and retrospective cohort analysis. SETTING: Not applicable. PATIENT(S): Patients undergoing IVF. INTERVENTION(S): Simulation model evaluation and implementation of ET simulation training. MAIN OUTCOME MEASURE(S): Pregnancy rates. RESULT(S): The REI fellow and faculty evaluation responses (n = 19/21 [90%]) of the model demonstrated realistic characteristics, with evaluators concluding the model was suitable for training in almost all evaluated areas. A total of 12 REI fellows who performed ET were analyzed: 6 before ET trainer and 6 after ET trainer. Pregnancy rates were 31% in the initial 10 ETs per fellow before simulator vs. 46% after simulator. One of six pre-ET trainer fellows (17%) had pregnancy rates ≥40% in their first 10 ETs; whereas four of six post-ET trainer fellows had pregnancy rates ≥40% in their first 10 ETs. The average number of ETs to obtain >40% pregnancy efficiency was 27 ETs before trainer vs. 15 ETs after trainer. Pregnancy rates were similar in the two groups after 20 ETs, and collective terminal pregnancy rates were >50% after 40 ETs. CONCLUSION(S): Embryo transfer simulation improved REI fellow pregnancy rates in their first 10 transfers and led to a more rapid ET proficiency. These data suggest potential value in adopting ET simulation, even in programs with a robust history of live ET in fellowship training.

Impact of an Interactive Diagnostic Case Simulator on a Medical Student Radiology Rotation.

OBJECTIVE: The objective of our study was to assess the short-term impact of adding an interactive simulator to a medical student radiology clerkship. We hypothesized that transitioning students from passive observers to active participants in the reading room would create an appealing and effective learning experience for the current generation of students. MATERIALS AND METHODS: An interactive workstation that provided diagnostic simulations of 84 cases selected to maximize exposure to important diagnoses in musculoskeletal (MSK) radiology was created. From February 2015 through July 2016, 83 students on the radiology elective rotated through MSK: 40 in the traditional observational role and 43 with the MSK simulator. At the end of the rotation, all students completed general radiology and MSK-based competency examinations. The students who used the interactive workstation completed a survey about their experience. RESULTS: MSK competency scores were significantly better for students who rotated with the interactive workstation compared with students in the traditional observational role (mean scores, 71% and 51%, respectively; p < 0.0001). There was no difference in end-of-rotation general competency scores between the groups (mean, 86% and 85%; p = 0.32). Ninety-one percent of students reported the simulator had at least a moderately positive impact on their radiology experience. All students (100%) reported that learning was improved and recommended establishing workstations for other subspecialties. Twenty-one percent of students reported that their experience using the simulator had a positive impact on considering radiology as a career choice. CONCLUSION: Using a reading room-based diagnostic radiology case simulator improves medical student learning, enables self-directed learning, and improves overall experience on the radiology clerkship, positively impacting consideration of radiology as a career.

Outcomes of a virtual-reality simulator-training programme on basic surgical skills in robot-assisted laparoscopic surgery.

BACKGROUND: The utility of the virtual-reality robotic simulator in training programmes has not been clearly evaluated. Our aim was to evaluate the impact of a virtual-reality robotic simulator-training programme on basic surgical skills. METHODS: A simulator-training programme in robotic surgery, using the da Vinci Skills Simulator, was evaluated in a population including junior and seasoned surgeons, and non-physicians. Their performances on robotic dots and suturing-skin pod platforms before and after virtual-simulation training were rated anonymously by surgeons experienced in robotics. RESULTS: 39 participants were enrolled: 14 medical students and residents in surgery, 14 seasoned surgeons, 11 non-physicians. Junior and seasoned surgeons' performances on platforms were not significantly improved after virtual-reality robotic simulation in any of the skill domains, in contrast to non-physicians. CONCLUSIONS: The benefits of virtual-reality simulator training on several tasks to basic skills in robotic surgery were not obvious among surgeons in our initial and early experience with the simulator. Copyright © 2016 John Wiley & Sons, Ltd.

[High fidelity simulation in Spain: from dreams to reality]. / Simulación de alta fidelidad en España: de la ensoñación a la realidad.

UNLABELLED: Clinical simulation has emerged as a powerful new tool for the learning and assessment of different skills and attitudes in patient care, by using innovative technology such as high fidelity simulators (HFS). OBJECTIVE: To describe the current state of high fidelity clinical simulation in Spain and its principal characteristics. METHODS: Descriptive observational study that analyzes information on the clinical centers that have HFS in our country. RESULTS: There are currently a total of 80 centers with HFS in our country, mainly distributed in university centers (43), hospital and emergency centers (27), simulation centers and institutes of simulation (5), and the rest (5) associated to entities of diverse ownership. The temporal development of HFS has been slowly progressive, with a significant growth in the last 6 years. The majority (74%) have specific facilities, auxiliary equipment (60%), and professionals with a shared commitment (80%). It is already integrated into the training programs in 56% of university centers with HFS. CONCLUSIONS: The development of HFS has been remarkable in our country, and is mainly related to university undergraduate and postgraduate clinical medical education. It would be useful to design a network of simulation training centers of Health Sciences in Spain, which would be operational, sustainable and recognized, to optimize the use of these facilities.