SBAR 'flattens the hierarchy' among caregivers.

As a young ensign in the US Navy on a nuclear submarine, Doug Bonacum had to brief the captain of the ship following his night-time shift, reporting about potentially dangerous situations that might emerge. He described the "situation, background, assessment, and recommendation". This nascent SBAR communication tool served temporarily to flatten the hierarchy between the ensign and the ship's captain. Years later at KP, Bonacum developed SBAR for facilitating effective conversations between obstetricians and nurses. SBAR has been implemented in "real-world" environments with excellent results. We are implementing SBAR to facilitate communication in CliniSpace among caregivers in this 3D immersive, virtual learning environment.

Development and management of public health education system against emerging infectious diseases.

With recent spread of infectious diseases, worldwide emergency strategies against them have been made. As one of such efforts we planned to develop an educational program for public health manpower using IT, and produced 4 to 8 minute-long flash animations of the following subjects selected by Education Training Expert Committee: Self-care guideline on H1N1; Instruction for medical hospital; Prevention of hospital acquired infections; Method of sampling & transporting. Demonstrative education using an online education system was conducted targeting 10 doctors working in a rural health center to evaluate the developed animations. They received good marks in the factors of credibility and accuracy, but needed to improve in that of interaction with educatees. Our suggestion is that we use the result of our study as a prototype of education contents on infectious diseases, and modify its contents accordingly when a specific disease breaks out.

Distance Learning During COVID-19 Mitigates Learning Loss for Interprofessional Education.

SUMMARY STATEMENT: On-site interprofessional education (IPE) simulation is primarily used to teach students teamwork, communication, and crisis resource management. Participants view it as an educational environment in which to acquire and consolidate skills. Virtual IPE simulation is traditionally seen as an opportunity to supplement, complement, and reinforce on-site IPE (OI). We used VI as the sole simulation method during the COVID-19 pandemic to provide IPE because of constraints of social distancing. The VI resulted in substantially achieving similar learning outcomes to OI. This suggests that VI, which has the advantage of being cheaper and more easily scalable than OI, may be an effective remote learning modality for IPE.

CliniSpace: a multiperson 3D online immersive training environment accessible through a browser.

Immersive online medical environments, with dynamic virtual patients, have been shown to be effective for scenario-based learning (1). However, ease of use and ease of access have been barriers to their use. We used feedback from prior evaluation of these projects to design and develop CliniSpace. To improve usability, we retained the richness of prior virtual environments but modified the user interface. To improve access, we used a Software-as-a-Service (SaaS) approach to present a richly immersive 3D environment within a web browser.

Training healthcare personnel for mass-casualty incidents in a virtual emergency department: VED II.

INTRODUCTION: Training emergency personnel on the clinical management of a mass-casualty incident (MCI) with prior chemical, biological, radioactive, nuclear, or explosives (CBRNE) -exposed patients is a component of hospital preparedness procedures. OBJECTIVE: The objective of this research was to determine whether a Virtual Emergency Department (VED), designed after the Stanford University Medical Center's Emergency Department (ED) and populated with 10 virtual patient victims who suffered from a dirty bomb blast (radiological) and 10 who suffered from exposure to a nerve toxin (chemical), is an effective clinical environment for training ED physicians and nurses for such MCIs. METHODS: Ten physicians with an average of four years of post-training experience, and 12 nurses with an average of 9.5 years of post-graduate experience at Stanford University Medical Center and San Mateo County Medical Center participated in this IRB-approved study. All individuals were provided electronic information about the clinical features of patients exposed to a nerve toxin or radioactive blast before the study date and an orientation to the "game" interface, including an opportunity to practice using it immediately prior to the study. An exit questionnaire was conducted using a Likert Scale test instrument. RESULTS: Among these 22 trainees, two-thirds of whom had prior Code Triage (multiple casualty incident) training, and one-half had prior CBRNE training, about two-thirds felt immersed in the virtual world much or all of the time. Prior to the training, only four trainees (18%) were confident about managing CBRNE MCIs. After the training, 19 (86%) felt either "confident" or "very confident", with 13 (59%) attributing this change to practicing in the virtual ED. Twenty-one (95%) of the trainees reported that the scenarios were useful for improving healthcare team skills training, the primary objective for creating them. Eighteen trainees (82%) believed that the cases also were instructive in learning about clinical skills management of such incidents. CONCLUSIONS: These data suggest that training healthcare teams in online, virtual environments with dynamic virtual patients is an effective method of training for management of MCIs, particularly for uncommonly occurring incidents.

Teleteaching endoscopy: the feasibility of real-time, uncompressed video transmission by using advanced-network technologies.

BACKGROUND: Teleteaching of endoscopy has been limited by the exorbitant cost and time inherent in high-quality digital endoscopy video transmission. The Digital Video Transport System (DVTS) transmitted over advanced networks, such as Internet2 and the Asia-Pacific Advanced Network (APAN), provides a unique infrastructure for sharing uncompressed digital videos of endoscopy. This may allow high-quality, real-time, international training of diagnostic and therapeutic endoscopy techniques at a low cost. OBJECTIVE: To test the proof of concept of long-distance teaching through live, interactive, high-resolution video transmission by using advanced networks and the DVTS. We used teleteaching of image-enhanced endoscopy techniques as a model. DESIGN: Prospective multicenter pilot study. SETTING AND PARTICIPANTS: Trainees, faculty, and staff at 3 international endoscopy units. INTERVENTION: An image-enhanced endoscopy video lecture with advanced-network technologies. MAIN OUTCOME MEASUREMENTS: We compared image-based prelecture and postlecture test scores and secondarily assessed technical feasibility and quality. RESULTS: The DVTS transmitted over advanced networks successfully transmitted uncompressed, high-resolution, digital lectures with endoscopic video (digital video format 720 x 480 pixels). Postsession scores improved. Participants highly rated the technical and informational quality. The majority reported a definite interest in participating in future sessions, with a mean rating (out of 5 [scale 1-5]) of 4.7 +/- 0.5. LIMITATIONS: Pilot study with a limited number of participants and sessions. CONCLUSION: The DVTS transmitted over advanced networks such as Internet2 and APAN can provide the infrastructure for transmission of high-resolution, uncompressed video endoscopy for the purpose of teleteaching endoscopy.

Orthopedic surgery core curriculum hip and knee reconstruction.

OBJECTIVE: To develop a core curriculum for orthopedic surgery and to conduct a national survey to assess the importance of 281 curriculum items. Attention was focused on 55 topics pertaining to hip and knee reconstruction. METHODS: A 281-item curriculum was developed. We completed a content review and cross-sectional survey of a random selection of orthopedic surgeons whose primary affiliation was nonuniversity. We analyzed the data descriptively and quantitatively, using histograms, a modified Hotelling's T2 statistic with the p value determined by a permutation test, and the Benjamini- Hochberg/Yekutieli procedure. Our analyses assumed that each respondent answered questions independently of the answers of any other respondent but that the answers to different questions by the same respondent might be dependent. RESULTS: Of 156 orthopedic surgeons, 131 (84%) participated in this study. Of 55 items ranked by all respondents, 42 received an average mean score greater than 3.5/4.0, and 51 received an average mean score equal to or greater than 3.0/40 (the standard deviation for each item ranged from 0.00 to 0.08), suggesting that 92.7% of the items are important or probably important to know by the end of residency. CONCLUSION: This study demonstrates agreement that it is important to include 92.7% of the items that pertain to hip and knee reconstruction in a core curriculum for orthopedic surgery. Residency training programs may need to ensure that appropriate educational opportunities focusing on complex primary and revision surgery are available to meet the future needs of orthopedic surgeons whose primary affiliation is nonuniversity.

Design and implementation of rule-based medical models: an In Silico patho-physiological trauma model for hypovolemic shock.

Trauma from 'Dirty' Bomb blasts presents complex clinical problems to healthcare providers who must make critical emergency care decisions with incomplete information, usually limited initially only to cursory observations and vital signs. A set of simple, HFSM patho-physiological models of hypovolemic shock based upon blood volume deficits and remedial therapeutic actions has been created for 10 Virtual World scenarios used for training healthcare personnel in the diagnosis and management of 'dirty' bomb victims. Several general rules define the models: * Virtual patients have individual characteristics of gender, age, health status. * An Expanded Organ Injury Scale (EOIS) indicates in descriptive terms the type, severity, and location of the injury. * Traumatic Hemorrhage Classes (THC) determine Blood Volume Deficit. * EOIS/THC Score and Volume Deficit are tightly linked to the Hemorrhage Rate. * Remedial actions include Wound care, Volume Replacement (0.9% saline, packed cells), and a Drug Formulary for Treating Hemorrhagic Shock. The above rules and their logical basis are derived from the literature on emergency medicine (trauma), with modifications for organ injury, and introducing progressive deterioration beyond the body's homeostatic capabilities, into failure of systems and organs, followed by death. The ten unique models and scenarios are designed to run simultaneously in a virtual emergency department to provide training experiences for healthcare personnel with trauma from a 'dirty' bomb blast event.

Learner-Adaptive Educational Technology for Simulation in Healthcare: Foundations and Opportunities.

STATEMENT: Despite evidence that learners vary greatly in their learning needs, practical constraints tend to favor ''one-size-fits-all'' educational approaches, in simulation-based education as elsewhere. Adaptive educational technologies - devices and/or software applications that capture and analyze relevant data about learners to select and present individually tailored learning stimuli - are a promising aid in learners' and educators' efforts to provide learning experiences that meet individual needs. In this article, we summarize and build upon the 2017 Society for Simulation in Healthcare Research Summit panel discussion on adaptive learning. First, we consider the role of adaptivity in learning broadly. We then outline the basic functions that adaptive learning technologies must implement and the unique affordances and challenges of technology-based approaches for those functions, sharing an illustrative example from healthcare simulation. Finally, we consider future directions for accelerating research, development, and deployment of effective adaptive educational technology and techniques in healthcare simulation.

Using Virtual Reality Simulation Environments to Assess Competence for Emergency Medicine Learners.

Immersive learning environments that use virtual simulation (VS) technology are increasingly relevant as medical learners train in an environment of restricted clinical training hours and a heightened focus on patient safety. We conducted a consensus process with a breakout group of the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change Through Health Care Simulation: Systems, Competency, and Outcomes." This group examined the current uses of VS in training and assessment, including limitations and challenges in implementing VS into medical education curricula. We discuss the role of virtual environments in formative and summative assessment. Finally, we offer recommended areas of focus for future research examining VS technology for assessment, including high-stakes assessment in medical education. Specifically, we discuss needs for determination of areas of focus for VS training and assessment, development and exploration of virtual platforms, automated feedback within such platforms, and evaluation of effectiveness and validity of VS education.

Orthopaedic surgery core curriculum: the spine.

OBJECTIVE: To develop a core curriculum for orthopaedic surgery and to conduct a national survey to assess the importance of 281 items in the curriculum. Attention was focused specifically on 24 items pertaining to the curriculum that are pertinent to the spine. STUDY DESIGN: A cross-sectional survey of a random sample of orthopaedic surgeons whose primary affiliation was non-academic, representing the provinces and territories of Canada METHODS: A questionnaire containing 281 items was developed. A random group of 131 (out of 156) orthopaedic surgeons whose primary affiliation is non-academic completed the questionnaire. The data were analysed quantitatively using average mean scores, histograms, the modified Hotelling's T2 test and the Benjimini-Hochberg procedure. RESULTS: 131 of 156 (84%) orthopaedic surgeons participated, in this study. 14 of 24 items were ranked at no less than 3 out of 4 thus suggesting that 58% of the items are important or probably important to know by the end of residency (SD< or =0.07). Residents need to learn the diagnosis and principles of managing patients with common conditions of the spine. CONCLUSIONS: The study shows, with reliable statistical evidence, that orthopaedic residents are no longer expected to be able to perform spinal fusions with proficiency on completion of residency. Is the exposure to surgical spine problems and the ability to be comfortable with operating expectations specific to the fellowship level? If so, the focus during residency or increasing accredited spine fellowships needs to be addressed to ensure that enough spine surgeons are educated to meet the future healthcare demands projected for Canada.

What orthopaedic surgery residents need to know about the hand and wrist?

BACKGROUND: To develop a Core Curriculum for Orthopaedic Surgery; and to conduct a national survey to assess the importance of curriculum items as judged by orthopaedic surgeons with primary affiliation non-academic. Attention for this manuscript was focused on determining the importance of topics pertaining to adult hand and wrist reconstruction. METHODS: A 281-item questionnaire was developed and consisted of three sections: 1) Validated Musculoskeletal Core Curriculum; 2) Royal College of Physician and Surgeons of Canada (RCPSC) Specialty Objectives and; 3) A procedure list. A random group of 131 [out of 156] orthopaedic surgeons completed the questionnaire. Data were analyzed descriptively and quantitatively using histograms, a Modified Hotel ling's T2-statistic 1 with p-value determined by a permutation test, and the Benjamini-Hochberg/Yekutieli procedure RESULTS: 131/156 (84%) orthopaedic surgeons participated in this study. 27/32 items received an average mean score of at least 3.0/4.0 by all respondents thus suggesting that 84% of the items are either "probably important" or "important" to know by the end of residency (SD range 0.007-0.228). The Benjamini-Hochberg procedure demonstrated that for 80% of the 32 x 31/2 = 496 possible pairs of hand and wrist questions did not appear to demonstrate the same distribution of ratings given that one question was different from that of another question. CONCLUSION: This study demonstrates with reliable statistical evidence, agreement on the importance of 27/32 items pertaining to hand and wrist reconstruction is included in a Core Curriculum for Orthopaedic Surgery. Residency training programs need ensure that educational opportunities focusing on the ability to perform with proficiency procedures pertaining to the hand and wrist is taught and evaluated in their respective programs.

Orthopaedic surgery core curriculum: foot and ankle reconstruction.

BACKGROUND: The purpose of this study was to develop a core curriculum for orthopaedic surgery and to conduct a national survey to assess the importance of 281 curriculum items. Attention was focused on 45 items pertaining to the foot and ankle. METHODS: A 281-item curriculum was developed. A content review and cross-sectional survey of a random selection of orthopaedic surgeons with primary nonacademic affiliations was completed. Data were analyzed descriptively and quantitatively using histograms, modified Hotelling's T(2)-statistic, and the Benjamini-Hochberg procedure. Our analyses assumed that each respondent answered questions independently of the answers of any other respondent but that the answers to different questions by the same respondent might be dependent. RESULTS: Of the 156 orthopaedic surgeons contacted, 131 (86%) participated in this study. Eighty-two percent (37 of 45) of the items were ranked by respondents with an average mean score higher than 3.5/4.0 and 42 higher than 3.0/40, thus suggesting that 93% of the items are important or probably important to know by the end of residency (p

Criterion-based training with surgical simulators: proficiency of experienced surgeons.

OBJECTIVE: In our effort to establish criterion-based skills training for surgeons, we assessed the performance of 17 experienced laparoscopic surgeons on basic technical surgical skills recorded electronically in 26 modules selected in 5 commercially available, computer-based simulators. METHODS: Performance data were derived from selected surgeons randomly assigned to simulator stations, and practicing repetitively during one and one-half day sessions on 5 different simulators. We measured surgeon proficiency defined as efficient, error-free performance and developed proficiency score formulas for each module. Demographic and opinion data were also collected. RESULTS: Surgeons' performance demonstrated a sharp learning curve with the most performance improvement seen in early practice attempts. Median scores and performance levels at the 10th, 25th, 75th, and 90th percentiles are provided for each module. Construct validity was examined for 2 modules by comparing experienced surgeons' performance with that of a convenience sample of less-experienced surgeons. CONCLUSION: A simple mathematical method for scoring performance is applicable to these simulators. Proficiency levels for training courses can now be specified objectively by residency directors and by professional organizations for different levels of training or post-training assessment of technical performance. But data users should be cautious due to the small sample size in this study and the need for further study into the reliability and validity of the use of surgical simulators as assessment tools.

Avatars alive! The integration of physiology models and computer generated avatars in a multiplayer online simulation.

In a mass casualty incident, injured and at-risk patients will pass through a continuum of care from many different providers acting as a team in a clinical environment. As presented at MMVR 14 [Kaufman, et al 2006], formative evaluations have shown that simulation practice is nearly as good as, and in some cases better than, live exercises for stimulating learners to integrate their procedural knowledge in new circumstances through experiential practice. However, to date, multiplayer game technologies have given limited physiological fidelity to their characters, thus limiting the realism and complexity of the scenarios that can be practiced by medical professionals. This paper describes the status of a follow-on program to merge medical and gaming technologies so that computer generated, but human-controlled, avatars used in a simulated, mass casualty training environment will exhibit realistic life signs. This advance introduces a new level of medical fidelity to simulated mass casualty scenarios that can represent thousands of injuries. The program is identifying the critical instructional challenges and related system engineering issues associated with the incorporation of multiple state-of-the-art physiological models into the computer generated synthetic representation of patients. The work is a collaboration between Forterra Systems and the SUMMIT group of Stanford University Medical School, and is sponsored by the US Army Medical Command's Telemedicine and Advanced Technologies Research Center (TATRC).

Virtual worlds for teaching the new CPR to high school students.

In this study we created a virtual 3D world for learning to manage medical emergencies and evaluated it with 24 high school students in the USA and Sweden. We found that students in both groups felt immersed and found the online simulation easy to use. Scores for flow and self-assessed flow were significantly higher for the RHS group as compared to the HG group (p=.001 and .023 respectively; Mann Whitney U test). Self-efficacy scores for the HG group were significantly higher after training (p=.016 Mann Whitney U test). Males in the RHS group scored significantly higher on flow and self assessed flow than females (p=.006 and p=.023 respectively; Mann Whitney U test). This study demonstrates the potential value of using MMOS for learning to respond to medical emergencies.

Virtually Nursing: Emerging Technologies in Nursing Education.

Augmented reality and virtual simulation technologies in nursing education are burgeoning. Preliminary evidence suggests that these innovative pedagogical approaches are effective. The aim of this article is to present 6 newly emerged products and systems that may improve nursing education. Technologies may present opportunities to improve teaching efforts, better engage students, and transform nursing education.

Using ontologies linked with geometric models to reason about penetrating injuries.

OBJECTIVE: Medical assessment of penetrating injuries is a difficult and knowledge-intensive task, and rapid determination of the extent of internal injuries is vital for triage and for determining the appropriate treatment. Physical examination and computed tomographic (CT) imaging data must be combined with detailed anatomic, physiologic, and biomechanical knowledge to assess the injured subject. We are developing a methodology to automate reasoning about penetrating injuries using canonical knowledge combined with specific subject image data. METHODS AND MATERIAL: In our approach, we build a three-dimensional geometric model of a subject from segmented images. We link regions in this model to entities in two knowledge sources: (1) a comprehensive ontology of anatomy containing organ identities, adjacencies, and other information useful for anatomic reasoning and (2) an ontology of regional perfusion containing formal definitions of arterial anatomy and corresponding regions of perfusion. We created computer reasoning services ("problem solvers") that use the ontologies to evaluate the geometric model of the subject and deduce the consequences of penetrating injuries. RESULTS: We developed and tested our methods using data from the Visible Human. Our problem solvers can determine the organs that are injured given particular trajectories of projectiles, whether vital structures--such as a coronary artery--are injured, and they can predict the propagation of injury ensuing after vital structures are injured. CONCLUSION: We have demonstrated the capability of using ontologies with medical images to support computer reasoning about injury based on those images. Our methodology demonstrates an approach to creating intelligent computer applications that reason with image data, and it may have value in helping practitioners in the assessment of penetrating injury.

Project hydra--a new paradigm of internet-based surgical simulation.

Computer-based surgical simulation systems have produced tremendous benefits and demonstrated validity as a better method for many areas of surgical skills acquisition. However, despite these benefits, broad proliferation of these systems has continued to be elusive. While in large part this lag in adoption of this technology is due to social factors (organizational momentum, curriculum integration difficulties, etc), the cost of computer-based simulation systems has certainly remained a major deterrent toward broad deployment. Instead, what if it were possible to eliminate the cost of the large computer completely from the system, yet provide a much more extensive and detailed simulation than currently available? Finally, what if a simulation with even greater detail over a wider anatomical area were possible?This is the genesis of Project Hydra- a shared simulation supercomputer were made available for free and all that is required to access it is a low-end Internet-connected computer and, optionally, interaction/haptics devices as needed for the particular task. This would enable supercomputer-class simulation at every desktop with much greater fidelity than any user could individually afford and provide an online community for simulation research and application. Further, Internet-based simulation provides for many other benefits as well. By the user merely plugging optional, additional hardware into their existing, low-end PC and using the Internet as a means of simulation dissemination, distribution, and delivery means that the user can have immediate access to simulation updates/upgrades and download/access new content (didactic curriculum and cases). Further, this ease of access and use could lead to accelerated adoption and use of simulation within the medical curriculum and this access is provided anywhere in the world 24 x 7. In addition, once connected, a server-based simulation system would be a natural point for performing easy, automated clinical studies of surgical performance and skills.