Bridging the Stressful Gap Between ICU and Home: Medical Simulation for Pediatric Patients and Their Families.

OBJECTIVES: Introduce an expanding role for pediatric critical care and medical simulation to optimize the care for children with technology dependence. DATA SOURCES: Limited review of literature and practice for current teaching paradigms, vulnerability of the patient population, and efficacy of simulation as a medical educational tool. CONCLUSIONS: In accordance with new care models and patient need, critical care requires parallel evolution of care practices, including new educational and care models, in order to maximally reduce risk, fear, and anxiety and to insure quality and consistent care in the community for patients and families transitioning between the ICU and home environments.

Development of a Standardized Kalamazoo Communication Skills Assessment Tool for Radiologists: Validation, Multisource Reliability, and Lessons Learned.

OBJECTIVE: The purpose of this study was to develop and test a standardized communication skills assessment instrument for radiology. MATERIALS AND METHODS: The Delphi method was used to validate the Kalamazoo Communication Skills Assessment instrument for radiology by revising and achieving consensus on the 43 items of the preexisting instrument among an interdisciplinary team of experts consisting of five radiologists and four nonradiologists (two men, seven women). Reviewers assessed the applicability of the instrument to evaluation of conversations between radiology trainees and trained actors portraying concerned parents in enactments about bad news, radiation risks, and diagnostic errors that were video recorded during a communication workshop. Interrater reliability was assessed by use of the revised instrument to rate a series of enactments between trainees and actors video recorded in a hospital-based simulator center. Eight raters evaluated each of seven different video-recorded interactions between physicians and parent-actors. RESULTS: The final instrument contained 43 items. After three review rounds, 42 of 43 (98%) items had an average rating of relevant or very relevant for bad news conversations. All items were rated as relevant or very relevant for conversations about error disclosure and radiation risk. Reliability and rater agreement measures were moderate. The intraclass correlation coefficient range was 0.07-0.58; mean, 0.30; SD, 0.13; and median, 0.30. The range of weighted kappa values was 0.03-0.47; mean, 0.23; SD, 0.12; and median, 0.22. Ratings varied significantly among conversations (χ26 = 1186; p < 0.0001) and varied significantly by viewing order, rater type, and rater sex. CONCLUSION: The adapted communication skills assessment instrument is highly relevant for radiology, having moderate interrater reliability. These findings have important implications for assessing the relational competencies of radiology trainees.

Teaching, coaching, or debriefing With Good Judgment: a roadmap for implementing "With Good Judgment" across the SimZones.

Simulation-based learning occurs in multiple contexts, and one teaching style cannot adequately cover the needs at each learning level. For example, reflective debriefing, often used following a complex simulation case, is not what is needed when learning new skills. When to use which facilitation style is a question that educators often overlook or struggle to determine. SimZones is a framework used to clarify the multiple contexts in simulation. This framework, combined with elements of Debriefing With Good Judgment, can help educators match the appropriate facilitation style with learner needs and learning context. We have distilled the core elements of the "with good judgment" approach to debriefing and applied them to the SimZones framework to guide educators with (1) what type of learning can be expected with each learning context, (2) what behaviors and activities can be expected of the learners in each learning context, (3) what instructional strategies are most effectively used at each stage, and (4) what are the implications for the teacher-learner relationship.

"Ready SIM Go": An Adapted Simulation "Service Line" for Patients and Caregivers.

SUMMARY STATEMENT: Changing healthcare systems and efforts to decrease medical costs have resulted in many more patients and caregivers (PCs) needing to manage life-sustaining therapies on their own. Given the potential for underpreparedness to result in increased morbidity and mortality, developing safe and efficient homecare training methods for PCs is essential. Medical simulation with PCs is an underused tool, which has the potential to decrease anxiety and increase preparedness through opportunities for repeated practice of medical procedures within a safe, controlled environment. This article describes the development of a hospital-based simulation service line for PCs, leveraging lessons learned from training for 250 patients and 450 caregivers in 14 different departments and subspecialties, and explains adaptations of standard simulation methods necessary for safe and effective use of simulation with this unique population. Process blueprint, examples of specific programs, as well as feedback from participants and clinicians are included.

Acoustic analysis of surgeons' voices to assess change in the stress response during surgical in situ simulation.

Introduction: Stress may serve as an adjunct (challenge) or hindrance (threat) to the learning process. Determining the effect of an individual's response to situational demands in either a real or simulated situation may enable optimisation of the learning environment. Studies of acoustic analysis suggest that mean fundamental frequency and formant frequencies of voice vary with an individual's response during stressful events. This hypothesis is reviewed within the otolaryngology (ORL) simulation environment to assess whether acoustic analysis could be used as a tool to determine participants' stress response and cognitive load in medical simulation. Such an assessment could lead to optimisation of the learning environment. Methodology: ORL simulation scenarios were performed to teach the participants teamwork and refine clinical skills. Each was performed in an actual operating room (OR) environment (in situ) with a multidisciplinary team consisting of ORL surgeons, OR nurses and anaesthesiologists. Ten of the scenarios were led by an ORL attending and ten were led by an ORL fellow. The vocal communication of each of the 20 individual leaders was analysed using a long-term pitch analysis PRAAT software (autocorrelation method) to obtain mean fundamental frequency (F0) and first four formant frequencies (F1, F2, F3 and F4). In reviewing individual scenarios, each leader's voice was analysed during a non-stressful environment (WHO sign-out procedure) and compared with their voice during a stressful portion of the scenario (responding to deteriorating oxygen saturations in the manikin). Results: The mean unstressed F0 for the male voice was 161.4 Hz and for the female voice was 217.9 Hz. The mean fundamental frequency of speech in the ORL fellow (lead surgeon) group increased by 34.5 Hz between the scenario's baseline and stressful portions. This was significantly different to the mean change of -0.5 Hz noted in the attending group (p=0.01). No changes were seen in F1, F2, F3 or F4. Conclusions: This study demonstrates a method of acoustic analysis of the voices of participants taking part in medical simulations. It suggests acoustic analysis of participants may offer a simple, non-invasive, non-intrusive adjunct in evaluating and titrating the stress response during simulation.

Simulation capacity building in rural Indian hospitals: a 1-year follow-up qualitative analysis.

Introduction: The benefits of simulation-based medical training are well described. The most effective way to plant and scale simulation training in rural locations remains undescribed. We sought to plant simulation training programmes for anaesthesia emergencies in two rural Indian hospitals. Methods: Two Indian consultant anaesthetists without experience in medical simulation underwent a 3-day course at the Boston Children's Hospital's (BCH) Simulator Program. They returned to their institutions and launched simulation programmes with an airway manikin and mock patient monitor. The 1-year experience was evaluated using individual, in-depth interviews of simulation facilitators. Three staff members (responsible for facilitating medical simulations over the prior year) at two rural hospitals in India were interviewed. None attended the BCH training; instead, they received on-the-job training from the BCH-trained, consultant anaesthetist colleagues. Results: Successes included organisational adoption of simulation training with exercises 1 year after the initial BCH-training, increased interdisciplinary teamwork and improved clinical competency in managing emergencies. Barriers to effective, local implementation of simulation programmes fell into three categories: time required to run simulations, fixed and rigid roles, and variable resources. Thematic improvement requests were for standardised resources to help train simulation facilitators and demonstrate to participants a well-run simulation, in addition to context-sensitive scenarios. Conclusion: An in-person training of simulation facilitators to promote medical simulation programmes in rural hospitals produced ongoing simulation programmes 1 year later. In order to make these programmes sustainable, however, increased investment in developing simulation facilitators is required. In particular, simulation facilitators must be prepared to formally train other simulation facilitators, too.

Assessing competency using simulation: the SimZones approach.

Introduction: Competency-based medical education (CBME) is a system of medical training that focuses on a structured approach to developing the clinical abilities of medical education graduates and practicing physicians. CBME requires a robust and multifaceted system of assessment in order to both measure and guide the progress of learners toward pre-established goals. Simulation has been proposed as one method for assessing competency in healthcare workers. However, a longitudinal framework for assessing competency using simulation has not been developed. Methods: Conjecture mapping methodology was used to map Miller's framework for competency assessment-'knows', 'knows how', 'shows how', and 'does'-to the five SimZones described by Roussin and Weinstock. The SimZones describe a system of organising the development and delivery of simulation-based education and offer a foundation for both guiding and organising assessment in a simulation context. Results: A conceptualised alignment of the SimZones with Miller's pyramid of assessment was developed, as well as a detailed conjecture map. SimZone 0 (auto-feedback) and SimZone 1 (foundational instruction) mapped to 'knows' and 'knows how'. SimZone 2 (acute care instruction) mapped to 'shows how'. SimZone 3 (team and system development) mapped to 'shows how'. SimZone 4 (real-life debriefing and development) mapped to 'does'. Conclusion: The SimZones system of competency assessment offers a robust, flexible, and multifaceted system to guide both formative and summative assessment in CBME. The SimZones approach adds to the many methods of competency assessment available to educators. Adding SimZones to the vocabulary of CBME may be helpful for the full deployment of CBME.

"This Is How Hard It Is". Family Experience of Hospital-to-Home Transition with a Tracheostomy.

Rationale: Expansion of chronic ventilation options and shared decision-making have contributed to an increasing population of technology-dependent children. One particularly vulnerable group is children with tracheostomy who depend on technology for basic respiratory functions. Chronic critical care is now provided in the homecare setting with implications for family caregivers.Objectives: This study explores the experience of family caregivers of children and young adults with a tracheostomy during the transition from hospital to home care. We sought to identify the specific unmet needs of families to direct future interventions.Methods: We recruited a convenience sample of families from an established home ventilation program to participate in semistructured interviews. Sessions were conducted in person or via teleconference. A grounded-theory qualitative analysis was performed.Results: Between March 2017 and October 2018, we interviewed 13 individuals representing 12 families of children and/or young adults with tracheostomy. Patients ranged in age from 9 months to 28 years, had a tracheostomy for 8 months to 18 years, and represented a variety of underlying diagnoses. Five key themes emerged: 1) navigating home nursing; 2) care coordination and durable medical equipment (DME) impediments; 3) learning as a process; 4) managing emergencies; and 5) setting expectations.Conclusions: Our findings support the need for family-centered discharge processes including coordination of care and teaching focused on emergency preparedness.

Self-Confidence in Endotracheal Intubation Among Pediatric Interns: Associations With Gender, Experience, and Performance.

BACKGROUND AND OBJECTIVE: Supervisors' decisions regarding procedural readiness are influenced by resident confidence. Confidence is a valuable metric if we understand how it correlates with trainee characteristics and procedural competence. Our objective was to evaluate the relationship between self-reported confidence in endotracheal intubation (ETI) and pediatric interns' characteristics (gender, prior intubation experience) and performance (airway management knowledge, demonstrated skills on airway trainers). METHODS: This was a secondary analysis of a randomized, controlled trial of an airway management curriculum. Gender and prior intubation experience were reported on a preparticipation questionnaire. Interns' performance was measured 1) using a 14-item knowledge-based assessment of airway management and 2) as time to successful intubation across 4 simulated intubation scenarios. After completing the curriculum and assessment, interns reported retrospective precurriculum and current postcurriculum confidence with ETI using a 10-point Likert scale. RESULTS: Forty-nine interns participated, of whom 16 (33%) were male. Eleven (22%) had ≥1 previous successful intubation. Median [interquartile range] pre- and postcurriculum confidence scores were 3 [2, 5] and 6 [5, 8], respectively. Male interns reported higher precurriculum confidence than females (median difference: 2.0; 95% confidence interval: 0.1, 3.9); postcurriculum confidence among males was also higher but not statistically significant. There was no correlation between self-reported precurriculum confidence and prior experience. There was no correlation between pre- or postcurriculum self-reported confidence and performance on the knowledge-based assessment or time to successful intubation on airway trainers. CONCLUSIONS: Male pediatric interns self-report higher initial confidence in ETI compared to females. Self-reported confidence did not correlate with prior experience, airway management knowledge, or intubation performance on airway trainers.

Maximizing Plastic Surgery Education Impact: Lessons from Resident Learning Styles and Experiential Learning Theory.

Residents in many surgical disciplines express a strong preference for hands-on learning, but no studies have focused on plastic surgery. This initial study aims to ascertain the learning styles of plastic surgery residents, and identify potential trends that may better guide curriculum development. METHODS: Kolb Learning Style Index v. 3.1 was administered to plastic surgery residents across all training levels at three residency programs. The Kolb Learning Style Index is a 12-item questionnaire that characterizes an individual's learning style into 1 of 4 major categories: converging; accommodating; assimilating; and diverging. RESULTS: The surveyed cohort of plastic surgery residents (n = 45) demonstrated a diverse mix of learning styles: converging (38%, n = 17); accommodating (24%, n = 11); diverging (20%, n = 9); and assimilating (16%, n = 7). One resident was balanced between converging and accommodating (2%, n = 1). Despite varied learning styles, the majority (64%, n = 29) demonstrated a preference for "active experimentation," for example, hands-on learning. CONCLUSIONS: A preliminary assessment of learning styles among plastic surgery residents suggests that they have mixed learning styles. This contrasts with the existing literature from other surgical specialties where a single learning style dominates. However, like these other specialties, active experimentation is particularly valued. As such, it behooves the plastic surgery educator to continue to strive for balance between book learning and hands-on experience for residents at all levels of training, to engage residents with all learning styles.

SimZones: An Organizational Innovation for Simulation Programs and Centers.

The complexity and volume of simulation-based learning programs have increased dramatically over the last decade, presenting several major challenges for those who lead and manage simulation programs and centers. The authors present five major issues affecting the organization of simulation programs: (1) supporting both single- and double-loop learning experiences; (2) managing the training of simulation teaching faculty; (3) optimizing the participant mix, including individuals, professional groups, teams, and other role-players, to ensure learning; (4) balancing in situ, node-based, and center-based simulation delivery; and (5) organizing simulation research and measuring value. They then introduce the SimZones innovation, a system of organization for simulation-based learning, and explain how it can alleviate the problems associated with these five issues.Simulations are divided into four zones (Zones 0-3). Zone 0 simulations include autofeedback exercises typically practiced by solitary learners, often using virtual simulation technology. Zone 1 simulations include hands-on instruction of foundational clinical skills. Zone 2 simulations include acute situational instruction, such as clinical mock codes. Zone 3 simulations involve authentic, native teams of participants and facilitate team and system development.The authors also discuss the translation of debriefing methods from Zone 3 simulations to real patient care settings (Zone 4), and they illustrate how the SimZones approach can enable the development of longitudinal learning systems in both teaching and nonteaching hospitals. The SimZones approach was initially developed in the context of the Boston Children's Hospital Simulator Program, which the authors use to illustrate this innovation in action.

Improved Safety and Cost Savings from Reductions in Cast-Saw Burns After Simulation-Based Education for Orthopaedic Surgery Residents.

BACKGROUND: The purpose of this investigation was to characterize the clinical efficacy and cost-effectiveness of simulation training aimed at reducing cast-saw injuries. METHODS: Third-year orthopaedic residents underwent simulation-based instruction on distal radial fracture reduction, casting, and cast removal using an oscillating saw. The analysis compared incidences of cast-saw injuries and associated costs before and after the implementation of the simulation curriculum. Actual and potential costs associated with cast-saw injuries included wound care, extra clinical visits, and potential total payment (indemnity and expense payments). Curriculum costs were calculated through time-derived, activity-based accounting methods. The researchers compared the costs of cast-saw injuries and the simulation curriculum to determine overall savings and return on investment. RESULTS: In the 2.5 years prior to simulation, cast-saw injuries occurred in approximately 4.3 per 100 casts cut by orthopaedic residents. For the 2.5-year period post-simulation, the injury rate decreased significantly to approximately 0.7 per 100 casts cut (p = 0.002). The total cost to implement the casting simulation was $2,465.31 per 6-month resident rotation. On the basis of historical data related to cast-saw burns (n = 6), total payments ranged from $2,995 to $25,000 per claim. The anticipated savings from averted cast-saw injuries and associated medicolegal payments in the 2.5 years post-simulation was $27,131, representing an 11-to-1 return on investment. CONCLUSIONS: Simulation-based training for orthopaedic surgical residents was effective in reducing cast-saw injuries and had a high theoretical return on investment. These results support further investment in simulation-based training as cost-effective means of improving patient safety and clinical outcomes. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Creation of a novel simulator for minimally invasive neurosurgery: fusion of 3D printing and special effects.

OBJECTIVE Recent advances in optics and miniaturization have enabled the development of a growing number of minimally invasive procedures, yet innovative training methods for the use of these techniques remain lacking. Conventional teaching models, including cadavers and physical trainers as well as virtual reality platforms, are often expensive and ineffective. Newly developed 3D printing technologies can recreate patient-specific anatomy, but the stiffness of the materials limits fidelity to real-life surgical situations. Hollywood special effects techniques can create ultrarealistic features, including lifelike tactile properties, to enhance accuracy and effectiveness of the surgical models. The authors created a highly realistic model of a pediatric patient with hydrocephalus via a unique combination of 3D printing and special effects techniques and validated the use of this model in training neurosurgery fellows and residents to perform endoscopic third ventriculostomy (ETV), an effective minimally invasive method increasingly used in treating hydrocephalus. METHODS A full-scale reproduction of the head of a 14-year-old adolescent patient with hydrocephalus, including external physical details and internal neuroanatomy, was developed via a unique collaboration of neurosurgeons, simulation engineers, and a group of special effects experts. The model contains "plug-and-play" replaceable components for repetitive practice. The appearance of the training model (face validity) and the reproducibility of the ETV training procedure (content validity) were assessed by neurosurgery fellows and residents of different experience levels based on a 14-item Likert-like questionnaire. The usefulness of the training model for evaluating the performance of the trainees at different levels of experience (construct validity) was measured by blinded observers using the Objective Structured Assessment of Technical Skills (OSATS) scale for the performance of ETV. RESULTS A combination of 3D printing technology and casting processes led to the creation of realistic surgical models that include high-fidelity reproductions of the anatomical features of hydrocephalus and allow for the performance of ETV for training purposes. The models reproduced the pulsations of the basilar artery, ventricles, and cerebrospinal fluid (CSF), thus simulating the experience of performing ETV on an actual patient. The results of the 14-item questionnaire showed limited variability among participants' scores, and the neurosurgery fellows and residents gave the models consistently high ratings for face and content validity. The mean score for the content validity questions (4.88) was higher than the mean score for face validity (4.69) (p = 0.03). On construct validity scores, the blinded observers rated performance of fellows significantly higher than that of residents, indicating that the model provided a means to distinguish between novice and expert surgical skills. CONCLUSIONS A plug-and-play lifelike ETV training model was developed through a combination of 3D printing and special effects techniques, providing both anatomical and haptic accuracy. Such simulators offer opportunities to accelerate the development of expertise with respect to new and novel procedures as well as iterate new surgical approaches and innovations, thus allowing novice neurosurgeons to gain valuable experience in surgical techniques without exposing patients to risk of harm.

Going the extra mile and feeling energized: An enrichment perspective of organizational citizenship behaviors.

Scholars have voiced concerns about the potential dark side of Organizational Citizenship Behavior (OCB), arguing that OCB consumes energy, which contributes to a depletion of personal resources and results in poorer well-being. Drawing from research on the meaningfulness of work, we propose a pattern opposite to depletion: that OCB enhances energy, which contributes to an enrichment of personal resources and results in better well-being. This idea was tested over the course of a workweek with 224 day-level ratings from 67 employees and 30 managers working in a service management firm. Three-level hierarchical linear modeling indicated that supervisor-rated daily OCB was positively associated with employees' vigor at the end of the workday, and multilevel structural equation modeling analyses showed that this relationship was mediated by meaningfulness of work. Moreover, we found that the association between OCB and work meaningfulness was stronger for employees with greater role ambiguity. Exploratory analyses revealed that daily in-role performance and daily OCB interacted to predict meaningfulness of work, such that the association between daily OCB and meaningfulness of work was more prominent among those who exhibited high levels of daily in-role performance. We discuss implications of these findings, limitations, and directions for future research.