Assessment of high fidelity simulation with actors in palliative care in nursing students: a mixed methods study.

OBJECTIVE: The most effective training methods are experiential, including those focused on experiences and emotions. Clinical simulation, especially high-fidelity simulation, is one of the most effective methodologies for the acquisition of competencies in care like palliative care. The simulation with actors can train future healthcare science professionals: in technical, intellectual, or interpersonal skills. The objective is to evaluate high-fidelity simulation with actors as a tool in palliative care training for nursing students. METHOD: Over three years, the study was conducted in a Faculty of Nursing of the south of Spain with nursing students. A mixed methods study with sequential explanatory design in three moments was conducted: (1) Quasi-experimental study in a single group (n = 12) before and after attending the palliative care course with Clinical Simulation with actors to assess the communication skills (CICAA scale), (2) Qualitative study with phenomenological perspective after Clinical Simulation (174 reflective students' narratives), (3) Cross-sectional observational study, one year later, to assess the transfer of knowledge and skills to the clinical practice (71 students). RESULTS: Students who interacted with actors in Clinical Simulation improved their communication skills and the ability to establish an effective helping relationship with both end-of-life patients and their families. The students perceived the Clinical Simulation as an innovative learning methodology that is useful to encourage reflection and transfer of learning during their clinical internship. CONCLUSIONS: Standardization of the use of active learning methodologies is recommended for a better acquisition of transversal skills such as communication skills in palliative care.

The effect of high-fidelity simulation technology on the competency of nursing students in managing chemotherapy extravasation in patients with cancer.

BACKGROUND: Nursing education suffers from a lack of high-quality clinical experiences for students, especially among medical specialty groups such as cancer patients, in Saudi Arabia. A paucity of empirical evidence is supporting simulation in education and the transfer of psychomotor skills to patient care. In particular, although generally recognized as an essential oncology nursing skill, effective strategies for teaching the management of chemotherapy extravasation to students have not been investigated. PURPOSE: To investigate the effects of high-fidelity simulation (HFS) technology on the competency of nursing students in the management of chemotherapy extravasation and the transfer of this skill from traditional learning labs to clinical settings. METHODS: A quasi-experimental study comprising a two-group pretest-posttest with repeated measures was used. The intervention was a scenario-based, HFS. Third-year students (n = 68) from a nursing program were randomly allocated to either intervention or control groups. Competency was measured in both groups using the same standardized assessment checklist. RESULTS: Competency scores were lower in the control group compared to the intervention group at both posttesting times. These results, however, were not statistically significant. There was no statistically significant difference between the groups regarding skill transfer. CONCLUSIONS: Nursing faculty can use either HFS or traditional learning methods to effectively teach students how to manage chemotherapy extravasation and transfer this skill to clinical settings.

Multidisciplinary, multisite trauma team training during COVID-19: lessons from the first virtual E-S.T.A.R.T.T. course.

Trauma care delivery is a complex team-based task that requires deliberate practice. The COVID-19 pandemic has not diminished the importance of excellent trauma team dynamics. However, the pandemic hampers our ability to gather safely and train together. A mitigating solution is the provision of high-fidelity simulation training in a virtual setting. The Simulated Trauma and Resuscitation Team Training (S.T.A.R.T.T.) course has provided multidisciplinary trauma team members with skills in crisis resource management (CRM) for nearly 10 years. It has promoted collaborative learning from coast to coast, as the course typically runs at our national surgical and trauma meetings. In response to COVID-19 challenges, the course content has been modified to virtually connect 2 centres in different provinces simultaneously. High participant satisfaction suggests that the new virtual E-S.T.A.R.T.T course is able to continue to help providers develop important CRM skills in a multidisciplinary setting while remaining compliant with COVID-19 safety precautions.

Virtual Reality Warm-up Before Robot-assisted Surgery: A Randomized Controlled Trial.

TRIAL DESIGN: This was a randomized controlled trial. BACKGROUND: Intraoperative errors correlate with surgeon skill and skill declines with intervals of inactivity. The goals of this research were to identify the optimal virtual reality (VR) warm-up curriculum to prime a surgeon's technical skill and validate benefit in the operating room. MATERIALS AND METHODS: Surgeons were randomized to receive six trial sessions of a designated set of VR modules on the da Vinci Skills Simulator to identify optimal VR warm-up curricula to prime technical skill. After performing their curricula, warm-up effect was assessed based on performance on a criterion task. The optimal warm-up curriculum was chosen from the group with the best task time and video review-based technical skill. Robot-assisted surgery-experienced surgeons were then recruited to either receive or not receive warm-up before surgery. Skill in the first 15 min of surgery was assessed by blinded surgeon and crowdworker review as well as tool motion metrics. The intervention was performing VR warm-up before human robot-assisted surgery. Warm-up effect was measured using objective performance metrics and video review using the Global Evaluative Assessment of Robotic Skills tool. Linear mixed effects models with a random intercept for each surgeon and nonparametric modified Friedman tests were used for analysis. RESULTS: The group performing only a Running Suture task on the simulator was on average 31.3 s faster than groups performing other simulation tasks and had the highest Global Evaluative Assessment of Robotic Skills scores from 41 surgeons who participated. This was chosen as the optimal curriculum. Thereafter, 34 surgeons completed 347 surgeries with corresponding video and tool motion data. No statistically significant differences in skill were observed with the warm-up intervention. CONCLUSIONS: We conclude that a robotic VR warm-up before performing the early stages of surgery does not impact the technical skill of the surgeon.

Diseño, elaboración y validación de un simulador realista y de bajo costo para exploración cardiaca / Design, assembly and validation of a low-cost, high-fidelity simulator for heart exploration

Resumen Introducción: La exploración cardiaca es una competencia clínica fundamental que requiere exposición o entrenamiento continuo. La baja disponibilidad y accesibilidad de pacientes con patología cardiaca constituye una barrera para adquirir esta competencia. Se han documentado inadecuadas habilidades de auscultación cardiaca en estudiantes de medicina, residentes y médicos graduados. Objetivo: Elaborar y validar un simulador de alta fidelidad y bajo costo para exploración cardiaca. Métodos: Se diseñó y elaboró un simulador para exploración cardiaca, realista y de bajo costo capaz de reproducir ruidos cardiacos normales. Posteriormente se realizó la validación del simulador por un grupo de expertos que emitieron su opinión de acuerdo con una escala tipo Likert. Resultados: El 94 % afirmó que el simulador motiva el aprendizaje de la exploración cardiaca y 92 % lo consideró un modelo realista; 91 % consideró que el simulador es una herramienta atractiva para fortalecer el aprendizaje y 98 % recomendó seguir utilizándolo. Conclusiones: El uso del simulador facilita la adquisición de competencias y estimula el aprendizaje en el estudiante, lo cual puede ser atribuido a la práctica deliberada, a un mayor tiempo de exposición y a la interacción cognitiva.

Abstract Introduction: Heart exploration is an essential clinical competence that requires continuous training and exposure. Low availability and accessibility to patients with heart disease constitutes a barrier to acquiring this competence. Inadequate cardiac auscultation skills in medical students, residents, and graduate physicians have been documented. Objective: To develop and validate a low-cost, high-fidelity simulator for heart exploration. Methods: A low-cost, high-fidelity heart examination simulator capable of reproducing normal cardiac sounds was designed and developed. Subsequently, the simulator was validated by a group of experts who gave their opinion according to a Likert scale. Results: Ninety-four percent agreed that the simulator motivates the learning of heart exploration, and 92 % considered it to be a realistic model; 91 % considered that the simulator is an attractive tool to reinforce learning and 98 % recommended its further use. Conclusions: The use of the simulator facilitates the acquisition of skills and stimulates learning in the student, which can be attributed to repeated practice, longer exposure time and cognitive interaction.

Synthetic Simulator for Surgical Training in Tracheostomy and Open Airway Surgery.

OBJECTIVE(S): To create and validate a synthetic simulator for teaching tracheostomy and laryngotracheal reconstruction (LTR) using anterior costal cartilage and thyroid ala cartilage grafts. METHODS: A late adolescent/adult neck and airway simulator was constructed based on CT scans from a cadaver and a live patient. Images were segmented to create three-dimensional printed molds from which anatomical parts were casted. To evaluate the simulator, expert otolaryngologists - head and neck surgeons performed tracheostomy and LTR using anterior costal cartilage and thyroid ala cartilage grafts on a live anesthetized porcine model (gold standard) followed by the synthetic simulator. They evaluated each model for face validity (realism and anatomical accuracy) and content validity (perceived effectiveness as a training tool) using a five-point Likert scale. For each expert, differences for each item on each simulator were compared using Wilcoxon Signed-Rank tests with Sidak correction. RESULTS: Nine expert faculty surgeons completed the study. Experts rated face and content validity of the synthetic simulator an overall median of 4 and 5, respectively. There was no difference in scores between the synthetic model and the live porcine model for any of the steps of any of the surgical procedures. CONCLUSION: The synthetic simulator created for this study has high face and content validity for tracheostomy and LTR with anterior costal cartilage and thyroid ala cartilage grafts and was not found to be different than the live porcine model for these procedures. LEVEL OF EVIDENCE: 5 Laryngoscope, 131:E2378-E2386, 2021.

Multi-Disciplinary Trauma Evaluation and Management Simulation (MD-TEAMS) training for emergency medicine and general surgery residents.

BACKGROUND: Successful trauma resuscitation relies on multi-disciplinary collaboration. In most academic programs, general surgery (GS) and emergency medicine (EM) residents rarely train together before functioning as a team. METHODS: In our Multi-Disciplinary Trauma Evaluation and Management Simulation (MD-TEAMS), EM and GS residents completed manikin-based trauma scenarios and were evaluated on resuscitation and communication skills. Residents were surveyed on confidence surrounding training objectives. RESULTS: Residents showed improved confidence running trauma scenarios in multi-disciplinary teams. Residents received lower communication scores from same-discipline vs cross-discipline faculty. EM residents scored higher in evaluation and planning domains; GS residents scored higher in action processes; groups scored equally in team management. Strong correlation existed between team leader communication and resuscitative skill completion. CONCLUSION: MD-TEAMS demonstrated correlation between communication and resuscitation checklist item completion and communication differences by resident specialty. In the future, we plan to evaluate training-related resident behavior changes and specialty-specific communication differences by residents.

Multimodal Cardiopulmonary Bypass Skills Assessment Within a High-Fidelity Simulation Environment.

BACKGROUND: A high-fidelity simulator that uses a perfused porcine heart, cannulae, and tubing has been demonstrated to be a useful training adjunct. We hypothesized that multimodal assessment of cardiopulmonary bypass (CPB) skills within this high-fidelity simulated environment could discern expert from trainee performance. METHODS: Three traditional fellows (postgraduate year 6-8) and 3 attending surgeons each performed 3 aortic cannulations. The third sequence included venous cannulation, commencement of CPB, and placement of a cardioplegia catheter and aortic cross-clamp. Performance across 20 cognitive and 21 technical domains was evaluated. Surgeon and assistant hand movements and economy of motion were assessed by electromagnetic motion sensors worn under sterile gloves. RESULTS: Analysis showed a significant difference in cognitive (6.7 ± 2.3 vs 4.6 ± 2.7, P = .03) but not technical (6.2 ± 2.5 vs 5.8 ± 2.2, P = .7) scores favoring the experts. In addition, experts showed higher efficiency by spending 64 ± 14 seconds to construct a nonpledgeted aortic purse-string suture and secure it with a Rummel, while trainees spent 82 ± 30 seconds to complete this task (P = .03). Motion analysis revealed similar path lengths between experts and trainees for cannulation and CPB but significantly shorter path lengths for experts in cross-clamp (47.5 ± 15.5 m vs 91.9 ± 20.3 m, P = .04). CONCLUSIONS: Multimodal assessment using cognitive, technical, and motion analysis of basic CPB tasks using a high-fidelity simulation environment is a valid system to measure performance and discriminate experts from trainees. This construct may allow for development of "competence thresholds" with important implications for training and certification in cardiothoracic surgery.

Using Virtual Augmented Reality to Remotely Proctor Overseas Surgical Outreach: Building Long-Term International Capacity and Sustainability.

BACKGROUND: Cleft lip affects one in 700 children globally, and the prevalence far surpasses capacity to deliver cleft care in underresourced and endemic regions. A hands-on educational presence is needed to promote overseas surgical autonomy, build overseas capacity, and ensure a sustained clinical and educational infrastructure. The goal of this study was to build and assess an augmented reality educational platform that allows a remote yet virtual interactive presence to transfer cleft surgery knowledge/skills to overseas colleagues. METHODS: A prospective study assessing a 13-month overseas augmented reality-based cleft surgery curriculum was conducted. Three semiannual site visits engaged two Peruvian surgeons in evidence-based didactics, on-site cleft surgery, and familiarization with the augmented reality platform. During 10 remote augmented reality visits, a surgeon stationed in United States guided the same Peruvian surgeons through cleft surgery. Quarterly assessments of the Peruvian surgeons were performed using visual analogue scale questionnaires. RESULTS: Visual analogue scale scores by both the remote and overseas surgeons demonstrated significant, progressive improvement in all facets of cleft lip repair throughout the curriculum. Site visits preferentially built capacity for cleft diagnosis and preoperative counseling (p < 0.001), principles of repair (p < 0.001), repair technique (p < 0.02) and intraoperative decision-making (p < 0.001). Remote sessions preferentially developed understanding of cleft operative design/anthropometry (p < 0.04), cleft anatomy (p < 0.01), and operative efficiency (p < 0.001). At 30-month follow-up, no children with cleft lip required transfer to tertiary care centers. CONCLUSION: A curriculum that combines on-site training and augmented reality-based hands-on remote teaching can build sustained capacity of comprehensive cleft care in underresourced areas.

Docencia innovadora en cirugía / Innovative teaching in surgery

Resumen La docencia innovadora en cirugía la asociamos habitualmente al uso de tecnología moderna para mejorar la educación que realizamos en nuestra especialidad. Sin embargo, en educación, la innovación está relacionada con la incorporación de aspectos más teóricos que tecnológicos. Esto está respaldado por una creciente cantidad de evidencia conducida principalmente por educadores, quienes utilizan la mirada de las ciencias sociales, que difieren ampliamente de cómo validamos la evidencia los cirujanos. Pese a esto, en los últimos 40 años, hemos visto globalmente como ha habido un importante cambio paradigmático en el modelo educativo con el que educamos en cirugía. Este ha sido impulsado básicamente por la introducción de técnicas mínimamente invasivas, cambios sociales y el progreso de las ciencias de la educación. Como sociedad científica tenemos aun el desafío de impulsar la formación de educadores quirúrgicos, establecer estándares nacionales según la experiencia de países líderes en la materia y regular los currículos de pre y postgrado introduciendo conceptos educacionales modernos como el profesionalismo y la educación basada en competencias. Nuestra meta debería ser una sola: profesionalizar la educación quirúrgica en nuestro país poniendo el foco en el residente o en el estudiante. Esto implica entre otras cosas, que se cambie el objetivo de formar profesionales que dominen una batería rígida de procedimientos a prepararlos para enfrentar competentemente un mundo profesional que se encuentra en constante cambio y evolución. Sólo así estaremos realmente realizando innovación en docencia quirúrgica y podremos enfocarnos entonces en la tecnología.

Innovative education in surgery is frequently associated with incorporating modern technology to facilitate learning in our specialty. Nevertheless, innovation in education is more dependent on restructuring the educational processes than introducing technology alone. This is underpinned by a consistent amount of evidence generated by education professionals, that usually conduct research under the paradigm of social sciences, which differ widely from the ways in which surgeons understand the world. However, during the last 40 years, there has been a well-recognized shift in the way we surgeons educate. It has been claimed that the determinants of such changes have been the introduction of minimal invasive procedures, sociocultural changes and the development of modern education theories. Our surgical scientific society still have the challenge of promoting the training of surgical educators, stablishing national standards according to the experience of the developed world and regulating undergraduate and graduate curricula by introducing modern educational concepts like competency-based education and professionalism. Our major goal is to professionalize medical education in our country, focusing in the learning process of the residents or students. This imply among other aspects, to change the focus from educating on a rigid set of technical procedures to train professionals that are capable of responding competently to a world that is in a rapid and constant change. I believe that this is the only way to innovate in surgical education. Once we have reach this, then we will be able to focus on the modern technology that can help us achieve such goals.

[High fidelity simulation training for medical oncology announcement consultation]. / Simulation haute-fidélité à la consultation d'annonce en oncologie médicale.

INTRODUCTION: Medical oncology bad news consultation is a particularly stressful situation for both the patient and the physician. High-fidelity simulation is a learning option that has never been evaluated in France in this field. MATERIALS AND METHODS: This is a feedback from simulated announcement consultations carried out from January 2018 to May 2019. Residents from the medical oncology and radiotherapy departments performed high-fidelity simulations at the announcement consultation with an announcement nurse, a psychologist, a certified coach and an oncologist. A competency assessment was completed in pre-test, immediate post-test and after 5 months. RESULTS: Fourteen of the 16 eligible interns participated. The pre-test competency assessment showed that interns over 5 semesters reported being more comfortable at the consultation (P=0.04) and thought they were clearly explaining the disease (P=0.03). However, all residents, regardless of the semester, felt stressed before a consultation. The evolution of parameters skills after the simulation was positive for all criteria, particularly for adaptation to patient reactions, use of appropriate vocabulary and reduction of stress (P<0.05). This evolution was independent of the gender, curriculum, semester, or previous completion of a medical oncology internship. More than 80% of the students were ready to repeat this type of training. CONCLUSION: This training demonstrates the value of simulation training for medical oncology advertising consultation.

Cadaveric Simulation Training in Cardiothoracic Surgery: A Systematic Review.

Simulation training has become increasingly relevant in the educational curriculum of surgical trainees. The types of simulation models used, goals of simulation training, and an objective assessment of its utility and effectiveness are highly variable. The role and effectiveness of cadaveric simulation in cardiothoracic surgical training has not been well established. The objective of this study was to evaluate the current medical literature available on the utility and the effectiveness of cadaveric simulation in cardiothoracic surgical residency training. A literature search was performed using PubMed, Cochrane Library, Embase, Scopus, and CINAHL from inception to February 2019. Of the 362 citations obtained, 23 articles were identified and retrieved for full review, yielding ten eligible articles that were included for analysis. One additional study was identified and included in the analysis. Extraction of data from the selected articles was performed using predetermined data fields, including study design, study participants, simulation task, performance metrics, and costs. Most of these studies were only descriptive of a cadaveric or perfused cadaveric simulation model that could be used to augment clinical operative training in cardiothoracic surgery. There is a paucity of evidence in the literature that specifically evaluates the utility and the efficacy of cadavers in cardiothoracic surgery training. Of the few studies that have been published in the literature, cadaveric simulation does seem to have a role in cardiothoracic surgery training beyond simply learning basic skills. Additional research in this area is needed.

Validation and educational impact study of the NANEP high-fidelity simulation model for open preperitoneal mesh repair of umbilical hernia.

OBJECTIVE: The aim of the study was to develop, validate and analyze the educational impact of a high-fidelity simulation model for open preperitoneal mesh repair of an umbilical hernia. The number of surgical simulators available for training residents is limited. Primary for ethical reasons and secondary for the emerging pay-per-quality policies, practicing-on simulators rather than patients is considered gold standard. Validated full-procedural surgical models will become more and more important in training residents. Such models may assure that evidence-based standards regarding technical aspects of the procedures become integral part of the curriculum. Furthermore, they can be employed as a quality control of residents' skills (Fonseca et al. in J Surg Educ 70:129-137, 2013). METHODS: In a repeated measures design, medical students, residents in their last year of training and attending surgeons performed an open preperitoneal mesh repair on the NANEP model [NANEP stands for the German acronym Nabelhernien-Netzimplatation-Präperitonal (English: Umbilical hernia mesh implantation preperitoneal)]. Subjects were categorized as "Beginners" (internship students) or "Experts" (residents and surgeons). Content validity was analyzed by criteria of subject-matter-experts. Blinded raters assessed surgical skills by means of the Competency Assessment Tool (CAT) using the online platform "CATLIVE". Differential validity was measured by group differences. Proficiency gain was analyzed by monitoring the learning curve (Gallagher et al. in Ann Surg 241:364-372, 2005). Post-operative examination of the simulators shed light on criterion validity. RESULTS: The NANEP model-proofed content and construct-valid significant Bonferroni-corrected differences were found between beginners and experts (p < 0.05). Beginners showed a significant learning increase from the first to the second surgery (p < 0.05). Post-operative examination data confirmed criterion validity. CONCLUSION: The NANEP model is an inexpensive, simple and efficient simulation model. It has highly realistic features, it has been shown to be of high-fidelity, full-procedural and benchtop-model. The NANEP model meets the main needs of surgical educational courses at the beginning of residency.

Evaluating Simulator-Based Teaching Methods for Endoscopic Sinus Surgery.

A multitude of simulator systems for endoscopic sinus surgery (ESS) are available as training tools for residents preparing to enter the operating room. These include human cadavers, virtual reality, realistic anatomic models, and low-fidelity gelatin molds. While these models have been validated and evaluated as independent tools for surgical trainees, no study has performed direct comparison of their outcomes. To address this deficiency, we aimed to evaluate the utility of high-fidelity and low-fidelity trainers as compared to a traditional control (no simulator exposure) for novice trainees acquiring basic ESS skills. Thirty-four first-year medical students were randomized to 3 groups and taught basic sinus anatomy and instrumentation. Two groups received training with either the high-fidelity or low-fidelity trainer, while 1 group served as control. These groups were then tested with cadaveric specimens. These sessions were recorded and graded by an expert. There was no statistical difference in performance between the 3 study groups with regard to identification of anatomy, endoscopic competency, or completion of basic tasks. When the high-fidelity and low-fidelity arms were grouped into a single "trained" cohort, they demonstrated significantly improved time to completion for basic anatomy (P = .043) and total time (P = .041). This is the first study to perform a direct comparison of performance between high-fidelity and low-fidelity ESS simulators and controls. Although we found no difference in performance of novice trainees with regard to basic anatomical identification or procedural tasks associated with ESS, the use of ESS simulators may improve time to completion.

Development of cadaver perfusion models for surgical training: an experimental study.

PURPOSE: Perfusion techniques on cadavers are heterogeneous and imperfect. The objective of this study was to improve the existing circulation model for surgical simulation on cadavers. METHODS: We used a three-step experimental approach. The first part of the experiment tested two variables: the type of circuit and the use of a heater for perfusion. The second approach evaluated two parameters: the injection fluid and the type of body conditioning (embalmed or freshly dead prepared using different washing techniques). The third one was an improvement on the best circulation obtained, which focused on the injection fluid. To compare the realism of these different techniques, we constructed a score with realism parameters: the volume of return flow, the presence of peripheral venous return and the perfusion of abdominal arteries. RESULTS: We found that the use of a heater seemed to improve the perfusion, while performing an arteriovenous bypass did not seem very effective. A correlation rate of 0.84 was found between the realism score and the injected fluid chosen. The best score (4/6) was found for a non-embalmed body with a low-pressure washing technique using a gelatin-based liquid at a concentration of 4 g/L for circulation. Scores obtained using embalmed bodies for both injection fluids for high-pressure washing or for 8-g/L gelatin injection fluid did not exceed 3/6. CONCLUSIONS: We showed that using a non-embalmed body with low-pressure washing and a 4-g/L gelatin-based fluid was the most effective technique for cadaver perfusion.

Quality with quantity? Evaluating interprofessional faculty prebriefs and debriefs for simulation training using video.

BACKGROUND: High-fidelity simulation-based training is used increasingly for prelicensure student teams. Such sessions rely on faculty who are able to provide quality prebriefing and debriefing to foster learning among participants. We investigated how well faculty conducted prebriefing and debriefing as part of high-fidelity simulation-based training for interprofessional education. METHODS: Two trained observers independently rated 38 video-recorded sessions of combinations of 4 faculty conducting prebriefings and debriefings of prelicensure student teams after high-fidelity simulation-based training. Assessment was undertaken using the Objective Structured Assessment of Debriefing, an 8-item tool using a 5-point Likert scale (1 as minimum and 5 as maximum). Mean scores for each item were calculated. Inter-rater agreement was determined using Cohen's kappa. A one-way between-subjects analysis of variance with post-hoc Tukey's studentized range procedure was conducted to compare the effect of team facilitator grouping on the quality of team performance of each Objective Structured Assessment of Debriefing element during a prebriefing or a debriefing. Trend analyses of teams with 4 or more observations were performed using Kendall's Tau coefficient test and linear regression analyses to identify whether teams showed improvement through time. Statistical significance was set at P < .05. RESULTS: A total of 7 combinations of faculty conducted between 1 to 14 prebriefings or debriefings. In general, faculty combinations performed better during debriefings compared with prebriefings, with only 1 team having 1 mean item score <3.50. Statistically significant differences between faculty combinations in mean item scores was more pronounced during the prebriefings (2 of 3 Objective Structured Assessment of Debriefing items rated) than during debriefings (1 of 8 Objective Structured Assessment of Debriefing items rated). Effect sizes were strong for all differences. Linear regression analysis revealed a statistically significant change through time for the 3 rated prebriefing items and for 7 of the 8 rated debriefing items. CONCLUSION: Interprofessional faculty combinations in this study tended to have good quality prebriefings and debriefings. The quality of the prebriefings and debriefings can, however, be influenced by the composition of the facilitator teams, most prominently for prebriefings, and team performance does appear to change through time, especially during the debriefing. Future work will focus on whether the quality of prebriefings and debriefings influences learning by trainees.

The Montreal Augmentation Mammaplasty Operation (MAMO) Simulator: An Alternative Method to Train and Assess Competence in Breast Augmentation Procedures.

BACKGROUND: Surgical residents' exposure to aesthetic procedures remains limited in residency training. The development of the Montreal augmentation mammaplasty operation (MAMO) simulator aims to provide an adjunctive training method and assessment tool to complement the evolving competency-based surgical curriculum. OBJECTIVES: To perform face, content, and construct validations of the MAMO simulator for subpectoral breast augmentation procedures and assess the reliability of the assessment scales used. METHODS: Plastic surgery staff and residents were recruited to perform a subpectoral breast augmentation on the simulator. Video recordings of their performance were blindly evaluated using the objective structured assessment of technical skills (OSATS) system consisting of the global rating scale (GRS), mammaplasty objective assessment tool (MOAT), and a surgery-specific Checklist score. RESULTS: Fourteen plastic surgery residents and seven expert plastic surgeons were enrolled. Experts' performance was significantly higher than residents' according to each of GRS, MOAT, and Checklist scores. Mean values of residents and experts were 23.4 (2.5) vs 36.9 (3.1) (P < 0.0001) for GRS score, 30.4 (2.2) vs 40 (3.2) (P < 0.0001) for MOAT scores, and 9.7 (1.5) vs 12 (1) (P < 0.001) for Checklist scores, respectively. Face and content validations showed excellent results among parameters evaluated, with an overall mean score of 4.8 (0.3) on 5. Cronbach's alpha was 0.96 and 0.83 for GRS and MOAT scores, respectively. Intraclass correlation coefficients for interrater reliability were excellent at 0.93, 0.92, and 0.89 for the GRS, MOAT, and Checklist scores, respectively. CONCLUSIONS: This study proves the construct simulator to be valid and the assessment scales to be reliable.

Diagnostic radiographers working in the operating theatre: An action research project.

INTRODUCTION: Failures in interprofessional communication are well-documented and are an established cause of medical error and negative health outcomes. Socio-historical issues like imbalances in power and status are particularly prevalent in the operating theatre environment, adding complications to interprofessional working. Simulation, used in healthcare education, may impact positively on interprofessional working. METHODS: The aim of this action research study was to develop, pilot and run a simulation experience for Diagnostic Radiography (DRAD) students. Action research was used to structure this study. The first phase of the action research was to look at the problem; this was undertaken using critical incident technique. Findings from the critical incident technique influenced the simulation event. A focus group was held immediately after the event for reflection. A second simulation using a cohort of 48 students and a reflection after a period of three months formed the second round of the project. The simulation took place in a hi-fidelity simulated operating theatre. Thematic content analysis was undertaken of the focus group, data from the critical incident technique, and the reflections. RESULTS: The findings are discussed under the themes; identification, clarity, preparation, and the expert. Identification and lack of clarity in communication were seen as an important issue in the operating theatre. Lack of preparation of the working environment was also highlighted. Lack of confidence in the operating theatre inhibits interprofessional working. CONCLUSION: Simulation can help prepare students for working in the operating theatre. Realism is important as is scheduling the event to ensure maximum benefit.

Medidas de acurácia da resposta disfuncional ao desmame ventilatório: subsídios para metodologia e aprimoramento do raciocínio diagnóstico através da simulação clínica / Accuracy measures os dysfunctional response to weaning: subsidies for methodology and improvement of diagnostic reasoning through clinical simulation

OBJETIVO: Analisar as medidas de acurácia diagnóstica da Resposta Disfuncional ao Desmame Ventilatório e os seus desfechos na extubação de pacientes de terapia intensiva e aplicar as medidas de acurácia da Resposta Disfuncional ao Desmame Ventilatório, utilizando- se a metodologia da simulação clínica. MÉTODO: Um estudo longitudinal do tipo coorte prospectiva com abordagem quantitativa. LOCAL: unidade de terapia intensiva de um hospital de ensino no Sudeste do Brasil e laboratório de simulação clínica em Portugal. PACIENTES: A amostra selecionada no estudo foi constituída por 46 pacientes ventilados mecanicamente. Em cada paciente foram verificadas as características definidoras em cinco tempos distintos, desmembrados em intervalos de 5, 10, 15, 30 e 60 minutos. Nesse caso, cada paciente era avaliado por cinco vezes, totalizando um quantitativo de 230 avaliações. MEDIDAS E PRINCIPAIS RESULTADOS: As principais causas de reintubação foram hipoxemia e aumento do trabalho respiratório. Prevalência de Insucesso foram de 14 eventos (33,3%) e a prevalência da RDDV foram de 13 eventos (30,95%). No total, foram obtidos 35 eventos, considerando-se a RDDV e os desfechos clínicos. A associação entre resposta disfuncional na extubação e o insucesso na extubação apresentou, por meio do teste do qui-quadrado um valor de 16,098 (p=0,00006). Os indicadores clínicos que mais se destacaram pelas métricas de acurácia diagnóstica foram: desconforto respiratório, respiração abdominal paradoxal, aumento da concentração respiratória, uso importante da musculatura acessória, ruídos adventícios respiratórios, percepção aumentada de oxigênio e fadiga. O desmame foi conduzido pela equipe multiprofissional (médicos, enfermeiros e fisioterapeutas). O desmame foi conduzido pela equipe multiprofissional (médicos, enfermeiros e fisioterapeutas). As características preditivas foram calculadas a partir dos testes de regressão logística e demonstraram que ruídos adventícios respiratórios, desconforto respiratório e uso importante da musculatura acessória respiratória foram estatisticamente significativas e constituíram o modelo de regressão. Apresentado modelo de regressão logística entre a variável dependente - presença de RDDV - e cada uma das variáveis independentes, os indicadores clínicos e desfechos da extubação orotraqueal. Essa análise permitiu identificar se a relação entre as variáveis testadas era distribuída ao acaso. Dessa forma, obteve-se a relação entre cada variável independente e a variável desfecho insucesso na extubação, sendo medida a força de associação através do teste do qui-quadrado, Odds Ratio (O.R.) e por seu intervalo de confiança (IC) de 95%. Os impactos gerados pelo insucesso de desmame e extubação são multifacetados e constituem indicadores de qualidade em UTIs, pois há aumento das infecções e da mortalidade hospitalar, o que onera expressivamente os custos da internação. A extubação deve ser guiada por julgamento clínico e dados objetivos para minimizar o risco de reintubações. Por meio da simulação clínica, construiu-se um caso clínico com bases conceituais e metodológicas na teoria do duplo processamento, por meio do qual foram desenvolvidas as cenas, a partir das habilidades esperadas dos enfermeiros, durante a simulação. A elaboração e a validação do cenário clínico para a simulação foram importantes para reduzir incertezas na sua construção. CONCLUSÕES: O estudo permitiu a distinção entre o constructo clínico da RDDV, numa avaliação das respostas apresentadas à experiência da extubação orotraqueal, na perspectiva de uma visão holística, e o insucesso de extubação, num modelo mais voltado à terapia e processos fisiopatológicos.

OBJECTIVE: To analyze the diagnostic accuracy measures of the Dysfunctional Ventilatory Weaning Response and their outcomes in extubation of intensive care patients and apply the measures of accuracy of the Dysfunctional Ventilatory Weaning Response using the clinical simulation methodology. METHOD: A prospective cohort longitudinal study with a quantitative approach. SETTING: Intensive care unit of a teaching hospital in southeastern Brazil and clinical simulation laboratory in Portugal. PATIENTS: The sample selected in the study consisted of 46 mechanically ventilated patients. In each patient, the defining characteristics were verified at five different times, broken down at intervals of 5, 10, 15, 30 and 60 minutes. Therefore, each patient was evaluated five times, for a total of 230 evaluations. MEASURES AND MAIN RESULTS: The main causes of reintubation were hypoxemia and increased respiratory work. Failure prevalence was 14 events (33.3%) and the prevalence of DVWR was 13 events (30.95%), in total, 35 events were obtained, considering DVWR and clinical outcomes. The association between dysfunctional response in extubation and failure in extubation showed, through the chi-square test, a value of 16.098 (p = 0.00006). The clinical indicators that most stood out for the metrics of diagnostic accuracy were respiratory distress, paradoxical abdominal breathing, increased respiratory concentration, important use of accessory muscles, adventitious respiratory sounds, increased oxygen perception and fatigue. Weaning was carried out by the multiprofessional team (doctors, nurses and physiotherapists). Predictive characteristics were calculated from logistic regression tests and demonstrated that adventitious respiratory sounds, respiratory distress and important use of respiratory accessory muscles were statistically significant and constituted the regression model. A logistic regression model was presents between the dependent variable- presence of DVWRr- and each of the independent variables, the clinical indicators and outcomes of orotracheal extubation. This analysis made it possible to identify whether the relationship between the variables tested was randomly distributed. Thus, the relationship between each independent variable and the outcome variable extubation failure was obtained, and the strength of association was measured using the chi-square test, OddsRatio (OR) and its 95% confidence interval (CI). The impacts generated by the failure of weaning and extubation are multi-faceted and constitute quality indicators in ICUs, since there is an increase in infections, in-hospital mortality and significantly increase the costs of hospitalization. Extubation should be guided by clinical judgment and objective data to minimize the risk of reintubations. Through clinical simulation, a clinical case was constructed with conceptual and methodological bases in the double processing theory, through which scenes were developed, based on the skills expected of nurses during the simulation. The elaboration and validation of the clinical scenario for the simulation was important to reduce uncertainties in its construction. CONCLUSIONS: The study allowed the distinction between the clinical construct of DVWR, in an evaluation of the responses presented, the experience of orotracheal extubation, from the perspective of a holistic view and the extubation failure, in a model more focused on therapy and pathophysiological processes.

OBJETIVO: Analizar las medidas de precisión diagnóstica de la Respuesta Ventilatoria Disfuncional al Destete y sus resultados en la extubación de pacientes de terapia intensiva, y aplicar las medidas de precisión de la Respuesta Ventilatoria Disfuncional al Destete utilizando simulación clínica. MÉTODO: Estudio longitudinal tipo cohorte prospectivo con abordaje cuantitativo. LUGAR: Unidad de terapia intensiva de hospital de enseñanza del Sudeste de Brasil y laboratorio de simulación clínica en Portugal. PACIENTES: Muestra integrada por 46 pacientes en ventilación mecánica. Fueron verificadas en cada paciente las características definitorias en cinco momentos distintos, separados en intervalos de 5, 10, 15, 30 y 60 minutos. Consecuentemente, cada paciente fue evaluado cinco veces, habiéndose realizado en total 230 evaluaciones. MEDIDAS Y RESULTADOS PRINCIPALES: Las principales causas de reintubación fueron: hipoxemia y aumento del trabajo respiratorio; El fracaso se manifestó en 14 eventos (33,3%), la prevalencia de RVDD se expresó en 13 eventos (30,95%). En total se registraron 35 eventos, considerando la RVDD y los resultados clínicos. La asociación entre respuesta disfuncional en extubación y fracaso en extubación presentó, según resultados del test Chi-cuadrado, valor de 16,098 (p=0,00006). Los indicadores clínicos más destacados en las mediciones de precisión diagnóstica fueron: incomodidad respiratoria, respiración abdominal paradojal, aumento de concentración respiratoria, uso significativo de musculatura accesoria, ruidos adventicios respiratorios, percepción aumentada de oxígeno y fatiga. El destete fue dirigido por el equipo multiprofesional (médicos, enfermeros y fisioterapeutas). Fue presentada la regresión logística entre la variable dependiente - presencia de RVDD- y cada variable independiente, los indicadores clínicos y resultados de la extubación ortotraqueal. Dicho análisis permitió identificar si la relación entre las variables testeadas tenía distribución aleatoria. Así, se obtuvo la relación entre cada variable independiente y la variable resultante en fracaso en la extubación, midiéndose la fuerza asociativa por test de Chi-cuadrado, Razón de Chances (OR) e intervalo de confianza (IC) del 95%. Los impactos determinados por el fracaso del destete y extubación presentan múltiples facetas y constituyen indicadores de calidad en UTIs, al existir incremento de infecciones, mortalidad hospitalaria y manifiesto aumento de costos de internación. La extubación debe orientarse por juicio clínico y datos objetivos, para minimizar el riesgo de reintubaciones. Se construyó un caso clínico mediante simulación con bases conceptuales y metodológicas de la teoría del doble procesamiento. En base al mismo se elaboraron escenarios, partiéndose de las habilidades esperadas de los enfermeros durante la simulación. La elaboración y validación del escenario clínico de la simulación resultó importante para reducir la incertidumbre en su construcción. CONCLUSIONES: El estudio permitió distinguir entre el constructo clínico de la RVDD, en una evaluación de las respuestas manifestadas ante la experiencia de la extubación ortotraqueal en la perspectiva de una visión holística, y el fracaso de la extubación en un modelo más orientado a la terapia y a procesos fisiopatológicos.