A scoping review of remote facilitation during simulation-based healthcare education.

BACKGROUND: Remote facilitation is a synchronous distance education method where instructors facilitate a lesson, in real-time, in physically separate conditions. In this scoping review, we aimed to describe types of remote facilitation used in a healthcare simulation, the influences on learner outcomes, and related factors. METHODS: We accessed PubMed, EMBASE, CINAHL, ERIC, and Web of Science using our search strategies. Five reviewers performed the review using the Preferred Reporting Items for Systematic Reviews and Meta Analysis extension for Scoping Reviews (PRISMA-ScR) framework, and the Johanna Briggs Institute (JBI) guidelines. RESULTS: We included a total of 29 articles presenting 28 simulation studies. The most common tool was videoconferencing (n = 26, 89.7%). Knowledge improvement was the most frequently measured outcome. There was no significant difference in learning outcomes between the two teaching modes. There were differences in learners' preferences and satisfaction with remote facilitators before and after COVID-19. CONCLUSIONS: Our scoping review indicates that remote facilitation has been widely accepted in many healthcare professions using various types of simulation modalities. Remote facilitation can be used to overcome logistical problems of synchronous multi-location education, and to improve learner knowledge, skills, and confidence measured by instructor evaluation or self-assessment.

Medical student medium-term skill retention following cardiac point-of-care ultrasound training based on the American Society of Echocardiography curriculum framework.

BACKGROUND: No studies have demonstrated medium- or long-term skill retention of cardiac point-of-care ultrasound (POCUS) curriculum for medical student. Based on the American Society of Echocardiography (ASE) curriculum framework, we developed a blended-learning cardiac POCUS curriculum with competency evaluation. The objective of this study was to investigate the curriculum impact on image acquisition skill retention 8 weeks after initial training. METHODS: This study was a prospective, pre-post education intervention study for first- and second-year medical students, with blinded outcome assessment. The curriculum included a pre-training ASE online module and healthy volunteer hands-on training to obtain 5 views: parasternal long-axis (PLAX), parasternal short-axis (PSAX), apical 4-chamber (A4C), subcostal 4-chamber (S4C), and subcostal inferior vena cava (SIVC) views. Students took 5-view image acquisition skill tests at pre-, immediate post-, and 8-week post-training, using a healthy volunteer. Three blinded assessors rated the image quality using a validated 10-point maximum scoring system. Students used a hand-held ultrasound probe (Butterfly iQ). RESULTS: Fifty-four students completed hands-on training, and pre- and immediate post-training skill tests. Twenty-seven students completed 8-week post-training skill tests. Skill test score improvement between pre- and 8-week post-training was 2.11 points (95% CI, 1.22-3.00; effect size, 1.13). CONCLUSION: The cardiac POCUS curriculum demonstrated medium-term skill retention. The curriculum was sufficient for S4C and SIVC skill retention, but inadequate for PLAX, PSAX, and A4C. Therefore, instructional design modifications or re-training for PLAX, PSAX, and A4C are needed to make the curriculum more effective for clinically relevant skill retention.

Umbilical catheterization training: Tissue hybrid versus synthetic trainer.

BACKGROUND: This study of umbilical catheterization deliberate practice training compared skill and knowledge outcomes of umbilical catheterization using a tissue-hybrid simulator (REAL) versus a synthetic simulated umbilical cord task trainer (ART). METHODS: This was a prospective randomized control study. Pediatric residents were randomized to REAL or ART umbilical catheterization deliberate practice training. Pre-post-training changes in skill performance and knowledge scores for REAL and ART groups were compared. Fidelity of REAL and ART were compared by neonatologists. RESULTS: Twenty-seven pediatric residents completed training. Post-training mean skill scores were improved compared to pre-test scores (REAL, P < 0.001; ART, P < 0.0001). Post-training skill, knowledge, and self-efficacy scores were not different between the REAL and ART groups. Fidelity of REAL was higher than ART for neonatologists (P < 0.01). CONCLUSIONS: The face validity of REAL was superior to ART, but resident umbilical cord deliberate practice training demonstrated no difference in skill, knowledge, and self-efficacy improvements between REAL and ART. Further studies on real patients are needed to evaluate the impact of using real or simulated umbilical cords for umbilical venous catheter/umbilical arterial catheter training.

Simulation intervention related to family presence during resuscitation for physicians and medical students: A scoping review.

Objective: Family presence during resuscitation (FPDR) is known as part of family-centered care. However, it is unknown or how physicians are educated for FPDR. We aim to review the current status of simulation related FPDR for physicians and medical students. Methods: A scoping review of literature published from 1999 to May 5 2023 and written in English was undertaken. The articles were searched for using keyword combinations of the following words; family, resuscitation, and simulation-related words. Results: Eight articles were included in the final review. This review of FPDR simulation for physicians and medical students revealed findings in three categories; measuring CPR quality, investigating participant responses after FPDR simulation, and extracting exemplar good communication elements. First, in four studies measuring resuscitation quality, physicians participated in adult resuscitation, and resuscitation quality was reduced with overt reaction family presence. Second, in three studies investigating the response to simulation training, interprofessional teams participating in pediatric resuscitation had negative responses to FPDR simulation. Third, in one study, good communication elements during FPDR were found in infant simulation, in which interprofessional teams participated. FPDR simulation training for medical students has not been reported. Conclusion: It highlighted a gap in FPDR simulations involving physicians and/or medical students. Physicians were more concerned with resuscitation quality than supporting families during resuscitation simulations. Medical students should be considered as the main participants for FPDR simulation. More high-evidence studies with interprofessional teams including physicians and/or medical students are needed to evaluate curriculum design and participant response changes following FPDR simulation.

Improving performance and self-efficacy of novice nurses using hybrid simulation-based mastery learning.

AIM: Acute chest pain is a commonly encountered symptom in hospital medical/surgical units; however, almost half of nurses in their second year of clinical experience in our facility have reported struggling to care for acute chest pain patients. We developed, implemented, and examined the effectiveness of a simulation-based, mastery learning clinical nursing educational program to improve self-efficacy and performance in caring for patients with acute chest pain. METHODS: The study adopted a single-site, single-cohort design using simulation-based performance assessment and self-efficacy surveys on a convenience sample of 37 second-year clinical nurse participants in multi-stage hybrid mastery learning educational intervention using asynchronous e-learning, and hands-on simulation training and assessment with feedback on caring for chest pain patients. Performance assessments and self-efficacy surveys were administered pre-, post-, and 5 months post-intervention. RESULTS: Clinical performance on the post- and 5 months follow-up assessments were significantly higher than those for the pre-test (P < .0001). The self-efficacy scores for the post- and the 5 months follow-up assessments were significantly higher than the pre-course scores (P < .0001). Participants' self-efficacy perceptions were positively correlated with their performances at 5 months post-intervention. CONCLUSION: Performance and self-efficacy of novice nurses in caring for acute chest pain patients improved significantly with the multi-stage hybrid mastery learning educational intervention, with improvements retained 5 months post-intervention. The results suggest the applicability of simulation-based mastery learning in a clinical setting for novice nurses to attain specific skills, and raise their self-perception of competence to care for patients in acute settings.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) for life-threatening isolated pulmonary anti-GBM disease.

Anti-glomerular basement membrane disease (anti-GBM disease) associated with renal and lung lesions has a poor prognosis. Diffuse alveolar hemorrhage (DAH) is a complication that worsens anti-GBM disease prognosis. We report a rescue case using veno-venous extracorporeal membrane oxygenation (VV-ECMO) for diffuse alveolar hemorrhage due to isolated pulmonary anti-GBM disease; a rare anti-GBM syndrome. A 30-year-old Japanese female with no past medical history. Presented with acute hypoxemic respiratory failure requiring mechanical ventilation. Progressive deterioration and refractory hypoxemia prompted therapy with VV-ECMO. Serum anti-GBM antibody confirmed the diagnosis of anti-GBM disease. Multi-modal systemic therapy with pulse-dosed methylprednisolone, plasma exchange, and rituximab resulted in significant clinical improvement. VV-ECMO for 10 days was uncomplicated. Renal replacement therapy was not required. The patient was extubated on day 18 and discharged from the hospital after 45 days. VV-ECMO supportive therapy for DAH with refractory respiratory failure was demonstrated to be effective pending definitive diagnostic and therapeutic management in this case of isolated pulmonary anti-GBM disease.

A Patient Safety Champion Program for Interprofessional Health Care Educators: Implementation and Outcomes.

INTRODUCTION: Health care educators are challenged with helping clinicians develop competencies beyond their foundational training. In health care systems where continuing professional development is not integral to practice, clinicians may have few opportunities. We describe the design, implementation, and evaluation of a professional development program in patient safety for Japanese clinical educators to acquire simulation instructional skills and become Patient Safety Champions at their organizations. METHODS: Mixed methods were used in a longitudinal pre/post study design. The Kirkpatrick evaluation model was used to evaluate outcomes of a workshop, overall program, on-site training experiences, and impact as Patient Safety Champions. Self-assessment data on skills and knowledge of patient safety, simulation instructional methods, interprofessional collaboration, and leadership were collected and analyzed. RESULTS: Eighty-nine percent of participants facilitated on-site patient safety training within 6 months of workshop completion. Skills and knowledge improvement were observed immediately postworkshop in four categories: patient safety, simulation instructional methods, interprofessional collaboration and communication, and leadership as a patient safety champion. Skills and knowledge increased at 6 months after facilitation of on-site safety training. Program mean satisfaction scores ranged from 84% to 92%. Mean Patient Safety Champion in-facility evaluations were 4.2 to 4.7 on a 5-point scale. DISCUSSION: High levels of knowledge, skill retention, and behavior change are attributed to goal setting, outcome-oriented pedagogy, and reflective sessions. The Patient Safety Champion model and experiential learning approach gave Japanese clinical educators in medicine, nursing, and pharmacy an opportunity to learn from each other in simulations reflecting the practice environment.

Student-written simulation scenarios: a novel cognitive assessment method in a trauma curriculum.

INTRODUCTION: Global cognitive and psychomotor assessment in simulation based curricula is complex. We describe assessment of novices' cognitive skills in a trauma curriculum using a simulation aligned facilitated discovery method. METHODS: Third-year medical students in a surgery clerkship completed two student-written simulation scenarios (SWSS) as an assessment method in a trauma curriculum employing high fidelity human patient simulators (manikins). SWSS consisted of written physiologic parameters, intervention responses, a performance evaluation form, and a critical interventions checklist. RESULTS: Seventy-one students participated. SWSS scores were compared to multiple choice test (MCQ), checklist-graded solo performance in a trauma scenario (STS), and clerkship summative evaluation grades. The SWSS appeared to be slightly better than STS in discriminating between Honors and non-Honors students, although the mean scores of Honors and non-Honors students on SWSS, STS, or MCQ were not significantly different. SWSS exhibited good equivalent form reliability (r=0.88), and higher interrater reliability versus STS (r=0.93 vs r=0.79). CONCLUSION: SWSS is a promising assessment method for simulation based curricula.

Physicians' perceptions of followership in resuscitation in Japan and the USA: a qualitative study.

OBJECTIVES: While leadership is accepted as a crucial aspect of a successful resuscitation team, the role of followership has not been sufficiently explored. This study aims to explore physicians' perceptions of common favourable followership in resuscitation teams in two different countries. DESIGN: A qualitative study with interviews and a reflexive thematic analysis. SETTING: The authors individually interviewed critical care and emergency physicians whose clinical experience exceeded 6 years in Japan and the USA. PARTICIPANTS: A total of 18 physicians participated in a face-to-face, semistructured and in-depth interviews. RESULTS: Five themes and nine subthemes related to followership in resuscitation were identified. Under technical skills, two themes (being knowledgeable and skilled) and three subthemes (understanding guidelines/algorithms, clinical course and being competent with procedural skills), were generated. Under non-technical skills, three themes (assuming roles, team communication and flattening hierarchy) and six subthemes (taking roles spontaneously, calm tone of voice, sharing information, closed-loop communication, respectful attitude and speaking up), were generated. Each generated theme involved commonly perceived favourable attributes of followership in resuscitation teams by experienced critical care and emergency physicians in both countries. CONCLUSIONS: This study clarified physicians' perception of common favourable followership attributes in resuscitation teams, both in Japan and in the USA. The results of this study shed light on followership-focused resuscitation education, where followership skills are generally underestimated.

Transesophageal Echocardiography Simulator Training: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

SUMMARY STATEMENT: We aimed to assess the learning effects of novice transesophageal echocardiography (TEE) simulator training and to identify gaps in existing studies. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the learning effects of novice TEE training with versus without simulators, searching published articles and proceedings in 6 major databases in June 2019. We included 9 RCTs (268 participants). Compared with nonsimulator training, TEE simulator training resulted in higher skill and knowledge posttraining test scores with large effect sizes (standardized mean difference = 0.81 for skill, 1.61 for knowledge; low-certainty evidence) and higher training satisfaction with a small effect size (standardized mean difference = 0.36; very low-certainty evidence). No RCTs reported training budget or patient outcomes. Additional well-designed studies with low risk of bias and large sample sizes are needed to provide reliable and robust findings and develop more effective TEE simulation-based training curricula.

Pre-clinical medical student cardiac point-of-care ultrasound curriculum based on the American Society of Echocardiography recommendations: a pilot and feasibility study.

BACKGROUND: Cardiac point-of-care ultrasound (POCUS) training has been integrated into medical school curricula. However, there is no standardized cardiac POCUS training method for medical students. To address this issue, the American Society of Echocardiography (ASE) proposed a framework for medical student cardiac POCUS training. The objective of this pilot study was to develop a medical student cardiac POCUS curriculum with test scoring systems and test the curriculum feasibility for a future definitive study. METHODS: Based on the ASE-recommended framework, we developed a cardiac POCUS curriculum consisting of a pre-training online module and hands-on training with a hand-held ultrasound (Butterfly iQ, Butterfly Network Inc., Guilford, CT, USA). The curriculum learning effects were assessed with a 10-point maximum skill test and a 40-point maximum knowledge test at pre-, immediate post-, and 8-week post-training. To determine the curriculum feasibility, we planned to recruit 6 pre-clinical medical students. We semi-quantitatively evaluated the curriculum feasibility in terms of recruitment rate, follow-up rate 8 weeks after training, instructional design of the curriculum, the effect size (ES) of the test score improvements, and participant satisfaction. To gather validity evidence of the skill test, interrater and test-retest reliability of 3 blinded raters were assessed. RESULTS: Six pre-clinical medical students participated in the curriculum. The recruitment rate was 100% (6/6 students) and the follow-up rate 8 weeks after training was 100% (6/6). ESs of skill and knowledge test score differences between pre- and immediate post-, and between pre- and 8-week post-training were large. The students reported high satisfaction with the curriculum. Both interrater and test-retest reliability of the skill test were excellent. CONCLUSIONS: This pilot study confirmed the curriculum design as feasible with instructional design modifications including the hands-on training group size, content of the cardiac POCUS lecture, hands-on teaching instructions, and hand-held ultrasound usage. Based on the pilot study findings, we plan to conduct the definitive study with the primary outcome of long-term skill retention 8 weeks after initial training. The definitive study has been registered in ClinicalTrials.gov (Identifier: NCT04083924).

Pediatric Simulation Training for Emergency Pre-Hospital Providers in Hawai'i: An Inter-Professional Curriculum Collaboration and Update.

Experience with pediatric transport and pediatric-specific training for paramedic students and practicing paramedics is lacking nationally. Kapi'olani Community College (KCC) conducts the only paramedic training program in the state and has recently expanded its pediatric training section. KCC and the John A. Burns School of Medicine (JABSOM) collaborated on a simulation-based pediatric pre-hospital provider training course titled PediSTEPPs-H (Pediatric Simulation Training for Emergency Pre-hospital Providers in Hawai'i), which was developed and piloted in 2019, to supplement the students' didactic and clinical experiences. The program was developed using Kern's 6-step approach to curriculum development in medical education. The PediSTEPPs-H pilot course was co-facilitated by faculty from both campuses and enrolled 12 students in the first cohort. Program evaluation demonstrated high student satisfaction and included feedback regarding curriculum elements for further refinement. The PediSTEPPs-H pilot program evaluation provided direction that the course be offered annually for all KCC paramedic students and as continuing professional development program for practicing paramedics in Hawai'i.

Teaching mass casualty triage skills using iterative multimanikin simulations.

OBJECTIVE: Effective mass casualty triage requires rapid and accurate decision making. First responders need to be trained, but opportunities to practice triage and receive individualized feedback during traditional mass casualty (MC) exercises are uncommon. It was hypothesized that novice learners would improve in speed, accuracy, and self-efficacy after deliberate practice triaging multiple simulated casualties in a MC exercise using high-fidelity manikins. METHODS: Learners initially developed baseline knowledge of MC triage by listening to four short podcasts and passing a written examination. They then experienced three sequential MC scenarios (A, B, and C) consisting of five manikin simulations each, coupled with individual feedback after each scenario. Students served as their own controls. A triage score (TS) and intervention score (IS) were recorded. For the TS, one point was awarded for each correctly identified main problem, required intervention, and triage category. For the IS, one point was awarded for each correctly applied intervention. Before-and-after surveys measured self-efficacy and reaction to the training. RESULTS: Twenty-one medical students were enrolled and 20 students passed the examination. The TS and IS improved significantly during scenario B (p < 0.001). Time to complete each scenario decreased significantly from scenario A (8 min 27 sec) to scenario B (6 min 19 sec) (p < 0.001), but not from scenario B to scenario C (5 min 40 sec). Self-efficacy improved significantly after scenario C for prioritizing treatment and resources, identifying high-risk casualties, and learning to be an effective first responder. CONCLUSION: Novice learners demonstrated improved triage and intervention scores, speed, and self-efficacy during an iterative, multimanikin MC training experience.

Alarm limit settings for early warning systems to identify at-risk patients.

AIM: This paper is a report of a study conducted to provide objective data to assist with setting alarm limits for early warning systems. BACKGROUND: Early warning systems are used to provide timely detection of patient deterioration outside of critical care areas, but with little data from the general ward population to guide alarm limit settings. Monitoring systems used in critical care areas are known for excellent sensitivity in detecting signs of deterioration, but give high false positive alarm rates, which are managed with nurses caring for two or fewer patients. On general wards, nurses caring for four or more patients will be unable to manage a high number of false alarms. Physiological data from a general ward population would help to guide alarm limit settings. METHODS: A dataset of continuous heart rate and respiratory rate data from a general ward population, previously collected from July 2003-January 2006, was analyzed for adult patients with no severe adverse events. Dataset modeling was constructed to analyze alarm frequency at varying heart rate and respiratory rate alarm limits. RESULTS: A total of 317 patients satisfied the inclusion criteria, with 780.71 days of total monitoring. Sample alarm settings appeared to optimize false positive alarm rates for the following settings: heart rate high 130-135, low 40-45; respiratory rate high 30-35, low 7-8. Rates for each selected limit can be added to calculate the total alarm frequency, which can be used to judge the impact on nurse workflow. CONCLUSION: Alarm frequency data will assist with evidence-based configuration of alarm limits for early warning systems.

Mass-casualty triage training for international healthcare workers in the Asia-Pacific region using manikin-based simulations.

INTRODUCTION: More than half of the world's disasters occur in the Asia-Pacific region. A simulation-based exercise to teach healthcare workers prehospital triage, tagging, and treatment methods was used to link disaster management theory to practice with a student-centered, hands-on educational activity. Various strategies for teaching disaster health education have been advocated, and best-practice disaster education models continue to be sought. METHODS: A manikin-based, primary triage and treatment course was adapted for international healthcare providers in the Asia-Pacific region using symbolic representations of triage categories and physical findings. The pedagogical construct that was used was an interactive, formative assessment in which faculty members mediated learner information gathering and interpretation during four simulation scenarios. After establishing a multi-casualty disaster context, a wireless, audience response system anonymously collected learner responses to four clinical situations: (1) leg wound (hemorrhagic shock/immediate); (2) chest wound (tension pneumothorax/immediate); (3) head wound (traumatic brain injury/expectant); and (4) limb trauma (leg fracture/delayed). RESULTS: There were 182 healthcare providers from eight Asia-Pacific countries (including the US) that participated in four simulation seminars. The simulation sessions were successfully tailored to groups of learners that varied in size and professional composition. Expectant and delayed triage categories posed the greatest challenge to learners. In one of two groups that were queried, learner self-confidence in applying principles of triage and treatment improved significantly. At the conclusion of the simulation sessions, learners strongly agreed that manikin-based simulation improved their understanding of triage, and should be used to teach principles of primary triage and treatment. CONCLUSIONS: Simulation training represents an opportunity to engage learners regardless of language and cultural barriers. Simulation-based training can be effective in introducing healthcare professionals to principles of primary triage and treatment in an effective and culturally sensitive manner. The characteristics of the course with respect to planned formative assessment and culturally competent scholarship were reviewed.