Global consensus statement on simulation-based practice in healthcare.

Simulation plays a pivotal role in addressing universal healthcare challenges, reducing education inequities, and improving mortality, morbidity and patient experiences. It enhances healthcare processes and systems, contributing significantly to the development of a safety culture within organizations. It has proven to be cost-effective and successful in enhancing team performance, fostering workforce resilience and improving patient outcomes.Through an international collaborative effort, an iterative consultation process was conducted with 50 societies operating across 67 countries within six continents. This process revealed common healthcare challenges and simulation practices worldwide. The intended audience for this statement includes policymakers, healthcare organization leaders, health education institutions, and simulation practitioners. It aims to establish a consensus on the key priorities for the broad adoption of exemplary simulation practice that benefits patients and healthcare workforces globally.Key recommendations Advocating for the benefits that simulation provides to patients, staff and organizations is crucial, as well as promoting its adoption and integration into daily learning and practice throughout the healthcare spectrum. Low-cost, high-impact simulation methods should be leveraged to expand global accessibility and integrate into system improvement processes as well as undergraduate and postgraduate curricula. Support at institutional and governmental level is essential, necessitating a unified and concerted approach in terms of political, strategic and financial commitment.It is imperative that simulation is used appropriately, employing evidence-based quality assurance approaches that adhere to recognized standards of best practice. These standards include faculty development, evaluation, accrediting, credentialing, and certification.We must endeavor to provide equitable and sustainable access to high-quality, contextually relevant simulation-based learning opportunities, firmly upholding the principles of equity, diversity and inclusion. This should be complemented with a renewed emphasis on research and scholarship in this field.Call for action We urge policymakers and leaders to formally acknowledge and embrace the benefits of simulation in healthcare practice and education. This includes a commitment to sustained support and a mandate for the application of simulation within education, training, and clinical environments.We advocate for healthcare systems and education institutions to commit themselves to the goal of high-quality healthcare and improved patient outcomes. This commitment should encompass the promotion and resource support of simulation-based learning opportunities for individuals and interprofessional teams throughout all stages and levels of a caregiver's career, in alignment with best practice standards.We call upon simulation practitioners to champion healthcare simulation as an indispensable learning tool, adhere to best practice standards, maintain a commitment to lifelong learning, and persist in their fervent advocacy for patient safety.This statement, the result of an international collaborative effort, aims to establish a consensus on the key priorities for the broad adoption of exemplary simulation practice that benefits patients and healthcare workforces globally.

Lego® bricks assisted training of the novice debriefers.

Lego® Serious Play® is a guided workshop in which participants construct Lego creations to represent symbolic and metaphorical ideas in response to assignments. How to encourage inexperienced debriefers to concentrate on dialogue and communications strategies rather than engage in an unstructured debate on technical or behavioral abilities is one of the main challenges in training people to debrief a high-fidelity simulation session. We explore the use of Lego bricks in this study to build straightforward, standardised situations that debriefers in training can use to practice leading discussion. With this method, the different debriefing methodologies may be practiced focusing exclusively on method and dialogue, without getting involved or having to concentrate on the technical aspects.

Improving learning by playing with an app: The FantaTraining ® experience with anesthesia trainees.

Background: FantaTraining ® is an app that simulates a football league. Each participant represents a team, and the game is played with the opposing team by answering a questionnaire. In the intervals between games, participants can practice by consulting the educational material (films, short texts, or slides) in the app. Various prizes are offered to the winners of the championship. In this study, we aimed to evaluate whether the use of the FantaTraining ® app could improve the learning of anesthesia trainees registered in an online obstetric anesthesia course. Methods: The study involved 282 trainees in anesthesia, from five Italian universities, registered in the Online Obstetric Anesthesia Course (OOAC) who were given the app. They were randomly allocated into two groups according to whether the app had been enabled to allow the participant to play the league (study group, n=137), or not (control group, n=145). All the trainees underwent entry and final tests, consisting of the same 40 multiple choice questions, respectively before and after completing the OOAC course. Results: There were no differences in the scores obtained in the pre-course test between the groups. The mean score obtained in the final test was significantly greater than that obtained in the entry one in both groups (P<0.05) but the final test score obtained by the participants of the study group was significantly greater than that obtained by the control group. (P<0.001), regardless of the university of origin and year of specialization. Trainees stated that the app had helped their study, improving understanding and motivation, without increasing the intensity of study. Conclusions: Using the FantaTraining ® app greatly improved trainees' final exam performance after the online obstetric anesthesia course. The FantaTraining ® app seems a promising tool to improve learning outcomes by strengthening learning behaviors and attitudes towards learning.

A Region-Wide All-Hazard Training Program for Prehospital Mass Casualty Incident Management: A Real-World Case Study.

OBJECTIVE: We report the development, implementation, and results of a sustainable region-wide mass-casualty management prehospital training program implemented by the Regione Lombardia emergency medical services (EMS) agency AREU in Italy. METHODS: The educational program learning objectives are: (1) command and control, communications, and resource management; (2) mass casualty triage and the START triage protocol; (3) on-scene management; (4) Regione Lombardia and AREU Mass Casualty standard operating procedures; and (5) inter-agency communications and relations. For each course edition data on participants' summative assessment, participants' feedback and costs were collected. RESULTS: Between June 26, 2013, and December 31, 2020, a total of 84 editions of the provider training event were delivered, training an overall 1329 prehospital providers; 1239 (93%) passed the summative assessment and were qualified as being operationally "ready." Regarding participant feedback, the overall program was rated 4.4 ± 0.7 out of 5. The overall cost of running the provider program during the study period was €321 510 (circa US $382 000). The average cost per edition was €3828 and €242 per participant. CONCLUSIONS: We have described a simple yet interactive simulation and blended-learning approach, which has yielded good pass rates, good participant satisfaction, and contained costs to systematically train emergency medical service personnel.

Adherence to guideline recommendations in the management of pediatric cardiac arrest: a multicentre observational simulation-based study.

BACKGROUND AND IMPORTANCE: Pediatric cardiac arrest is a rare emergency with associated high mortality. Its management is challenging and deviations from guidelines can affect clinical outcomes. OBJECTIVES: To evaluate the adherence to guideline recommendations in the management of a pediatric cardiac arrest scenario by teams of pediatric residents. Secondarily, the association between the use of the Pediatric Advanced Life Support-2015 (PALS-2015) pocket card, and the teams' adherence to international guidelines, were explored. DESIGN, SETTINGS AND PARTICIPANTS: Multicentre observational simulation-based study at three Italian University Hospitals in 2018, including PALS-2015 certified pediatric residents in their 3rd-5th year of residency program, divided in teams of three. INTERVENTION OR EXPOSURE: Each team conducted a standard nonshockable pediatric cardiac arrest scenario and independently decided whether to use the PALS-2015 pocket card. OUTCOME MEASURE AND ANALYSIS: The primary outcome was the overall number and frequency of individual deviations from the PALS-2015 guidelines, measured by the novel c-DEV15plus score (range 0-15). Secondarily, the performance on the validated Clinical Performance Tool for asystole scenarios, the time to perform resuscitation tasks and cardiopulmonary resuscitation (CPR) quality metrics were compared between the teams that used and did not use the PALS-2015 pocket card. MAIN RESULTS: Twenty-seven teams (81 residents) were included. Overall, the median number of deviations per scenario was 7 out of 15 [interquartile range (IQR), 6-8]. The most frequent deviations were delays in positioning of a CPR board (92.6%), calling for adrenaline (92.6%), calling for help (88.9%) and incorrect/delayed administration of adrenaline (88.9%). The median Clinical Performance Tool score was 9 out of 13 (IQR, 7-10). The comparison between teams that used ( n = 13) and did not use ( n = 14) the PALS-2015 pocket card showed only significantly higher Clinical Performance Tool scores in the former group [9 (IQR 9-10) vs. 7 (IQR 6-8); P = 0.002]. CONCLUSIONS: Deviations from guidelines, although measured by means of a nonvalidated tool, were frequent in the management of a pediatric cardiac arrest scenario by pediatric residents. The use of the PALS-2015 pocket card was associated with better Clinical Performance Tool scores but was not associated with less deviations or shorter times to resuscitation tasks.

Logistic Red Flags in Mass-Casualty Incidents and Disasters: A Problem-Based Approach.

BACKGROUND: Mass-casualty incidents (MCIs) and disasters are characterized by a high heterogeneity of effects and may pose important logistic challenges that could hamper the emergency rescue operations.The main objective of this study was to establish the most frequent logistic challenges (red flags) observed in a series of Italian disasters with a problem-based approach and to verify if the 80-20 rule of the Pareto principle is respected. METHODS: A series of 138 major events from 1944 through 2020 with a Disaster Severity Score (DSS) ≥ four and five or more victims were analyzed for the presence of twelve pre-determined red flags.A Pareto graph was built considering the most frequently observed red flags, and eventual correlations between the number of red flags and the components of the DSS were investigated. RESULTS: Eight out of twelve red flags covered 80% of the events, therefore not respecting the 80-20 rule; the number of red flags showed a low positive correlation with most of the components of the DSS score. The Pareto analysis showed that potential hazards, casualty nest area > 2.5km2, number of victims over 50, evacuation noria over 20km, number of nests > five, need for extrication, complex access to victims, and complex nest development were the most frequently observed red flags. CONCLUSIONS: Logistic problems observed in MCIs and disaster scenarios do not follow the 80-20 Pareto rule; this demands for careful and early evaluation of different logistic red flags to appropriately tailor the rescue response.

PediAppRREST: effectiveness of an interactive cognitive support tablet app in reducing deviations from guidelines in the management of paediatric cardiac arrest: protocol for a simulation-based randomised controlled trial.

INTRODUCTION: Paediatric cardiac arrest (PCA), despite its low incidence, has a high mortality. Its management is complex and deviations from guideline recommendations occur frequently. We developed a new interactive tablet app, named PediAppRREST, to support the management of PCA. The app received a good usability evaluation in a previous pilot trial. The aim of the study is to evaluate the effectiveness of the PediAppRREST app in reducing deviations from guideline recommendations in PCA management. METHODS AND ANALYSIS: This is a multicentre, simulation-based, randomised controlled, three-parallel-arm study. Participants are residents in Paediatric, Emergency Medicine, and Anaesthesiology programmes in Italy. All 105 teams (315 participants) manage the same scenario of in-hospital PCA. Teams are randomised by the study statistician into one of three study arms for the management of the PCA scenario: (1) an intervention group using the PediAppRREST app or (2) a control group Paediatric Advanced Life Support (CtrlPALS+) using the PALS pocket reference card; or (3) a control group (CtrlPALS-) not allowed to use any PALS-related cognitive aid. The primary outcome of the study is the number of deviations (delays and errors) in PCA management from PALS guideline recommendations, according to a novel checklist, named c-DEV15plus. The c-DEV15plus scores will be compared between groups with a one-way analysis of variance model, followed by the Tukey-Kramer multiple comparisons adjustment procedure in case of statistical significance. ETHICS AND DISSEMINATION: The Ethics Committee of the University Hospital of Padova, coordinating centre of the trial, deemed the project to be a negligible risk study and approved it through an expedited review process. The results of the study will be disseminated in peer-reviewed journals, and at national and international scientific conferences. Based on the study results, the PediAppRREST app will be further refined and will be available for download by institutions/healthcare professionals. TRIAL REGISTRATION NUMBER: NCT04619498; Pre-results.

Assessing anaesthesiology and intensive care specialty physicians: An Italian language multisource feedback system.

BACKGROUND: Physician professionalism, including anaesthesiologists and intensive care doctors, should be continuously assessed during training and subsequent clinical practice. Multi-source feedback (MSF) is an assessment system in which healthcare professionals are assessed on several constructs (e.g., communication, professionalism, etc.) by multiple people (medical colleagues, coworkers, patients, self) in their sphere of influence. MSF has gained widespread acceptance for both formative and summative assessment of professionalism for reflecting on how to improve clinical practice. METHODS: Instrument development and psychometric analysis (feasibility, reliability, construct validity via exploratory factor analysis) for MSF questionnaires in a postgraduate specialty training in Anaesthesiology and intensive care in Italy. Sixty-four residents at the Università del Piemonte Orientale (Italy) Anesthesiology Residency Program. Main outcomes assessed were: development and psychometric testing of 4 questionnaires: self, medical colleague, coworker and patient assessment. RESULTS: Overall 605 medical colleague questionnaires (mean of 9.3 ±1.9) and 543 coworker surveys (mean 8.4 ±1.4) were collected providing high mean ratings for all items (> 4.0 /5.0). The self-assessment item mean score ranged from 3.1 to 4.3. Patient questionnaires (n = 308) were returned from 31 residents (40%; mean 9.9 ± 6.2). Three items had high percentages of "unable to assess" (> 15%) in coworker questionnaires. Factor analyses resulted in a two-factor solution: clinical management with leadership and accountability accounting for at least 75% of the total variance for the medical colleague and coworker's survey with high internal consistency reliability (Cronbach's α > 0.9). Patient's questionnaires had a low return rate, a limited exploratory analysis was performed. CONCLUSIONS: We provide a feasible and reliable Italian language MSF instrument with evidence of construct validity for the self, coworkers and medical colleague. Patient feedback was difficult to collect in our setting.

Use of backboards in cardiopulmonary resuscitation: a systematic review and meta-analysis.

To achieve optimal chest compression depth, victims of cardiac arrest should be placed on a firm surface. Backboards are usually placed between the mattress and the back of a patient in the attempt to increase cardiopulmonary resuscitation (CPR) quality, but their effectiveness remains controversial. A systematic search was performed to include studies on humans and simulation manikins assessing CPR quality with or without backboards. The primary outcome of the meta-analysis was the difference in chest compression depth between these two conditions. Out of 557 records, 16 studies were included in the review and all were performed on manikins. The meta-analysis, performed on 15 articles, showed that the use of backboards during CPR increases chest compression depth by 1.46 mm in manikins. Despite statistically significant, this increase could have a limited clinical impact on CPR, due to the substantial heterogeneity of experimental conditions and the scarcity of other CPR quality indicators.

Role of health simulation centres in the COVID-19 pandemic response in Italy: a national study.

Introduction: The COVID-19 pandemic has dramatically affected the Italian health systems and drastically impacted healthcare workers' daily routine and training. Simulation is an efficient tool to provide medical education, especially in the case of incoming public health emergencies. This study investigated the role and activities of Italian simulation centres (SCs) during the acute phase of the COVID-19 pandemic. Methods: The population was identified through a web search. The directors of Italian SCs were contacted via email and then enrolled. A structured interview was created, internally validated and administrated by phone to participants. Results: Following the government's ordinance, 37 (88.37%) SCs had to be closed to the public. Twenty (46.51%) SCs organised in situ simulation while 7 (16.28%) of them organised simulation inside the centre. Twenty-three (53.49%) SCs resorted to telematic modalities to provide training about COVID-19 and 21 (48.84%) of them for other training. Up to date, 13 SCs are still closed to the public. Conclusions: Italy has been severely hit by COVID-19, with differences between the regions. Almost all the SCs were closed, with only a few delivering training. The SCs took advantage of emergent technologies to create new ways to train people safely. Unfortunately, nearly one-fourth of Italian SCs have not reopened yet. The evolution of the COVID-19 epidemic calls for reconsideration about training activities including adequate safety measures implemented for all individuals involved.

Use of Simulated Patients in Disaster Medicine Training: A Systematic Review.

Simulation is an effective teaching tool in disaster medicine education, and the use of simulated patients (SPs) is a frequently adopted technique. Throughout this article, we critically analyzed the use and the preparation of SPs in the context of simulation in disaster medicine. A systematic review of English, French, and Italian language articles was performed on PubMed and Google Scholar. Studies were included if reporting the use of SPs in disaster medicine training. Exclusion criteria included abstracts, citations, theses, articles not dealing with disaster medicine, and articles not using human actors in simulation. Eighteen papers were examined. All the studies were conducted in Western countries. Case reports represent 50% of references. Only in 44.4% of articles, the beneficiaries of simulations were students, while in most of cases were professionals. In 61.1% of studies SPs were moulaged, and in 72.2%, a method to simulate victim symptoms was adopted. Ten papers included a previous training for SPs and their involvement in the participants' assessment at the end of the simulation. Finally, this systematic review revealed that there is still a lack of uniformity about the use of SPs in the disaster medicine simulations.

An Island-Wide Disaster Drill to Train the Next Generation of Anesthesiologists: The SIAARTI Academy Experience.

OBJECTIVE: Anesthesiologists play a pivotal role in mass-casualty incidents management. Disaster medicine is part of the anesthesiologist's core skills; however, dedicated training is still scarce and, often, it does not follow a standardized program. METHODS: We designed and delivered a crash course in disaster medicine for Italian anesthesiology residents participating in the nationwide program, Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) Academy Critical Emergency Medicine 2019. Residents totaling 145, from 39 programs, participated in a 75-minute workstation on the principles of disaster management. Following this, each participant was involved in a full-scale mass-casualty drill. A plenary debriefing followed to present simulation data, maximize feedback, and highlight all situations needing improvement. RESULTS: Overall, participant performance was good: Triage accuracy was 85% prehospital and 84% in-hospital. Evacuation flow respected triage priority. During the debriefing, residents were very open to share and reflect on their experiences. A narrative qualitative analysis of the debriefing highlights that many participants felt overwhelmed by events during the exercise. Participants in coordination positions shared how they appreciated the need to switch from a clinical mindset to a managerial role. CONCLUSION: This was an invaluable experience for anesthesiology trainees, providing them with the skill set to understand the fundamental principles of a mass-casualty response.

COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought.

BACKGROUND: The world is facing a massive burden from the coronavirus disease 2019 (COVID-19) pandemic. Governments took the extraordinary step of locking down their own countries to curb the spread of the coronavirus. After weeks of severe restrictions, countries have begun to relax their strict lockdown measures. However, reopening will not be back to normal.Simulation facilities (SF) are training spaces that enable health professionals and students to learn skills and procedures in a safe and protected environment. Today's clinicians and students have an expectation that simulation laboratories are part of lifelong healthcare education. There is great uncertainty about how COVID-19 will impact future training in SF. In particular, the delivery of training activities will benefit of adequate safety measures implemented for all individuals involved.This paper discusses how to safely reopen SF in the post-lockdown phase. MAIN BODY: The paper outlines 10 focus points and provides operational tips and recommendations consistent with current international guidelines to reopen SF safely in the post-lockdown phase. Considering a variety of national advices and regulations which describe initial measures for the reopening of workplaces as well as international public health recommendations, we provide points of reflection that can guide decision-makers and SF leaders on how to develop local approaches to specific challenges. The tips have been laid out taking also into account two main factors: (a) the SF audience, mainly consisting of undergraduate and postgraduate healthcare professionals, who might face exposure to COVID-19 infection, and (b) for many simulation-based activities, such as teamwork training, adequate physical distancing cannot be maintained. CONCLUSIONS: The planning of future activities will have to be based not only on safety but also on flexibility principles.Sharing common methods consistent with national and international health guidelines, while taking into account the specific characteristics of the different contexts and centres, will ultimately foster dissemination of good practices.This article seeks to further the conversation. It is our hope that this manuscript will prompt research about the impact of such mitigation procedures and measures in different countries.

Augmented Reality Learning Environment for Basic Life Support and Defibrillation Training: Usability Study.

BACKGROUND: Basic life support (BLS) is crucial in the emergency response system, as sudden cardiac arrest is still a major cause of death worldwide. Unfortunately, only a minority of victims receive cardiopulmonary resuscitation (CPR) from bystanders. In this context, training could be helpful to save more lives, and technology-enhanced BLS simulation is one possible solution. OBJECTIVE: The aim of this study is to assess the feasibility and acceptability of our augmented reality (AR) prototype as a tool for BLS training. METHODS: Holo-BLSD is an AR self-instruction training system, in which a standard CPR manikin is "augmented" with an interactive virtual environment that reproduces realistic scenarios. Learners can use natural gestures, body movements, and spoken commands to perform their tasks, with virtual 3D objects anchored to the manikin and the environment. During the experience, users were trained to use the device while being guided through an emergency simulation and, at the end, were asked to complete a survey to assess the feasibility and acceptability of the proposed tool (5-point Likert scale; 1=Strongly Disagree, 5=Strongly Agree). RESULTS: The system was rated easy to use (mean 4.00, SD 0.94), and the trainees stated that most people would learn to use it very quickly (mean 4.00, SD 0.89). Voice (mean 4.48, SD 0.87), gaze (mean 4.12, SD 0.97), and gesture interaction (mean 3.84, SD 1.14) were judged positively, although some hand gesture recognition errors reduced the feeling of having the right level of control over the system (mean 3.40, SD 1.04). CONCLUSIONS: We found the Holo-BLSD system to be a feasible and acceptable tool for AR BLS training.

Cognitive appraisals and team performance under stress: A simulation study.

OBJECTIVES: The present study explored how challenge and threat responses to stress relate to performance, anxiety, confidence, team identity and team characteristics (time spent in training and postgraduate experience) in a medical simulation-based team competition. METHODS: The study was conducted during a national simulation-based training event for residents, the SIMCUP Italia 2018. The SIMCUP is a simulation competition in which teams of four compete in simulated medical emergency scenarios. Cross-sectional data were collected prior to the 3 days of the competition. Subjects included 95 participants on 24 teams. Before the competition on each day, participants completed brief self-report measures that assessed demands and resources (which underpin challenge and threat responses to stress), cognitive and somatic anxiety, self-confidence and team identification. Participants also reported time (hours) spent practising as a team and years of postgraduate experience. A team of referees judged each scenario for performance and assigned a score. A linear mixed model using demands and resources was built to model performance. RESULTS: The data showed that both demands and resources have positive effects on performance (31 [11-50.3] [P < .01] and 54 [25-83.3] [P < .01] percentage points increase for unitary increases in demands and resources, respectively); however, this is balanced by a negative interaction between the two (demands * resources interaction coefficient = -10 [-16 to -4.2]). A high level of resources is associated with better performance until demands become very high. Cognitive and somatic anxieties were found to be correlated with demands (Pearson's r = .51 [P < .01] and Pearson's r = .48 [P < .01], respectively). Time spent training was associated with greater perceptions of resources (Pearson's r = .36 [P < .01]). CONCLUSIONS: We describe a model of challenge and threat that allows for the estimation of performance according to perceived demands and resources, and the interaction between the two. Higher levels of resources and lower demands were associated with better performance.

The August 24, 2016, Central Italy Earthquake: Validation of the "Modified Utstein Template for Hospital Disaster Response Reporting" As a New Tool for Reporting Hospitals' Response to Disasters.

BACKGROUND: After-action reports analyze events and improve knowledge about how to prevent and react to unexpected situations. Anyway, there is no consensus among the templates developed for disaster events reporting, and there is not a specific model for reporting hospital disaster response. OBJECTIVE: The study was aimed to pilot the use of a new assessment tool for hospital response to natural disasters. METHODS: A data collection tool, focused on hospital disaster response to natural disasters, was created modifying the "Utstein-Style Template for Uniform Data Reporting of Acute Medical Response in Disasters" and tested the reaction of the nearest hospitals to the epicenter after the August 24, 2016, Central Italy earthquake. RESULTS: Four hospitals were included. The completion rate of the tool was 97.10%. A total of 613 patients accessed the 4 emergency departments, most of them in Rieti Hospital (178; 29.04%). Three hundred thirty-six (54.81%) patients were classified as earthquake-related, most with trauma injuries (260; 77.38%). CONCLUSIONS: This template seemed to be a valid instrument for hospital disaster management reporting and could be used for better comprehension of hospital disaster reaction, debriefing activities, and hospital disaster plan revisions.

Manufacture of a Multi-Purpose Low-Cost Animal Bench-Model for Teaching Tracheostomy.

Tracheostomy is one of the most frequent procedures, performed through various techniques in the intensive care unit and emergency situations. Despite this, there is a lack of training on this procedure that affects its outcome, which is also dependent on operator's dexterity. Here, we take the specific training and simulation into consideration. This article aims to describe every step of the manufacture of a new multi-purpose low-cost animal bench-model, with the support of video and images, and to obtain an opinion about the quality of this model by administering a questionnaire to professionals with experience in the procedures. Ten experts in the technique were enrolled. The model scored an average of 3.45/5 for its anatomical realism; 4.75/5 for its usefulness as a training tool for simulation courses and assessments. The time necessary to build the model was 15 minutes, and the cost amounted to 10€. The animal bench-model was considered a very useful simulator for tracheostomy training and assessments. Therefore, it could be used as a tool for medical courses and residencies.