Society for Simulation in Healthcare Guidelines for Simulation Training.

BACKGROUND: Simulation has become a staple in the training of healthcare professionals with accumulating evidence on its effectiveness. However, guidelines for optimal methods of simulation training do not currently exist. METHODS: Systematic reviews of the literature on 16 identified key questions were conducted and expert panel consensus recommendations determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. OBJECTIVE: These evidence-based guidelines from the Society for Simulation in Healthcare intend to support healthcare professionals in decisions on the most effective methods for simulation training in healthcare. RESULTS: Twenty recommendations on 16 questions were determined using GRADE. Four expert recommendations were also provided. CONCLUSIONS: The first evidence-based guidelines for simulation training are provided to guide instructors and learners on the most effective use of simulation in healthcare.

Understanding the Effects of Health Care Distance Simulation: A Systematic Review.

ABSTRACT: The use of distance simulation has rapidly expanded in recent years with the physical distance requirements of the COVID-19 pandemic. With this development, there has been a concurrent increase in research activities and publications on distance simulation. The authors conducted a systematic review of the peer-reviewed distance health care simulation literature. Data extraction and a risk-of-bias assessment were performed on selected articles. Review of the databases and gray literature reference lists identified 10,588 titles for review. Of those, 570 full-text articles were assessed, with 54 articles included in the final analysis. Most of these were published during the COVID-19 pandemic (2020-2022). None of the included studies examined an outcome higher than a Kirkpatrick level of 2. Most studies only examined low-level outcomes such as satisfaction with the simulation session. There was, however, a distinction in studies that were conducted in a learning environment where all participants were in different locations ("distance only") as compared with where some of the participants shared the same location ("mixed distance"). This review exclusively considered studies that focused solely on distance. More comparative studies exploring higher level outcomes are required to move the field forward.

Health Care Simulation in Person and at a Distance: A Systematic Review.

ABSTRACT: Distance simulation is a method of health care training in which the learners and facilitators are in different physical locations. Although methods of distance simulation have existed in health care for decades, this approach to education became much more prevalent during the COVID-19 pandemic. This systematic review studies a subset of distance simulation that includes combined in-person and distance simulation elements, identified here as "mixed- distance simulation." A review of the distance simulation literature identified 10,929 articles. Screened by inclusion and exclusion criteria, 34 articles were ultimately included in this review. The findings of this review present positive and negative aspects of mixed-distance simulation formats, a description of the most frequent configurations related to delivery, terminology challenges, as well as future directions including the need for faculty development, methodological rigor, and reporting details.

Debriefing Methods for Simulation in Healthcare: A Systematic Review.

ABSTRACT: Debriefing is a critical component in most simulation experiences. With the growing number of debriefing concepts, approaches, and tools, we need to understand how to debrief most effectively because there is little empiric evidence to guide us in their use. This systematic review explores the current literature on debriefing in healthcare simulation education to understand the evidence behind practice and clarify gaps in the literature. The PICO question for this review was defined as "In healthcare providers [P], does the use of one debriefing or feedback intervention [I], compared to a different debriefing or feedback intervention [C], improve educational and clinical outcomes [O] in simulation-based education?" We included 70 studies in our final review and found that our current debriefing strategies, frameworks, and techniques are not based on robust empirical evidence. Based on this, we highlight future research needs.

Development of Distance Simulation Educator Guidelines in Healthcare: A Delphi Method Application.

INTRODUCTION: The abrupt disruption of in-person instruction in health care during the COVID-19 pandemic resulted in the rapid adoption of distance simulation as an immediate alternative to providing in-person simulation-based education. This massive instructional shift, combined with the lack of educator training in this domain, led to challenges for both learners and educators. This study aimed to disseminate the first set of competencies required of and unique to effective distance simulation educators. METHODS: This was a multiphasic and iterative modified Delphi study validating the content of carefully and rigorously synthesized literature. Experts were invited from around the globe to participate in this study with mandatory attendance at an annual health care simulation conference to openly discuss the guidelines presented as competencies in this document. We divided each competency into "Basic" and "Advanced" levels, and agreement was sought for these levels individually. The experts provided their opinion by choosing the options of "Keep, Modify, or Delete." A free-marginal kappa of 0.60 was chosen a priori. RESULTS: At the conclusion of the Delphi process, the number of competencies changed from 66 to 59, basic subcompetencies from 216 to 196, and advanced subcompetencies from 179 to 182. CONCLUSIONS: This article provides the first set of consensus guidelines to distance simulation educators in health care, and paved the way for further research in distance simulation as a modality.

Exploring cultural sensitivity during distance simulations in pediatric emergency medicine.

Background: Cultural sensitivity (CS) training is vital to pediatric emergency medicine (PEM) curricula. This study aimed to explore CS in Yale PEM fellows and emergency medicine (EM) residents at Indus Hospital and Health Network (IHHN) in Pakistan through distance simulation activities. Methods: This mixed-methods analysis of an educational intervention was conducted at Yale University in collaboration with IHHN. We approached seven U.S. PEM fellows and 22 Pakistani EM residents. We performed a baseline CS assessment using the Clinical Cultural Competency Questionnaire (CCCQ). Afterward, the U.S. PEM fellows facilitated the Pakistani EM residents through six distance simulation sessions. Qualitative data were collected through online focus groups. The CCCQ was analyzed using descriptive statistics, and content analysis was used to analyze the data from the focus groups. Results: Seven U.S. PEM fellows and 18 of 22 Pakistani EM residents responded to the CCCQ at the beginning of the module. The mean (±SD) CCCQ domain scores for the U.S. PEM fellows versus the Pakistani EM residents were 2.56 (±0.37) versus 2.87 (±0.72) for knowledge, 3.02 (±0.41) versus 3.33 (±0.71) for skill, 2.86 (±0.32) versus 3.17 (±0.73) for encounter/situation, and 3.80 (±0.30) versus 3.47 (±0.47) for attitude (each out of 5 points). Our qualitative data analysis showed that intercultural interactions were valuable. There is a common language of medicine among the U.S. PEM fellows and Pakistani EM residents. The data also highlighted a power distance between the facilitators and learners, as the United States was seen as the standard of "how to practice PEM." The challenges identified were time differences, cultural practices such as prayer times, the internet, and technology. The use of local language during debriefing was perceived to enhance engagement. Conclusion: The distance simulation involving U.S. PEM fellows and Pakistani EM residents was an effective approach in assessing various aspects of intercultural education, such as language barriers, technical challenges, and religious considerations.

Distance simulation in the health professions: a scoping review.

BACKGROUND: Distance simulation is defined as simulation experiences in which participants and/or facilitators are separated from each other by geographic distance and/or time. The use of distance simulation as an education technique expanded rapidly with the recent COVID-19 pandemic, with a concomitant increase in scholarly work. METHODS: A scoping review was performed to review and characterize the distance simulation literature. With the assistance of an informationist, the literature was systematically searched. Each abstract was reviewed by two researchers and disagreements were addressed by consensus. Risk of bias of the included studies was evaluated using the Risk of Bias 2 (RoB 2) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tools. RESULTS: Six thousand nine hundred sixty-nine abstracts were screened, ultimately leading to 124 papers in the final dataset for extraction. A variety of simulation modalities, contexts, and distance simulation technologies were identified, with activities covering a range of content areas. Only 72 papers presented outcomes and sufficient detail to be analyzed for risk of bias. Most studies had moderate to high risk of bias, most commonly related to confounding factors, intervention classification, or measurement of outcomes. CONCLUSIONS: Most of the papers reviewed during the more than 20-year time period captured in this study presented early work or low-level outcomes. More standardization around reporting is needed to facilitate a clear and shared understanding of future distance simulation research. As the broader simulation community gains more experience with distance simulation, more studies are needed to inform when and how it should be used.

Factors Associated With Improved Pediatric Resuscitative Care in General Emergency Departments.

OBJECTIVES: To describe the quality of pediatric resuscitative care in general emergency departments (GEDs) and to determine hospital-level factors associated with higher quality. METHODS: Prospective observational study of resuscitative care provided to 3 in situ simulated patients (infant seizure, infant sepsis, and child cardiac arrest) by interprofessional GED teams. A composite quality score (CQS) was measured and the association of this score with modifiable and nonmodifiable hospital-level factors was explored. RESULTS: A median CQS of 62.8 of 100 (interquartile range 50.5-71.1) was noted for 287 resuscitation teams from 175 emergency departments. In the unadjusted analyses, a higher score was associated with the modifiable factor of an affiliation with a pediatric academic medical center (PAMC) and the nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. In the adjusted analyses, a higher CQS was associated with modifiable factors of an affiliation with a PAMC and the designation of both a nurse and physician pediatric emergency care coordinator, and nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. A weak correlation was noted between quality and pediatric readiness scores. CONCLUSIONS: A low quality of pediatric resuscitative care, measured using simulation, was noted across a cohort of GEDs. Hospital factors associated with higher quality included: an affiliation with a PAMC, designation of a pediatric emergency care coordinator, higher pediatric volume, and geographic location. A weak correlation was noted between quality and pediatric readiness scores.

Setting an Agenda: Results of a Consensus Process on Research Directions in Distance Simulation.

BACKGROUND: The COVID-19 pandemic forced rapid implementation and refinement of distance simulation methodologies in which participants and/or facilitators are not physically colocated. A review of the distance simulation literature showed that heterogeneity in many areas (including nomenclature, methodology, and outcomes) limited the ability to identify best practice. In April 2020, the Healthcare Distance Simulation Collaboration was formed with the goal of addressing these issues. The aim of this study was to identify future research priorities in the field of distance simulation using data derived from this summit. METHODS: This study analyzed textual data gathered during the consensus process conducted at the inaugural Healthcare Distance Simulation Summit to explore participant perceptions of the most pressing research questions regarding distance simulation. Participants discussed education and patient safety standards, simulation facilitators and barriers, and research priorities. Data were qualitatively analyzed using an explicitly constructivist thematic analysis approach, resulting in the creation of a theoretical framework. RESULTS: Our sample included 302 participants who represented 29 countries. We identified 42 codes clustered within 4 themes concerning key areas in which further research into distance simulation is needed: (1) safety and acceptability, (2) educational/foundational considerations, (3) impact, and (4) areas of ongoing exploration. Within each theme, pertinent research questions were identified and categorized. CONCLUSIONS: Distance simulation presents several challenges and opportunities. Research around best practices, including educational foundation and psychological safety, are especially important as is the need to determine outcomes and long-term effects of this emerging field.

Characterizing preferred terms for geographically distant simulations: distance, remote and telesimulation.

Background: Simulationists lack standard terms to describe new practices accommodating pandemic restrictions. A standard language around these new simulation practices allows ease of communication among simulationists in various settings. Methods: We explored consensus terminology for simulation accommodating geographic separation of participants, facilitators or equipment. We used an iterative process with participants of two simulation conferences, with small groups and survey ranking. Results: Small groups (n = 121) and survey ranking (n = 54) were used with distance, remote, and telesimulation as leading terms. Each was favored by a third of the participants without consensus. Conclusion: This research has deepened our understanding of how simulationists interpret this terminology, including the derived themes: (1) physical distance/separation, (2) overarching nature of the term and (3) implications from existing terms. We further deepen the conceptual discussion on healthcare simulation aligned with the search of the terminologies. We propose there are nuances that prevent an early consensus recommendation. A taxonomy of descriptors specifying the conduct of distance, remote and telesimulation is preferred.

PRG3 and PRG5 C-Termini: Important Players in Early Neuronal Differentiation.

The functional importance of neuronal differentiation of the transmembrane proteins' plasticity-related genes 3 (PRG3) and 5 (PRG5) has been shown. Although their sequence is closely related, they promote different morphological changes in neurons. PRG3 was shown to promote neuritogenesis in primary neurons; PRG5 contributes to spine induction in immature neurons and the regulation of spine density and morphology in mature neurons. Both exhibit intracellularly located C-termini of less than 50 amino acids. Varying C-termini suggested that these domains shape neuronal morphology differently. We generated mutant EGFP-fusion proteins in which the C-termini were either swapped between PRG3 and PRG5, deleted, or fused to another family member, plasticity-related gene 4 (PRG4), that was recently shown to be expressed in different brain regions. We subsequently analyzed the influence of overexpression in immature neurons. Our results point to a critical role of the PRG3 and PRG5 C-termini in shaping early neuronal morphology. However, the results suggest that the C-terminus alone might not be sufficient for promoting the morphological effects induced by PRG3 and PRG5.

Formative Assessments Promote Procedural Learning and Engagement for Senior Pediatric Residents on Rotation in the Pediatric Emergency Department.

Introduction: Procedural training is a universal concern amongst pediatric residents and their teachers. We developed and implemented formative assessments to generate direct and indirect procedural feedback. We analyzed changes in residents' perceived procedural knowledge, skills, confidence, and entrustment. Methods: Senior pediatric residents rotating in the pediatric emergency department participated in video-recorded formative assessments of informed consent OSCEs and simulated toddler forehead laceration repair and infant lumbar puncture. Residents reflected on their perceived procedural knowledge, skills, confidence, and entrustment through Likert and entrustment scales. Secondary outcomes of formative assessment completion rates and proportions of procedures performed by pediatric residents tracked feasibility and potential clinical impact, respectively. Results: Including the pilot period, 89% of residents (31 out of 35) received direct and indirect procedural feedback. Perceived composite competency and entrustment improved for laceration repair (competency: from 3.1 to 3.9, p < .001; entrustment: from 4.0 to 5.1, p < .001) and lumbar puncture (competency: from 3.5 to 4.0, p < .001; entrustment: from 4.6 to 5.6, p = .001). We observed an increase in the proportion of clinical laceration repairs (11% [97 out of 885] vs. 23% [218 out of 946], p < .001) and lumbar punctures (23% [12 out of 54] vs. 41% [21 out of 52], p = .05) performed by pediatric residents. Discussion: Integrating feasible procedural formative assessments into the pediatric emergency department rotation had a positive impact on senior pediatric residents' perceptions of their procedural knowledge, skills, confidence, and entrustment and was associated with increased procedural engagement.

Plasticity-Related Gene 5 Is Expressed in a Late Phase of Neurodifferentiation After Neuronal Cell-Fate Determination.

During adult neurogenesis, neuronal stem cells differentiate into mature neurons that are functionally integrated into the existing network. One hallmark during the late phase of this neurodifferentiation process is the formation of dendritic spines. These morphological specialized structures form the basis of most excitatory synapses in the brain, and are essential for neuronal communication. Additionally, dendritic spines are affected in neurological disorders, such as Alzheimer's disease or schizophrenia. However, the mechanisms underlying spinogenesis, as well as spine pathologies, are poorly understood. Plasticity-related Gene 5 (PRG5), a neuronal transmembrane protein, has previously been linked to spinogenesis in vitro. Here, we analyze endogenous expression of the PRG5 protein in different mouse brain areas, as well as on a subcellular level. We found that native PRG5 is expressed dendritically, and in high abundance in areas characterized by their regenerative capacity, such as the hippocampus and the olfactory bulb. During adult neurogenesis, PRG5 is specifically expressed in a late phase after neuronal cell-fate determination associated with dendritic spine formation. On a subcellular level, we found PRG5 not to be localized at the postsynaptic density, but at the base of the synapse. In addition, we showed that PRG5-induced formation of membrane protrusions is independent from neuronal activity, supporting a possible role in the morphology and stabilization of spines.

From Concept to Publication: Effectiveness of the International Network for Simulation-Based Pediatric Innovation, Research, and Education Project Development Process at Generating Simulation Scholarship.

BACKGROUND: As simulation matures, it is critical to develop pathways for researchers. A recent analysis, however, demonstrates a low conversion rate between abstract and peer-reviewed journal publication in our field. The International Network for Simulation-based Pediatric Innovation, Research, and Education has used the ALERT Presentation process for the past decade as a means of accelerating research. In this study, we analyze the scholarly products attributable to ALERT Presentations. METHODS: Surveys were distributed to all International Network for Simulation-based Pediatric Innovation, Research, and Education Advanced Look Exploratory Research Template (ALERT) Presentation first authors from January 2011 through January 2020. Presenters were asked to provide information on abstracts, grants, journal publications, and book chapters related to their ALERT Presentation, as well as basic demographic information. A structured literature search was conducted for those ALERT Presentations whose authors did not return a survey. The resulting database was descriptively analyzed, and statistical correlations between demographic variables and scholarship were examined. RESULTS: One hundred sixty-five new ALERT presentations were presented over 10 years. We identified 361 associated scholarly works (170 conference abstracts, 125 peer-reviewed journal publications, 65 grants, and 1 book chapter). Sixty-one percent (101 of 165) of ALERT Presentations produced at least 1 item of scholarship, and 59% (34 of 58) of ALERT Presentations that resulted in at least 1 abstract also led to at least 1 peer-reviewed journal article. Presenter gender was associated with likelihood of journal publication. CONCLUSIONS: The ALERT Presentation process is an effective approach for facilitating the development of projects that result in disseminated scholarship. Wider adoption may benefit other simulation and education research networks.

Point-of-Care Ultrasound to Evaluate the Acute Abdomen: A Case of Bowel Perforation After Unknown Single Magnet Ingestion.

ABSTRACT: We report the case of a 3-year-old boy who presented to the pediatric emergency department in undifferentiated shock with an acute abdomen. Point-of-care ultrasound revealed viscous perforation with a large amount of free fluid. Intraoperatively, a single magnet was discovered as the likely cause of bowel perforation and the resulting state of shock.

Systematic expression analysis of plasticity-related genes in mouse brain development brings PRG4 into play.

BACKGROUND: Plasticity-related genes (Prgs/PRGs) or lipid phosphate phosphatase-related proteins (LPPRs) comprise five known members, which have been linked to neuronal differentiation processes, such as neurite outgrowth, axonal branching, or dendritic spine formation. PRGs are highly brain-specific and belong to the lipid phosphate phosphatases (LPPs) superfamily, which influence lipid metabolism by dephosphorylation of bioactive lipids. PRGs, however, do not possess enzymatic activity, but modify lipid metabolism in a way that is still under investigation. RESULTS: We analyzed mRNA expression levels of all Prgs during mouse brain development, in the hippocampus, neocortex, olfactory bulbs, and cerebellum. We found different spatio-temporal expression patterns for each of the Prgs, and identified a high expression of the uncharacterized Prg4 throughout brain development. Unlike its close family members PRG3 and PRG5, PRG4 did not induce filopodial outgrowth in non-neuronal cell lines, and does not localize to the plasma membrane of filopodia. CONCLUSION: We showed PRG4 to be highly expressed in the developing and the adult brain, suggesting that it is of vital importance for normal brain function. Despite its similarities to other family members, it seems not to be involved in changes of cell morphology; instead, it is more likely to be associated with intracellular signaling.

Visual attention during pediatric resuscitation with feedback devices: a randomized simulation study.

BACKGROUND: The aim of this study was to investigate the effect of feedback devices on visual attention and the quality of pediatric resuscitation. METHODS: This was a randomized cross-over simulation study at the Medical University of Vienna. Participants were students and neonatal providers performing four resuscitation scenarios with the support of feedback devices randomized. The primary outcome was the quality of resuscitation. Secondary outcomes were total dwell time (=total duration of visit time) on areas of interest and the workload of participants. RESULTS: Forty participants were analyzed. Overall, chest compression (P < 0.001) and ventilation quality were significantly better (P = 0.002) when using a feedback device. Dwell time on the feedback device was 40.1% in the ventilation feedback condition and 48.7% in the chest compression feedback condition. In both conditions, participants significantly reduced attention from the infant's chest and mask (72.9 vs. 32.6% and 21.9 vs. 12.7%). Participants' subjective workload increased by 3.5% (P = 0.018) and 8% (P < 0.001) when provided with feedback during a 3-min chest compression and ventilation scenario, respectively. CONCLUSIONS: The quality of pediatric resuscitation significantly improved when using real-time feedback. However, attention shifted from the manikin and other equipment to the feedback device and subjective workload increased, respectively. IMPACT: Cardiopulmonary resuscitation with feedback devices results in a higher quality of resuscitation and has the potential to lead to a better outcome for patients. Feedback devices consume attention from resuscitation providers. Feedback devices were associated with a shift of visual attention to the feedback devices and an increased workload of participants. Increased workload for providers and benefits for resuscitation quality need to be balanced for the best effect.

Pediatric Emergency Medicine ECHO (Extension for Community Health Care Outcomes): Cultivating Connections to Improve Pediatric Emergency Care.

BACKGROUND: An Extension for Community Health Care Outcomes (ECHO) provides the opportunity for specialists at academic medical centers (AMCs) and frontline community generalists to engage in bidirectional learning. Specialists provide generalists with the current best evidence, and generalists share the local challenges applying this evidence to their practice. All ECHO participants strategize how to navigate these challenges together. Pediatric emergency medicine (PEM) may benefit from this knowledge translation strategy because most children seek emergency care from generalists in community emergency departments (CEDs) where variations in care between the AMC and the CED have been reported. METHODS: Our objective was to use ECHO to cultivate a PEM community of practice that facilitated knowledge translation and generated future CED pediatric improvement initiatives. As such, we developed, implemented, and evaluated a PEM ECHO. We conducted general and targeted needs assessments to inform our curriculum and formatted the sessions to generate bidirectional learning. A postparticipation evaluation collected self-reported perceptions about knowledge translation, planned provider practice changes, and perceptions of the formation of a community of practice. Additionally, we solicited information on the implementation of any pediatric improvement activities attributed to the PEM ECHO. RESULTS: Thirteen 1-hour sessions covered the chosen PEM topics. Participants represented diverse CEDs, with varied experience and roles in caring for children. All respondents (13/13) appreciated the ECHO learning format, reported improved PEM knowledge, and perceived the cultivation of a community of practice. Nine (85%) individuals attributed implementation of new pediatric improvement activities to the PEM ECHO. CONCLUSIONS: Our PEM ECHO was associated with improved perceptions of PEM knowledge, cultivated a community of practice, and facilitated the implementation of CED pediatric improvement activities. The PEM ECHO's bidirectional learning format generated new initiatives and partnerships aiming to improve the emergency care of children.

Pediatric Emergency Medicine Didactics and Simulation (PEMDAS): Pediatric Diabetic Ketoacidosis.

Introduction: Diabetic ketoacidosis (DKA) is a life-threatening illness which classically presents with polyuria, polydipsia, and polyphagia that can rapidly progress to severe dehydration and altered mental status from cerebral edema. Younger patients may present with subtle or atypical symptoms that are critical to recognize and emergently act upon. Such patients are often cared for by teams in the emergency department (ED) requiring multidisciplinary collaboration. Methods: This simulation case was designed for pediatric emergency medicine fellows and residents. The case was a 14-month-old male who presented to the ED with respiratory distress and dehydration. The team was required to perform an assessment, manage airway, breathing and circulation, and recognize and initiate treatment for DKA including judicious fluid administration and an insulin infusion. The patient developed altered mental status with signs of cerebral edema requiring the initiation of cerebral protection strategies. We created a debriefing guide and a participant evaluation form. Results: Forty-two participants completed this simulation across seven institutions including attendings, residents, fellows, and nurses. The scenario was rated by participants on a 5-point Likert scale and was generally well received (M = 5.0). Participants rated the simulation case as effective in teaching how to recognize (M = 4.8) and manage (M = 4.5) DKA with cerebral edema in a pediatric patient. Discussion: This simulation represents a resource for learners in the pediatric ED in the recognition and management of a toddler with DKA and can be adapted to learners at all levels and tailored to various learning environments.

Closing the gap: a call for a common blueprint for remote distance telesimulation.

The physical requirements mandated by the COVID-19 pandemic have presented a challenge and an opportunity for simulation educators. Although there were already examples of simulation being delivered at a distance, the pandemic forced this technique into the mainstream. With any new discipline, it is important for the community to agree on vocabulary, methods and reporting guidelines. This editorial is a call to action for the simulation community to start this process so that we can best describe and use this technique.