Twelve tips for developing and implementing an effective critical care simulation programme.

Simulation training in healthcare settings has become a valuable training tool. It provides an ideal formative assessment for interdisciplinary teaching. It provides a high fidelity and highly immersive environment where healthcare staff and students can practice developing their skills in a safe and controlled manner. Simulation training allows staff to practice skills that better prepare them for clinical emergencies, therefore possibly optimising clinical care. While the benefits of simulation education are well understood, establishing a programme for use by critical care staff is complex. Complexities include the highly specialised scenarios that are not typically encountered in non-critical care areas, as well as the need for advanced monitoring equipment, ventilation equipment etc. These 12 tips are intended to assist healthcare educators in navigating the complexities in the establishment of a critical care simulation programme, providing advice on selecting target audiences, learning outcomes, creating a critical care simulation environment and recommendations on evaluation and development of the programme.

Prospective Analysis of Decision Making During Joint Cardiology Cardiothoracic Conference in Treatment of 107 Consecutive Children with Congenital Heart Disease.

The complexity and potential biases involved in decision making have long been recognised and examined in both the aviation and business industries. More recently, the medical community have started to explore this concept and its particular importance in our field. Paediatric cardiology is a rapidly expanding field and for many of the conditions we treat, there is limited evidence available to support our decision-making. Variability exists within decision-making in paediatric cardiology and this may influence outcomes. There are no validated tools available to support and examine consistent decision-making for various treatment strategies in children with congenital heart disease in a multidisciplinary cardiology and cardiothoracic institution. Our primary objective was to analyse the complexity of decision-making for children with cardiac conditions in the context of our joint cardiology and cardiothoracic conference (JCC). Two paediatric cardiologists acted as investigators by observing the weekly joint cardiology-cardiothoracic surgery conference and prospectively evaluating the degree of complexity of decision-making in the management of 107 sequential children with congenital heart disease discussed. Additionally, the group consensus on the same patients was prospectively assessed to compare this to the independent observers. Of 107 consecutive children discussed at our JCC conference 32 (27%) went on to receive surgical intervention, 20 (17%) underwent catheterisation and 65 (56%) received medical treatment. There were 53 (50%) cases rated as simple by one senior observer, while 54 (50%) were rated as complex to some degree. There was high inter-observer agreement with a Krippendorff's alpha of ≥ 0.8 between 2 observers and between 2 observers and the group consensus as a whole for grading of the complexity of decision-making. Different decisions were occasionally made on patients with the same data set. Discussions revisiting the same patient, in complex cases, resulted in different management decisions being reached in this series. Anchoring of decision-making was witnessed in certain cases. Potential application of decision making algorithms is discussed in making decisions in paediatric cardiology patients. Decision-making in our institution's joint cardiology-cardiothoracic conference proved to be complex in approximately half of our patients. Inconsistency in decision-making for patients with the same diagnosis, and different decisions made for the same complex patient at different time points confounds the reliability of the decision-making process. These novel data highlight the absence of evidence-based medicine for many decisions, occasional lack of consistency and the impact of anchoring, heuristics and other biases in complex cases. Validated decision-making algorithms may assist in providing consistency to decision-making in this setting.

Design and utilisation of a novel, high-fidelity, low-cost, hybrid-tissue simulation model to facilitate training in robot-assisted partial nephrectomy.

Robot-assisted partial nephrectomy (RAPN) has rapidly evolved as the standard of care for appropriately selected renal tumours, offering key patient benefits over radical nephrectomy or open surgical approaches. Accordingly, RAPN is a key competency that urology trainees wishing to treat kidney cancer must master. Training in robotic surgery is subject to numerous challenges, and simulation has been established as valuable step in the robotic learning curve. However, simulation models are often both expensive and suboptimal in fidelity. This means that the number of practice repetitions for a trainee may limited by cost restraints, and that trainees may struggle to reconcile the skills obtained in the simulation laboratory with real-world practice in the operating room. We have developed a high-fidelity, low-cost, customizable model for RAPN simulation based on porcine tissue. The model has been utilised in teaching courses at our institution, confirming both feasibility of use and high user acceptability. We share the design of our model in this proof-of-concept report.

Collating evidence to support the validation of a simulated laparotomy incision and closure-training model.

BACKGROUND: It is essential to evaluate the functionality of surgical simulation models, in order to determine whether they perform as intended. In this study, we assessed the use of a simulated laparotomy incision and closure-training model by collating validity evidence to determine its utility as well as pre and post-test interval data. METHOD: This was a quantitative study design, informed by Messick's unified validity framework. In total, 93 participants (surgical trainees â€‹= â€‹80, experts â€‹= â€‹13) participated in this study. Evaluation of content validity and the models' relationships with other variables was conducted, along with a pre and post-test confidence assessment. RESULTS: The model was deemed realistic and useful as a teaching tool, providing strong content validity evidence. In assessment of relationships with other variables, the expert group out-performed the novice group conclusively. Pre and post-test evaluation reported a statistically significant increase in confidence levels. CONCLUSION: We present strong validity evidence of a novel laparotomy incision and closure simulation-training model.

Performance in Irish Selection and Future Performance in Surgical Training.

Importance: Selection processes for surgical training should aim to identify candidates who will become competent independent practitioners and should aspire to high standards of reliability and validity. Objective: To determine the association between measured candidate factors at the time of an Irish selection and assessment outcomes in surgical training, examined via rate of progression to Higher Specialist Training (HST), attrition rates, and performance as assessed through a multimodal framework of workplace-based and simulation-based assessments. Design, Setting, and Participants: This retrospective observational cohort study included data from all successful applicants to the Royal College of Surgeons in Ireland (RCSI) national Core Surgical Training (CST) program. Participants included all trainees recruited to dedicated postgraduate surgical training from 2016 to 2020. These data were analyzed from July 11, 2016, through July 10, 2022. Exposures: Selection decisions were based on a composite score that was derived from technical aptitude assessments, undergraduate academic performance, and a 4-station multiple mini-interview. Main outcomes and measures: Assessment data, attrition rates, and rates of progression to HST were recorded for each trainee. CST performance was assessed using workplace-based and simulation-based technical and nontechnical skill assessments. Potential associations between selection and assessment measures were explored using Pearson correlation, logistic regression, and multiple linear-regression analyses. Results: Data were available for 303 trainees. Composite scores were positively associated with progression to HST (odds ratio [OR], 1.09; 95% CI, 1.05-1.13). There was a weak positive correlation, ranging from 0.23 to 0.34, between scores and performance across all CST assessments. Multivariable linear regression analysis showed technical aptitude scores at application were associated with future operative performance assessment scores, both in the workplace (ß = 0.31; 95% CI, 0.14-0.48) and simulated environments (ß = 0.57; 95% CI, 0.33-0.81). There was evidence that the interpersonal skills interview station was associated with future performance in simulated communication skill assessments (ß = 0.55; 95% CI, 0.22-0.87). Conclusions and Relevance: In this study, performance at the time of Irish national selection, measured across technical and nontechnical domains in a multimodal fashion, was associated with future performance in the workplace and in simulated environments. Future studies will be required to explore the consequential validity of selection, including potential unintended effects of selection and ranking on candidate performance.

Remote feedback in endovascular simulation training: a mixed-methods study.

BACKGROUND: There is an increasing need to increase simulation-based learning opportunities for vascular surgery residents in endovascular skills training. This study aims to explore the effectiveness of remote expert instructional feedback of endovascular simulation-based education, as a means of increasing training opportunities in this area for vascular surgery residents. METHODS: A mixed-methods study design was adopted. Twelve vascular surgery residents from Ireland were tasked with completing two endovascular renal artery procedures: one with in-person expert feedback and the other with remote instruction. Participants ranged in experience levels from second year to final year of residency. Following the training activities, interviews and a questionnaire were employed to gather information on the usefulness of remote feedback. RESULTS: There was no significant difference reported by participants using a post-event validated questionnaire between remote and in-person feedback. During the interviews, participants expressed mixed feelings about the presence of the educator while practicing, but they eventually saw no limiting factors to their practice when the trainer provided remote feedback. When receiving performance feedback remotely, clear communication and a shared knowledge of the task development are critical to success. CONCLUSIONS: We believe these findings can inform the design and development of remote learning and assessment of endovascular skills training and ultimately provide increased opportunities for more skills practice for vascular surgical residents.

Assessing operative competence in core surgical training: A reliability analysis.

BACKGROUND: This study quantifies the number of observations required to reliably assess the operative competence of Core Surgical Trainees (CSTs) in Ireland, using the Supervised Structured Assessment of Operative Performance (SSAOP) tool. METHODS: SSAOPs (April 2016-February 2021) were analysed across a mix of undifferentiated procedures, as well as for three commonly performed general surgery procedures in CST: appendicectomy, abdominal wall hernia repair, and skin/subcutaneous lesion excision. Generalizability and Decision studies determined the number of observations required to achieve dependability indices ≥0.8, appropriate for use in high-stakes assessment. RESULTS: A total of 2,294 SSAOPs were analysed. Four assessors, each observing 10 cases, can generate scores sufficiently reliable for use in high-stakes assessments. Focusing on a selection of core procedures yields more favourable reliability indices. CONCLUSION: Trainers should conduct repeated assessments across a smaller number of procedures to improve reliability. Programs should increase the assessor mix to yield sufficient dependability indices for high-stakes assessment.

Resident Training for Successful Professional Interactions.

BACKGROUND: Conflict between healthcare professionals is a common feature of modern healthcare environments, contributing to more stressful working conditions and burnout in frontline staff. In the Royal College of Surgeons in Ireland we undertook to design and deliver a course called 'Professional Interactions' which would equip junior residents in surgery and other acute care specialties with the skills to better manage conflict and bullying. METHODS: The design of this course was based on a Transformative Learning Theory conceptual framework. Key teaching modalities included rational discourse, role-playing, simulations, case studies, reflection exercises and experience with critical incidents and feedback. This experiential learning session was followed with an online short course to reinforce the learning objectives. RESULTS: We in the National Surgical Training Programme have been delivering structured mandatory education to our residents on this topic for over a decade. Each iteration of this programme has been modified based on resident and faculty feedback as well as emerging evidence in the field of communication skills. Recent course evaluation data included feedback from 203 course participants, which represented a 66% response rate. Ninety-two percent of those respondents rated the course as 'Excellent' or 'Good' and that they would use the skills learned 'Daily or 'Weekly'. 85 percent reported a perceived improvement in conflict management skills. CONCLUSIONS: Conflicts and difficult interactions between colleagues in the workplace are a frequent feature of healthcare practice. Teaching residents skills to manage these interactions more successfully may help towards developing a culture of mutual respect in hospital-based practice.

The importance of expert feedback during endovascular simulator training.

OBJECTIVES: Complex endovascular skills are difficult to obtain in the clinical environment. Virtual reality (VR) simulator training is a valuable addition to current training curricula, but is there a benefit in the absence of expert trainers? METHODS: Eighteen endovascular novices performed a renal artery angioplasty/stenting (RAS) on the Vascular Interventional Surgical Trainer simulator. They were randomized into three groups: Group A (n = 6, control), no performance feedback; Group B (n = 6, nonexpert feedback), feedback after every procedure from a nonexpert facilitator; and Group C (n = 6, expert feedback), feedback after every procedure from a consultant vascular surgeon. Each trainee completed RAS six times. Simulator-measured performance metrics included procedural and fluoroscopy time, contrast volume, accuracy of balloon placement, and handling errors. Clinical errors were also measured by blinded video assessment. Data were analyzed using SPSS version 15. RESULTS: A clear learning curve was observed across the six trials. There were no significant differences between the three groups for the general performance metrics, but Group C made fewer errors than Groups A (P = .009) or B (P = .004). Video-based error assessment showed that Groups B and C performed better than Group A (P = .002 and P = .000, respectively). CONCLUSION: VR simulator training for novices can significantly improve general performance in the absence of expert trainers. Procedure-specific qualitative metrics are improved with expert feedback, but nonexpert facilitators can also enhance the quality of training and may represent a valuable alternative to expert clinical faculty.

Developing a human factors and patient safety programme at the Royal College of Surgeons in Ireland.

Personal skills are now recognised to be important components of effective medical practice. These skills are explicit in the CANMED competencies from Canada, the recommendations of the ACGME from the United States and the recently revised 'Tomorrow's Doctors' paper from the Medical Council in the United Kingdom. The recommended core competencies which encompass personal skills in these international manifestos highlight a paradigm shift in a system which emphasised technical skills and knowledge to a recognition of the key role played by personal skills.

Predictors of attendance at diabetic retinopathy screening among people with type 2 diabetes: Secondary analysis of data from primary care.

AIMS: To estimate the uptake of diabetic retinopathy screening among adults with type 2 diabetes and to identify and compare factors associated with attendance at the national diabetic retinal screening programme, and other screening services provided by ophthalmic surgeons, community ophthalmologists and optometrists. METHODS: An observational retrospective cohort study was carried out using data from the 2016 audit of care delivered by general practices (n = 30) enrolled in a structured diabetes care initiative. Attendance at any screening in the previous 12 months, and attendance across different types of service (national programme and other screening services) was calculated. Logistic regression was performed to examine predictors associated with (1) attendance at any screening and (2) attendance at the national programme (RetinaScreen). Sociodemographic, clinical, and lifestyle factors were examined as predictors. RESULTS: Data were available for 1106 people with type 2 diabetes aged ≥18 years. Overall, 863 (78%) of patients had a record of screening attendance in the previous 12 months. Of those screened, 494 (57.2%) attended RetinaScreen only, 258 (28.7%) attended other screening services only, and 111 (12.9%) attended both services. Statistically significant predictors of attendance at any screening were tablet/injectable controlled diabetes, attendance at a diabetes nurse specialist (DNS) in the past 12 months and a blood glucose level which was not on target (HbA1c >7.0% or >53 mmol/mol). In addition to these factors, when examining predictors of attendance at the national screening programme specifically, females were less likely to attend. CONCLUSIONS: Most patients managed in a structured diabetes care programme in primary care attended screening. Those with on target blood glucose control, those who were on oral or injectable medication or had been seen by a DNS were more likely to attend for annual screening. Of those who attended screening, almost one-third attended other screening services and so were not availing of the national programme, which is free, quality assured and has an integrated treatment arm.

A multidirectional two-tube method for chemical pleurodesis could improve distribution of the sclerosing agent within the pleural cavity - A pilot study.

INTRODUCTION: Malignant pleural effusion (MPE) affects approximately 200,000 people in the United States per annum. Chemical pleurodesis is a recommended first line treatment in the management of MPE, however, success rates as low as 43% has been reported. A bedside chemical pleurodesis can cost up to $11,224 and an estimated inpatient annual expenditure of more than $5 billion in the US alone. This study aims to assess the distribution of the talc slurry within the pleural space using human cadaveric models and to determine the force required to push the talc slurry though a 14 Fr chest tube. MATERIALS AND METHODS: The force required to administer the talc slurry through a 14 Fr chest tube was tested using a Zwick/Roelle Z005 mechanical tester, using a porcine thoracic biomodel. Talc slurry distribution within the pleural cavity was assessed by direct visualisation following administration to the human cadaveric models using single and multidirectional two-tube methods. RESULTS: Maximum force required to push the talc slurry through a 14 Fr chest tube was 11.36 N ± 2.79 N. Distribution of the talc slurry within the pleural cavity was found to be poor with a single tube method. Multidirectional two-tube method of administration showed more even distribution. CONCLUSION: The experimental multidirectional two-tube method results in wider distribution of the talc slurry within the pleural cavity and could further improve success rate of the talc pleurodesis.

Objective assessment of surgical trainees' non-technical skills: Improved performance following a two-year program of instruction.

BACKGROUND: Non-technical skills (NTS) encompass personal skills such as communication, situational awareness, decision making, teamwork and leadership. Poor performance of these skills has been shown to contribute to medical error. The Royal College of Surgeons in Ireland (RCSI) has delivered a mandatory program of instruction in NTS to all surgical trainees since 2005. We investigated whether the NTS of surgical trainees improved after the first two years of this program. METHODS: Baseline data was collected in a three-station OSCE assessment of NTS at the beginning of Year one and again at end of Year two of surgical training. RESULTS: Trainees' mean percentage NTS scores improved significantly over the two-year period for the NTS assessment (P < .001). A significant difference was demonstrated using within-subject (paired) t-tests between the Year one and two time points for all three OSCE stations: Consent (-5.39; P < .001); Colleague Conflict (-8.63; P < .001); and Disclosure of Error (-7.56; P < .001). CONCLUSIONS: RCSI offers a unique mandatory program of instruction in NTS. There was a statistically and practically significant improvement in the NTS scores of surgical trainees over the two-year period of the program.

Use of a Novel Measure of Nontechnical Skills in Surgical Trainees: Is There an Association With Technical Skills Performance?

OBJECTIVE: To investigate whether scores on a psychological measure of concentration and interpersonal characteristics, The Attentional and Interpersonal Style Inventory (TAIS), are associated with performance of surgical skills. DESIGN: Postgraduate surgical trainees completed an operative surgical skills assessment in the simulation laboratory and the psychological measure (TAIS). The surgical skills assessment consisted of 6 tasks (3 per trainee): laceration suturing; lipoma excision; incision and closure of a laparotomy wound; bowel anastomosis; saphenofemoral junction ligation and basic laparoscopic skills. The association between operative surgical skill performance and TAIS factors was investigated. SETTING: The TAIS assessments and surgical skills assessments were conducted at the National Surgical Training Centre at the Royal College of Surgeons in Ireland (RCSI). PARTICIPANTS: One hundred and two surgical trainees in years one and two (PGY 2-3 equivalent) participated in the study. RESULTS: Performance on 2 of the 6 tasks assessed (bowel anastomosis and lipoma excision) were positively associated with multiple TAIS factors (energy, confidence, competitiveness, extroversion, self-criticism and performing under pressure). Another factor, focus over time, was significantly associated with scores on the lipoma excision task. CONCLUSIONS: Trainees with high levels of energy, confidence, competitiveness, extroversion, and focus over time and low levels of self-criticism demonstrated better performance on specific technical skills tasks.

Development and evaluation of a trauma decision-making simulator in Oculus virtual reality.

BACKGROUND: Consumer-available virtual-reality technology was launched in 2016 with strong foundations in the entertainment-industry. We developed an innovative medical-training simulator on the Oculus™ Gear-VR platform. This novel application was developed utilising internationally recognised Advanced Trauma Life Support (ATLS) principles, requiring decision-making skills for critically-injured virtual-patients. METHODS: Participants were recruited in June, 2016 at a single-centre trauma-course (ATLS, Leinster, Ireland) and trialled the platform. Simulator performances were correlated with individual expertise and course-performance measures. A post-intervention questionnaire relating to validity-aspects was completed. RESULTS: Eighteen(81.8%) eligible-candidates and eleven(84.6%) course-instructors voluntarily participated. The survey-responders mean-age was 38.9(±11.0) years with 80.8% male predominance. The instructor-group caused significantly less fatal-errors (p < 0.050) and proportions of incorrect-decisions (p < 0.050). The VR-hardware and trauma-application's mean ratings were 5.09 and 5.04 out of 7 respectively. Participants reported it was an enjoyable method of learning (median-6.0), the learning platform of choice (median-5.0) and a cost-effective training tool (median-5.0). CONCLUSION: Our research has demonstrated evidence of validity-criteria for a concept application on virtual-reality headsets. We believe that virtual-reality technology is a viable platform for medical-simulation into the future.

Operative team communication during simulated emergencies: Too busy to respond?

BACKGROUND: Ineffective communication among members of a multidisciplinary team is associated with operative error and failure to rescue. We sought to measure operative team communication in a simulated emergency using an established communication framework called "closed loop communication." We hypothesized that communication directed at a specific recipient would be more likely to elicit a check back or closed loop response and that this relationship would vary with changes in patients' clinical status. METHODS: We used the closed loop communication framework to code retrospectively the communication behavior of 7 operative teams (each comprising 2 surgeons, anesthesiologists, and nurses) during response to a simulated, postanesthesia care unit "code blue." We identified call outs, check backs, and closed loop episodes and applied descriptive statistics and a mixed-effects negative binomial regression to describe characteristics of communication in individuals and in different specialties. RESULTS: We coded a total of 662 call outs. The frequency and type of initiation and receipt of communication events varied between clinical specialties (P < .001). Surgeons and nurses initiated fewer and received more communication events than anesthesiologists. For the average participant, directed communication increased the likelihood of check back by at least 50% (P = .021) in periods preceding acute changes in the clinical setting, and exerted no significant effect in periods after acute changes in the clinical situation. CONCLUSION: Communication patterns vary by specialty during a simulated operative emergency, and the effect of directed communication in eliciting a response depends on the clinical status of the patient. Operative training programs should emphasize the importance of quality communication in the period immediately after an acute change in the clinical setting of a patient and recognize that communication patterns and needs vary between members of multidisciplinary operative teams.

Ebola Emergency Preparedness: Simulation Training for Frontline Health Care Professionals.

INTRODUCTION: At Brigham and Women's Hospital, we identified the need for a comprehensive training program designed to prepare frontline staff to safely manage a patient with Ebola viral disease (EVD). The primary goal of this program was to ensure the safety of staff, patients, and the general public by training staff in the correct use of personal protective equipment (PPE) before, during, and after care of patients with EVD. METHODS: We delivered a 4-hour experiential training program to frontline health care professionals who would be expected to care for a patient with EVD. The program occurred in a simulation center with multiple flexible spaces and consisted of demonstration, multiple skills practice sessions, and a patient simulation case. We analyzed completed pre- and posttraining questionnaires. The questionnaire assessed their subjective level of confidence in three key areas: donning and doffing PPE, performing clinical skills while wearing PPE, and management of a contamination breach. RESULTS: This program was effectively deployed in the STRATUS Center for Medical Simulation over a 4-month period, with 220 health care professionals participating in the training and 195 participants completing the pre-/posttraining questionnaires. Our intervention significantly increased the confidence of participants on each primary objective (p = .001 for all three stations). DISCUSSION: This interprofessional simulation-based program has been shown to be a well-received method of training clinicians to manage patients collaboratively during an EVD outbreak. Our intent is that the skills taught in this training program would also be transferable to management of other infectious diseases in the clinical setting.

Are residents accurate in their assessments of their own surgical skills?

BACKGROUND: An appropriate level of awareness of one's own technical skill is essential to being an effective self-directed learner. The aim of this study was to analyze surgical residents' self-awareness by examining their ability to predict and assess their own performance in an objective surgical skills examination. METHODS: Surgical residents' (n = 216) pre-examination self-predicted scores and post-examination self-assessed scores were compared with objectively measured scores. Accuracy of score prediction and self-assessment were compared with resident demographics (age, gender, year of training, and nationality). RESULTS: Post-examination self-assessed scores correlated with objectively assessed scores (r = .34; P < .001). Higher year of training, older age, and non-European nationality were predictive of accuracy in self-prediction and self-assessment. CONCLUSIONS: Demographic variables that predict more accurate self-awareness of technical skill have been identified. Surgical training programs may use these data to anticipate the trainees who need assistance in developing better self-awareness.