Search

Background The influence of music on the performance of surgical procedures such as laparoscopy is controversial and methodologically difficult to quantify. Here, outcome measurements using laparoscopic box training tools under standardized conditions might offer a feasible approach. To date, the effect of music exposure at different sound pressure levels (SPL) on outcome has not been evaluated systematically for laparoscopic novices. Methods Between May 2017 and October 2018, n = 87 students (49 males, 38 females) from Heidelberg University Medical School performed three different laparoscopy exercises using the “Luebecker Toolbox” that were repeated twice under standardized conditions. Time was recorded for each run. All students were randomly assigned to four groups exposed to the same music compilation but at different SPLs (50–80 dB), an acoustically shielded (earplug) group, or a control group (no intervention). Results Best absolute performance was shown under exposure to 70 dB in all three exercises (a, b, c) with mean performance time of 121, 142, and 115 s (p p > 0.05) except for exercise (a) (p = 0.011). Conclusion Music exposure seems to have beneficial effects on training performance. In comparison to the control group, significantly better results were reached at 70 dB SPL, while exposure to lower (50 or 60 dB) or higher (80 dB) SPL as well as under acoustic shielding did not influence performance.

This article examines how a virtual case that prepares students for practical scenario training affects police students' performance in a practical scenario training. This study included 69 Swedish police students at the Basic Training Programme for Police Officers – 35 assigned to a virtual police case (VCASE) and 34 assigned to a conventional teacher-led (CON) lesson. A questionnaire captured how students experience training conditions and a blind assessment by police officers evaluated the students' performance in the practical scenario training. The results show that both the VCASE and CON participants thought that the training they received before the practical training was meaningful and motivating. However, to a significantly higher degree than the CON students, the VCASE students thought that their preparation helped them during the practical training. The expert assessment of one practical scenario (stopping a suspected stolen car) showed that the VCASE participants performed better than the CON participants in three out of five criteria. In conclusion, the VCASE and the CON training had different effects on the students' performance in the practical scenario: compared to the CON training, the VCASE training seemed to more effectively help the police students solve the situations presented in the practical scenario training.

Purpose: Virtual reality (VR) simulation surgical skills training is well established, but self-directed practice is often associated with a learning curve plateau. In this study, we investigate the effects of structured self-assessment as a means to improve performance in mastoidectomy training. Methods: The study was a prospective, educational study. Two cohorts of novices (medical students) were recruited for practice of anatomical mastoidectomy in a training program with five distributed training blocks. Fifteen participants performed structured self-assessment after each procedure (intervention cohort). A reference cohort of another 14 participants served as controls. Performances were assessed by two blinded raters using a modified Welling Scale and simulator-recorded metrics. Results: The self-assessment cohort performed superiorly to the reference cohort (mean difference of final product score 0.87 points, p = 0.001) and substantially reduced the number of repetitions needed. The self-assessment cohort also had more passing performances for the combined metrics-based score reflecting increased efficiency. Finally, the self-assessment cohort made fewer collisions compared with the reference cohort especially with the chorda tympani, the facial nerve, the incus, and the malleus. Conclusions: VR simulation training of surgical skills benefits from having learners perform structured self-assessment following each procedure as this increases performance, accelerates the learning curve thereby reducing time needed for training, and induces a safer performance with fewer collisions with critical structures. Structured self-assessment was in itself not sufficient to counter the learning curve plateau and for continued skills development additional supports for deliberate practice are needed.

Background In the health care environment, teamwork is paramount, especially when referring to patient safety. We are interested in recent and innovative solutions such as escape games, which is a type of adventure game that may be highly useful as an educational tool, potentially combining good communication skills with successful gamification. They involve teams of 5 to 10 individuals who are “locked” in the same room and must collaborate to solve puzzles while under pressure from a timer. Objective The purpose of this paper was to describe the steps involved in creating and implementing an educational escape game. This tool can then be put into service or further developed by trainers who wish to use it for learning interprofessional collaboration. Therefore, we started with an experience of creating an educational escape game for emergency medicine teams. Methods We chose to develop an educational escape game by using 6 successive steps. First, we built a team. Second, we chose the pedagogical objectives. Third, we gamified (switched from objectives to scenario). Next, we found the human and material resources needed. Thereafter, we designed briefing and debriefing. Lastly, we tested the game. Results By following these 6 steps, we created the first ambulant educational escape game that teaches people, or nurses, doctors, and paramedics, working in emergency medicine to work as a team. Conclusions From a pedagogic point of view, this game may be a good tool for helping people in multidisciplinary fields (medical and paramedical teams) to learn how to work collaboratively and to communicate as a group. Above all, it seems to be an innovative tool that complements medical simulation–based learning and thus consolidates traditional education.

Objectives The coronavirus disease 2019 pandemic presents in-person exposure risk during surgical education. We aimed to validate the feasibility of fully remote faculty-supervised surgical training sessions focused on coronary artery bypass grafting using a synthetic simulator and online videochat software. Methods This observational study organized 24 sessions of 2-hour remote training. Each session involved 3 trainees, 1 faculty member, and 1 host. A total of 70 trainees and 24 faculty members were enrolled. The participants joined the remote sessions via online videochat and performed focused training in coronary artery anastomosis using a commercially available simulator. A survey was conducted to validate the feasibility of the remote sessions. Performance improvement of the trainees who repeatedly participated (n = 13) were analyzed comparing initial and final scores of various performance indicators. Results All trainees and faculty members were satisfied with the efficacy of the remote session. Additionally, most trainees (79%) and faculty members (95%) agreed that the remote training sessions were equivalent to conventional onsite training seminars. A significant improvement between initial and last sessions was observed in the scoring components of near side (3.4 ± 1.0 vs 4.1 ± 0.9; P = .02), far side (3.3 ± 0.8 vs 3.9 ± 0.8; P = .03), external appearance (3.5 ± 0.8 vs 4.2 ± 0.7; P = .01), and internal appearance (2.8 ± 0.9 vs 4.0 ± 0.9; P = .004). Conclusions Faculty-supervised remote surgical training sessions were executed with satisfactory results. This methodology may have important implications for surgical education during the coronavirus disease 2019 pandemic., Graphical abstract

Introduction: In 2017, approximately 295,000 women died during and immediately following pregnancy and childbirth worldwide, with 94% of these deaths occurring in low-resource settings. The Dominican Republic (DR) exhibits one of the highest maternal mortality ratios in the region of Latin America and the Caribbean despite the fact that 99% of registered births in the country are reportedly attended by a skilled birth attendant. This paradox implies that programs to support healthcare worker knowledge and skills improvement are vital to improving maternal health outcomes in the DR. Helping Mothers Survive (HMS) is a provider training program developed by Jhpiego and global partners. The goal of HMS is to combat maternal mortality by contributing to quality improvement efforts that reinforce maternal health skills of local healthcare workers.Methods: An international, multisectoral group of stakeholders collaborated in the implementation of two HMS curricula, Bleeding After Birth (BAB) and pre-eclampsia & eclampsia (PE&E). Demographic information as well as pre- and post-training knowledge scores were recorded for each participant. Knowledge score improvement was assessed in order to support effectiveness of the program on knowledge acquisition of healthcare workers.Results: Three hundred and twenty healthcare workers participated in the HMS training workshops between October 2016–August 2020. Of the 320 participants, 132 were trained as master trainers. The majority of participants identified as attending physicians, followed by residents/interns, nurses, students, and “other.” A significant improvement in knowledge scores was observed for both the BAB and PE&E curricula, with a 21.24 and 30.25% change in average score (pre- to post-test), respectively. In response to COVID-19 pandemic restrictions, flexibility of the local team led to a PE&E virtual training pilot workshop in August 2020.Discussion/Conclusions: Simulation-based training improved the knowledge levels of healthcare workers for both HMS curricula. These results suggest that simulation-based workshops have an impact on knowledge acquisition and skills of healthcare workers immediately following training. For the PE&E curriculum, no significant difference in knowledge acquisition was observed between in-person and virtual training sessions. The ongoing pandemic poses challenges to program implementation; however, these preliminary results provide evidence that conducting virtual workshops may be a viable alternative to in-person training.

Despite many advancements in extracorporeal membrane oxygenation (ECMO), the procedure is still correlated with a high risk of patient complications. Simulation-based training provides the opportunity for ECMO staff to practice on real-life scenarios without exposing ECMO patients to medical errors while practicing. At Hamad Medical Corporation (HMC) in Qatar, there is a critical need of expert ECMO staff. Thus, a modular ECMO simulator is being developed to enhance the training process in a cost-effective manner. This ECMO simulator gives the instructor the ability to control the simulation modules and run common simulation scenarios through a tablet application. The core modules of the simulation system are placed in the patient unit. The unit is designed modularly such that more modules can be added throughout the simulation sessions to increase the realism of the simulation sessions. The new approach is to enclose the patient unit in a trolley, which is custom-designed and made to include all the components in a modular fashion. Each module is enclosed in a separate box and then mounted to the main blood simulation loop box using screws, quick connect/disconnect liquid fittings, and electrical plugs. This method allows fast upgrade and maintenance for each module separately as well as upgrading modules easily without modifying the trolley’s design. The prototype patient unit has been developed for portability, maintenance, and extensibility. After implementation and testing, the prototype has proven to successfully simulate the main visual and audio cues of the real emergency scenarios, while keeping costs to a minimum Qatar University Scopus

The surgical education environment has been changing significantly due to restricted work hours, limited resources, and increasing public concern for safety and quality, leading to the evolution of simulation-based training in surgery. Of the various simulators, low-fidelity simulators are widely used to practice surgical skills such as sutures because they are portable, inexpensive, and easy to use without requiring complicated settings. However, since low-fidelity simulators do not offer any teaching information, trainees do self-practice with them, referring to textbooks or videos, which are insufficient to learn open surgical procedures. This study aimed to develop a new suture training system for open surgery that provides trainees with the three-dimensional information of exemplary procedures performed by experts and allows them to observe and imitate the procedures during self-practice. The proposed system consists of a motion capture system of surgical instruments and a three-dimensional replication system of captured procedures on the surgical field. Motion capture of surgical instruments was achieved inexpensively by using cylindrical augmented reality (AR) markers, and replication of captured procedures was realized by visualizing them three-dimensionally at the same position and orientation as captured, using an AR device. For subcuticular interrupted suture, it was confirmed that the proposed system enabled users to observe experts’ procedures from any angle and imitate them by manipulating the actual surgical instruments during self-practice. We expect that this training system will contribute to developing a novel surgical training method that enables trainees to learn surgical skills by themselves in the absence of experts.

Simulation-based education (SBE) is increasingly used as an education tool to improve learning for healthcare providers. In newborn care practice, SBE is used in the Neonatal Resuscitation Program (NRP) and training in procedural skills. The NRP is a mandatory course in Malaysia for all house officers (interns) and medical officers (residents) during their pediatric rotation. Almost 30,000 of NRP providers have been trained over the last 5 years. The recent establishment of the Allied Healthcare Center of Excellence (AHCoE), an organization dedicated to promoting SBE, and Malaysian Society for Simulation in Healthcare (MaSSH) aims to enhance the integration of SBE into the healthcare training curriculum and set up a local healthcare simulation educator training program. Our experience in implementing SBE necessitated that we made several important choices. As there was no strong evidence to favor high-fidelity over low-fidelity simulation, and because simulation centers can be very costly to set up with limited resources, we chose SBE mainly in the form of low-fidelity andin situsimulation. We also identified an important developmental goal to train Malaysian instructors on structured debriefing, a critical activity for learning in SBE. Currently, debriefing is often carried out in our centers at anad hocbasis because of time limitation and the lack of personnel trained. Finally, we aim to implement SBE further in Malaysia, with two axes: (1) the credentialing and recertification of physicians and nurses, and (2) the education of lay caregivers of high-risk infants before discharge from the neonatal intensive care unit.

International audience; In our healthcare system, mindful of patient safety and the reduction of medical errors, simulation-based training has emerged as the cornerstone of medical education, allowing quality training in complete safety for patients. Initiated by anaesthesiologists, this teaching mode effectively allows a gradual transfer of learning, and has become an essential tool in cardiology teaching. Cardiologists are embracing simulation to master complex techniques in interventional cardiology, to manage crisis situations and unusual complications and to develop medical teamwork. Simulation methods in cardiology include high-fidelity simulators, clinical scenarios, serious games, hybrid simulation and virtual reality. Simulation involves all fields of cardiology: transoesophageal echocardiography, cardiac catheterization, coronary angioplasty and electrophysiology. Beyond purely technical issues, simulation can also enhance communication skills, by using standardized patients, and can improve the management of situations related to the announcement of serious diseases. In this review of recent literature, we present existing simulation modalities, their applications in different fields of cardiology and their advantages and limitations. Finally, we detail the growing role for simulation in the teaching of medical students following the recent legal obligation to use simulation to evaluate medical students in France.

Although remote teaching and learning is not new to medical education, the Covid-19 pandemic has heightened its importance as a mode of education delivery. This scoping review aims to provide a narrative/iterative summary of the current literature in assessing the acceptability, educational value and technological feasibility of remotely facilitated (RF) simulation-based training (SBT) – ‘telesimulation’, for medical students and facilitators. The review was conducted using the method described by Arksey and O’Malley. A systematic process was followed to search multiple electronic databases supplemented with a general internet search to identify any relevant grey literature. The search strategy was developed in collaboration with medical students and educators familiar with SBT. Nine articles were identified as fitting the review inclusion criteria. The results indicated that RF SBT was positively viewed by participants but may not be viewed as equivalent to locally facilitated SBT. Participants of RF SBT felt confident to deal with common acute scenarios, believed it could expand their knowledge and skills and in turn would improve patient care in the clinical setting. Facilitators found RF SBT to be technologically feasible, promoting the acquisition of desired learning outcomes. Future research should assess the reaction to, and learning acquired during RF SBT, particularly, the perception and attitudes of facilitators. A clear research gap was identified in literature assessing the role of RF SBT in behavioural change and improved clinical care outcomes. Addresing these gaps will clarify the role of RF SBT in medical education.

IntroductionThe 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.MethodsThe 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.ResultsFollowing 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.ConclusionsItaly 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.

Robot-assisted surgery systems are a recent breakthrough in minimally invasive surgeries, offering numerous benefits to both patients and surgeons including, but not limited to, greater visualization of the operation site, greater precision during operation and shorter hospitalization times. Training on robot-assisted surgery (RAS) systems begins with the use of high-fidelity simulators. Hence, the increasing demand of employing RAS systems has led to a rise in using RAS simulators to train medical doctors. The aim of this study was to investigate the brain activity changes elicited during the skill acquisition of resident surgeons by measuring hemodynamic changes from the prefrontal cortex area via a neuroimaging sensor, namely, functional near-infrared spectroscopy (fNIRS). Twenty-four participants, who are resident medical doctors affiliated with different surgery departments, underwent an RAS simulator training during this study and completed the sponge suturing tasks at three different difficulty levels in two consecutive sessions/blocks. The results reveal that cortical oxygenation changes in the prefrontal cortex were significantly lower during the second training session (Block 2) compared to the initial training session (Block 1) (p &lt, 0.05).

Simulation in healthcare is rapidly replacing more traditional educational methods, becoming a fundamental step in the medical training path. Medical simulations have a remarkable impact not only on learners’ competencies and skills but also on their attitudes, behaviors, and emotions such as anxiety, stress, mental effort, and frustration. All these aspects are transferred to the real practice and reflected on patients’ safety and outcomes. The design of medical simulations passes through a careful analysis of learning objectives, technology to be used, instructor’s and learners’ roles, performance assessment, and so on. However, an overall methodology for the simulation assessment and consequent optimization is still lacking. The present work proposes a transdisciplinary framework for the analysis of simulation effectiveness in terms of learners’ performance, ergonomics conditions, and emotional states. It involves collaboration among different professional figures such as engineers, clinicians, specialized trainers, and human factors specialists. The aim is to define specific guidelines for the simulation optimization, to obtain enhanced learners’ performance, improved ergonomics, and consequently positively affect the patient treatment, leading to cost savings for the healthcare system. The proposed framework has been tested on a low-fidelity simulation for the training of rachicentesis and has allowed the definition of general rules for its enhancement.

Brent Bauman,1 Peter Kernahan,1,2 Anthony Weinhaus,2 Michael J Walker,2 Eric Irwin,1 Andrew Sundin,1 Derek Yerxa,3 Victor Vakayil,1 James V Harmon1,2 1Department of Surgery, University of Minnesota, Minneapolis, MN, USA; 2Program in Human Anatomy, University of Minnesota, Minneapolis, MN, USA; 3College of Biological Sciences, University of Minnesota, Minneapolis, MN, USACorrespondence: James V Harmon 420 Delaware St SE, MMC 195, Minneapolis, MN 55455, USATel +1 612-625-7911Email harm0031@umn.eduPurpose: Senior medical students are variably prepared to begin surgical training; and a national curriculum was established through the American College of Surgeons to better prepare senior medical students for surgical training. The purpose of our course is to prepare senior medical students to more effectively enter surgical training programs. We recently enhanced our independently developed surgical training preparation course by increasing exposure to surgical anatomy, medical physiology, surgical skills, and point-of-care ultrasound. We evaluated the impact of our interprofessional training course to increase confidence and readiness among senior medical students entering surgical training.Methods: The course focused on pre- and post-operative patient care, surgical anatomy, human physiology, and bedside ultrasound. Didactic lectures in anatomy, human physiology, and bedside ultrasound were provided prior to all hands-on simulated patient care sessions and mock surgical procedures. To evaluate our interprofessional curriculum, we administered pre- and post-course surveys, pre- and post-course knowledge tests, and a final surgical anatomy laboratory practical examination to 22 senior medical students who were enrolled in the course. All students created a final surgical anatomy presentation.Results: The students demonstrated a 100% pass rate in surgical anatomy. The knowledge test, which included assessment of knowledge on perioperative surgical decision making, human physiology, and bedside ultrasound, demonstrated an average improvement of 10%. Statistically significant improvements in median confidence values were identified in 10 of 32 surveyed categories, including surgical skills (p < 0.05); 84% of student goals for the course were achieved. The medical students’ surveys confirmed increased confidence related to the use of point-of-care ultrasound, teamwork experience, and basic surgical skills through small group interactive seminars and surgical simulation exercises.Conclusion: Our preparation for surgical training course resulted in high student satisfaction and demonstrated an increased sense of confidence to begin surgical training. The 10% improvement in medical student knowledge, as evaluated by a written examination, and the significant improvement in confidence level self-assessment scores confirms this surgery preparation course for senior medical students successfully achieved the desired goals of the course.Keywords: surgical trainee, simulation-based training, clinical anatomy, medical student education

Background Facilitators plays a key role in nursing student’s learning when briefing them for simulation scenarios. However, few studies have explored the importance of the facilitator’s role in preparing students from the students’ perspective. The aim of this study was to explore undergraduate nursing students’ perspectives of the facilitator’s role in briefing. Methods An explorative, qualitative approach was used. Four focus group interviews with a total of 30 nursing students constituted the data source. Data collection took place in December 2017 and in May 2018. The data was analysed using systematic text condensation. Results Two main categories were identified: “The importance of framing the subsequent scenario” and “The importance of instructing students how to execute nursing actions in the subsequent scenario”. The first category consisted of three subcategories: providing predictability, providing emotional support and providing challenges. The second main category also consisted of three subcategories: providing information about medical and technical equipment, providing a demonstration of the monitor and providing a demonstration of the manikin. Conclusion A briefing is more than a general introduction to a simulation scenario, learning objectives, roles, simulation environment and medical equipment. The information provided in a briefing is important for nursing students’ understanding of what they will encounter in the simulation scenario and what is being simulated, as well as possibly being a prerequisite for mastery. The facilitator’s role in the briefing is complex and requires a high level of educational expertise to balance the diversity of students’ learning approaches. Students have to learn how to simulate before the briefing. Therefore, we suggest separating the concepts of prebriefing and presimulation from the concept of briefing, introducing prebriefing and presimulation preparation before briefing, and possibly dividing students into groups based on their learning approach. Such interventions will make it possible for facilitators to balance between students’ needs and the time available for briefing.

Objective: It is important to train clinicians to maintain and optimise maternal and neonatal outcomes after vaginal twin delivery. Simulation-based training provides opportunities for training in a realistic way without harming patients. The aim of this study is to evaluate the effect of simulation-based training concerning twin vaginal delivery on knowledge and comfort of obstetrician-gynaecologists. Study design: Obstetrician-gynaecologists participated in a twin vaginal delivery simulation between March 2018 and May 2019. Simulation-based training consisted of standardized patient interviews, didactic sessions and three different simulation-based scenarios: internal podalic version and breech extraction, assisted vaginal delivery and vaginal breech delivery with problems of aftercoming head. Pre- and posttraining, participants were asked to fill out questionnaires exploring knowledge concerning vertex-vertex twin deliveries and vertex-nonvertex twin deliveries, level of comfort performing various obstetric manoeuvres and counselling on mode of delivery for women pregnant with twins. Our primary outcome of interest was a change in knowledge or comfort surrounding vaginal twin delivery after completion of the simulation-based training. Results: The estimated median number of vaginal twin deliveries performed by the participating thirty-four obstetrician-gynaecologists was 50 (IQR 20–100). Significant improvements were seen in knowledge regarding twin deliveries with vertex-nonvertex presentation (p < 0.01). In two of three questions regarding twin delivery with vertex-vertex presentation significant improvements were seen as well (p < 0.01). Before training, 40.6% of participants felt comfortable to perform internal podalic version compared to 91.2% afterwards (p < 0.01). Comfort with breech extraction increased from 69.7% to 97.1% pre- and posttraining, respectively (p < 0.01). Before training only 55.9% would strongly counsel patients towards vaginal twin delivery as opposed to 73.5% after training (p = 0.07). Conclusions: Simulation-based training results in beneficial effects on knowledge and comfort concerning vaginal twin deliveries for obstetrician-gynaecologists. This training suggested a potential impact on provider practice with a more favourable attitude towards twin vaginal birth.

Background: Child cardiac arrest is rare, but more frequent among infants, requiring immediate cardiopulmonary resuscitation (CPR). Many studies have reported that simulation-based training (SBT) increased CPR performance of healthcare providers. However, the CPR performance of laypeople using basic life support remains poorly known. The aim of this study was to assess nursery assistants' (non-healthcare providers) CPR performance and knowledge, before and after SBT.Methods: The study was carried out from January to June 2018 in the city of Poitiers, France. Two teaching sessions (T1 and T2) and two evaluation sessions (E1 and E2) were performed. Performance in infant CPR on a manikin at E1 and E2 were videotaped and assessed automatically with Resusci Baby QCPR® and a SimPad PLUS SkillReporter (QCPR Global Score and skills) and by an observer using an original CPR performance checklist (MCPR Global-Score and skills). Nursery assistant's CPR knowledge was assessed by a questionnaire at the beginning and the end of the session T1, E1, and E2.Results: Twenty-Seven nursery assistants over 30 contacted were included. There was an improvement between E1 and E2 in QCPR Global-Score (E1: 42.4 ± 23.6 vs. E2: 55.1 ± 23.7%, p = 0.032), MCPR Global-Score (E1: 50.0+11.9 vs. E2: 72.3+8.5%; p < 0.001) and theoretical knowledge with score (over 45) of 16.9+5.4 before T1 and 35.2+2.7 after E2, respectively (p < 0.001). The improvement mainly concerned QCPR and MCPR compression steps scores. MCPR Global-Score was strongly correlated to QCPR Global-Score (r = 0.61; p < 0.01) and predictive to CPR quality determined by QCPR Global-Score (AUC = 0.77; p < 0.01) with a high sensitivity and negative predictive values. Moreover, these improvements were maintained 2 months after training with no difference between scores obtained by the three groups 15, 30, or 60 days after simulation-based training session T2.Conclusion: SBT could significantly improve knowledge and skills in infant CPR management by nursery assistants especially for chest compression. CPR performance checklist appeared as an interesting tool to assess CPR performance quality.

BackgroundIn a setting in which learning of basic procedural skills commences upon graduation from medical school, and as a first step towards integration of simulation-based learning into the anesthesiology training program, a preparatory course for new anesthesia trainees was designed. Three educational strategies were sequentially combined (e-learning, simulation-based hands on workshops, and on-site observational learning), and performance was assessed in a stepwise approach on five procedural skills considered essential for early anesthetic management (peripheral intravenous cannulation, sterile hand wash and gowning, anesthesia workstation preparation, face-mask ventilation, and orotracheal intubation). The primary aim of this study was to determine if this preparatory training course at the onset of anesthesiology residency is useful to achieve a competent trainee performance in the clinical setting.MethodsThis prospective study was carried out at a university-affiliated hospital in Buenos Aires, Argentina, from 2017 to 2019. The 24 participants, comprising three cohorts of 8 residents each, underwent a preparatory course at the onset of residency. Diverse, consecutive educational strategies, and assessments (three stages: 1, 2, 3) took place using task-specific tools (checklists) and global rating scales for five procedural skills. The primary outcome was achievement of competent scores (85%) in final assessments, and the secondary outcomes were performance improvement between assessment stages and compliance with predefined safety items.ResultsTwenty trainees (83.3%) were found to be globally competent (both assessment tools for all procedures) during final assessments (stage 3). Statistically significant improvement was found for all procedural skills between baseline and after workshop assessment scores (stages 1–2), except for orotracheal intubation in checklists, and for all procedural skills between stages 2 and 3 except for sterile hand wash and gowning in checklists.ConclusionsIn our single-center experience, the gap for competent trainee performance in essential early anesthetic management skills can be effectively covered by conducting an intensive, preparatory course using the combination of three educational strategies (e-learning, simulation-based hands on workshops, and observational learning) at the onset of residency. This course has allowed learning to be generated in a secure environment for both patients and trainees.

Purpose: Ultra-high-fidelity (UHF) graphics in virtual reality (VR) simulation might improve surgical skill acquisition in temporal bone training. This study aims to compare UHF VR simulation training with conventional, screen-based VR simulation training (cVR) with respect to performance and cognitive load (CL). Methods: In a randomized trial with a cross-over design, 24 students completed a total of four mastoidectomies in a VR temporal bone surgical simulator: two performances under UHF conditions using a digital microscope and two performances under conventional conditions using screen-based VR simulation. Performances were assessed by two blinded raters using an established assessment tool. In addition, CL was estimated as the relative change in secondary-task reaction time during simulation when compared with individual baseline measurements. Data were analyzed using linear mixed model analysis for repeated measurements. Results: The mean final-product performance score was significantly lower in UHF VR simulation compared to cVR simulation [mean difference 1.0 points out of 17 points, 95% CI (0.2–1.7), p = 0.02]. The most important factor for performance during UHF simulation was the ability to achieve stereovision (mean difference = 3.4 points, p < 0.001). Under the UHF VR condition, CL was significantly higher than during cVR (28% vs. 18%, respectively, p < 0.001). Conclusion: UHF graphics in VR simulation training reduced performance and induced a higher CL in novices than conventional, screen-based VR simulation training. Consequently, UHF VR simulation training should be preceded by cVR training and might be better suited for the training of intermediates or experienced surgeons.

Objective: Often the assessment of mastoidectomy performance requires time-consuming manual rating. Virtual reality (VR) simulators offer potentially useful automated assessment and feedback but should be supported by validity evidence. We aimed to investigate simulator metrics for automated assessment based on the expert performance approach, comparison with an established assessment tool, and the consequences of standard setting. Methods: The performances of 11 experienced otosurgeons and 37 otorhinolaryngology residents. Participants performed three mastoidectomies in the Visible Ear Simulator. Nine residents contributed additional data on repeated practice in the simulator. One hundred and twenty-nine different performance metrics were collected by the simulator and final-product files were saved. These final products were analyzed using a modified Welling Scale by two blinded raters. Results: Seventeen metrics could discriminate between resident and experienced surgeons’ performances. These metrics mainly expressed various aspects of efficiency: Experts demonstrated more goal-directed behavior and less hesitancy, used less time, and selected large and sharp burrs more often. The combined metrics-based score (MBS) demonstrated significant discriminative ability between experienced surgeons and residents with a mean difference of 16.4% (95% confidence interval [12.6–20.2], P << 0.001). A pass/fail score of 83.6% was established. The MBS correlated poorly with the final-product score but excellently with the final-product score per time. Conclusion: The MBS mainly reflected efficiency components of the mastoidectomy procedure, and although it could have some uses in self-directed training, it fails to measure and encourage safe routines. Supplemental approaches and feedback are therefore required in VR simulation training of mastoidectomy. Level of Evidence: 2b. Laryngoscope, 129:2170–2177, 2019.

The article describes the topicality of simulation-based technologies as a part of the practical training of anesthesiologists and emergency physicians. It validates the theoretical and practical background for inclusion of simulation-based technologies into the training in order to decrease the number of medical errors in one of the most highly technical fields of modern medicine. The authors share the experience of staged simulation-based training of anesthesiologists and emergency physicians in the Simulation Center of Altai State Medical University by the Russian Ministry of Health.

Background Inadequate non-technical skills (NTSs) among employees in the Norwegian prehospital emergency medical services (EMSs) are a risk for patient and operational safety. Simulation-based training and assessment is promising with respect to improving NTSs. The frequency of simulation-based training in and assessment of NTSs among crewmembers in the Norwegian helicopter emergency medical service (HEMS) has gained increased attention over recent years, whereas there has been much less focus on the Norwegian ground emergency medical service (GEMS). The aim of the study was to compare and document the frequencies of simulation-based training in and assessment of seven NTSs between the Norwegian HEMS and GEMS, conditional on workplace and occupation. Method A comparative study of the results from cross-sectional questionnaires responded to by employees in the Norwegian prehospital EMSs in 2016 regarding training in and assessment of NTSs during 2015, with a focus on the Norwegian GEMS and HEMS. Professional groups of interest are: pilots, HEMS crew members (HCMs), physicians, paramedics, emergency medical technicians (EMTs), EMT apprentices, nurses and nurses with an EMT licence. Results The frequency of simulation-based training in and assessment of seven generic NTSs was statistically significantly greater for HEMS than for GEMS during 2015. Compared with pilots and HCMs, other health care providers in GEMS and HEMS undergo statistically significantly less frequent simulation-based training in and assessment of NTSs. Physicians working in the HEMS appear to be undergoing training and assessment more frequently than the rest of the health trust employees. The study indicates a tendency for lesser focus on the assessment of NTSs compared to simulation-based training. Conclusion HEMS has become superior to GEMS, in terms of frequency of training in and assessment of NTSs. The low frequency of training in and assessment of NTSs in GEMS suggests that there is a great potential to learn from HEMS and to strengthen the focus on NTSs. Increased frequency of assessment of NTSs in both HEMS and GEMS is called for.

© 2019 Elsevier B.V. All rights reserved., Objectives: The objective of this study was to evaluate the effect of simulation-based training on the accuracy of fetal head position determination by junior residents during the second stage of labour. Study design: This prospective study was conducted in a tertiary care university hospital. During an initial period of 12 weeks, 13 junior residents were asked to routinely evaluate fetal head position by digital examination during the second stage of labour, in women with term singletons in cephalic presentation. Digital examination was followed immediately by transabdominal ultrasound to confirm fetal head position, performed by an experienced physician. Following this initial period, all participants attended a workshop where simulation-based training of fetal head position determination was provided. A second 12-week period was subsequently completed, with similar characteristics to the initial one. The accuracy of clinical evaluations was assessed by the percentage of exact evaluations, the percentage of correct evaluations within a 45° error margin, and by Cohen's kappa coefficient of agreement. Results: A total of 83 observations were performed in the initial period of the study and 74 observations were performed in the second period. The accuracy of fetal head position determination during the first period of the study was 59.0% (95% CI 47.7-69.7), k = 0.517 (95%CI 0.391 - 0.635), corresponding to a moderate agreement. Considering a 45° margin of error, accuracy was 71.1% (95% CI 60.1-80.5), k = 0.656 (95% CI 0.538 - 0.763), corresponding to substantial agreement. Following simulation-based training, the accuracy of fetal head position determination was 70.3% (95% CI 58.5-80.3), k = 0.651 (95% CI 0.526 - 0.785), corresponding to a substantial agreement. Considering a 45° margin of error, accuracy was 78.4% (95% CI 67.3-87.1), k = 0.745 (95% CI 0.631 - 0.854), corresponding to a substantial agreement. Conclusions: Although a trend towards increased accuracy in fetal head position determination was observed after simulation-based training, the difference was not statistically significant. Further studies are needed to clarify the role of simulation-based training for fetal head position determination during residency.

Background Simulation-based training improves residents’ skills for end-of-life (EOL) care. In the field, staff providers play a significant role in handling those situations and in shaping practice by role modeling. We initiated an educational intervention to train healthcare providers for improved communication skills at EOL using simulation of sensitive encounters with patients and families. Methods Hospital physicians and nurses (n = 1324) attended simulation-based workshops (n = 100) in a national project to improve EOL care. We analyzed perceptions emerging from group discussions following simulations, from questionnaires before and after each workshop, and from video-recorded simulations using a validated coding system. We used the simulation setting as a novel tool for action research. We used a participatory inquiry paradigm, with repetitive cycles of exploring barriers and challenges with participants in an iterative pattern of observation, discussion and reflection – including a description of our own responses and evolution of thought as well as system effects. Results The themes transpiring included lack of training, knowledge and time, technology overuse, uncertainty in decision-making, poor skills for communication and teamwork. Specific scenarios demonstrated lack of experience at eliciting preferences for EOL care and at handling conflicts or dilemmas. Content analysis of simulations showed predominance of cognitive utterances - by an order of magnitude more prevalent than emotional expressions. Providers talked more than actors did and episodes of silence were rare. Workshop participants acknowledged needs to improve listening skills, attention to affect and teamwork. They felt that the simulation-based workshop is likely to ameliorate future handling of EOL situations. We observed unanticipated consequences from our project manifested as a field study of preparedness to EOL in nursing homes, followed by a national survey on quality of care, leading to expansion of palliative care services and demand for EOL care education in various frameworks and professional areas. Conclusions Reflective simulation exercises show barriers and paths to improvement among staff providers. When facing EOL situations, physicians and nurses use cognitive language far more often than emotions related expressions, active listening, or presence in silence. Training a critical mass of staff providers may be valuable to induce a cultural shift in EOL care.

International audience

Background: Cannulation, in extracorporeal membrane oxygenation (ECMO), is the act of inserting a cannula through the body1. For femoral veins, femoral arteries, and the jugular vein, the cannula stops at the inferior vena cava (IVC) beside the hepatic vein and at the beginning of the distal aorta, and the superior vena cava at the right atrium, respectively. Cannulation is considered a critical operation and requires intensive training. Simulation-based training (SBT) is the gold standard, allowing for training in risk-free, versatile, and realistic environments2. A research collaboration was established between Hamad Medical Corporation and Qatar University College of Engineering to support the development of the ECMO training programme. Initially an ECMO machine simulator was developed with thermochromic ink to simulate blood and modules that simulate common emergencies practitioners may face during ECMO runs3. This cannulation simulator is now being designed to close the gap in the market in relation to cost and fidelity4,5. Methods: The cannulation simulator is composed of several modules. Firstly, a 3D-printed femoral pad mold was constructed to facilitate the production of cannulation pads (Figure 1(a), (c)). Secondly, cannulation pads were designed so they are anatomically correct and ultrasound compatible. For the arteries, the superficial artery was added at the access point to simulate possible incorrect routes for the cannula. Furthermore, the orientation of the veins and arteries were set to further resemble the human anatomy, where the arteries are situated above the veins (Figure 1(a), (b)). In addition to the implementation of a closed loop linking the jugular to the femoral, cannulation access points with a pump connected to a tank between them to regulate the flow. The blood flow in the arteries was enhanced with a pump to simulate a pulsatile flow while the flow in the veins is laminar as seen in the single loop implementation (Figure 1(h)). The connection of the pump to the embedded system is shown in Figure 1(g). The junctional point in the IVC was designed in the venous loop to allow for two cannulas to pass and an alternative path simulating the renal vein was added. A force sensing resistor (FSR) was connected to detect and measure incorrect entry of the guide-wire as this, in real-time scenarios, could cause internal bleeding to the patient (Figure 1(g)). Lastly, the Y-connector showing the renal vein entry is shown in Figure 1(d) and (e). Results: Tests were done on the system namely on the FSR to recalibrate it in the presence of liquid. Tests on the pulsatile flow were conducted to optimize for realism in terms of pressure. Since both jugular and femoral cannulation access points are included, the simulator can be used for training for all ECMO modes including veno-arterial and veno-venous. After testing, the main limitations of the current prototype include the flexibility of the tubes, limits on FSR measurements, and the rigidity of the available 3D printing material. Conclusion: After implementing the stated features, the anticipated outcome is a realistic and cost-efficient ECMO cannulation simulator.

The aim of this review is to highlight the latest movements surrounding Emergency Manual (EM) implementation nationally and abroad within perioperative medicine with a focus on studies linking EM to patient safety. This is a comprehensive literature review which includes a brief introduction to the definition and history of EM as well as an overview of a successful implementation strategy, international influence and correlations to patient safety. The recent changes in healthcare and healthcare reimbursement have directed the focus throughout healthcare to quality improvement and patient safety. The potential of EMs' application to improve patient outcomes has influential implications both on patient outcomes as well as reimbursements. This study includes relevant citations with the large majority published in the last five years. EM implementation in healthcare has grown within the US and internationally over the last decade. Prominent organizations have created EMs containing principles of evidence-based medicine and widely accepted protocols that have been endorsed by major entities in the medical field. Successful implementation strategies primarily focus on different forms of simulation training and have been found to increase adherence to protocols through EM use. An increasing amount of educational institutions and healthcare facilities worldwide are perpetuating such implementation and a growing number of successful cases are being published.

Background The purpose of this study was to perform a systematic review of the current literature on simulator-based training in vitreoretinal surgery (VRS). We examined the results regarding simulated VRS and provided an overview of how the current results may be employed in VRS training. Lastly, we evaluated the quality of these results. Methods The databases of Pubmed, Embase and Cochrane Library were searched for articles in English involving simulated VRS training. A qualitative analysis was performed, since the studies which met our inclusion criteria did not allow for a quantitative meta-analysis. Results We identified 203 articles of which seven met the inclusion criteria. Of these, six studies investigated simulation with EyeSi® Surgical (VRMagic, Mannheim, Germany). Six studies reported positive performance curves. Four studies showed construct validity. One study attempted to show skill transfer from simulator to vitrectomies performed on cadavers. Methodological quality of the included studies was moderate but lacking in instrument validation. Conclusion Simulator-based training in VRS can assess and possibly assist acquisition of a variety of VRS skills. Further research is needed to support transfer from simulator to operating room. Future studies should strive to follow established validation frameworks and streamline study designs. Electronic supplementary material The online version of this article (10.1186/s12886-019-1098-x) contains supplementary material, which is available to authorized users.

Objectives There is a paucity of research on how to improve the functioning of health service boards, despite their importance in influencing patient care. We examined the impact of simulation-based training on health service board members’ perceptions of their skills in communicating during board meetings and of board meeting processes. Design Prospective, cluster randomised controlled trial. Setting Health service boards in Victoria, Australia. Participants Twelve boards were randomised, and pre- and post-intervention data were collected and analysed from 57 members of these boards. Interventions Boards were randomly allocated to either a treatment condition in which they received a 2-hour simulation-based training session or to a wait list control condition. Primary and secondary outcome measures Primary outcome variables were board members’ perceptions regarding: (1) their skill and confidence in communicating during board meetings and (2) processes at their board meetings. Measures were collected in the intervention group before and 3 months post-training and compared with a wait list control group. Results Skills and confidence in communicating during board meetings was higher after training (control marginal mean=5.11, intervention marginal mean=5.42, mean difference=0.31, 90% CI (−0.03 to 0.66), one-sided p=0.068, d=0.40). Board meeting processes were also improved after training (control marginal mean=4.97, intervention marginal mean=5.37, mean difference=0.40, 90% CI (0.14 to 0.65), one-sided p=0.005, d=0.54). Conclusions Simulation-based training appeared to improve board members’ skills and confidence, and perceptions of board meeting processes. A larger scale trial is needed to examine possible impacts on patient outcomes. Trial registration Open Science Framework: http://osf.io/jaxt6/; Pre-results.

Background Essentials Skills in the Management of Surgical Cases – ESMSC is an International Combined Applied Surgical Science and Wet Lab course addressed at the Undergraduate level. Laparoscopic Skills is a fundamental element of Surgical Education and various Simulation-Based Learning (SBL) models have been endorsed. This study aims to explore if there is any significant difference in delegates' performance depending on whether they completed In Vivo module prior to the equivalent in the laparoscopic simulator. Materials and methods 37 Medical Students from various EU countries were divided in 2 groups, and both completed the “Fundamentals in Laparoscopic Surgery” module in the Dry-lab Laparoscopic Simulator as well as the same module “In Vivo” on a swine model. Group A (18 students, 48.6%) completed the “Fundamentals in Laparoscopic Surgery - FLS” module prior to the “In Vivo”, whereas group B completed the “In Vivo” module first. Direct Observation of Procedural Skills (DOPS) were used to assess delegates' performance. Results The mean DOPS scores for the “FLS” and “In Vivo” models were 2.27 ± 0.902 and 2.03 ± 0.833, respectively, and the delegates' performance was not statistically significantly different between them (p = 0.128). There was no statistically significant difference in the scores among different gender, year of study, school and handedness groups. The alteration in the sequence between Dry-lab “FLS” and “In Vivo” modules did not affect the performance in neither the “FLS” nor the “In Vivo” models. Conclusions The inexpensive, but low-fidelity “FLS” model could serve an equal alternative Simulation-Based Learning model for the early undergraduate training. Our study demonstrated that high fidelity In Vivo simulation for laparoscopic skills does not affect significantly the improvement in the delegates' performance at the undergraduate level. Further studies should be conducted to identify at which stage of training should high fidelity simulation be introduced., Highlights • Low-fidelity laparoscopic simulation model is an equal alternative at the early undergraduate training. • No statistically significant difference was noted in the scores among different gender, year of study, school and handedness of students. • There was no statistically significant difference in the scores among different gender, year of study, school and handedness groups.

Background: Pediatric resuscitations are rare events. Simulation-based training improves clinical and non-clinical skills, as well as survival rate. We assessed the effectiveness of using blindfolds to further improve leadership skills in pediatric simulation-based training. Methods: Twelve teams, each composed of 1 pediatric emergency fellow, 1 pediatric resident, and 2 pediatric emergency nurses, were randomly assigned to the blindfold group (BG) or to the control group (CG). All groups participated in one session of five simulation-based resuscitation scenarios. The intervention was using a blindfold for the BG leader for the scenarios B, C, and D. Three evaluators, who were blinded to the allocation, assessed leadership skills on the first and last video-recorded scenarios (A and E). Questionnaires assessed self-reported changes in stress and satisfaction about skills after the first and the last scenarios. Results: Improvement in leadership skills doubled in the BG compared with the CG (11.4 vs. 5.4%, p = 0.04), whereas there was no increase in stress or decrease in satisfaction. Conclusion: Blindfold could be an efficient method for leadership training during pediatric resuscitation simulated scenarios. Future studies should further assess its effect at a follow-up and on clinical outcomes after pediatric resuscitation.

Introduction Unobtrusive metrics that can auto-assess performance during clinical procedures are of value. Three approaches to deriving wearable technology-based metrics are explored: (1) eye tracking, (2) psychophysiological measurements [e.g. electrodermal activity (EDA)] and (3) arm and hand movement via accelerometry. We also measure attentional capacity by tasking the operator with an additional task to track an unrelated object during the procedure. Methods Two aspects of performance are measured: (1) using eye gaze and psychophysiology metrics and (2) measuring attentional capacity via an additional unrelated task (to monitor a visual stimulus/playing cards). The aim was to identify metrics that can be used to automatically discriminate between levels of performance or at least between novices and experts. The study was conducted using two groups: (1) novice operators and (2) expert operators. Both groups made two attempts at a coronary angiography procedure using a full-physics virtual reality simulator. Participants wore eye tracking glasses and an E4 wearable wristband. Areas of interest were defined to track visual attention on display screens, including: (1) X-ray, (2) vital signs, (3) instruments and (4) the stimulus screen (for measuring attentional capacity). Results Experts provided greater dwell time (63% vs 42%, p = 0.03) and fixations (50% vs 34%, p = 0.04) on display screens. They also provided greater dwell time (11% vs 5%, p = 0.006) and fixations (9% vs 4%, p = 0.007) when selecting instruments. The experts’ performance for tracking the unrelated object during the visual stimulus task negatively correlated with total errors (r = − 0.95, p = 0.0009). Experts also had a higher standard deviation of EDA (2.52 µS vs 0.89 µS, p = 0.04). Conclusions Eye tracking metrics may help discriminate between a novice and expert operator, by showing that experts maintain greater visual attention on the display screens. In addition, the visual stimulus study shows that an unrelated task can measure attentional capacity. Trial registration This work is registered through clinicaltrials.gov, a service of the U.S. National Health Institute, and is identified by the trial reference: NCT02928796.

Objectives. New training methods such as simulation have been introduced in cardiology as in other specialties; however, the development of effective simulation-based training programs is challenging. They are often unstructured and based on convenience or coincidence. The objective of this study was to perform a nationwide general needs assessment to identify and prioritize technical procedures that should be included in a simulation-based curriculum for cardiology residency in Denmark. Design. We completed a needs assessment using the Delphi method among key opinion leaders in cardiology. Brainstorming in round 1 identified technical procedures that future cardiologists should learn. Round 2 was a survey to examine frequency of procedure, number of cardiologists performing the procedure, operator-related risk and/or discomfort for patients and feasibility for simulation. Round 3 was final elimination and prioritization of procedures. Results. Ninety-four key opinion leaders were included, and the response rates were 77% (round 1), 62% (Round 2), and 68% (Round 3). Twenty-four technical procedures were identified in Round 1 and pre-prioritized in Round 2. In round 3, 13 procedures were included in the final prioritized list. The five highly prioritized procedures eligible for simulation-based training were advanced life support, pleurocentesis, transesophageal echocardiography, coronary angiography, and pericardiocentesis. Conclusion. The general needs assessment following the Delphi process identified and prioritized 13 technical procedures in cardiology that should be integrated in a simulation-based curriculum. The final list provides educators a guide when developing simulation-based training programmes for cardiology residents.

Background Deficient non-technical skills (NTS) among providers of critical care in helicopter emergency medical services (HEMS) is a threat to patient and operational safety. Skills can be improved through simulation-based training and assessment. A previous study indicated that physicians underwent less frequent training compared to pilots and HEMS crew members (HCM) and that all professional groups in Norwegian HEMS received limited training in how to cope with fatigue. Since then, training initiatives and a fatigue risk management project has been initiated. Our study aimed to explore if the frequency of simulation-based training and assessment of NTS in Norwegian HEMS has changed since 2011 following these measures. Methods A cross-sectional web-based survey from October through December 2016, of physicians, HCM and pilots from all civilian Norwegian HEMS-bases reporting the overall extent of simulation-based training and assessment of NTS. Results Of 214 invited, 109 responses were eligible for analysis. The frequency of simulation-based training and assessment of NTS has increased significantly for all professional groups in Norwegian HEMS, most prominently for the physicians. For all groups, the frequency of assessment is generally lower than the frequency of training. Conclusions Physicians in Norwegian HEMS seem to have adjusted to the NTS training culture of the other crew member groups. This might be a consequence of improved NTS training programs. The use of behavioural marker systems systematically in HEMS should be emphasized. Electronic supplementary material The online version of this article (10.1186/s13049-018-0583-1) contains supplementary material, which is available to authorized users.

Minimally-invasive endovascular procedures have been established as fundamental and incredibly effective interventions in the treatment of aneurysms. Daily operations incorporate thousands of hours of experience sourced from the operating room and extensive literature. In particular, neurointerventional angiography requires extensive hands-on training under the guidance of an expert interventionalist in order to learn nuanced navigational and procedural strategies. The presence of a high learning curves and inter-center training variability creates difficulties in developing standardized training and assessment models in this field. Surgical workflow analysis has been gaining traction in recent years as a favorable technical approach to understanding surgical procedures. Through the breakdown of clinical performance into its core steps and events, workflow models allow for the visualization, statistical analysis and standardization of performance from clinically representative arrays of data points. Simulation-based training in cerebral aneurysm diagnosis and coiling has seen great technical advancement over the last decade, with the production of affordable, tactile computer-based simulators. Although these tools hold much potential, there is little data supporting the extent of their abilities to teach and standardize clinically-transferable skills. Using surgical workflow analysis software, we aim to dissect the core steps and events that occur during a cerebral aneurysm coiling procedure in order to identify the average occurrence and length of significant procedural steps and events. Using this data, we aim to develop a standardized model of performance that can be applied as a guide to simulation-based training and as a performance metric to simulation-based clinical skills transfer. A total of three video cameras are placed around the Angio Suite focusing on significant areas of clinical importance: (1) the femoral access site and hands of the surgical team, (2) the imaging monitors, and (3) angiography pedals. Video data from 20 patients undergoing a cerebral angiography coiling procedure are collected and analyzed using Annotate. Data analysis will focus on quantitative data, such as event occurrence and length, and summative qualitative data on procedural overview. This data will be used to develop an averaged expert performance model for this procedure. The results of this study will provide important guidelines for translational simulation-based training work that is representative of the steps performed in the Angio Suite. Workflow analysis in cerebral aneurysm coiling can provide answers to many uncertainties existing in the field, such as metrics for performance among experts, accuracy of simulation-based training in comparison to clinical practice and potential areas of development in clinical training. Furthermore, the development of a performance model in neurointerventional angiography would create potential for automated workflow analyses and application of statistical data towards the treatment recommendations for novel and difficult cases.

Background: Anesthetized pigs may be useful for training with regional anesthesia techniques. This model animal was used to assess the impact of simulation-based training for ultrasound-guided transversus abdominis plane (TAP) block. Methods: In this prospective study, 23 participating residents (10 in their second year, 13 in their third year) underwent simulation-based training for ultrasound-guided TAP block. The residents completed standard questionnaires comprising ten multiple-choice questions regarding essential general knowledge of abdominal ultrasound and TAP block before and after the training session. On a five-point Likert scale, they reported their levels of comfort with the use of ultrasound and block equipment, subject/operator positioning, proper block technique, image documentation, needle handling, and anxiety, as well as their overall confidence with the procedure. Results: Compared with those before training, the comfort levels of the residents significantly improved for all measures, except needle handling (all P < 0.05). The participants also indicated significantly reduced anxiety for performing the TAP block technique (P < 0.05). Conclusion: The use of anesthetized pigs in simulation-based training for the ultrasound-guided TAP block procedure improves the procedural knowledge and confidence while reducing the associated anxiety in anesthesiology trainees. Keywords: Porcine; simulation-based training; transversus abdominis plane block

Introduction: Extracorporeal membrane oxygenation (ECMO) training programs employ real ECMO components, causing them to be extremely expensive while offering little realism in terms of blood oxygenation and pressure. To overcome those limitations, we are developing a standalone modular ECMO simulator that reproduces ECMO’s visual, audio and haptic cues using affordable mechanisms. We present a central component of this simulator, capable of visually reproducing blood oxygenation color change using thermochromism. Methods: Our simulated ECMO circuit consists of two physically distant modules, responsible for adding and withdrawing heat from a thermochromic fluid. This manipulation of heat creates a temperature difference between the fluid in the drainage line and the fluid in the return line of the circuit and, hence, a color difference. Results: Thermochromic ink mixed with concentrated dyes was used to create a recipe for a realistic and affordable blood-colored fluid. The implemented “ECMO circuit” reproduced blood’s oxygenation and deoxygenation color difference or lack thereof. The heat control circuit costs 300 USD to build and the thermochromic fluid costs 40 USD/L. During a ten-hour in situ demonstration, nineteen ECMO specialists rated the fidelity of the oxygenated and deoxygenated “blood” and the color contrast between them as highly realistic. Conclusions: Using low-cost yet high-fidelity simulation mechanisms, we implemented the central subsystem of our modular ECMO simulator, which creates the look and feel of an ECMO circuit without using an actual one.

International audience; Objective - Deep brain stimulation (DBS) is an increasingly common treatment for neurodegenerative diseases. Neurosurgeons must have thorough procedural, anatomical, and functional knowledge to plan electrode trajectories and thus ensure treatment efficacy and patient safety. Developing this knowledge requires extensive training. We propose a training approach with objective assessment of neurosurgeon proficiency in DBS planning. Methods - To assess proficiency, we propose analyzing both the viability of the planned trajectory and the manner in which the operator arrived at the trajectory. To improve understanding, we suggest a self-guided training course for DBS planning using real-time feedback. To validate the proposed measures of proficiency and training course, two experts and six novices followed the training course, and we monitored their proficiency measures throughout. Results - At baseline, experts planned higher quality trajectories and did so more efficiently. As novices progressed through the training course, their proficiency measures increased significantly, trending toward expert measures. Conclusion - We developed and validated measures which reliably discriminate proficiency levels. These measures are integrated into a training course, which quantitatively improves trainee performance. The proposed training course can be used to improve trainees' proficiency, and the quantitative measures allow trainees' progress to be monitored.

Introduction: Under five mortality rates (UFMR) remain high for children in low and middle-income countries (LMICs) in the developing world. Education for practitioners in these environments is a key factor to improve outcomes that will address United Nations Sustainable Development Goals 3 and 10 (good health and well being and reduced inequalities). In order to appropriately contextualize a curriculum using simulation, it is necessary to first conduct a needs assessment of the target learner population. The World Health Organization (WHO) has published a tool to assess capacity for emergency and surgical care in LMICs that is adaptable to this goal. Materials and Methods: The WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was modified to assess pediatric resuscitation capacity in clinical settings in two LMICs: Uganda and Myanmar. Modifications included assessment of self-identified learning needs, current practices, and perceived epidemiology of disease burden in each clinical setting, in addition to assessment of pediatric resuscitation capacity in regard to infrastructure, procedures, equipment and supplies. The modified tool was administered to 94 respondents from the two settings who were target learners of a proposed simulation-based curriculum in pediatric and neonatal resuscitation. Results: Infectious diseases (respiratory illnesses and diarrheal disease) were cited as the most common causes of pediatric deaths in both countries. Self-identified learning needs included knowledge and skill development in pediatric airway/breathing topics, as well as general resuscitation topics such as CPR and fluid resuscitation in shock. Equipment and supply availability varied substantially between settings, and critical shortages were identified in each setting. Current practices and procedures were often limited by equipment availability or infrastructural considerations. Discussion and Conclusions: Epidemiology of disease burden reported by respondents was relatively consistent with WHO country-specific UFMR statistics in each setting. Results of the needs assessment survey were subsequently used to refine goals and objectives for the simulation curriculum, and to ensure delivery of pragmatic educational content with recommendations that were contextualized for local capacity and resource availability. Effective use of the tool in two different settings increases its potential generalizability.

Scenario-based training provides valuable opportunities for practice and assessment of cross-cultural skills in representative environments. Cross-cultural training that is presented within scenarios can help to motivate trainees and to increase perceptions of relevance and validity. Further, with immersive computer simulations, a sufficiently rich representation can enable tailoring of content, delivering support or challenge for individual trainees when scenario events play out in a variety of ways. However, training scenarios delivered via a computer simulation can be difficult for end users such as instructors to create or to change after they are created. One source of this difficulty is the lack explicit representation of the goals of training or rationales for their design. As a consequence, technical personnel are typically required to make changes, resulting in a process that is costly, slow, and prone to communication errors. Further, training scenarios can become obsolete or fail to reflect the varied needs of different instructors. In this paper, we identify specific limitations to the scenario definition and describe an alternative approach based on computational narrative. The new approach is designed to enable a training system to reason about what training content to tailor and why to deliver suitably tailored and individualized training.

Background Simulation-based training improves residents’ skills for end-of-life (EOL) care. In the field, staff providers play a significant role in handling those situations and in shaping practice by role modeling. We initiated an educational intervention to train healthcare providers for improved communication skills at EOL using simulation of sensitive encounters with patients and families. Methods Hospital physicians and nurses (n = 1324) attended simulation-based workshops (n = 100) in a national project to improve EOL care. We analyzed perceptions emerging from group discussions following simulations, from questionnaires before and after each workshop, and from video-recorded simulations using a validated coding system. We used the simulation setting as a novel tool for action research. We used a participatory inquiry paradigm, with repetitive cycles of exploring barriers and challenges with participants in an iterative pattern of observation, discussion and reflection – including a description of our own responses and evolution of thought as well as system effects. Results The themes transpiring included lack of training, knowledge and time, technology overuse, uncertainty in decision-making, poor skills for communication and teamwork. Specific scenarios demonstrated lack of experience at eliciting preferences for EOL care and at handling conflicts or dilemmas. Content analysis of simulations showed predominance of cognitive utterances - by an order of magnitude more prevalent than emotional expressions. Providers talked more than actors did and episodes of silence were rare. Workshop participants acknowledged needs to improve listening skills, attention to affect and teamwork. They felt that the simulation-based workshop is likely to ameliorate future handling of EOL situations. We observed unanticipated consequences from our project manifested as a field study of preparedness to EOL in nursing homes, followed by a national survey on quality of care, leading to expansion of palliative care services and demand for EOL care education in various frameworks and professional areas. Conclusions Reflective simulation exercises show barriers and paths to improvement among staff providers. When facing EOL situations, physicians and nurses use cognitive language far more often than emotions related expressions, active listening, or presence in silence. Training a critical mass of staff providers may be valuable to induce a cultural shift in EOL care. Electronic supplementary material The online version of this article (doi:10.1186/s13584-017-0169-9) contains supplementary material, which is available to authorized users.

Background: Postpartum haemorrhage (PPH) is a major cause of maternal mortality. Prevention and adequate treatment are therefore important. However, most births in low-resource settings are not attended by skilled providers, and knowledge and skills of healthcare workers that are available are low. Simulation-based training effectively improves knowledge and simulated skills, but the effectiveness of training on clinical behaviour and patient outcome is not yet fully understood. The aim of this study was to assess the effect of obstetric simulation-based training on the incidence of PPH and clinical performance of basic delivery skills and management of PPH.Methods: A prospective educational intervention study was performed in a rural referral hospital in Tanzania. Sixteen research assistants observed all births with a gestational age of more than 28 weeks from May 2011 to June 2013. In March 2012 a half-day obstetric simulation-based training in management of PPH was introduced. Observations before and after training were compared. The main outcome measures were incidence of PPH (500-1000 ml and > 1000 ml), use and timing of administration of uterotonic drugs, removal of placenta by controlled cord traction, uterine massage, examination of the placenta, management of PPH (> 500 ml), and maternal and neonatal mortality at 24 h.Results: Three thousand six hundred twenty two births before and 5824 births after intervention were included. The incidence of PPH (500-1000 ml) significantly reduced from 2.1% to 1.3% after training (effect size Cohen's d = 0.07). The proportion of women that received oxytocin (87.8%), removal of placenta by controlled cord traction (96.5%), and uterine massage after birth (93.0%) significantly increased after training (to 91.7%, 98.8%, 99.0% respectively). The proportion of women who received oxytocin as part of management of PPH increased significantly (before training 43. 0%, after training 61.2%). Other skills in management of PPH improved (uterine massage, examination of birth canal, bimanual uterine compression), but these were not statistically significant.Conclusions: The introduction of obstetric simulation-based training was associated with a 38% reduction in incidence of PPH and improved clinical performance of basic delivery skills and management of PPH.

OBJECTIVE: Simulation-based training is well recognized in the transforming field of urological surgery; however, integration into the curriculum is often unstructured. Development of simulation-based curricula should follow a stepwise approach starting with a needs assessment. This study aimed to identify technical procedures in urology that should be included in a simulation-based curriculum for residency training.MATERIALS AND METHODS: A national needs assessment was performed using the Delphi method involving 56 experts with significant roles in the education of urologists. Round 1 identified technical procedures that newly qualified urologists should perform. Round 2 included a survey using an established needs assessment formula to explore: the frequency of procedures; the number of physicians who should be able to perform the procedure; the risk and/or discomfort to patients when a procedure is performed by an inexperienced physician; and the feasibility of simulation training. Round 3 involved elimination and reranking of procedures according to priority.RESULTS: The response rates for the three Delphi rounds were 70%, 55% and 67%, respectively. The 34 procedures identified in Round 1 were reduced to a final prioritized list of 18 technical procedures for simulation-based training. The five procedures that reached the highest prioritization were cystoscopy, transrectal ultrasound-guided biopsy of the prostate, placement of ureteral stent, insertion of urethral and suprapubic catheter, and transurethral resection of the bladder.CONCLUSION: The prioritized list of technical procedures in urology that were identified as highly suitable for simulation can be used as an aid in the planning and development of simulation-based training programs.

Introduction The learning curve in minimally invasive surgery is much longer than in open surgery. This is thought to be due to the higher demands made on the surgeon’s skills. Therefore, the question raised at the outset of training in laparoscopic surgery is how such skills can be acquired by undergoing training outside the bounds of clinical activities to try to shorten the learning curve. Simulation-based training courses are one such model. Methods In 2011, the surgery societies of Germany adopted the “laparoscopic surgery curriculum” as a recommendation for the learning content of systematic training courses for laparoscopic surgery. The curricular structure provides for four 2-day training courses. These courses offer an interrelated content, with each course focusing additionally on specific topics of laparoscopic surgery based on live operations, lectures, and exercises carried out on bio simulators. Results Between 1st January, 2012 and 31st March, 2016, a total of 36 training courses were conducted at the Vivantes Endoscopic Training Center in accordance with the “laparoscopic surgery curriculum.” The training courses were attended by a total of 741 young surgeons and were evaluated as good to very good during continuous evaluation by the participants. Conclusion Training courses based on the “laparoscopic surgery curriculum” for acquiring skills in laparoscopy are taken up and positively evaluated by young surgeons.

Ce texte présente la synthèse d’une entrevue avec Dr Kirsten Johnson, un médecin canadien pleinement engagé dans la formation des médecins à l’intervention humanitaire. Dr Johnson démontre que la formation basée sur la simulation est essentielle au développement des compétences humanitaires de base ainsi qu’au façonnement de l’attitude éthique. Elle insiste sur le devoir du Canada d’assurer la formation appropriée de ses professionnels de la santé avant de les envoyer en mission humanitaire., This text presents a synthesis of an interview with Dr. Kirsten Johnson, a Canadian physician fully engaged in training health professionals in humanitarian response and intervention. Dr. Johnson shows that simulation-based training is essential to the development of core humanitarian competencies and to the shaping of ethical attitudes as well. She stresses Canada’s duty to assure appropriate training of its health professionals before sending them out on humanitarian missions., Compte-rendu / Review

This article describes a framework that has been developed to monetize the real value of simulation-based training in health care. A significant consideration has been given to the incorporation of the intangible and qualitative benefits, not only the tangible and quantitative benefits of simulation-based training in health care. The framework builds from three works: the value measurement methodology (VMM) used by several departments of the US Government, a methodology documented in several books by Dr Jack Phillips to monetize various training approaches, and a traditional return on investment methodology put forth by Frost and Sullivan, and Immersion Medical. All 3 source materials were adapted to create an integrated methodology that can be readily implemented. This article presents details on each of these methods and how they can be integrated and presents a framework that integrates the previous methods. In addition to that, it describes the concept and the application of the developed framework. As a test of the applicability of the framework, a real case study has been used to demonstrate the application of the framework. This case study provides real data related to the correlation between the pediatric patient cardiopulmonary arrest (CPA) survival rates and a simulation-based mock codes at the University of Michigan tertiary care academic medical center. It is important to point out that the proposed framework offers the capability to consider a wide range of benefits and values, but on the other hand, there are several limitations that has been discussed and need to be taken in consideration.

Background: Almost half of pediatric third-year residents surveyed in 2000 had never led a resuscitation event. With increasing restrictions on residency work hours and a decline in patient volume in some hospitals, there is potential for fewer opportunities. Purpose: Our primary purpose was to test the hypothesis that an unannounced mock resuscitation in a high-fidelity in-situ simulation training program would improve both residents’ self-confidence and observed performance of adopted best practices in neonatal resuscitation. Methods: Each pediatric and medicine–pediatric resident in one pediatric residency program responded to an unannounced scenario that required resuscitation of the high fidelity infant simulator. Structured debriefing followed in the same setting, and a second cycle of scenario response and debriefing occurred before ending the 1-hour training experience. Measures included pre- and post-program confidence questionnaires and trained observer assessments of live and videotaped performances. Results: Statistically significant pre–post gains for self-confidence were observed for 8 of the 14 NRP critical behaviors (p=0.00–0.03) reflecting knowledge, technical, and non-technical (teamwork) skills. The pre–post gain in overall confidence score was statistically significant (p=0.00). With a maximum possible assessment score of 41, the average pre–post gain was 8.28 and statistically significant (p

This article provides a qualitative review of the published literature dealing with the design, implementation, and evaluation of simulation-based team training (SBTT) in healthcare with the purpose of providing synthesis of the present state of the science to guide practice and future research. A systematic literature review was conducted and produced 27 articles meeting the inclusion criteria. These articles were coded using a low-inference content analysis coding scheme designed to extract important information about the training program. Results are summarized in 10 themes describing important considerations for what occurs before, during, and after a training event. Both across disciplines and within Emergency Medicine (EM), SBTT has been shown to be an effective method for increasing teamwork skills. However, the literature to date has underspecified some of the fundamental features of the training programs, impeding the dissemination of lessons learned. Implications of this study are discussed for team training in EM.

Background Simulation has been suggested as a suitable approach to train home health care professionals for telecare practice. The potentials in using simulation to prepare organizations and staff for telecare implementation are however unexplored. Methods A collaborative action research approach involving key stakeholders from two home health care organizations was used to develop a simulation-based telecare training program for home health care professionals. Results and Conclusion The collaborative approach to simulation-based training design described here can facilitate genuine stakeholder participation in the development of training objectives, methods and content which will best respond to real staff needs, as well as local organizational conditions and concerns associated with telecare implementation.