Distance assessment of counselling skills using virtual patients during the COVID-19 pandemic

Background: Reports on using virtual patients to assess counselling skills is scarce. Aim(s): This paper describes the feasibility and acceptability of assessing patient counselling skills of pharmacy students using a virtual patient simulator. Description: In this innovative method, a high quality simulator 'Virtual Patient Learning' (VPL) was developed at Gulf Medical University (GMU) and was used to assess the counselling skills of 15 pharmacy graduate students. Counselling skills were measured using a four-domain scoring rubric of 1 to 5 marks followed by instant feedback for improvements. Student and faculty satisfaction scores were collected based on the feasibility and acceptability of the assessment method. Evaluation: The average counselling skills score for all students was 68.4 (85.5%) out of 80 (range 54-76), with a standard deviation of 5.8. The overall student agreement on the feasibility and acceptability of the assessment method was 92.8%;it was 100% agreement for faculty. Conclusion(s): The use of a high quality VPL simulator in assessing counselling skills was deemed feasible and acceptable for students and faculty. The assessment was repeated among 30 Doctor of Pharmacy (Pharm.D.) graduates with similar outcomes. The virtual counselling method will be used in the programme exit exams, as well as in students entering their experiential year. Further studies are required to assess its validity and reliability with more students. Copyright © 2020, International Pharmaceutical Federation. All rights reserved.

Efficacy Of Distance Learning For Cardiopulmonary Resuscitation Training Utilizing Smartphone App And Mannikin Delivery-collection System

Aim of the study: Effective CPR training is important for provision of high-quality bystander cardiopulmonary resuscitation (CPR). However, the COVID-19 pandemic has hindered conventional face-to-face CPR training. To overcome the limitation, we developed a distance learning CPR training course (HEROS-Remote) that utilized a smartphone app and a delivery-collection system for CPR training manikins. The objective of the study was to evaluate the efficacy of the HEROSRemote course by comparing chest compression quality between trainees who participated in the conventional CPR training (C-training) and HEROS-Remote course (R-training). Method(s): The non-inferiority trial included adult nonhealthcare providers who applied for CPR training. Both groups underwent 2-minute post-training chest compression test followed by course survey on trainees' course and delivery system satisfaction. The primary outcome of the study was mean chest compression depth during the 2-minute post-training test. Result(s): A total of 180 trainees were enrolled with 90 trainees for each training group. There was no statistically significant difference in chest compression depth between R-training and C-training groups (67.4 vs. 67.8, p=0.78) as well as proportion of adequate chest compression depth, chest compression rate, proportion of chest compressions with complete chest recoil and chest compression score (90.8 vs. 92.1, p=0.69;110.8 vs. 110.4, p=0.60;89.8 vs. 94.7, p=0.05;92.7 vs. 95.5, p=0.16, respectively). In the R-training group, 90.0% of the trainees were satisfied with the course, 96% responded that the delivery system was satisfactory and convenient. Conclusion(s): The R-training course was noninferior to the C-training course. The distance learning CPR training method utilizing smartphone app and mannikin delivery-collection system had high user satisfaction and was logistically feasible.

MENTAL HEALTH MEDICAL EDUCATION LEAD: UNIVERSITY OF QUEENSLAND, BRISBANE - PATIENT SIMULATION AS AN EFFECTIVE 'COVID SAFE' TOOL FOR TEACHING MENTAL HEALTH

Background: The University of Queensland Medical School Mental Health (MH) curriculum had a large online presence prior to 2020, with interactive learning resources and assessments. However, the teaching of clinical skills such as history-taking and mental state examination was typically conducted through small group-based learning and clinical placement. Objectives: To describe The University of Queensland Medical School MH rotation adaptations to teaching clinical skills to account for appropriate social distancing and lockdown learning. Methods: The benefits and challenges associated with physically distanced and online patient simulation for clinical psychiatric skills will be explored. The organisational requirements will also be detailed. Findings: Online patient simulation sessions, facilitated by psychiatrist tutors, allowed appropriate progression of learning and assessment of clinical skills during times when medical students were unable to undertake clinical placement. Feedback provided by students, tutors and patient simulators did not indicate a difference in quality or tolerability. Additional advantages included allowing for increased consistency of teaching across multiple clinical sites and improvement of telehealth interviewing skills. There were significantly increased tutor time requirements, as well as administrative and financial implications. Conclusion: Future development of MH curriculums, including patient simulation, can be enhanced with the MHMELANZ network.

Virtual auscultation course via video chat in times of COVID-19 improves cardiac auscultation skills compared to literature self-study in third-year medical students: a prospective randomized controlled cross-over study.

Background: Cardiac auscultation is a core clinical skill taught in medical school. Due to contact restrictions during the SARS-CoV-2 pandemic, interaction with patients was very limited. Therefore, a peer-to-peer virtual case-based auscultation course via video conference was established. Methods: A randomized controlled cross-over study was conducted to evaluate whether participation in a virtual auscultation course could improve heart auscultation skills in 3rd-year medical students. A total of sixty medical students were randomly assigned to either the experimental or control group after informed consent was obtained. Due to no-shows, 55 students participated. Depending on allocation, students attended three ninety-minute courses in intervals of one week in a different order: a virtual case-based auscultation course held via video chat, literature self-study, and an on-site course using a high-fidelity auscultation simulator (SAM II). The study's primary endpoint was the performance of the two groups at the simulator after participating in the virtual auscultation course or literature self-study. To evaluate their auscultation skills, students participated in five assessments using the same six pathologies: stenosis and regurgitation of the aortic and mitral valve, ventricular septal defect, and patent ductus arteriosus. Moreover, participants rated their satisfaction with each course and provided a self-assessment of competence. Results: Compared to literature self-study, participation in the virtual auscultation course led to a significantly improved description of heart murmurs at the auscultation simulator with regard to the presence in systole and diastole, low- and high-pitched sounds, and volume dynamics. There was no significant difference between the groups in diagnostic accuracy and identification of the point of maximal intensity. After the virtual course, students showed higher satisfaction rates and a higher increase in self-assessed competence compared to participants who engaged in literature self-study. Conclusions: For the first time, this study demonstrates that a case-based virtual auscultation course can improve aspects of cardiac auscultation skills on a simulator. This may facilitate the further acquisition of an essential clinical skill, even when contact restrictions will be lifted.

The impact of small-group virtual patient simulator training on perceptions of individual learning process and curricular integration: a multicentre cohort study of nursing and medical students.

BACKGROUND: The COVID-19 pandemic has precipitated rapid changes in medical education to protect students and patients from the risk of infection. Virtual Patient Simulators (VPS) provide a simulated clinical environment in which students can interview and examine a patient, order tests and exams, prioritize interventions, and observe response to therapy, all with minimal risk to themselves and their patients. Like high-fidelity simulators (HFS), VPS are a tool to improve curricular integration. Unlike HFS, VPS require limited infrastructure investment and can be used in low-resource settings. Few studies have examined the impact of VPS training on clinical education. This international, multicenter cohort study was designed to assess the impact of small-group VPS training on individual learning process and curricular integration from the perspective of nursing and medical students. METHODS: We conducted a multi-centre, international cohort study of nursing and medical students. Baseline perceptions of individual learning process and curricular integration were assessed using a 27-item pre-session questionnaire. Students subsequently participated in small-group VPS training sessions lead by a clinical tutor and then completed a 32-item post-session questionnaire, including 25 paired items. Pre- and post-session responses were compared to determine the impact of the small-group VPS experience. RESULTS: Participants included 617 nursing and medical students from 11 institutions in 8 countries. At baseline, nursing students reported greater curricular integration and more clinical and simulation experience than did medical students. After exposure to small-group VPS training, participants reported significant improvements in 5/6 items relating to individual learning process and 7/7 items relating to curricular integration. The impact of the VPS experience was similar amongst nursing and medical students. CONCLUSIONS: In this multi-centre study, perceptions of individual learning process and curricular integration improved after exposure to small-group VPS training. Nursing and medical students showed similar impact. Small-group VPS training is an accessible, low-risk educational strategy that can improve student perceptions of individual learning process and curricular integration.

Biomechanical effects of using a passive back support exoskeleton during prone-positioning maneuver: A pilot study

Introduction Musculoskeletal disorders associated with patients care and manipulation are frequent among healthcare workers, due to force exertion and sustained awkward postures (EU Commission 2011, Davis 2015). During the COVID-19 pandemic, intensive care units (ICUs) staffs had to perform prone-positioning (PP) of a large number of intubated patients suffering from Acute Respiratory Distress Syndrome (ARDS) many times a day. PP maneuver consists in repositioning a patient from a supine position (on the back) to a prone position (on the front side), which improves oxygenation and ventilatory mechanisms in ARDS patients (Guérin et al. 2013). PP is a delicate procedure (risk of extubation) which requires the medical staff to remain bent forward for several minutes (Figure 1). This posture result in back loading and in the long-term potential injuries in the low-back. Similar postures are common in industrial tasks, and recently occupational exoskeletons have started to be commercialized to help reduce physical load on workers (DeLooze et al. 2016). Exoskeletons therefore appear as a promising solution to support healthcare workers, though few studies focused on this sector (e.g. Miura et al. 2020;Iishi et al. 2015). But while studies overall agree that back-support exoskeletons, and specifically passive devices, have the potential to reduce lumbar muscle activity in tasks involving trunk bending, the exact efficacy and usability of such devices appear largely device-and task-dependent (Theurel et al. 2019). A preliminary study of our team (Settembre et al. 2020) identified the Laevo passive exoskeleton for lumbar support (Laevo, the Netherlands) as the exoskeleton that best matched the PP maneuver and ICU constraints, among 4 exoskeletons that were available at the time of the test during the COVID-19 first wave. The present study presents a pilot investigation of the biomechanical effects of using the Laevo during PP maneuver. 2. Methods 2.1. Experimental protocol Two healthy volunteers with PP experience performed PP maneuvers both with and without wearing the Laevo, on a patient simulator (manikin) at the Hospital Simulation Center of the University of Lorraine (Figure 1). Each maneuver lasted about 4 min. In a first experiment, the participants were equipped with the Xsens MVN Link inertial motion capture system (capture rate 240 Hz) to record wholebody kinematics. In a subsequent experiment, the participants were equipped with a Delsys Trigno EKG sensor to measure heart rate, and 12 Delsys Trigno sEMG sensors (sampling rate 4370 sa/sec) placed according to the Seniam recommendations bilaterally on the erector spinae longissimus (ESL), erector spinae iliocostalis (ESI), trapezius ascendens (TA), and biceps femoris long head (BF), and laterally on the right rectus abdominis at T10 level (RA), rectus femoris (RF), gluteus maximus (GM) and tibialis anterior (TAL). 2.2. Data analysis In order to analyze the kinematics and dynamics of the maneuver, we replayed the recorded motions in a physics-engine based simulation using a 43 degrees of freedom digital human model (DHM). The recorded motions were retargeted on the DHM directly in the Cartesian space by using a quadratic programming controller (QP) typically used for humanoid robots (Maurice et al. 2019). The QP control directly estimates the joint torques associated with the motion. This method has the advantage to blend the traditional inverse kinematics and inverse dynamics steps into one faster step, since the computation runs in close to real-time. Since we did not have a direct measurement of the support torque provided by the Laevo, we used the empirical calibration curve published by (Koopman et al. 2019) to estimate the lumbar support torque depending on the trunk flexion angle. We used the resulting L5/S1 flexion/extension estimated joint torque as a complement to the physiological measurements obtained with the sEMG. 3. Results and discussion Kinematic results: Using the Laevo did not significantly modify the kinematics of the motion during PP. Specific lly, the profile of the lumbar flexion angle remained overall similar (Figure 2). This result was confirmed by the subjective feedback of the participants who reported that they did not feel the exoskeleton was affecting the way they performed the task. Dynamic results: The median value of the estimated L5/S1 flexion/extension torque decreased by about 12% when using the Laevo (Figure 2). This result agrees with the reduced perceived lumbar effort reported by participants, and is aligned with the 15% reduction observed by (Koopman et al. 2019) in a similar static forward bending task. Yet those results should be considered cautiously, since only the assistive torque of the exoskeleton was modeled, and not the full effect of the load transfer. Physiological results: We did not observe any major change in heart rate when using the Laevo. This might be due to the short duration of the experimental task (4 min). The activity of the back extensor muscles (except ESI) and hip extensor muscles overall decreased when using the Laevo (Table 1). The other recorded muscles remained mostly unaffected by the exoskeleton. Those results are consistent with the perceived reduced effort reported by the participants. 4. Conclusions Our pilot study, though limited to a small number of participants, suggests that using the Laevo could help reduce the musculoskeletal load on the low back during PP maneuver, without causing any significant negative side-effect nor modifying the practice. Following this study, 2 Laevos have been successfully deployed in the ICU of CHRU Nancy and have been used there for the past 6 months. Recording quantitative measurements during this fieldtesting is not possible. However subjective feedback from users is collected through questionnaires and interviews, and will be analyzed in a future study.

Tailored Pharmacokinetic model to predict drug trapping in long-term anesthesia.

Introduction: In long-term induced general anesthesia cases such as those uniquely defined by the ongoing Covid-19 pandemic context, the clearance of hypnotic and analgesic drugs from the body follows anomalous diffusion with afferent drug trapping and escape rates in heterogeneous tissues. Evidence exists that drug molecules have a preference to accumulate in slow acting compartments such as muscle and fat mass volumes. Currently used patient dependent pharmacokinetic models do not take into account anomalous diffusion resulted from heterogeneous drug distribution in the body with time varying clearance rates. Objectives: This paper proposes a mathematical framework for drug trapping estimation in PK models for estimating optimal drug infusion rates to maintain long-term anesthesia in Covid-19 patients. We also propose a protocol for measuring and calibrating PK models, along with a methodology to minimize blood sample collection. Methods: We propose a framework enabling calibration of the models during the follow up of Covid-19 patients undergoing anesthesia during their treatment and recovery period in ICU. The proposed model can be easily updated with incoming information from clinical protocols on blood plasma drug concentration profiles. Already available pharmacokinetic and pharmacodynamic models can be then calibrated based on blood plasma concentration measurements. Results: The proposed calibration methodology allow to minimize risk for potential over-dosing as clearance rates are updated based on direct measurements from the patient. Conclusions: The proposed methodology will reduce the adverse effects related to over-dosing, which allow further increase of the success rate during the recovery period.

A Natural Language Processing-Based Virtual Patient Simulator and Intelligent Tutoring System for the Clinical Diagnostic Process: Simulator Development and Case Study.

BACKGROUND: Shortage of human resources, increasing educational costs, and the need to keep social distances in response to the COVID-19 worldwide outbreak have prompted the necessity of clinical training methods designed for distance learning. Virtual patient simulators (VPSs) may partially meet these needs. Natural language processing (NLP) and intelligent tutoring systems (ITSs) may further enhance the educational impact of these simulators. OBJECTIVE: The goal of this study was to develop a VPS for clinical diagnostic reasoning that integrates interaction in natural language and an ITS. We also aimed to provide preliminary results of a short-term learning test administered on undergraduate students after use of the simulator. METHODS: We trained a Siamese long short-term memory network for anamnesis and NLP algorithms combined with Systematized Nomenclature of Medicine (SNOMED) ontology for diagnostic hypothesis generation. The ITS was structured on the concepts of knowledge, assessment, and learner models. To assess short-term learning changes, 15 undergraduate medical students underwent two identical tests, composed of multiple-choice questions, before and after performing a simulation by the virtual simulator. The test was made up of 22 questions; 11 of these were core questions that were specifically designed to evaluate clinical knowledge related to the simulated case. RESULTS: We developed a VPS called Hepius that allows students to gather clinical information from the patient's medical history, physical exam, and investigations and allows them to formulate a differential diagnosis by using natural language. Hepius is also an ITS that provides real-time step-by-step feedback to the student and suggests specific topics the student has to review to fill in potential knowledge gaps. Results from the short-term learning test showed an increase in both mean test score (P<.001) and mean score for core questions (P<.001) when comparing presimulation and postsimulation performance. CONCLUSIONS: By combining ITS and NLP technologies, Hepius may provide medical undergraduate students with a learning tool for training them in diagnostic reasoning. This may be particularly useful in a setting where students have restricted access to clinical wards, as is happening during the COVID-19 pandemic in many countries worldwide.