A smartphone-based online platform for clinical skills training and assessment with standardized patients: platform development and pilot study outcomes.

There are limitations and difficulties in the management of traditional in-person standardized patient (SP) practice. The latest developments in online communication tools and the COVID-19 pandemic have promoted the needs for online clinical skills training objectively. However, existing commercial online platforms may not meet the requests for SP-based medical simulation. This paper described the methodology applied to develop a smartphone-based online platform for the management of clinical skills training and assessment with remote SPs, and aimed to determine whether this new platform is acceptable or useful through a pilot run in September 2020. The post-run survey including questionnaire inspired by technological acceptance model and determinants of the perceived ease of use was used to assess the acceptability and usefulness of the platform. Twenty four-year students of clinical medicine participated in the pilot study with twenty SPs and ten faculties. Data from the post-run survey showed that there was a general recognition that the platform is easy to use among all the users. Two questions regarding the usefulness of the platform showed significant differences between the SPs/faculties and the students. More SPs found the platform useful as a training method than the students did. The faculties showed more attempts than the students to use this platform for clinical skills training in the future. This smartphone-based online platform was widely accepted among the tested students, SPs and faculties, which meets the requests and challenges of the new era. It provides an effective approach for clinical skills training and assessment with remote SPs.

An online case-based teaching and assessment program on clinical history-taking skills and reasoning using simulated patients in response to the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has created unprecedented challenges for medical students and educators worldwide. Groups 1, 2 and 3 of year 3, semester 2 medical students at the Royal College of Surgeons in Ireland (n = 275) had only completed 2, 5 and 7 weeks, respectively, of their scheduled 10-week clinical medicine and surgery attachments, prior to the Irish shutdown of all in-person non-essential activities, including medical student education. METHODS: We developed and delivered an online case-based program, focused on history-taking skills and clinical reasoning, using simulated patients and video technologies. 12 tutorials were delivered over 6 weeks to 35 subgroups of 8 students in line with program learning outcomes. Both simulated patients (n = 36), and tutors (n = 45, from retired clinical professors to newly graduated physicians), were rapidly upskilled in Blackboard Collaborate and Microsoft Teams, and also in the provision of constructive feedback. We evaluated this newly developed program by the following three criteria: student attendance, achieved grades, and student feedback. RESULTS: Attendance at the 12 tutorials was higher amongst group 1 and 2 students (75 and 73%) by comparison with group 3 students (60%) (p = < 0.001). Of the 273 students that sat the Year 3 Semester 2 online long case assessment, 93% were successful. Despite group 1 students having the least prior clinical experience, results were similar to those of groups 2 and 3 (1st honors, 2nd honors, pass, and fail grades for group 1, 39%, 33%, 23% and 6%; group 2, 34%, 41%, 17% and 8%; group 3, 39%, 25%, 28% and 7%) (p = 0.48). An increased attendance rate at tutorials was associated with higher numbers of honors grades (p = < 0.001). Anonymous feedback from the students demonstrated considerable satisfaction with program: > 85% agreed that the online program was interactive and very educational. CONCLUSIONS: Use of online video technology, tutors of varied experience, and simulated patients were demonstrated to replicate patient encounters, and to facilitate the development of clinical skills remotely during the COVID-19 pandemic.

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.

The impact of design elements on undergraduate nursing students' educational outcomes in simulation education: protocol for a systematic review.

BACKGROUND: Although simulation-based education (SBE) has become increasingly popular as a mode of teaching in undergraduate nursing courses, its effect on associated student learning outcomes remains ambiguous. Educational outcomes are influenced by SBE quality that is governed by technology, training, resources and SBE design elements. This paper reports the protocol for a systematic review to identify, appraise and synthesise the best available evidence regarding the impact of SBE on undergraduate nurses' learning outcomes. METHODS: Databases to be searched from 1 January 1990 include the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Medical Literature Analysis and Retrieval System Online (MEDLINE), American Psychological Association (APA) PsycInfo and the Education Resources Information Centre (ERIC) via the EBSCO host platform. The Excerpta Medica database (EMBASE) will be searched via the OVID platform. We will review the reference lists of relevant articles for additional citations. A combination of search terms including 'nursing students', 'simulation training, 'patient simulation' and 'immersive simulation' with common Boolean operators will be used. Specific search terms will be combined with either MeSH or Emtree terms and appropriate permutations for each database. Search findings will be imported into the reference management software (Endnote© Version.X9) then uploaded into Covidence where two reviewers will independently screen the titles, abstracts and retrieved full text. A third reviewer will be available to resolve conflicts and moderate consensus discussions. Quantitative primary research studies evaluating the effect of SBE on undergraduate nursing students' educational outcomes will be included. The Mixed Methods Appraisal Tool (MMAT) will be used for the quality assessment of the core criteria, in addition to the Cochrane RoB 2 and ROBINS-I to assess the risk of bias for randomised and non-randomised studies, respectively. Primary outcomes are any measure of knowledge, skills or attitude. DISCUSSION: SBE has been widely adopted by healthcare disciplines in tertiary teaching settings. This systematic review will reveal (i) the effect of SBE on learning outcomes, (ii) SBE element variability and (iii) interplay between SBE elements and learning outcome. Findings will specify SBE design elements to inform the design and implementation of future strategies for simulation-based undergraduate nursing education. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021244530.

Pandemic-Related Disruptions in Nursing Education: Zooming Out for an Innovative Interprofessional Simulation.

When the COVID-19 global pandemic began, many higher education systems had to restructure their educational delivery system and transition to online learning. This posed a challenge for students in health professions education programs as it impacted their ability to participate in hands-on learning regarding patient care. As a result, the University of Cincinnati College of Nursing developed and implemented simulation-based learning experiences to allow graduate-level social worker, counselor, and psychiatric-mental health nurse practitioner students the opportunity to learn as an interdisciplinary team in a virtual format. The Opioid Use Disorder Simulation Case Study discussed in this article was developed as part of the Serving At-risk Youth Fellowship Experience Training program with the overarching aim to prepare culturally competent providers to deliver direct patient care and education around prevention and recovery services to individuals with substance use disorders.

Innovative Teaching Strategies Using Simulation for Pediatric Nursing Clinical Education During the Pandemic: A Case Study.

Existing challenges associated with pediatric clinical placements for prelicensure nursing students were heightened when clinical agencies halted nursing student entry in response to the COVID-19 pandemic. At the same time, the pandemic created opportunities for innovative teaching strategies for pediatric clinical rotations in nursing education. The purpose of this project was to design, develop, and implement meaningful, interactive, and intentional clinical experiences for nursing students that enhanced their pediatric assessment skills, reduced their anxiety about pediatric inpatient care, and advanced their proficiency in the nursing process. Two simulated clinical experiences were created: (1) a virtual pediatric physical assessment checkoff and (2) a pediatric escape room. The pediatric physical assessment checkoff was performed in a remote, virtual setting while students used personal resources to demonstrate their assessment skills. For the escape room, students worked in small, in-person groups using the nursing process to unlock clues to improve their client's health condition. Students reported gaining meaningful clinical experiences through simulation that allowed them to apply their nursing knowledge and increased their confidence in pediatric assessment skills, dosage calculation competency, communications and interactions with the pediatric population, and teamwork abilities. The virtual pediatric physical assessment checkoff and the pediatric escape room were enjoyable and beneficial educational events that facilitated student learning.

Overcoming COVID-19 Challenges: Using Remote and Hybrid Simulation Designs in DNP Programs.

Simulation is a critical component of nursing and medical education used to teach skills and assess student performance. In March 2020, faculty members-including the authors-at the Grace Center for Innovation in Nursing Education at the Edson College of Nursing and Health Innovation (Edson College) simulation programs at Arizona State University quickly responded to the crisis presented by COVID-19. Within a few days, all nursing simulations were transitioned from a predominately in-person design to fully online. Maintaining simulation activities throughout the first several months of the pandemic allowed students at Edson College to meet clinical assessment objectives. This transition, implemented in 2 phases, included a detailed plan of action for all Doctor of Nursing Practice (DNP) nurse practitioner objective structured clinical exams (OSCEs). The challenges required innovative planning and flexibility while maintaining the integrity of the OSCE and simulation experience. The methods implemented out of necessity are now an important part of the authors' curricular toolbox, providing options for continued and future educational practice. This paper details the simulations designed and implemented in 2 DNP programs: the family nurse practitioner and acute care pediatric nurse practitioner programs.

Updates on Simulation in Obstetrical Anesthesiology Through the COVID-19 Pandemic.

Simulation has played a critical role in medicine for decades as a pedagogical and assessment tool. The labor and delivery unit provides an ideal setting for the use of simulation technology. Prior reviews of this topic have focused on simulation for individual and team training and assessment. The COVID-19 pandemic has provided an opportunity for educators and leaders in obstetric anesthesiology to rapidly train health care providers and develop new protocols for patient care with simulation. This review surveys new developments in simulation for obstetric anesthesiology with an emphasis on simulation use during the COVID-19 pandemic.

Using simulation exercises to improve student skills and patient safety.

The COVID-19 pandemic has affected the delivery of nursing training in higher education and how workforce development programmes are delivered. Using simulated practice is an opportunity for experiential and immersive learning in a safe and supported environment that replaces real life. This article discusses the use of simulation in nurse education to improve patient safety.

Standardized Vaccine-Hesitant Patients in the Assessment of the Effectiveness of Vaccine Communication Training.

OBJECTIVES: To determine if training residents in a structured communication method elicits specific behaviors in a laboratory model of interaction with vaccine-hesitant parents. STUDY DESIGN: Standardized patients portraying vaccine-hesitant parents were used to assess the effectiveness of training in the Announce, Inquire, Mirror, Secure (AIMS) Method for Healthy Conversations. Blinded pediatric residents were pseudorandomized to receive AIMS or control training and underwent pre- and post-training encounters with blinded standardized patients. Encounters were assessed by blinded raters using a novel tool. Participant confidence and standardized patient evaluations of the participants' general communication skills were assessed. RESULTS: Ratings were available for 27 AIMS and 26 control participants. Statistically significant increases in post-training scores (maximum = 30) were detected in AIMS, but not in control, participants (median, 21.3 [IQR, 19.8-24.8] vs 18.8 [IQR, 16.9-20.9]; P < .001). Elements (maximum score = 6) with significant increases were Inquire (0.67 [IQR, 0-1.76] vs -0.33 [IQR, -0.67 to 0.33]; P < .001); Mirror (1.33 [IQR, 0 to 2] vs -0.33 [IQR, -0.92 to 0]; P < .001) and Secure (0.33 [IQR, 0 to 1.67] vs -0.17 [IQR, -0.67 to 0.33]; P = .017). Self-confidence increased equally in both groups. Standardized patients did not detect a difference in communication skills after training and between groups. Internal consistency and inter-rater reliability of the assessment tool were modest. CONCLUSIONS: Standardized patients proved useful in studying the effectiveness of structured communication training, but may have been limited in their ability to perceive a difference between groups owing to the predetermined encounter outcome of vaccine refusal. AIMS training should be studied in real-world scenarios to determine if it impacts vaccine acceptance.

Crisis as a chance. A digital training of social competencies with simulated persons at the Medical Faculty of RWTH Aachen, due to the lack of attendance teaching in the SARS-Cov-2 pandemic.

Objective: The AIXTRA Competence Center for Training and Patient Safety at RWTH Aachen University has developed a concept to enable learning of communication skills with simulated persons (SP) digitally. Methodology: Existing SP cases in curricular teaching were checked for digital applicability and modified. Digital seminars with the methodology of simulated conversations with SP, for planned 690 students for the courses "history taking", 6th semester, conversations in psychiatry, 8th semester, and in the clinical competence course, 10th semester, were conducted via video conferencing software. The structure is similar to SP-seminars in classroom teaching with a case presentation, a doctor/patient dialogue and a feedback session. In the 6th and 10th semester, the seminars were evaluated anonymously by the students using an online questionnaire. SP were asked by e-mail for their assessment. The lecturers were asked about their experience with the digital seminars by means of qualitative interviews. Results: The survey of students with 92 completed questionnaires indicates a high level of acceptance. Digital teaching with SP was rated "very good" by 63% of the students and "good" by 37% as an overall mark for the course. The digital implementation is well practicable, the retention and accessibility of all learning goals is rated as given. Conclusion: Digital teaching with SP can be well realized with appropriate preparation. Specific aspects of digital implementation (e.g. role and data protection) must be taken into account. The differentiated evaluation of the surveys will bring further results and deductive questions.

Public health impact of delaying second dose of BNT162b2 or mRNA-1273 covid-19 vaccine: simulation agent based modeling study.

OBJECTIVE: To estimate population health outcomes with delayed second dose versus standard schedule of SARS-CoV-2 mRNA vaccination. DESIGN: Simulation agent based modeling study. SETTING: Simulated population based on real world US county. PARTICIPANTS: The simulation included 100 000 agents, with a representative distribution of demographics and occupations. Networks of contacts were established to simulate potentially infectious interactions though occupation, household, and random interactions. INTERVENTIONS: Simulation of standard covid-19 vaccination versus delayed second dose vaccination prioritizing the first dose. The simulation runs were replicated 10 times. Sensitivity analyses included first dose vaccine efficacy of 50%, 60%, 70%, 80%, and 90% after day 12 post-vaccination; vaccination rate of 0.1%, 0.3%, and 1% of population per day; assuming the vaccine prevents only symptoms but not asymptomatic spread (that is, non-sterilizing vaccine); and an alternative vaccination strategy that implements delayed second dose for people under 65 years of age, but not until all those above this age have been vaccinated. MAIN OUTCOME MEASURES: Cumulative covid-19 mortality, cumulative SARS-CoV-2 infections, and cumulative hospital admissions due to covid-19 over 180 days. RESULTS: Over all simulation replications, the median cumulative mortality per 100 000 for standard dosing versus delayed second dose was 226 v 179, 233 v 207, and 235 v 236 for 90%, 80%, and 70% first dose efficacy, respectively. The delayed second dose strategy was optimal for vaccine efficacies at or above 80% and vaccination rates at or below 0.3% of the population per day, under both sterilizing and non-sterilizing vaccine assumptions, resulting in absolute cumulative mortality reductions between 26 and 47 per 100 000. The delayed second dose strategy for people under 65 performed consistently well under all vaccination rates tested. CONCLUSIONS: A delayed second dose vaccination strategy, at least for people aged under 65, could result in reduced cumulative mortality under certain conditions.

The aerosol box for intubation in coronavirus disease 2019 patients: an in-situ simulation crossover study.

The coronavirus disease 2019 pandemic has led to the manufacturing of novel devices to protect clinicians from the risk of transmission, including the aerosol box for use during tracheal intubation. We evaluated the impact of two aerosol boxes (an early-generation box and a latest-generation box) on intubations in patients with severe coronavirus disease 2019 with an in-situ simulation crossover study. The simulated process complied with the Safe Airway Society coronavirus disease 2019 airway management guidelines. The primary outcome was intubation time; secondary outcomes included first-pass success and breaches to personal protective equipment. All intubations were performed by specialist (consultant) anaesthetists and video recorded. Twelve anaesthetists performed 36 intubations. Intubation time with no aerosol box was significantly shorter than with the early-generation box (median (IQR [range]) 42.9 (32.9-46.9 [30.9-57.6])s vs. 82.1 (45.1-98.3 [30.8-180.0])s p = 0.002) and the latest-generation box (52.4 (43.1-70.3 [35.7-169.2])s, p = 0.008). No intubations without a box took more than 1 min, whereas 14 (58%) intubations with a box took over 1 min and 4 (17%) took over 2 min (including one failure). Without an aerosol box, all anaesthetists obtained first-pass success. With the early-generation and latest-generation boxes, 9 (75%) and 10 (83%) participants obtained first-pass success, respectively. One breach of personal protective equipment occurred using the early-generation box and seven breaches occurred using the latest-generation box. Aerosol boxes may increase intubation times and therefore expose patients to the risk of hypoxia. They may cause damage to conventional personal protective equipment and therefore place clinicians at risk of infection. Further research is required before these devices can be considered safe for clinical use.

Validation of the soft-embalmed Thiel cadaver as a high-fidelity simulator of pressure during targeted nerve injection.

INTRODUCTION: Although administration of regional anesthesia nerve blocks has increased during the COVID-19 pandemic, training opportunities in regional anesthesia have reduced. Simulation training may enhance skills, but simulators must be accurate enough for trainees to engage in a realistic way-for example, detection of excessive injection pressure. The soft-embalmed Thiel cadaver is a life-like, durable simulator that is used for dedicated practice and mastery learning training in regional anesthesia. We hypothesized that injection opening pressure in perineural tissue, at epineurium and in subepineurium were similar to opening pressures measured in experimental animals, fresh frozen cadavers, glycol soft-fix cadavers and patients. METHODS: We systematically reviewed historical data, then conducted three validation studies delivering a 0.5 mL hydrolocation bolus of embalming fluid and recording injection pressure. First, we delivered the bolus at 12 mL/min at epimysium, perineural tissue, epineurium and in subepineurium at 48 peripheral nerve sites on three cadavers. Second, we delivered the bolus at using three infusion rates: 1 mL/min, 6 mL/min and 12 mL/min on epineurium at 70 peripheral nerve sites on five cadavers. Third, we repeated three injections (12 mL/min) at 24 epineural sites over the median and sciatic nerves of three cadavers. RESULTS: Mean (95%) injection pressure was greater at epineurium compared with subepineurium (geometric ratio 1.2 (95% CI: 0.9 to 1.6)), p=0.04, and perineural tissue (geometric ratio 5.1 (95% CI: 3.7 to 7.0)), p<0.0001. Mean (95%) injection pressure was greater at 12 mL/min compared with 1 mL/min (geometric ratio 1.6 (95% CI: 1.2 to 2.1), p=0.005). Pressure measurements were similar in study 3 (p>0.05 for all comparisons). DISCUSSION: We conclude that the soft-embalmed Thiel cadaver is a realistic simulator of injection opening pressure.

'I'm just ringing to get a repeat prescription for my contraceptive pill, doctor': developing authentic simulated telephone consultations for medical students.

Within normal surgery hours telephone consultations have been previously shown to make up between 10-20% of patient contacts with General Practitioners (GPs) and to comprise a large proportion of a GP's daily workload. Although obviously very useful, such doctor-patient interactions can be fraught with risk. The General Medical Council (GMC) requires that newly graduated doctors should be adaptable to the challenge of delivering treatment advice and management remotely. Yet, currently, there is limited specific training in telephone consultation skills in both undergraduate and postgraduate curricula.Authentic and properly supervised exposure of medical students to GP telephone consultations can be difficult to achieve in clinical placements. Therefore, we have developed emergency telephone consultations within our primary care Safe and Effective Clinical Outcomes (SECO) clinics which are simulated GP surgeries organised for our final year students. We have expanded the range of patients presenting in these clinics by including trained, simulated patients requesting an urgent telephone consultation with a GP. In doing so we aim to enhance our student's skills and confidence in conducting telephone consultations.This teaching exchange paper aims to describe the ideas behind the construction of simulated patient telephone scripts together with the difficulties and successes encountered in introducing telephone consultations into our GP SECO clinic. We hope these ideas and processes will stimulate and enable others to help students prepare for this challenging area of clinical medicine made increasingly significant by the Covid-19 pandemic.

Virtually prepared! Student-led online clinical assessment.

The transition of medical education from a face-to-face to virtual setting due to the ongoing COVID-19 restrictions has been challenging. While both students and educators have now somewhat settled into new teaching methods, from Zoom™ lectures to online tutorials, the adaption of clinical skills teaching to the virtual setting has lagged behind. As a result, many students have been left feeling anxious and concerned about practicing practical and communication skills that are central to being a competent and safe doctor. In light of this, medical students at the Queen's University Belfast General Practice (GP) Society organised a series of virtual, mock Objective Structured Clinical Examinations (OSCEs) for students in Years 2-5 conducted via Zoom™. Medical students and doctors acted as examiners and simulated patients (SPs) with 'breakout rooms' being used to simulate distinct OSCE stations. This collaborative project was well received by participants and doctors alike, who found the virtual OSCEs improved their confidence in performing key clinical skills and virtual consultations. As medical students ourselves, we gained early career exposure to designing and delivering assessments and developed transferable skills, relevant both to medicine and teaching. Lastly, the peer-led approach disrupted the traditional hierarchy in medical education. Students are a key, and often overlooked, resource to overcoming challenges in medical education and educators should encourage students to become involved in medical education at an early stage in their careers.

Aerosol Exposure During Surgical Tracheotomy in SARS-CoV-2 Positive Patients.

INTRODUCTION: Since December 2019, the novel coronavirus SARS-CoV-2 has been spreading worldwide. Since the main route of infection with SARS-CoV-2 is probably via contact with virus-containing droplets of the exhaled air, any method of securing the airway is of extremely high risk for the health care professionals involved. We evaluated the aerosol exposure to the interventional team during a tracheotomy in a semiquantitative fashion. In addition, we present novel protective measures. PATIENTS AND METHODS: To visualize the air movements occurring during a tracheotomy, we used a breathing simulator filled with artificial fog. Normal breathing and coughing were simulated under surgery. The speed of aerosol propagation and particle density in the direct visual field of the surgeon were evaluated. RESULTS: Laminar air flow (LAF) in the OR reduced significantly the aerosol exposure during tracheostomy. Only 4.8 ±â€Š3.4% of the aerosol was in contact with the surgeon. Without LAF, however, the aerosol density in the inspiratory area of the surgeon is 10 times higher (47.9 ±â€Š10.8%, P < 0.01). Coughing through the opened trachea exposed the surgeon within 400 ms with 76.0 ±â€Š8.0% of the aerosol-independent of the function of the LAF. Only when a blocked tube was inserted into the airway, no aerosol leakage could be detected. DISCUSSION: Coughing and expiration during a surgical tracheotomy expose the surgical team considerably to airway aerosols. This is potentially associated with an increased risk for employees being infected by airborne-transmitted pathogens. Laminar airflow in an operating room leads to a significant reduction in the aerosol exposure of the surgeon and is therefore preferable to a bedside tracheotomy in terms of infection prevention. Ideal protection of medical staff is achieved when the procedure is performed under endotracheal intubation and muscle relaxation.

Bacterial Dispersion Associated With Various Patient Face Mask Designs During Simulated Intravitreal Injections.

PURPOSE: We sought to investigate bacterial dispersion with patient face mask use during simulated intravitreal injections. DESIGN: Prospective cross-sectional study. METHODS: Fifteen healthy subjects were recruited for this single-center study. Each participant was instructed not to speak for 2 minutes, simulating a "no-talking" policy, while in an ophthalmic examination chair with an blood agar plate secured to the forehead and wearing various face masks (no mask, loose fitting surgical mask, tight-fitting surgical mask without tape, tight-fitting surgical mask with adhesive tape securing the superior portion of the mask, N95 mask, and cloth mask). Each scenario was then repeated while reading a 2-minute script, simulating a talking patient. The primary outcome measures were the number of colony-forming units (CFUs) and microbial species. RESULTS: During the "no-talking" scenario, subjects wearing a tight-fitting surgical mask with tape developed fewer CFUs compared with subjects wearing the same mask without tape (difference 0.93 CFUs [95% confidence interval 0.32-1.55]; P = .003). During the speech scenarios, subjects wearing a tight-fitting surgical mask with tape had significantly fewer CFUs compared with subjects without a face mask (difference 1.07 CFUs; P = .001), subjects with a loose face mask (difference 0.67 CFUs; P = .034), and subjects with a tight face mask without tape (difference 1.13 CFUs; P < .001). There was no difference between those with a tight-fitting surgical mask with tape and an N95 mask in the "no-talking" (P > .99) and "speech" (P = .831) scenarios. No oral flora were isolated in "no-talking" scenarios but were isolated in 8 of 75 (11%) cultures in speech scenarios (P = .02). CONCLUSION: The addition of tape to the superior portion of a patient's face mask reduced bacterial dispersion during simulated intravitreal injections and had no difference in bacterial dispersion compared with wearing N95 masks.

Alternative approaches for clinical clerkship during the COVID-19 pandemic: online simulated clinical practice for inpatients and outpatients-A mixed method.

BACKGROUND: The COVID-19 pandemic has created a need for educational materials and methods that can replace clinical clerkships (CCs) for online simulated clinical practice (online-sCP). This study evaluates the impact of using simulated electronic health records (sEHR) for inpatients, and electronic problem-based learning (e-PBL) and online virtual medical interviews (online-VMI) for outpatients, for an online-sCP using a learning management system (LMS) and online meeting system facilitated by a supervising physician. METHODS: The sEHR was reviewed by medical students and subsequently discussed with a supervising physician using an online meeting system. In the e-PBL, medical students reviewed the simulated patients and discussed on the LMS. For the online-VMI, a faculty member acted as an outpatient and a student acted as the doctor. Small groups of students discussed the clinical reasoning process using the online meeting system. A mixed-method design was implemented. Medical students self-assessed their clinical competence before and after the online-sCP. They answered questionnaires and participated in semi-structured focus group interviews (FGIs) regarding the advantages and disadvantages of the practice. RESULTS: Forty-three students completed the online-sCP during May and June 2020. All students indicated significant improvement in all aspects of self-evaluation of clinical performance after the online-sCP. Students using sEHR reported significant improvement in writing daily medical records and medical summaries. Students using e-PBL and online-VMI reported significant improvement in medical interviews and counseling. Students also indicated CCs as more useful for learning associated with medical interviews, physical examinations, and humanistic qualities like professionalism than the online-sCP. Eight FGIs were conducted (n = 42). The advantages of online-sCP were segregated into five categories (learning environment, efficiency, accessibility, self-paced learning, and interactivity); meanwhile, the disadvantages of online-sCP were classified into seven categories (clinical practice experience, learning environment, interactivity, motivation, memory retention, accessibility, and extraneous cognitive load). CONCLUSIONS: Online-sCP with sEHR, e-PBL, and online-VMI could be useful in learning some of the clinical skills acquired through CC. These methods can be implemented with limited preparation and resources.