Simulating extracorporeal membrane oxygenation emergencies to improve human performance. Part I: methodologic and technologic innovations.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a form of long-term cardiopulmonary bypass used to treat infants, children, and adults with respiratory and/or cardiac failure despite maximal medical therapy. Mechanical emergencies on extracorporeal membrane oxygenation (ECMO) have an associated mortality of 25%. Thus, acquiring and maintaining the technical, behavioral, and critical thinking skills necessary to manage ECMO emergencies is essential to patient survival. Traditional training in ECMO management is primarily didactic in nature and usually complemented with varying degrees of hands-on training using a water-filled ECMO circuit. These traditional training methods do not provide an opportunity for trainees to recognize and interpret real-time clinical cues generated by human patients and their monitoring equipment. Adult learners are most likely to acquire such skills in an active learning environment. To provide authentic, intensive, interactive ECMO training without risk to real patients, we used methodologies pioneered by the aerospace industry and our experience developing a simulation-based training program in neonatal resuscitation to develop a similar simulation-based training program in ECMO crisis management, ECMO Sim. METHODS: A survey was conducted at the 19th Annual Children's National Medical Center ECMO Symposium to determine current methods for ECMO training. Using commercially available technology, we linked a neonatal manikin with a standard neonatal ECMO circuit primed with artificial blood. Both the manikin and circuit were placed in a simulated neonatal intensive care unit environment equipped with remotely controlled monitors, real medical equipment and human colleagues. Twenty-five healthcare professionals, all of whom care for patients on ECMO and who underwent traditional ECMO training in the prior year, participated in a series of simulated ECMO emergencies. At the conclusion of the program, subjects completed a questionnaire qualitatively comparing ECMO Sim with their previous traditional ECMO training experience. The amount of time spent engaged in active and passive activities during both ECMO Sim and traditional ECMO training was quantified by review of videotape of each program. RESULTS: Hospitals currently use lectures, multiple-choice exams, water drills, and animal laboratory testing for their ECMO training. Modification of the circuit allowed for physiologically appropriate circuit pressures (both pre- and postoxygenator) to be achieved while circulating artificial blood continuously through the circuit and manikin. Realistic changes in vital signs on the bedside monitor and fluctuations in the mixed venous oxygen saturation monitor were also effectively achieved remotely. All subjects rated the realism of the scenarios as good or excellent and described ECMO Sim as more effective than traditional ECMO training. They reported that ECMO Sim engaged their intellect to a greater degree and better developed their technical, behavioral, and critical thinking skills. Active learning (eg, hands-on activities) comprised 78% of the total ECMO Sim program compared with 14% for traditional ECMO training (P < 0.001). Instructor-led lectures predominated in traditional ECMO training. CONCLUSION: Traditional ECMO training programs have yet to incorporate simulation-based methodology. Using current technology it is possible to realistically simulate in real-time the clinical cues (visual, auditory, and tactile) generated by a patient on ECMO. ECMO Sim as a training program provides more opportunities for active learning than traditional training programs in ECMO management and is overwhelmingly preferred by the experienced healthcare professionals serving as subjects in this study. Subjects also indicated that they felt that the acquisition of key cognitive, technical, and behavioral skills and transfer of those skills to the real medical domain was better achieved during simulation-based training.

Simulating extracorporeal membrane oxygenation emergencies to improve human performance. Part II: assessment of technical and behavioral skills.

BACKGROUND: Healthcare professionals are expected to make rapid, correct decisions in critical situations despite what may be a lack of real practical experience in a particular crisis situation. Successful resolution of a medical crisis depends upon demonstration not only of appropriate technical skills but also of key behavioral skills (eg, leadership, communication, and teamwork). We have developed a hands-on, high fidelity, simulation-based training program (ECMO Sim) to provide healthcare professionals with the opportunity to learn and practice the technical and behavioral skills necessary to manage ECMO emergencies. METHODS: Nine ECMO nurse specialists participated in two sequential randomly assigned simulated ECMO emergencies. The simulated emergencies were captured on videotape and reviewed with the subjects during facilitated debriefings that occurred immediately following each scenario. All videotapes were scored for key technical and behavioral skills by reviewers blinded to the sequence of the scenarios. The ratings of the subjects' technical and behavioral skills in each scenario were compared. RESULTS: Subjects performed key technical skills correctly more often in the second simulated ECMO emergency. In addition, their response times for three out of five specific technical tasks improved from the first to the second simulated emergency by an average of 27 seconds. Subjects' behavioral skills were rated more highly by masked reviewers in the second simulated ECMO emergency. The improvement in comprehensive behavioral scores from the first to the second scenario reached statistical significance in eight of nine subjects. CONCLUSION: After exposure to high-fidelity simulated ECMO emergencies, subjects demonstrated significant improvements in their technical and behavioral skills. ECMO Sim creates a learning environment that readily supports the acquisition of the technical and behavioral skills that are important in solving clinically significant, potentially life-threatening problems that can occur when patients are on ECMO.