Establishment of a simulation centre: Challenges and solutions.

The change in curriculum and increasing need for active healthcare professionals providing quality patient care has emphasised simulation-based regular training, reskilling and simulation centres to deliver these. However, there is limited literature on how to establish a simulation centre and overcome the challenges relating to developing faculty and maintaining the financial viability of these centres. Our review focuses on this gap in the current literature. The findings are presented as 1) identification of the methods of establishing a simulation centre, 2) setting up the resource in a simulation centre and 3) faculty development and curricular integration in a simulation centre. The space of a simulation centre depends on the organisation's or training body's needs. There is no single design which is recommended. Establishing a simulation centre should consider the needs of the organisation, educators and learners along with the available resources and ensure that curriculum integration and standards are met.

Impact of repeated simulation on learning curve characteristics of residents exposed to rare life threatening situations.

Background: Little is known about the learning curve characteristics of residents undertaking simulation-based education. It is important to understand the time for acquisition and decay of knowledge and skills needed to manage rare and difficult clinical situations. Method: Ten anaesthesiology residents underwent simulation-based education to manage a cannot intubate cannot ventilate scenario during general anaesthesia for caesarean section. Their performance was measured using an assessment tool and debriefed by two experienced anaesthesiologists. The parameters against which the performance was judged were grouped into preoperative assessment, preoperative patient care, equipment availability, induction sequence, communication and adherence to airway algorithm protocol. The scenario was repeated at 6 and 12 months thereafter. The residents' acquisition of knowledge, technical and non-technical skills were assessed and compared at baseline, 6 months and end of 12 months. Result: The skills of preoperative assessment, preoperative care and communication quickly improved but the specific skill of managing a difficult airway as measured by adherence to an airway algorithm required more than 6 months (CI at 6 vs 12 months: -3.4 to -0.81, p=0.016). The skills of preoperative assessment and preoperative care improved to a higher level quickly and were retained at this improved level. Communication (CI at 0 vs 6 months: -3.78 to -0.22, p=0.045 and at 6 vs 12 months : -3.39 to -1.49, p=0.007) and difficult airway management skill were slower to improve but continued to do so over the 12 months. The compliance to machine check was more gradual and showed an improvement at 12 months. Conclusion: Our study is unique in analysing the learning curve characteristics of different components of a failed obstetric airway management skill. Repeated simulations over a longer period of time help in better reinforcement, retention of knowledge, recapitulation and implementation of technical and non-technical skills.

Simulation-based education to improve communication skills: a systematic review and identification of current best practice.

Background: Good communication in healthcare between professionals and between professionals and patients is important in delivering high-quality care. Evidence of translation of technical skills taught through simulation into the clinical environment has been demonstrated, but the evidence for the impact of communication skills is less well known. Objectives: To identify and critically appraise the evidence for the impact of communication taught through simulation-based education (SBE) and use this evidence to suggest a model for future SBE interventions for communication skills. Study selection: MEDLINE, CINAHL, EMBASE and PsycINFO were searched for articles pertaining to communication skills taught through simulation. A content expert was consulted to suggest additional studies. 1754 studies were initially screened for eligibility, with 274 abstracts screened further. 147 full-text articles were further assessed for eligibility, with 79 of these excluded. The remaining 68 studies were reviewed and 18 studies were included in the qualitative synthesis as studies designed to show benefits beyond the simulation centre. Findings: The 18 identified studies with an impact at a Kirkpatrick level of ≥3, are analysed; 4 looking specifically at communication between healthcare professionals and 14 looking at communication between health professionals and patients or relatives. Conclusions: There is some evidence that the improvements in communication taught through simulation can be translated into benefits measurable beyond the simulation centre, but this evidence is limited due to the way that most of the studies are designed. We suggest a model for SBE aimed at teaching communication skills that is informed by the current evidence and takes into account the need to collect higher-level outcome data.

ASPiH standards for simulation-based education: process of consultation, design and implementation.

There is widespread enthusiasm and emerging evidence of the efficacy of simulation-based education (SBE) but the full potential of SBE has not been explored. The Association for Simulated Practice in Healthcare (ASPiH) is a not-for-profit membership association with members from healthcare, education and patient safety background. ASPiH's National Simulation Development Project in 2012 identified the lack of standardisation in the approach to SBE with failure to adopt best practice in design and delivery of SBE programmes. ASPiH created a standards project team in 2015 to address this need. The article describes the iterative process modelled on implementation science framework, spread over six stages and 2 years that resulted in the creation of the standards. The consultation process supported by Health Education England resulted in a unique document that was driven by front line providers while also having strong foundations in evidence base. The final ASPiH document consisting of 21 standards for SBE has been extensively mapped to regulatory and professional bodies in the UK and abroad ensuring that the document is relevant to a wide healthcare audience. Underpinning the standards is a detailed guidance document that summarises the key literature evidence to support the standard statements. It is envisaged the standards will be widely used by the simulation community for quality assurance and improving the standard of SBE delivered.

Comparison of oral and video debriefing and its effect on knowledge acquisition following simulation-based learning.

Introduction: Learning from simulation takes place to a large extent in debriefing; however, there is still sparse knowledge about the advantages and disadvantages of debriefing methods. 2 common forms are video-assisted and oral only debriefing. We set out to determine if there is increased knowledge acquisition for candidates undergoing video, rather than oral debriefing. Methods: Second year doctors were randomised to a training day with oral or video feedback. Candidates underwent an emergency clinical scenario followed by feedback. The candidates completed 30 multiple choice questions related to managing common clinical emergencies presimulation and postsimulation training. Results: There was no significant difference in the postscore mean for the oral debriefing (128.3, SD 5.16) and video-assisted debriefing group (127.1, SD=5.96). There was significant interaction between precourse and postcourse scores with superior knowledge acquisition for candidates with lower precourse scores (p=0.008). The candidates with lowest precourse score showed significant improvement in the orally debriefed group in comparison to video debriefed group. Discussion: Our results showed that video debriefing has equivocal effect to oral debriefing. Oral debriefing provides superior knowledge acquisition to learners with lower precourse test scores.

A randomized control trial comparing use of a novel electrocardiogram simulator with traditional teaching in the acquisition of electrocardiogram interpretation skill.

BACKGROUND: Accurate interpretation of the electrocardiogram (ECG) remains an essential skill for medical students and junior doctors. While many techniques for teaching ECG interpretation are described, no single method has been shown to be superior. PURPOSE: This randomized control trial is the first to investigate whether teaching ECG interpretation using a computer simulator program or traditional teaching leads to improved scores in a test of ECG interpretation among medical students and postgraduate doctors immediately after and 3months following teaching. Participants' opinions of the program were assessed using a questionnaire. CONCLUSIONS: There were no differences in ECG interpretation test scores immediately after or 3months after teaching in the lecture or simulator groups. At present therefore, there is insufficient evidence to suggest that ECG simulator programs are superior to traditional teaching.

Teaching the interpretation of electrocardiograms: which method is best?

BACKGROUND: Electrocardiogram (ECG) interpretation is poorly performed at undergraduate and post-graduate level. Incorrect ECG interpretation can lead to serious clinical error. Despite the incorporation of computerized ECG interpretation software into modern ECG machines, the sensitivity and specificity of current technology remain poor, emphasizing the on-going need for doctors to perform ECG interpretation accurately. PURPOSE: This is the first review in this important area and aims to critically evaluate the current literature in relation to the optimal format and method of teaching ECG interpretation at undergraduate and postgraduate level. CONCLUSIONS: No single method or format of teaching is most effective in delivering ECG interpretation skills; however, self-directed learning appears to be associated with poorer interpretation competence. Summative in preference to formative assessment is associated with improved interpretation competence. Web-based learning offers a promising modern approach to learning ECG interpretation, though caution must be exercised in accessing user-uploaded content to supplement learning.

In situ simulation as a tool for patient safety: a systematic review identifying how it is used and its effectiveness.

Background: In situ simulation is an emerging technique involving interdisciplinary teams working through simulated scenarios which replicate events encountered in healthcare institutions, particularly those which are either low frequency or associated with high risk to patients. Since it takes place in the clinical environment, it is ideally suited to improving patient safety outcomes. Objective: To identify and appraise all studies assessing contribution of in situ simulation to patient safety, identify gaps in knowledge and areas for future research, as well as suggesting strategies for maximising its impact on patient safety within an institution. Study selection: Three electronic databases (MEDLINE, PubMed and EMBASE) as well as the Cochrane Library were searched for articles relating to patient safety outcomes in in situ simulation. In addition a subject expert was approached to suggest any additional articles not identified by electronic searches. A total of 1795 abstracts were identified and screened, 35 full articles assessed for eligibility for inclusion and a total of 18 full articles included in the review after unsuitable articles were excluded. Conclusions: In situ simulation can improve real-life patient safety outcomes, with 2 studies demonstrating improved morbidity and mortality outcomes following initiation of in situ simulation. There is good evidence to suggest that its implementation leads to improved clinical skills, teamwork and observed behaviours. Additionally, it is ideally suited to detecting latent safety errors (errors identified within a scenario which, if they had occurred in real life, could have led to a degree of harm occurring to a patient).

CUSUM analysis to assess competence: what failure rate is acceptable?

INTRODUCTION: Cumulative sum (CUSUM) analysis is used to assess competency in practical procedures. Previous studies have used CUSUM to assess competence in administering labour epidural, but these assessments were mainly performed with novice trainees. Different acceptable failure rates for the same procedure, such as administering labour epidural, have been used. In this article, we describe our experience of using CUSUM for the continuing assessment of competence among experienced trainees. We also tested the hypothesis that setting different failure rates can lead to different conclusions about a trainee's competency. METHODS: After obtaining departmental approval, we collected the records of the first 50 labour epidurals performed by trainees at specialty training (ST) 3/4 level, and plotted two CUSUM graphs for each trainee. For the first CUSUM graph, we used 10 and 20 per cent as acceptable and unacceptable failure rates, respectively. In the second CUSUM graph, we used 15 and 30 per cent as acceptable and unacceptable failure rates, respectively. RESULTS: We analysed the CUSUM data of six trainees. With 10 and 20 per cent as acceptable and unacceptable failure rates, only four trainees demonstrated competence. The median number of attempts required was 25, with a range of 25-32 attempts. However, with 15 and 30 per cent used as the acceptable and unacceptable failure rates, five out of six trainees demonstrated competence, with a median of 18 and range of 14-33 attempts. DISCUSSION: Our study shows that CUSUM analysis can be successfully used for the continued assessment of competence in experienced trainees. It also shows that setting different failure rates can produce different results, leading to confusion and inconsistency when comparing CUSUM results. With the increasing use of CUSUM analysis, we believe that the organisations responsible for training, such as the Royal College of Anaesthetists, should provide guidance on what is an acceptable failure rate for different procedures, such as the administration of an epidural during labour, at different stages of training.

Unexpected prolonged neuromuscular block after mivacurium: a case report.

OBJECTIVE: To present a case of unexpected prolonged apnoea following the administration of mivacurium, a short-acting muscle relaxant and to identify the factors for early diagnosis and management. CLINICAL PRESENTATION AND INTERVENTION: A 19-year-old physically fit lady without personal or family history suggestive of anaesthetic problems had an excision of fibro-adenoma from the breast. She did not recover as quickly as was expected from the anaesthetic, which included the administration of mivacurium. She had prolonged neuromuscular blockade. She was kept ventilated and sedated. Five hours after the last dose of mivacurium, she showed signs of spontaneous respiration and at 6 h she was extubated and fully recovered. It was shown later that the patient had a pseudocholinesterase deficiency. CONCLUSION: Pseudocholinesterase deficiency is an uncommon occurrence but should be highly suspected in cases of prolonged paralysis following the administration of a short-acting muscle relaxant. The use of a nerve stimulator is recommended whenever muscle relaxants are used. Muscle relaxants should be used only when facilities for prolonged ventilation are available.