Understanding the Effects of Health Care Distance Simulation: A Systematic Review.

ABSTRACT: The use of distance simulation has rapidly expanded in recent years with the physical distance requirements of the COVID-19 pandemic. With this development, there has been a concurrent increase in research activities and publications on distance simulation. The authors conducted a systematic review of the peer-reviewed distance health care simulation literature. Data extraction and a risk-of-bias assessment were performed on selected articles. Review of the databases and gray literature reference lists identified 10,588 titles for review. Of those, 570 full-text articles were assessed, with 54 articles included in the final analysis. Most of these were published during the COVID-19 pandemic (2020-2022). None of the included studies examined an outcome higher than a Kirkpatrick level of 2. Most studies only examined low-level outcomes such as satisfaction with the simulation session. There was, however, a distinction in studies that were conducted in a learning environment where all participants were in different locations ("distance only") as compared with where some of the participants shared the same location ("mixed distance"). This review exclusively considered studies that focused solely on distance. More comparative studies exploring higher level outcomes are required to move the field forward.

Distance simulation in the health professions: a scoping review.

BACKGROUND: Distance simulation is defined as simulation experiences in which participants and/or facilitators are separated from each other by geographic distance and/or time. The use of distance simulation as an education technique expanded rapidly with the recent COVID-19 pandemic, with a concomitant increase in scholarly work. METHODS: A scoping review was performed to review and characterize the distance simulation literature. With the assistance of an informationist, the literature was systematically searched. Each abstract was reviewed by two researchers and disagreements were addressed by consensus. Risk of bias of the included studies was evaluated using the Risk of Bias 2 (RoB 2) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tools. RESULTS: Six thousand nine hundred sixty-nine abstracts were screened, ultimately leading to 124 papers in the final dataset for extraction. A variety of simulation modalities, contexts, and distance simulation technologies were identified, with activities covering a range of content areas. Only 72 papers presented outcomes and sufficient detail to be analyzed for risk of bias. Most studies had moderate to high risk of bias, most commonly related to confounding factors, intervention classification, or measurement of outcomes. CONCLUSIONS: Most of the papers reviewed during the more than 20-year time period captured in this study presented early work or low-level outcomes. More standardization around reporting is needed to facilitate a clear and shared understanding of future distance simulation research. As the broader simulation community gains more experience with distance simulation, more studies are needed to inform when and how it should be used.

Setting an Agenda: Results of a Consensus Process on Research Directions in Distance Simulation.

BACKGROUND: The COVID-19 pandemic forced rapid implementation and refinement of distance simulation methodologies in which participants and/or facilitators are not physically colocated. A review of the distance simulation literature showed that heterogeneity in many areas (including nomenclature, methodology, and outcomes) limited the ability to identify best practice. In April 2020, the Healthcare Distance Simulation Collaboration was formed with the goal of addressing these issues. The aim of this study was to identify future research priorities in the field of distance simulation using data derived from this summit. METHODS: This study analyzed textual data gathered during the consensus process conducted at the inaugural Healthcare Distance Simulation Summit to explore participant perceptions of the most pressing research questions regarding distance simulation. Participants discussed education and patient safety standards, simulation facilitators and barriers, and research priorities. Data were qualitatively analyzed using an explicitly constructivist thematic analysis approach, resulting in the creation of a theoretical framework. RESULTS: Our sample included 302 participants who represented 29 countries. We identified 42 codes clustered within 4 themes concerning key areas in which further research into distance simulation is needed: (1) safety and acceptability, (2) educational/foundational considerations, (3) impact, and (4) areas of ongoing exploration. Within each theme, pertinent research questions were identified and categorized. CONCLUSIONS: Distance simulation presents several challenges and opportunities. Research around best practices, including educational foundation and psychological safety, are especially important as is the need to determine outcomes and long-term effects of this emerging field.

Active Bleeding Control - Can Pediatricians Stem the Tide of Lives Lost From Trauma Through 'Stop the Bleed' Training?

Trauma is a global challenge and India has one of the highest trauma deaths in the world. Despite the United Nations' target to halve the global number of deaths and injuries from road traffic crashes by 2030, death tolls from road traffic injuries (RTI) are rising in India. In the pediatric age group, falls from height add to the burden of trauma. Uncontrolled bleeding from exsanguination on scene is estimated to account for nearly 40% of RTI trauma related mortality. Stopping the bleeding in the first few minutes is crucial for meaningful survival and hence the role of training lay public who can reach the scene in minutes. Active bleeding control (ABC) pilot research project to simulation train the bystanders to stop the bleed showed promising outcomes in Hyderabad, India. This paper describes the ABC project and discusses the role of pediatricians in training the public to reduce morbidity and mortality from uncontrolled bleeding at the trauma scene.

Breaking barriers in establishing simulation in India-A collaborative approach by pediatric simulation training and research society (PediSTARS).

Simulation based training (SBT) plays a pivotal role in quality improvement and patient safety. Simulation is not only for training health care professionals but also an excellent tool for systems and facility changes which will potentially improve patient safety and ultimately outcomes. SBT is already established both as a training modality, and as a quality improvement tool in high income countries. It's use in low and middle-income countries (LMIC), including India, however, is sporadic and variable because of multiple barriers. The barriers for establishment of simulation are lack of knowledge about benefits of simulation, psychological resistance, cost, and lack of trained faculty. PediSTARS (Pediatric Simulation Training and Research Society), a simulation society was founded in August 2013 to spread the simulation across India and thus improve the quality and safety of health care using SBT. In this article we discuss various barriers for healthcare simulation in India and also our attempts to overcome some of these barriers by collaborative practice.

Low-Cost "Telesimulation" Training Improves Real Patient Pediatric Shock Outcomes in India.

Introduction: Pediatric shock, especially septic shock, is a significant healthcare burden in low-income countries. Early recognition and management of shock in children improves patient outcome. Simulation-based education (SBE) for shock recognition and prompt management prepares interdisciplinary pediatric emergency teams in crisis management. COVID-19 pandemic restrictions on in-person simulation led us to the development of telesimulation for shock. We hypothesized that telesimulation training would improve pediatric shock recognition, process of care, and patient outcomes in both simulated and real patient settings. Materials and Methods: We conducted a prospective quasi-experimental interrupted time series cohort study over 9 months. We conducted 40 telesimulation sessions for 76 participants in teams of 3 or 4, utilizing the video telecommunication platform (Zoom©). Trained observers recorded time-critical interventions on real patients for the pediatric emergency teams composed of residents, fellows, and nurses. Data were collected on 332 pediatric patients in shock (72% of whom were in septic shock) before, during, and after the intervention. The data included the first hour time-critical intervention checklist, patient hemodynamic status at the end of the first hour, time for the resolution of shock, and team leadership skills in the emergency room. Results: There was a significant improvement in the percent completion of tasks by the pediatric emergency team in simulated scenarios (69% in scenario 1 vs. 93% in scenario 2; p < 0.001). In real patients, completion of tasks as per time-critical steps reached 100% during and after intervention compared to the pre-intervention phase (87.5%), p < 0.05. There was a significant improvement in the first hour hemodynamic parameters of shock patients: pre (71%), during (79%), and post (87%) intervention (p < 0.007 pre vs. post). Shock reversal time reduced from 24 h pre-intervention to 6 h intervention and to 4.5 h post intervention (p < 0.002). There was also a significant improvement in leadership performance assessed by modified Concise Assessment of Leader Management (CALM) instrument during the simulated (p < 0.001) and real patient care in post intervention (p < 0.05). Conclusion: Telesimulation training is feasible and improved the process of care, time-critical interventions, leadership in both simulated and real patients and resolution of shock in real patients. To the best of our knowledge, this is one of the first studies where telesimulation has shown improvement in real patient outcomes.

Simulathon 2020: Integrating Simulation Period Prevalence Methodology Into the COVID-19 Disaster Management Cycle in India.

SUMMARY STATEMENT: The disaster management cycle is an accepted model that encompasses preparation for and recovery from large-scale disasters. Over the past decade, India's Pediatric Simulation Training and Research Society has developed a national-scale simulation delivery platform, termed the Simulathon , with a period prevalence methodology that integrates with core aspects of this model. As an exemplar of the effectiveness of this approach, we describe the development, implementation, and outcomes of the 2020 Simulathon, conducted from April 20 to May 20 in response to the nascent COVID-19 pandemic disaster. We conclude by discussing how aspects of the COVID-19 Simulathon enabled us to address key aspects of the disaster management cycle, as well as challenges that we encountered. We present a roadmap by which other simulation programs in low- and middle-income countries could enact a similar process.

Closing the gap: a call for a common blueprint for remote distance telesimulation.

The physical requirements mandated by the COVID-19 pandemic have presented a challenge and an opportunity for simulation educators. Although there were already examples of simulation being delivered at a distance, the pandemic forced this technique into the mainstream. With any new discipline, it is important for the community to agree on vocabulary, methods and reporting guidelines. This editorial is a call to action for the simulation community to start this process so that we can best describe and use this technique.

A Road Map for Simulation Based Medical Students Training in Pediatrics: Preparing the Next Generation of Doctors.

Current Medical training in India is generally didactic and pedagogical, and often does not systematically prepare newly graduated doctors to be competent, confident and compassionate. After much deliberation, the Medical Council of India (MCI) has recently introduced a new outcome-driven curriculum for undergraduate medical student training with specific milestones and an emphasis on simulation-based learning and guided reflection. Simulation-based education and debriefing (guided reflection) has transformed medical training in many countries by accelerating learning curves, improving team skills and behavior, and enhancing provider confidence and competence. In this article, we provide a broad framework and roadmap suggesting how simulation-based education might be incorporated and contextualized by undergraduate medical institutions, especially for pediatric training, using local resources to achieve the goals of the new MCI competency-based and simulation-enhanced undergraduate curriculum.

¿Debemos simplificar el método o, por el contrario, entrenar más y mejor?... Rompiendo barreras y cambiando la cultura de la Reanimación / Should we "dumb it down"... or "train it up"?... Breaking barriers and changing the culture of resuscitation

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Extracorporeal membrane oxygenation and severe acute respiratory distress secondary to Legionella: 10 year experience.

Legionella-associated respiratory failure has a high mortality, despite modern ventilation modalities. Extracorporeal membrane oxygenation (ECMO) is used to achieve gas exchange independent of pulmonary function in patients with severe respiratory failure. This was a retrospective review of the management and outcome of patients with Legionella-associated respiratory failure treated with ECMO support in a large ECMO center over the past 10 years. A retrospective review of patients with confirmed Legionella-associated severe respiratory failure managed with ECMO support at a single center. Between 2000 and 2010, 19 patients with severe respiratory failure caused by Legionella were managed with ECMO after failure to respond to conventional intensive care management. Median PaO2/FiO2 ratio was 66 and median pCO2 was 60 torr. Sixteen patients (84%) survived to hospital discharge. Extracorporeal membrane oxygenation should be considered in patients with Legionella-associated respiratory failure, who have failed conventional ventilation.

Consistency between guidelines and reported practice for reducing the risk of catheter-related infection in British paediatric intensive care units.

PURPOSE: Optimal strategies for reducing catheter-related blood stream infection (CR-BSI) differ for adults and children. National guidelines do not make child-specific recommendations. We determined whether evidence explained the inconsistencies between guidelines and reported practice in paediatric intensive care units (PICUs). METHODS: We conducted a survey of eight interventions for reducing CR-BSI in all 25 British PICUs in 2009. Interventions were categorised as requiring child-specific evidence, generalisable to adults and children, or organisational recommendations. RESULTS: Twenty-four of the 25 PICUs responded. For child-specific interventions, practice diverged from guidelines for "Insert into subclavian/jugular veins" (18 PICUs frequently used femoral veins, supported by observational evidence for increased safety in children). Practice reflected guidelines for "Use standard but consider antimicrobial-impregnated central venous catheters (CVCs) for high-risk patients" (14 used standard only, 3 used standard and antimicrobial-impregnated despite no randomised controlled trial (RCT) evidence for antimicrobial-impregnated CVCs in children, 7 used heparin-bonded for some or all children); "Use 2% chlorhexidine for skin preparation" (20 PICUs); "Avoid routine CVC replacement" (20 PICUs). For generalisable interventions, practice was consistent with guidelines for "Administration set replacement" (21 PICUs) but deviated for "Maintenance of CVC asepsis" (11 PICUs used alcohol due to inconclusive evidence for chlorhexidine). Practice diverged from guidelines for organisational interventions: "Train healthcare workers in CVC care" (9 PICUs); "Monitor blood stream infection (BSI) rates" (8 PICUs). CONCLUSIONS: Guidelines should explicitly address paediatric practice and report the quality of evidence and strength of recommendations. Organisations should ensure doctors are trained in CVC insertion and invest in BSI monitoring, especially in PICUs. The type of CVC and insertion site are important gaps in evidence for children.

The challenges of prompt identification and resuscitation in children with acute fulminant myocarditis: case series and review of the literature.

AIM: To describe the clinical presentation, triage, resuscitation and outcome of acute fulminant myocarditis in children presenting to district hospitals and referred for cardiac intensive care. METHODS: Case series describing five patients (from 2 weeks to 12 years old) with a diagnosis of acute fulminant myocarditis, presented to outlying hospitals between December 2006 and December 2007 and retrieved to a cardiac intensive care unit. RESULTS: All children were admitted with non-specific symptoms such as vomiting, cough and poor feeding to their local hospital, where various provisional diagnoses such as viral gastroenteritis, bronchitis or renal failure were considered. Acute physiological deterioration usually prompted the referral for intensive care. Two children died at the referring hospital during stabilisation by the retrieval team. Three children survived transport to intensive care and to hospital discharge; two received mechanical support and one underwent urgent orthotopic heart transplantation. Enterovirus and parvovirus were identified as causative agents in two patients. In one case, macrophage activation syndrome was diagnosed although no clear viral trigger was identified. Median length of hospitalisation among survivors was 33 days, and mechanical cardiac support was required for a median of 12 days. CONCLUSIONS: The diagnosis and initial management of acute fulminant myocarditis is extremely challenging. Prognosis for patients admitted to a cardiac centre for early mechanical support can be very favourable, while a delay in considering the diagnosis may result in poor outcome. The diagnosis of myocarditis should be considered in any previously well child presenting with a viral prodrome and non-specific organ dysfunction associated with dysrhythmias, shock or acute heart failure, even in the absence of cardiomegaly.