Using Virtual Reality Simulation Environments to Assess Competence for Emergency Medicine Learners.

Immersive learning environments that use virtual simulation (VS) technology are increasingly relevant as medical learners train in an environment of restricted clinical training hours and a heightened focus on patient safety. We conducted a consensus process with a breakout group of the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change Through Health Care Simulation: Systems, Competency, and Outcomes." This group examined the current uses of VS in training and assessment, including limitations and challenges in implementing VS into medical education curricula. We discuss the role of virtual environments in formative and summative assessment. Finally, we offer recommended areas of focus for future research examining VS technology for assessment, including high-stakes assessment in medical education. Specifically, we discuss needs for determination of areas of focus for VS training and assessment, development and exploration of virtual platforms, automated feedback within such platforms, and evaluation of effectiveness and validity of VS education.

A Novel Multiplayer Screen-Based Simulation Experience for African Learners Improved Confidence in Management of Postpartum Hemorrhage.

INTRODUCTION: Postpartum hemorrhage (PPH) remains a global challenge, affecting thirteen million women each year. In addition, PPH is a leading cause of maternal mortality in Asia and Africa. In the U.S.A., care of critically ill patients is often practiced using mannequin-based simulation. Mannequin-based simulation presents challenges in global health, particularly in low- or middle-income countries. We developed a novel multiplayer screen-based simulation in a virtual world enabling the practice of team coordination with PPH. We used this simulation with learners in Mulago, Uganda. We hypothesized that a multiplayer screen-based simulation experience would increase learner confidence in their ability to manage PPH. METHODS: The study design was a simple pre- and a post-intervention survey. Forty-eight interprofessional subjects participated in one of nine 1-h simulation sessions using the PPH software. A fifteen-question self-assessment administered before and after the intervention was designed to probe the areas of learning as defined by Bloom and Krathwohl: affective, cognitive, and psychomotor. RESULTS: Combined confidence scores increased significantly overall following the simulation experience and individually in each of the three categories of Bloom's Taxonomy: affective, cognitive, and psychomotor. CONCLUSION: We provide preliminary evidence that multiplayer screen-based simulation represents a scalable, distributable form of learning that may be used effectively in global health education and training. Interestingly, despite our intervention being screen-based, our subjects showed improved confidence in their ability to perform psychomotor tasks. Although there is precedent for mental rehearsal improving performance, further research is needed to understand this finding.

Toward Designing Information Display to Support Critical Care. A Qualitative Contextual Evaluation and Visioning Effort.

OBJECTIVES: Electronic health information overload makes it difficult for providers to quickly find and interpret information to support care decisions. The purpose of this study was to better understand how clinicians use information in critical care to support the design of improved presentation of electronic health information. METHODS: We conducted a contextual analysis and visioning project. We used an eye-tracker to record 20 clinicians' information use activities in critical care settings. We played video recordings back to clinicians in retrospective cued interviews and queried: 1) context and goals of information use, 2) impacts of current display design on use, and 3) processes related to information use. We analyzed interview transcripts using grounded theory-based content analysis techniques and identified emerging themes. From these, we conducted a visioning activity with a team of subject matter experts and identified key areas for focus of design and research for future display designs. RESULTS: Analyses revealed four unique critical care information use activities including new patient assessment, known patient status review, specific directed information seeking, and review and prioritization of multiple patients. Emerging themes were primarily related to a need for better representation of dynamic data such as vital signs and laboratory results, usability issues associated with reducing cognitive load and supporting efficient interaction, and processes for managing information. Visions for the future included designs that: 1) provide rapid access to new information, 2) organize by systems or problems as well as by current versus historical patient data, and 3) apply intelligence toward detecting and representing change and urgency. CONCLUSIONS: The results from this study can be used to guide the design of future acute care electronic health information display. Additional research and collaboration is needed to refine and implement intelligent graphical user interfaces to improve clinical information organization and prioritization to support care decisions.

Operating Room-to-ICU Patient Handovers: A Multidisciplinary Human-Centered Design Approach.

BACKGROUND: Patient handovers (handoffs) following surgery have often been characterized by poor teamwork, unclear procedures, unstructured processes, and distractions. A study was conducted to apply a human-centered approach to the redesign of operating room (OR)-to-ICU patient handovers in a broad surgical ICU (SICU) population. This approach entailed (1) the study of existing practices, (2) the redesign of the handover on the basis of the input of hand over participants and evidence in the medical literature, and (3) the study of the effects of this change on processes and communication. METHODS: The Durham [North Carolina] Veterans Affairs Medical Center SICU is an 11-bed mixed surgical specialty unit. To understand the existing process for receiving postoperative patients in the SICU, ethnographic methods-a series of observations, surveys, interviews, and focus groups-were used. The handover process was redesigned to better address providers' work flow, information needs, and expectations, as well as concerns identified in the literature. RESULTS: Technical and communication flaws were uncovered, and the handover was redesigned to address them. For the 49 preintervention and 49 postintervention handovers, the information transfer score and number of interruptions were not significantly different. However, staff workload and team behaviors scores improved significantly, while the hand over duration was not prolonged by the new process. Handover participants were also significantly more satisfied with the new handover method. CONCLUSIONS: An HCD approach led to improvements in the patient handover process from the OR to the ICU in a mixed adult surgical population. Although the specific handover process would unlikely be optimal in another clinical setting if replicated exactly, the HCD foundation behind the redesign process is widely applicable.

Leveraging Health Care Simulation Technology for Human Factors Research: Closing the Gap Between Lab and Bedside.

OBJECTIVE: We describe health care simulation, designed primarily for training, and provide examples of how human factors experts can collaborate with health care professionals and simulationists-experts in the design and implementation of simulation-to use contemporary simulation to improve health care delivery. BACKGROUND: The need-and the opportunity-to apply human factors expertise in efforts to achieve improved health outcomes has never been greater. Health care is a complex adaptive system, and simulation is an effective and flexible tool that can be used by human factors experts to better understand and improve individual, team, and system performance within health care. METHOD: Expert opinion is presented, based on a panel delivered during the 2014 Human Factors and Ergonomics Society Health Care Symposium. RESULTS: Diverse simulators, physically or virtually representing humans or human organs, and simulation applications in education, research, and systems analysis that may be of use to human factors experts are presented. Examples of simulation designed to improve individual, team, and system performance are provided, as are applications in computational modeling, research, and lifelong learning. CONCLUSION: The adoption or adaptation of current and future training and assessment simulation technologies and facilities provides opportunities for human factors research and engineering, with benefits for health care safety, quality, resilience, and efficiency. APPLICATION: Human factors experts, health care providers, and simulationists can use contemporary simulation equipment and techniques to study and improve health care delivery.

Twitter-Augmented Journal Club: Educational Engagement and Experience So Far.

Social media is a nascent medical educational technology. The benefits of Twitter include (1) easy adoption; (2) access to experts, peers, and patients across the globe; (3) 24/7 connectivity; (4) creation of virtual, education-based communities using hashtags; and (5) crowdsourcing information using retweets. We report on a novel Twitter-augmented journal club for anesthesia residents: its design, implementation, and impact. Our inaugural anesthesia Twitter-augmented journal club succeeded in engaging the anesthesia community and increasing residents' professional use of Twitter. Notably, our experience suggests that anesthesia residents are willing to use social media for their education.

Simulation in Neurosurgery-A Brief Review and Commentary.

Neurosurgery is one of the most technically demanding and liable of all medical professionals. More than 75% of neurosurgical errors are deemed as preventable and technical in nature. Yet in a specialty that requires such high level of technical expertise, with large consequences for error, there are even fewer opportunities for residents in training to practice on the most complicated cases. Although there is no replacement for actual experiences in the operating room, interpersonal mentorship, coaching, and training, there is room to supplement residency education through simulation. Here we review the evidence to support surgical simulation, describe the strengths and weaknesses of existing technologies in direct neurosurgery specific and indirect simulation applications, and advocate for the development of more neurosurgery-specific applications using emerging kinetic technologies.

Patient load effects on response time to critical arrhythmias in cardiac telemetry: a randomized trial.

OBJECTIVES: Remotely monitored patients may be at risk for a delayed response to critical arrhythmias if the telemetry watchers who monitor them are subject to an excessive patient load. There are no guidelines or studies regarding the appropriate number of patients that a single watcher may safely and effectively monitor. Our objective was to determine the impact of increasing the number of patients monitored on response time to simulated cardiac arrest. DESIGN: Randomized trial. SETTING: Laboratory-based experiment. SUBJECTS: Forty-two remote telemetry technicians and nurses from cardiac units. INTERVENTIONS: Number of patients monitored in a simulation of cardiac telemetry monitoring work. MEASUREMENTS AND MAIN RESULTS: We carried out a study to compare response times to ventricular fibrillation across five patient loads: 16, 24, 32, 40, and 48 patients. The simulation replicated the work of telemetry watchers using a combination of real recorded patient electrocardiogram signals and a simulated patient experiencing ventricular fibrillation. Study participants were assigned to one of the five patient loads and completed a 4-hour monitoring session, during which they performed tasks-including event documentation and phone calls to report events-similar to real monitoring work. When the simulated patient sustained ventricular fibrillation, the time required to report this arrhythmia was recorded. As patient loads increased, there was a statistically significant increase in response times to the ventricular fibrillation. In addition, frequency of failure to meet a response time goal of less than 20 seconds was significantly higher in the 48-patient condition than in all other conditions. Task performance decreased as patient load increased. CONCLUSIONS: As participants monitored more patients in a laboratory setting, their performance with respect to recognizing critical and noncritical events declined. This study has implications for the design of remote telemetry work and other patient monitoring tasks in critical and intermediate care units.

Standardized assessment for evaluation of team skills: validity and feasibility.

INTRODUCTION: The authors developed a Standardized Assessment for Evaluation of Team Skills (SAFE-TeamS) in which actors portray health care team members in simulated challenging teamwork scenarios. Participants are scored on scenario-specific ideal behaviors associated with assistance, conflict resolution, communication, assertion, and situation assessment. This research sought to provide evidence of the validity and feasibility of SAFE-TeamS as a tool to support the advancement of science related to team skills training. METHODS: Thirty-eight medical and nursing students were assessed using SAFE-TeamS before and after team skills training. The SAFE-TeamS pretraining and posttraining scores were compared, and participants were surveyed. Generalizability analysis was used to estimate the variance in scores associated with the following: examinee, scenario, rater, pretraining/posttraining, examinee type, rater type (actor-live vs. external rater-videotape), actor team, and scenario order. RESULTS: The SAFE-TeamS scores reflected improvement after training and were sensitive to individual differences. Score variance due to rater was low. Variance due to scenario was moderate. Estimates of relative reliability for 2 raters and 8 scenarios ranged from 0.6 to 0.7. With fixed scenarios and raters, 2 raters and 2 scenarios, reliability is greater than 0.8. Raters believed SAFE-TeamS assessed relevant team skills. Examinees' responses were mixed. CONCLUSIONS: The SAFE-TeamS was sensitive to individual differences and team skill training, providing evidence for validity. It is not clear whether different scenarios measure different skills and whether the scenarios cover the necessary breadth of skills. Use of multiple scenarios will support assessment across a broader range of skills. Future research is required to determine whether assessments using SAFE-TeamS will translate to performance in clinical practice.

To die or not to die? A review of simulated death.

SUMMARY STATEMENT: Simulation as an educational technique is increasingly used in health care to teach about managing critical events and life-threatening situations and, infrequently, to teach about death. There is considerable controversy over whether to allow the simulator to die during a session when death is not a predefined learning objective. Some educators never allow the simulator to die unless death is the objective of the scenario, and others allow the simulator to die unexpectedly during any scenario. We do not know whether such a fatal event may affect a student's learning process and emotions, and no randomized trials have been conducted to determine the impact of simulated death. In this narrative review, we survey the literature on simulated death during health care training, present arguments for and against the broad incorporation of such training in curricula for health care providers, and outline recommendations for using death scenarios in health care simulation.

A Cognitive Modeling Approach to Decision Support Tool Design for Anesthesia Provider Crisis Management.

Prior research has revealed existing operating room (OR) patient monitors to provide limited support for prompt and accurate decision making by anesthesia providers during crises. Decision support tools (DSTs) developed for this purpose typically alert the anesthesia provider to existence of a problem but do not recommend a treatment plan. There is a need for a human-centered approach to the design and development of a crisis management DST. A hierarchical task analysis was conducted to identify anesthesia provider procedures in detecting, diagnosing, and treating a critical incident and a cognitive task analysis to elicit goals, decisions, and information requirements. This information was coded in a computational cognitive model using GOMS (Goals, Operators, Methods, Selection rules) Language. An OR monitor interface was prototyped to present output from the cognitive model following ecological interface design principles. A preliminary assessment of the DST was performed with anesthesiology and usability experts. The anesthesiologists indicated they would use the tool in the perioperative environment and would recommend its use by junior anesthesia providers. Future research will focus on formal validation of the DST design approach and comparison of tool output to actual anesthesia provider decisions in real or simulated crises.

The "Simulation Roulette" game.

INTRODUCTION: "Simulation Roulette" is a new method of "on-the-fly" simulation scenario creation that incorporates a game-like approach to critical scenarios and emphasizes prescenario preparation. We designed it to complement our traditional anesthesia simulation curriculum, in which residents are exposed to predefined "critical" scenarios. During typical scenarios, trainees are often given minimum preparatory information; they then start the scenario knowing only that "something bad" is going to happen. As a result, trainees often report anxiety, which can be a barrier to learning. To overcome this barrier and to augment traditional critical incident training, we developed the "Simulation Roulette" game. METHODS: "Simulation Roulette" consists of premade cards that are randomly selected to create a patient, another set of premade cards to assist in selecting "complications," worksheets to guide a thorough "prebrief" discussion before the scenario, and scoresheets to facilitate the "debrief" discussion at the end. Similar to traditional scenarios, it requires coordination by a facilitator to ensure plausible scenarios and evaluation of trainee performance. RESULTS: Although we have not conducted formal testing, we believe that (1) incorporating an element of random chance to scenario selection, (2) using a game-like framework, and (3) emphasizing the "prebrief" portion of simulation all have the potential to decrease trainee anxiety. CONCLUSIONS: We present the rationale for designing such a game; examples of instructions, cards, and scoresheets; and our initial experience with implementing this game within our simulation curriculum.

Teamwork training with nursing and medical students: does the method matter? Results of an interinstitutional, interdisciplinary collaboration.

OBJECTIVES: The authors conducted a randomised controlled trial of four pedagogical methods commonly used to deliver teamwork training and measured the effects of each method on the acquisition of student teamwork knowledge, skills, and attitudes. METHODS: The authors recruited 203 senior nursing students and 235 fourth-year medical students (total N = 438) from two major universities for a 1-day interdisciplinary teamwork training course. All participants received a didactic lecture and then were randomly assigned to one of four educational methods didactic (control), audience response didactic, role play and human patient simulation. Student performance was assessed for teamwork attitudes, knowledge and skills using: (a) a 36-item teamwork attitudes instrument (CHIRP), (b) a 12-item teamwork knowledge test, (c) a 10-item standardised patient (SP) evaluation of student teamwork skills performance and (d) a 20-item modification of items from the Mayo High Performance Teamwork Scale (MHPTS). RESULTS: All four cohorts demonstrated an improvement in attitudes (F(1,370) = 48.7, p = 0.001) and knowledge (F(1,353) = 87.3, p = 0.001) pre- to post-test. No educational modality appeared superior for attitude (F(3,370) = 0.325, p = 0.808) or knowledge (F(3,353) = 0.382, p = 0.766) acquisition. No modality demonstrated a significant change in teamwork skills (F(3,18) = 2.12, p = 0.134). CONCLUSIONS: Each of the four modalities demonstrated significantly improved teamwork knowledge and attitudes, but no modality was demonstrated to be superior. Institutions should feel free to utilise educational modalities, which are best supported by their resources to deliver interdisciplinary teamwork training.