Simulation in Healthcare

Simulation-Based Mastery Learning to Teach Distal Radius Fracture Reduction Introduction Distal radius fractures are common orthopedic injuries managed in emergency departments. Simulation-based mastery learning is widely recognized to improve provider competence for bedside procedures but has not been studied to teach fracture management. This study evaluated the effectiveness of a simulation-based mastery learning curriculum to teach distal radius fracture reduction to novice orthopedic surgery and emergency medicine residents. Methods We created a novel mastery learning checklist using the Mastery Angoff method of standard setting, paired with a new simulation model designed for this project, to teach orthopedic surgery and emergency medicine interns (N = 22) at the study site. Orthopedic surgery and emergency medicine faculty members participated in checklist development, curriculum design, and implementation. Training included just-in-time asynchronous education with a readiness assessment test, in-classroom expert demonstration, and deliberate practice with feedback. Residents completed a pretest/posttest skills examination and a presurvey/postsurvey assessing procedural confidence. Results Standard setting resulted in a 41-item checklist with minimum passing score of 37/41 items. All participants met or surpassed the minimum passing score on postexamination. Postsurvey confidence levels were significantly higher than presurvey in all aspects of the distal radius fracture procedure (P < 0.05). Conclusions This study demonstrated that a simulation-based mastery learning curriculum improved skills and confidence performing distal radius fracture reductions for orthopedic surgery and emergency medicine interns. Future planned studies include curriculum testing across additional institutions, examination of clinical impact, and application of mastery learning for other orthopedic procedures. Correspondence to: William Dixon, MD, 900 Welch Rd, Suite 350, Palo Alto, CA, 94304 (e-mail: wdixon@stanford.edu). W.D. was the recipient of a grant from the Stanford Teaching and Mentoring Academy to support this project, which will be paid to the Department of Emergency Medicine. The other authors declare no conflict of interest. Work should be attributed to the Stanford Medicine Department of Emergency Medicine. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.simulationinhealthcare.com). © 2020 Society for Simulation in Healthcare

Feasibility of an Interprofessional, Simulation-Based Curriculum to Improve Teamwork Skills, Clinical Skills, and Knowledge of Undergraduate Medical and Nursing Students in Uganda: A Cohort Study Introduction Many deaths in Sub-Saharan Africa are preventable with provision of skilled healthcare. Unfortunately, skills decay after training. We determined the feasibility of implementing an interprofessional (IP) simulation-based educational curriculum in Uganda and evaluated the possible impact of this curriculum on teamwork, clinical skills (CSs), and knowledge among undergraduate medical and nursing students. Methods We conducted a prospective cohort study over 10 months. Students were divided into 4 cohorts based on clinical rotations and exposed to rotation-specific simulation scenarios at baseline, 1 month, and 10 months. We measured clinical teamwork scores (CTSs) at baseline and 10 months; CSs at baseline and 10 months, and knowledge scores (KSs) at baseline, 1 month, and 10 months. We used paired t tests to compare mean CTSs and KSs, as well as Wilcoxon rank sum test to compare group CS scores. Results One hundred five students (21 teams) participated in standardized simulation scenarios. We successfully implemented the IP, simulation-based curriculum. Teamwork skills improved from baseline to 10 months when participants were exposed to: (a) similar scenario to baseline {baseline mean CTS = 55.9% [standard deviation (SD) = 14.4]; 10-month mean CTS = 88.6%; SD = 8.5, P = 0.001}, and (b) a different scenario to baseline [baseline mean CTS = 55.9% (SD = 14.4); 10-month CTS = 77.8% (SD = 20.1), P = 0.01]. All scenario-specific CS scores showed no improvement at 10 months compared with baseline. Knowledge was retained in all scenarios at 10 months. Conclusions An IP, simulation-based undergraduate curriculum is feasible to implement in a low-resource setting and may contribute to gains in knowledge and teamwork skills. Correspondence to: Santorino Data, MMed, Pediatrics and Child Health, Department of Pediatrics and Child Health, Center for Innovation and Technology Transfer, Mbarara University of Science and Technology, Plot 8 - 18, Mbarara - Kabale Road P.O Box 1410, Mbarara, Uganda (e-mail: sdata@must.ac.ug; boymukedata@gmail.com). The authors declare no conflict of interest. Supported by the Laerdal Foundation for Acute Medicine (Grant Number: 40162), the Elma Foundation (Grant Number: 16-F0021), and the International Development Research Center, Canada (Grant Number: 108217-001). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.simulationinhealthcare.com). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2020 Society for Simulation in Healthcare

Is Technology Enhanced Learning Cost-effective to Improve Skills?: The Monash Objective Structured Clinical Examination Virtual Experience Introduction Objective Structured Clinical Examinations (OSCEs) are an accepted technique for evaluation of clinical competence in healthcare. However, the economic imperative requires faculty to control cost, using innovative educational strategies such as virtual simulation. The objective of this study was to evaluate the cost implications of implementing an online interactive learning module [Monash OSCE Virtual Experience (MOVE)]. Methods All fourth-year pharmacy students enrolled in Monash University in 2017 were provided access to MOVE. Cost-minimization analyses were performed to evaluate the cost of introducing MOVE in the pharmacy course using the smallest cohort size (Malaysia campus) of 40 students as the base case. We also determined under what circumstances MOVE would be more cost-effective, considering the different operational situations such as when student numbers increased or when the number of simulation modules created were increased. Results The overall cost of setup and implementation of MOVE in the first year of implementation among 40 students was US $94.38 per student. In comparison, the face-to-face workshop cost was US $64.14 per student. On the second year of implementation, the ongoing cost of operation of MOVE was US $32.86 per student compared with US $58.97 per student using face-to-face workshop. A net benefit using MOVE was observed after the third year of implementation. Larger savings were noted when the cohort size extends larger than 100 students. Conclusions Monash OSCE Virtual Experience was a flexible and cost-effective approach to aid students in preparation for an OSCE and enhanced students' learning experience. The wider applicability of these findings will need to be explored in other settings. Correspondence to: Shaun Wen Huey Lee, MPharm, PhD, School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Selangor, 47500, Malaysia (e-mail: shaun.lee@monash.edu). The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.simulationinhealthcare.com). © 2020 Society for Simulation in Healthcare

Implementation of Simulation Training During the COVID-19 Pandemic: A New York Hospital Experience Summary Statement Simulation played a critical role in our institution's response to the COVID-19 pandemic in New York City. With the rapid influx of critically ill patients, resource limitations, and presented safety concerns, simulation became a vital tool that provided solutions to the many challenges we faced. In this article, we describe how simulation training was deployed at our institution throughout the course of the pandemic, which included the period of our medical surge. Simulation helped refine protocols, facilitate practice changes, uncover safety gaps, and train redeployed healthcare workers in unfamiliar roles. We also discuss the obstacles we encountered with implementing simulations during the pandemic, the measures we took to adapt to our limitations, and the simulation strategies and end products that were derived from these adaptations. Correspondence to: Di Pan, DO, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, New York, NY 10065 (e-mail: dip9063@nyp.org). The authors declare no conflict of interest. This work is attributed to the Division of Pulmonary and Critical Care Medicine at the New York Presbyterian Hospital/Weill Cornell Medical Center. This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections. © 2020 Society for Simulation in Healthcare

Development and Considerations for Virtual Reality Simulations for Resuscitation Training and Stress Inoculation Introduction Resuscitation simulations immerse learners into the complexity of emergency patient management. Head-Mounted Display Virtual Reality (VR) has been used for stress inoculation therapy for phobias and posttraumatic stress disorder. However, VR for stress inoculation in resuscitation leadership training has not been studied. We sought to develop VR simulation for stress inoculation, as exposure therapy training, for resuscitations. Methods We explain the conceptual design, development, production, and initial evaluation process for 2 VR simulations in infant status epilepticus and pediatric anaphylactic shock. We further describe deliberate game mechanic choices to maximize psychological fidelity. In–virtual reality performance data for time-to-critical actions and stress physiology markers (heart rate, salivary cortisol) were collected from expert pediatric emergency physicians and novice pediatric residents. Data were analyzed to examine differences between the 2 groups for both outcome types to determine the extent of stress response or performance deficit the VR induced. Results Multiple difficulties and distractions were designed for the 2 scenarios; we evaluated the highest difficulty and environmental distraction versions. Between 19 expert physicians and 15 novice physicians, no performance differences were found in typical airway, breathing, and circulation actions. Residents preferred more lorazepam first-line antiepileptics than attendings (P = 0.003) and performed a cricothyrotomy later than attendings (P = 0.02). Residents, however, manifested higher salivary cortisol levels than attendings (+0.07 μg/dL, 95% confidence interval = 0.03–0.12, P = 0.001). Conclusions A VR resuscitation simulation manifested expected stress physiology changes in physicians. Further evaluation is needed to determine the effect of VR simulation as longitudinal stress inoculation for healthcare providers. Correspondence to: Todd P. Chang, MD, MAcM, Division of Emergency Medicine – Mailstop 113, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027 (e-mail: dr.toddchang@gmail.com). J.M.S. has ownership in a medical consulting group for virtual reality developers, SBC Med Sim, LLC. T.D. is employed by A.i.Solve, one of the development companies for the product described in this Report. Study and salary support were provided by Oculus from Facebook through the VR for Good Campaign. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.simulationinhealthcare.com). © 2020 Society for Simulation in Healthcare

Predicting Trainee Clinical Success From Performance at Simulated Endotracheal Intubation Introduction Multiple attempts and failure at endotracheal intubation (ETI) are common for inexperienced practitioners and can cause patient morbidity. A test to predict a provider's likelihood of success at patient ETI could assist decisions about training. This project investigated whether trainees' performance at laryngoscopy on airway mannequins predicted their laryngoscopy outcomes in patients. Methods Twenty-one consenting first-year anesthesiology residents, emergency medicine residents, and medical students enrolled in this prospective, observational study. They performed laryngoscopy and ETI with a curved laryngoscope on 4 airway mannequins. Metrics included peak dental force, procedure duration, esophageal intubation, laryngeal view, and first-pass ETI success on the mannequins. Trainee data from 203 patient ETIs were collected over a roughly 2-month period centered around the simulation test. Multivariable logistic regression analyzed the relationship of mannequin metrics, participant experience, and a patient difficult airway score with trainee ETI outcomes in patients. Results Median trainee first-pass success rate at patient ETI was 63%, the rate of ETI problems was 16%, and the esophageal intubation rate was 6%. Laryngoscopy peak dental force, first-pass ETI success, and duration on individual mannequins were significant predictors of patient ETI first-pass success. Metrics from 2 of the 4 mannequins predicted ETI problems. Discussion Performance metrics from simulated laryngoscopy predicted trainee outcomes during patient ETI. First-pass success and ETI problems affect patient safety and are related to trainee skill. Mannequin laryngoscopy tests could identify trainees who would benefit from additional practice. The metrics could be surrogate end points in research to optimize simulated laryngoscopy training. Correspondence to: Randolph H. Hastings, MD, PhD, VA San Diego Healthcare System, 3350 La Jolla Village Dr. 125, San Diego, CA (e-mail: rhhastings@ucsd.edu). The authors declare no conflict of interest. Department of Anesthesiology and School of Medicine, UC San Diego, Anesthesiology Service, VA San Diego Healthcare System. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.simulationinhealthcare.com). © 2020 Society for Simulation in Healthcare

Use of Simulation to Measure the Effects of Just-in-Time Information to Prevent Nursing Medication Errors: A Randomized Controlled Study Introduction Medication administration error (MAE) is the improper dispensing of medication. It is a significant contributor to the occurrence of medical errors. A novel systems thinking approach using a pediatric simulation and student nurses were used to evaluate the benefit of applying just-in-time information (JITI) to reduce medication errors. Just-in-time information applies highly focused information delivered when needed. Methods A smart device app was developed to provide JITI medication administration information. The effect JITI had on MAE occurrence was assessed via a controlled study. The study population included 38 teams having 2 to 3 senior nursing students on each team. The teams were separated into a control and 2 intervention groups to complete a medication administration simulation. Results The intervention groups (100%, N = 10) that made significant use of the JITI app demonstrated improved performance for medication administration over the control group. Familiarity with the app was pivotal to how frequently it was used and to the success of the groups in administering medications. Although those with access to the app having limited training successfully executed the simulation 27.3% (n = 11) of the time, those with extended training had a success rate of 77.8% (n = 9). Conclusions Providing JITI significantly reduced the occurrence of MAEs for these student nurses. Familiarity with the app, including extended training opportunities, contributed significantly to student success. Correspondence to: Thomas A. Berg, PhD, College of Nursing, University of Tennessee, 1200 Volunteer Blvd, Knoxville, TN 37996 (e-mail: tberg1@utk.edu). The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.simulationinhealthcare.com). © 2020 Society for Simulation in Healthcare

Gender Minorities in Simulation: A Mixed Methods Study of Medical School Standardized Patient Programs in the United States and Canada Purpose A provider's ability to translate knowledge about transgender health to affirming patient care is key to addressing disparities. However, standardized patient (SP) programs have little published guidance for gender-affirming care or addressing disparities experienced by transgender and nonbinary patients. Method Between 2018 and 2019, we invited all 208 accredited US and Canadian medical schools to participate in a study to determine how gender minorities are represented in SP encounters. Responding programs (n = 59, response rate = 28%) that represented patients with diverse gender identities were invited to complete semistructured interviews about SP case content, impact, and barriers to this work. Discussions were analyzed using a modified grounded theory method. Results Fifty nine of 208 eligible programs (response rate = 28.3%) completed our survey and 24 completed interviews. More than half of programs used gender minority SPs (n = 35, 59.3%). More than half of the programs also reported portraying gender minority cases (n = 31, 52.5%). Interviewees described how effective SP simulation required purposeful case development, engaging subject matter experts with lived experience, and ensuring psychological safety of gender minority SPs. Barriers included recruitment, fear of disrespecting gender minority communities, and transphobia. Engaging gender minorities throughout case development, training, and implementation of SP encounters was perceived to reduce bias and stereotyping, but respondents unanimously desired guidance on best practices on SP methodology regarding gender identity. Conclusions Many programs have established or are developing SP activities that portray gender minority patients. Effective SP simulation hinges on authenticity, but the decisions around case development and casting vary. Specifically, programs lack consensus about who should portray gender minority patients. This research suggests that input from gender minority communities both to inform best practices at the macro level and in an ongoing advisory capacity at the program level will be essential to teach gender-affirming care. Correspondence to: Carrie A. Bohnert, MPA, Department of Undergraduate Medical Education, University of Louisville School of Medicine, 500 S Preston St, B308, Louisville, KY 40202 (e-mail: carrie.bohnert@louisville.edu). The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.simulationinhealthcare.com). © 2020 Society for Simulation in Healthcare

A Novel Application of the Modified Angoff Method to Rate Case Difficulty in Simulation-Based Research Introduction Simulation use in research is often limited by controlling for scenario difficulty when using repeated measures. Our study assesses the feasibility of the Modified Angoff Method to reach expert consensus regarding difficulty of medical simulations. We compared scores with participant physiologic stress. Methods Emergency medicine physicians with expertise in simulation education were asked to review 8 scenarios and estimate the percentage of resident physicians who would perform all critical actions using the modified Angoff method. A standard deviation (SD) of less than 10% of estimated percentage correct signified consensus. Twenty-five residents then performed the 6 scenarios that met consensus and heart rate variability (HRV) was measured. Results During round 1, experts rated 4/8 scenarios within a 10% SD for postgraduate year 3 (PGY3) and 3/8 for PGY4 residents. In round 2, 6/8 simulation scenarios were within an SD of 10% points for both years. Intraclass correlation coefficient was 0.84 for PGY3 ratings and 0.89 for PGY4 ratings. A mixed effects analysis of variance showed no significant difference in HRV change from rest to simulation between teams or scenarios. Modified Angoff Score was not a predictor of HRV (multiple R2 = 0.0176). Conclusions Modified Angoff ratings demonstrated consensus in quantifying the estimated percentage of participants who would complete all critical actions for most scenarios. Although participant HRV did decrease during the scenarios, we were unable to significantly correlate this with ratings. This modified Angoff method is a feasible approach to evaluate simulation difficulty for educational and research purposes and may decrease the time and resources necessary for scenario piloting. Correspondence to: Melissa Joseph, MD, Department of Emergency Medicine, Yale School of Medicine, 728 Howard Ave, New Haven, CT 06519 (e-mail: melissa.joseph@yale.edu). The authors declare no conflict of interest. © 2020 Society for Simulation in Healthcare

Co-constructive Patient Simulation: A Learner-Centered Method to Enhance Communication and Reflection Skills Introduction In simulation sessions using standardized patients (SPs), it is the instructors, rather than the learners, who traditionally identify learning goals. We describe co-constructive patient simulation (CCPS), an experiential method in which learners address self-identified goals. Methods In CCPS, a designated learner creates a case script based on a challenging clinical encounter. The script is then shared with an actor who is experienced working as an SP in medical settings. An instructor with experience in the model is involved in creating, editing, and practicing role play of the case. After co-creation of the case, learners with no prior knowledge of the case (peers or a supervisor) interview the SP. The clinical encounter is followed by a group debriefing session. Results We conducted 6 CCPS sessions with senior trainees in child and adolescent psychiatry. Topics that are difficult to openly talk about may be especially appropriate for the CCPS model—without overt guidance or solicitation, the scripts developed by learners for this series involved: medical errors and error disclosure; racial tensions, including overt racism; interprofessional conflict; transphobia; patient-on-provider violence; sexual health; and the sharing of vulnerability and personal imperfections in the clinical setting. Conclusions Co-constructive patient simulation provides an alternative multistage and multimodal approach to traditional SP simulation sessions that can adapt iteratively and in real time to new clinical vicissitudes and challenges This learner-centered model holds promise to enrich simulation-based education by fostering autonomous, meaningful, and relevant experiences that are in alignment with trainees' self-identified learning goals. Correspondence to: Andrés Martin, MD, MPH, Yale Child Study Center, 230 South Frontage Rd, New Haven, CT 06520-7900 (e-mail: andres.martin@yale.edu). The authors declare no conflict of interest. Supported by the Riva Ariella Ritvo Endowment at the Yale School of Medicine and by National Institute of Mental Health R25 MH077823, "Research Education for Future Physician-Scientists in Child Psychiatry." The Yale Human Investigations Committee approved the study (Protocol # 2000026241). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.simulationinhealthcare.com). © 2020 Society for Simulation in Healthcare

#

Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,