stpierre_eja_2002_usefulness of simulator training_abstr.pdf

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European Journal of Anaesthesiology 2003; 20: 1–15© 2003 European Academy of Anaesthesiology

ISSN 0265-0215

AbstractsThe senior author of each article has confirmed that the ethical aspects of these studies have been approved(a) for clinical studies by the Institution or an Ethics Committee and, if applicable, that informed patientconsent has been obtained, (b) for experimental studies, involving the use of animals, by the institution andthat the animals have been treated according to good practice.

Meeting of the Society in Europe for Simulation Applied toMedicine (SESAM), 10–11 May 2002: Santander, Spain

SANTANDER-02-01

The usefulness of simulator training incombination with psychological trainingsessions for the improvement of non-technical skillsG. Hofinger*, H. Harms*, C. Buerschaper, M. St. Pierre†, M. Grapengeter¶

*Institute of Theoretical Psychology, University ofBamberg, †Institute of Anaesthesia, University of Erlangen, ¶Institute of Anaesthesia, Groningen, GermanyGood management of medical crises requires non-technical skills like communication, team co-operation, planning, etc. In current medicaltraining these competencies are not systematicallybeing trained. Simulator trainings of crisis manage-ment use psychological knowledge for the improve-ment of non-technical skills.Objective: To evaluate the usefulness of simulatortraining in combination with psychological trainingmodules for the improvement of soft skills. The firstmodule is “communication and team co-operation”.Here, first results of the evaluation are given. “Mentalmodels” is the next module to follow.Methods: 34 anaesthetists (1 to 4 yr experience inanaesthesia) took part in either a 2 h training sessionon team co-operation and co-ordination (treatment,n � 20) or heard a talk on human factors in the OR(control, n � 14). All subjects then performed oneout of three simulator scenarios with specific require-ments of team co-ordination and communication.Having obtained informed consent, the simulatorsessions were video-taped. Subjects answered anevaluation questionnaire immediately after the courseand were interviewed 4 weeks later about behav-ioural changes in the OR and memory of the course.The video tapes were analysed on three levels: behav-ioural markers for the quality of communication and

team co-ordination, a protocol system for action regulation and problem solving, and two medicalexperts’ assessment of the medical management.Results: The relevance of communication and teamcoordination in the OR is highlighted by the corre-lation between medical management scores andbehavioural markers (r � 0.56). The need for recur-rent training in these domains is emphasized bymost participants in the follow-up-interviews. Thesimulator course is evaluated by both groups asinteresting, relevant, and challenging. Significantdifferences between the groups: The treatmentgroup (communication training) remembers more ofthe training than the control group. Relevance andpracticability of the course are rated higher. For thetreatment group the scenario was more stressful, dueto the attention they gave to communication andteam processes. Participants of the training groupreport 4–8 weeks later more changes in their teambehaviour and in self-reflection than those of thecontrol group. They draw more personal conclusionsand give more specific ‘lessons learned’. Analysis of behavioural data show significant differencesbetween training and control group: the traininggroup addresses the surgeon more often. They alsohave more conflicts with the surgeon, but the reac-tion to conflicts is more often problem-orientated orde-escalating or ignoring than in the control group.In the training group, more utterances refer to theprocess of problem-solving, and hypotheses play astronger role.Conclusions: The training of crisis managementwith simulator scenarios is evaluated as useful andpracticable. Psychological training sessions are seenas important and valuable. The combination leads tosignificant changes in behaviour. Results indicatethat time and opportunity for practising new behav-iour is needed. We conclude that soft skills shouldnot only be trained in crisis scenarios but also in the

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2 Abstracts

© 2003 European Academy of Anaesthesiology, European Journal of Anaesthesiology 20: 1–15

real OR and perhaps in special training sessions out-side the simulator.

SANTANDER-02-02

How effective is simulator-based training of emergency care in UK general practitioners?M. Bloch, N. Munro, K. Haire, S. Bajenov, R. Tandon, S. Seig, M. MazeTraining Simulator Unit, Chelsea and WestminsterHospital, London, UKSimulator based training in emergency care is wellestablished within UK hospital specialties. Theimpact of this form of training among general prac-titioners has not been reported.Objective: To evaluate the effectiveness of simulator-based training in emergency care among UK generalpractitioners (GPs).Methods: A cohort of GP registrars (n � 11) fromthe Guildford vocational training scheme partici-pated in a day’s training in emergency care at theChelsea and Westminster Resuscitation SimulatorUnit, UK. Participants were asked, at the beginningand at the end of the day, to rate, on a five pointLikert scale, the extent to which they agreed with 11 items in a validated self-reporting questionnaire.Results: Completed questionnaires were receivedfrom 10 participants. Initial mean scores were high-est for valuing feedback (mean 4.8, SD 0.41) andrecognising acute situations (mean 4.4, SD 0.81) andlowest for knowledge (mean 2.3, SD 0.79) and confi-dence (mean 2.7, SD 1.1). Before and after mean dif-ferences for each questionnaire item were analysedusing paired t-tests. Marked improvements in confi-dence (t �3.464, P 0.006), knowledge (t �4.892, P 0.001), skills (t �2.667, P 0.024) and valuingbeing videoed (t �3.317, P 0.008) were noted. Nosignificant changes were seen in terms of own per-formance (t �1.174, P 0.267) or clinical experience(t �1.456, P 0.176).Conclusions: These initial findings among a smallcohort of GP registrars suggest that simulator basedtraining, over a single day, may significantly improveknowledge, skills and confidence of participants inemergency care as well as enhance willingness toundertake critical review of professional standards. Itis hoped that the participants continue developing anapproach to incorporating the concepts, which theyare exposed to on this day, into the daily clinicalactivities and practice. The potential for simulatortraining to directly impact on care of critically illpatients in the community is an exciting develop-ment for all Primary Care Organisations.

SANTANDER-02-03

Using a high fidelity patient simulator fortraining dentists in crisis managementA. Rodríguez-Caballero*, I. Del Moral*, J. C. Díaz de Terán*, J. M. Rabanal*, F. Ezquerra†,M. Berrazueta†

*Santander Simulation Centre, H.U.M. Valdecilla,†Dentist from the Official College of Cantabria, SpainBased on David Buckley’s lecture at the 2000 annualmeeting of the Society of European SimulatorsApplied to Medicine in Mainz, and Girdler’s paperon Resuscitation, the Santander Simulation Centrehas developed a half-day course for training dentistsin crisis management using a high fidelity patientsimulator [1,2]. Medical emergencies arising in den-tal practice are generally perceived as being uncom-mon. However, when an emergency does occur it can be life-threatening. No dental procedure can evertake priority over a patient’s life and thus, it is reallyimportant for dentists to be able to recognize andinitiate first responses to emergencies. The ability ofthe dentist to initiate primary management is thekey to minimizing morbidity and mortality. Theaim of the courses is to train dentists as first respon-ders in crisis management in both human factors and medical aspects of the crisis. One objective is toprovide guidelines as to which emergency drugs andequipment should be stocked in dentistry. Thecourse is designed for six participants. The structureof the course is shown in Table 1.Results: Between January 2001 and March 2002we have held 12 courses (72 participants). All par-ticipants filled in a questionnaire at the end of thecourse (rating scale 1 to 5; 1 minimum, 5 maximum).The results are shown in Table 2.Conclusions: There is a need for dentists to trainand to learn how to recognize and manage medicalemergencies. These courses should be recognized forcontinuing medical education in dental practice, as the British General Dental Council guidelines

Table 1.

08:00–08:15 Introduction08:15–09:15 Behaviour and skills for managing medical crisis09:15–11:15 Protocols for treating most frequent events in

dentist practice (vasovagal syncope,hypoglycaemia, angina, epileptic fit, anaphylaxisand cardiac arrest)

11:15–12:00 Airway management workshop12:00–14:00 Clinical scenarios and debriefing sessions

(vasovagal syncope, hypoglycaemia, angina,epileptic fit, anaphylaxis and cardiac arrest)

14:00–14:15 Assessment and farewell

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clearly state that ‘resuscitation routines should bepractised in a simulated emergency’ [3]. High-fidelitypatient simulators are a useful tool for training dentistsas first responders in a medical crisis. The scheduleof our programme is useful for training dentists incrisis management.

References

1. Buckley D. Assessment of clinical performance duringsimulated crises occuring in dental conscious sedation. Eur J Anaesthesiol 2000; 17: 519.

2. Girdler NM, et al. Prevalence of emergency events inBritish dental practice and emergency management skillsof British dentists. Resuscitation 1999; 41: 159–167.

3 General Dental Council. Maintaining Standards: Guidancefor dentists on professional and personal conduct. London, UK:General Medical Council, 1998.

SANTANDER-02-04

Enhancement of medical student’s self-confidence first time performing general anaesthesiaC-J. Wallin*, E. Johnson†, L. Tsai¶, H. Hjelmqvist*

*Department of Anaesthesia and Intensive Care,Huddinge University Hospital, †Department of Technical and Social Change, University of Linköping,¶Department of Orthopaedics, Huddinge UniversityHospital, SwedenDuring their fourth year medical students have a 2 week course in anaesthesiology. The students areintroduced to general anaesthesia by an anaesthesio-logist in the operating room on a patient during routine clinical work. Our hypothesis was that anintroduction using a full-scale patient simulatorshould give the students better self-confidence and

less anxiety the first time they participated in givinga patient general anaesthesia.Methods: Twenty-four students were randomised tobe introduced the traditional way or by using a METI Human Patient Simulator (HPS). The ‘simu-lator students’, in groups of 3 or 4, had a short lecturein the cognitive loop of observation, assessment, deci-sion making, action, and re-evaluation as applied tothe anaesthetic procedure. In a scenario each studentacted as anaesthetist performing a highly realisticinduction, endotracheal intubation and awakening ofthe patient. Each student also experienced the identi-cal sequence in the roles of the anaesthetic nurse,operating nurse, surgeon or observer. The instructorgave the student close guidance resulting in error-free anaesthesia management. The cognitive loop,communication and resource management was dis-cussed during a debriefing session. After this intro-duction the ‘simulator group’ had the same 2 weekclinical training in anaesthesia as the ‘traditionalgroup’. At the end of the 2 weeks all studentsanswered a questionnaire. Thirteen questions focusedon the student’s feelings the first time he/she partici-pated in giving general anaesthesia to a patient.Answers were given on a scale from 1 to 10. Data aregiven as median; the Mann-Whitney rank sum testwas used as post hoc test and P � 0.05 was consideredsignificant.Results: For 10 of the questions there was no sig-nificant difference between the two groups, includ-ing the question ‘Were you calm when you enteredthe operating room?’ (P � 0.86). The ‘simulatorgroup’ had significantly higher scores than the control group for the questions ‘Did you under-stand how and when the anaesthesia machine should be used?’ (7.5 vs. 4.5, P � 0.04), ‘Was thesituation at the induction familiar to you?’ (7.0 vs.3.5, P � 0.006), and ‘How much responsibility didyou feel you had for the patient?’ (6.5 vs. 3.0,P � 0.02).Discussion: The ‘simulator group’ recognised theanaesthesia procedure in the messy anaesthetic work-ing environment better than the ‘traditional group’.This also supports the assumption that the simulatorscenario was realistic. In reality the anaesthesiologistin charge has the medical responsibility for thepatient, not the student. However, the ‘simulatorgroup’ was prepared to shoulder more responsibilityfor the patient. This is probably due to more knowl-edge and training. Thus, we conclude that ‘simula-tor’ training enhances the student’s self-confidence.An increased awareness of inherent risks in theanaesthetic procedure may explain that there was nodifference regarding anxiety between the twogroups.

Abstracts 3


Table 2.

Questions Score

Has the course been useful for your job? 4.89 � 0.8Do you think the schedule is suitable? 4.78 � 0.4Have you got set goals for this course? 4.73 � 0.8Have these objectives been achieved? 4.85 � 0.31Has the course improved your skills in 4.71 � 0.3airway management?

Did the scenarios seem realistic? 4.62 � 0.34Would you retake the course? 100%How often would you retake the course, if so? 12 months [6–24]

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SANTANDER-02-05

Pharmacokinetic parameter transformationsfor educational simulationsL. F. Bastos*†, W. L. van Meurs*†¶‡

*Instituto de Engenharia Biomédica, Universidade doPorto, †Departamento de Matemática Aplicada,Faculdade de Ciências, Universidade do Porto, Portugal,¶Medical Education Technologies, Inc., Sarasota,Florida, ‡Department of Anesthesiology, University ofFlorida College of Medicine, Gainesville, USASimulations developed for training of health careprofessionals typically use computerized mathemati-cal models of human physiology and pharmacology.Educational simulations may involve many drugsand patient groups. Pharmacokinetic (PK) data inthe scientific literature are presented in a wide varietyof PK parameter set formats. This complicates theincorporation of PK data in a simulation model witha given structure and associated parameter format.To solve this problem, we defined three sets of independent parameters, referring as much as possibleto the pharmacokinetic literature [1], and localizedand/or derived the analytical relationships betweenthem.Methods: Figure 1 shows the names of the definedparameter sets and the transformations betweenthem, and Tables 1 and 2 define the ‘Clinical’ and‘Base’ sets for 2nd order PKs, respectively.

Strictly speaking, half-life is the time required for the plasma concentration to be reduced by 50%.

The half-times used in the clinical set directly referto the individual exponentials and disposition rateconstants of the response to a unit bolus dose:

which is the model underlying the base set. The rela-tionships between the half-times and the dispositionrate constants reflect this observation. Assuming thatthe plasma concentration data can be described bythe parametric bolus response function we can calcu-late the areas under the concentration-time curve andunder the first moment of the concentration timecurve, respectively [1]. The parameter A1 is derivedfrom the clinical set based on this observation.Results: Table 3 shows examples of derived transformations.

The complete analytical relationships between theparameter sets for first, second, and third order PKsfacilitate the incorporation of diverse pharmaco-kinetic data in educational simulations.Acknowledgements: This work was funded in partby a grant from Medical Education Technologies,Inc., Sarasota, Florida, USA. The ‘Fundação para a

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Table 2. Second order base set.

Typical Symbol units Description

�1 min�1 Disposition rate constant of the fast decaying exponential

�2 min�1 Disposition rate constant of the slowly decaying exponential

A1 – Relative amplitude of the fast decaying exponential

V1 L kg�1 Initial volume of distribution

Base set

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Figure 1.Pharmacokinetic parameter sets and transformations.

Table 1. Second order clinical set.

Symbol Typical units Description

t1 min Half-time of the fast decaying exponential

t2 min Half-time of the slowly decaying exponential

Cl L kg�1min�1 Total drug clearanceV1 L kg�1 Initial volume of distribution

Table 3. Parameter transformations from the second order clinicalset to the second order base set.

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Ciência e a Tecnologia’, of the Portuguese Ministry ofScience and Technology provided funds for participa-tion in this conference.

Reference

1. Gibaldi M, et al. Pharmacokinetics, 2nd edn. New York,USA: Marcel Dekker, 1982.

SANTANDER-02-06

Simulation of fetal heart rate during hypoxic stressP. M. Sá Couto*, W. L. van Meurs*†¶, J. F. Bernardes*‡, J. P. Marques de Sá*§, J. A. Goodwin¶||

*Instituto de Engenharia Biomédica, Universidade doPorto, Portugal, †Medical Education Technologies, Inc.,Sarasota, Florida, ¶Department of Anesthesiology,University of Florida College of Medicine, Gainesville,USA, ‡Faculdade de Medicina, Universidade do Porto,§Faculdade de Engenharia, Universidade do Porto,Portugal, ||Department of Anesthesiology, NemoursChildren’s Clinic, Jacksonville, Florida, USAMaternal hypotension following spinal anaesthesiaor cardiac arrest, maternal hypoxia associated withventilatory complications, and fetal asphyxia causedby compression of the umbilical cord are examples ofcritical situations in obstetrics and in anaesthesia for the pregnant woman. These incidents are oftenassociated with a high risk to the woman and fetus.Therefore, simulation is a valuable tool in teachingthe diagnostic and therapeutic skills in this context.We have described a mathematical model for theeducational simulation of the oxygen delivery to thefetus [1]. Here we present a second component of oureducational fetal distress simulator (FDS) generatinga fetal heart rate (FHR) signal in its response tohypoxic stress.Methods: We used an empirical approach for simu-lating this response (Fig. 1). The FHR signal isdecoded to its individual components for clinicalanalysis: baseline, decelerations, heart rate variabil-ity (HRV) and accelerations. The decelerationsdepend directly on the partial pressure of oxygen inthe fetal arterial blood, PafO2, an output of the pre-sented model [1], reflecting an important componentof the chemoreflex. HRV depends on a pathophysio-logical state variable. This qualitative variabledepends on the magnitude and duration of hypoxicstress and can take on the values: Normal, suspi-cious, pathological, and death. The accelerationsdepend on the spontaneous fetal activity, which isonly present with a normal pathophysiological state.Results: Consider a situation where PafO2 reducesfrom normal values to 2.1 kPa. The chemoreflex

mediates a deceleration for the duration of the fall.The pathophysiological state evolves from normal tosuspicious, HRV is reduced accordingly, and acceler-ations disappear. Figure 2 shows a simulation of theeffect of a brief maternal cardiac arrest followed bysuccessful resuscitation.Conclusions: An on-going clinical validationaddresses the question of whether the simulated FHRresponse is ‘realistic enough’ for educational simula-tions. We presented an original empirical model foreducational simulation of the effect of hypoxic stresson fetal heart rate.Acknowledgements: This work was partly fundedby a grant from Medical Education Technologies,Inc., Sarasota, Florida, USA. The ‘Fundação para aCiência e a Tecnologia’ of the Portuguese Ministry ofScience and Technology provided funds for partici-pation in this conference.

Reference

1. Sá Couto PM, et al. Mathematical model for educationalsimulation of the oxygen delivery to the fetus. Cont EngPract 2002; 10: 59–66.

Abstracts 5


Fetalarterialoxygen

Finite statealgorithm forphysiological

�Heart ratevariability

Acceleration

Deceleration

Pathophysiologicalstate mediated

heart rate

Oxygen deficitrelated

decelerations

Fetal activitymediated

accelerations

Fetalheartrate

Spontaneousfetal activitygenerator

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Pathophysiological

Figure 1.Block diagram of the system for simulating the fetal heart rateresponse to hypoxic stress.

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Figure 2. FHR (beats min�1) during maternal cardiac arrest. Contractionscorresponding to false labour.

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SANTANDER-02-07

Graphical and mathematical representationof congenital heart diseaseD. Sá Couto*, W. L. van Meurs*†¶, J. A. Goodwin¶‡

*Instituto de Engenharia Biomédica, Universidade doPorto, Portugal, †Medical Education Technologies, Inc.,Sarasota, Florida, ¶Department of Anesthesiology,University of Florida College of Medicine, Gainesville,Florida, ‡Department of Anesthesiology, NemoursChildren’s Clinic, Jacksonville, Florida, USAThe aim of this work is to represent congenital heartdiseases graphically and mathematically for use ineducational simulations of the neonate and infant.This work is based on a previously published modelfor the adult cardiovascular system [1] (Fig. 1).Methods: A model for the term fetus [2] containsstructural elements representing a patent ductusarteriosus and an open foramen ovale. These struc-tures, as well as those necessary for the simulation ofa ventricular septal defect were incorporated in theBeneken model (Fig. 2).

As an example of how the mathematical model isderived from the graphical representations, we pres-ent the equations for the patent ductus arteriosus(PDA). The flow rate trough the PDA is a new statevariable:

where F(t): flow rate; P(t): pressures; R: resistances;L: inertia; da: ductus arteriosus; itha: intrathoracicarteries; pa: pulmonary arteries. Fda(t) is positive inthe systemic → pulmonary direction.

Conservation of mass in the intrathoracic and pul-monary arteries is reformulated as follows:

where V: volumes; lv: left ventricle; rv: right ventri-cle. Flow rates are compartment outflow rates

This model was simulated with the parametersreflecting a 6-month-old infant [3].Results: Table 1 shows preliminary simulation resultswith and without a moderate PDA. The relativepressure changes are similar to the ones reported forneonates in [4]. We are currently pursuing a specificreference for infants.Acknowledgements: This work was funded in partby a grant from Medical Education Technologies,Inc., Sarasota, Florida, USA. The Fundação para aCiência e a Tecnologia, of the Portuguese Ministry ofScience and Technology provided funds for participa-tion in this conference.

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Pulmonaryveins

Symbols

Time-variantelastanceValve

Resistance

Elastance

Inertia

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Intrathoracicarteries

Extrathoracicarteries

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Figure 1. Hydraulic analog of the Beneken model.

Pulmonaryveins

Left atrium

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Figure 2. Hydraulic analog of the cardiovascular model reflecting congenitalheart diseases.

Table 1. Simulation results: Normal infant and an infant with a moderate PDA.

Pressures (mmHg)Co

RV LV PA Ao PV (L min�1)

Normal 19/3 90/3 15/6 84/55 6 1.7PDA 29/4 82/3 25/14 73/25 10 1.1

RV: right ventricle; LV: left ventricle; PA: pulmonary arteries; Ao: aorta; PV: pulmonary veins; Co: cardiac output (from RV).

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References

1. Beneken JEW. A mathematical approach to cardiovascu-lar function. The uncontrolled human system. Utrecht, The Netherlands: Ph.D. thesis, 1965.

2. Huikeshoven F, et al. Mathematical model of the fetal cardiovascular system: the uncontrolled case. Am J Physiol1980; 239: R317–325.

3. Goodwin JA, et al. Modeling infant cardiovascular physi-ology for educational simulations. In preparation, 2002.

4. Klaus MH, et al. Care of the high-risk neonate, 5th edn.Philadelphia, USA: W.B. Saunders Company, 2001.

SANTANDER-02-08

The Simulation Training Centre of theDepartment of Anaesthesiology of the Maria Sklodowska-Curie Memorial CancerCentre, Warsaw, PolandM. Czaplinska, A. Lukaszewska, P. Sowinski, J. Jarosz, M. SymonidesThe Maria Sklodowska-Curie Memorial Cancer Centreand Institute of Oncology, Warsaw, PolandOur Simulation Training Centre was established inJanuary 2001, in cooperation with the Danish firmMath-Tech. The program used for simulation is theSIMA 1.1, compatible with Dameca and Datexequipment. In order to carry out simulation we usethe SimMan mannequin (Laerdal), equipped with itsown simulation program. The Simulation Centre ismanned by two anaesthesiologists-instructors andtwo trained nurses, who act as operating theatre per-sonnel during the training courses.

Training courses are aimed at medical personnel of all levels. Courses covering behaviour in case ofcardiac arrest (including special techniques andadvanced resuscitation equipment) are the most pop-ular and are aimed at doctors/non-anaesthesiologistsand the nursing staff.

Anaesthesiologist training deals with new equip-ment (e.g. for difficult airway management) and newdrugs (e.g. desflurane anaesthesia). The most sophis-ticated simulation programmes cover such areas ascirculatory, respiratory and neurologic complications,malignant hypertermia, anaphylactic shock or hor-monal crises both intraoperatively and in the ICU.The scenarios concerning difficult airway manage-ment and hormonal crises have been prepared accord-ing to the experiences of our anaesthesiologists.

Since its opening the Centre has trained 55 doctorsand 400 nurses. On the completion of training special certificates are issued to the trainees. The mainissues limiting the number of trainees are, besidesfinancial problems, negative attitudes towards test-ing one’s own knowledge/practical skills and a beliefthat the training is highly stressing. The effects of

our research was presented at the IMMS 2001 – thepaper which we presented dealt with training in thetreatment of intraoperative hormonal crisis.

SANTANDER-02-09

Evaluation after training in the procedicusendoscopic simulator: a study amongundergraduate medical studentsL. Felländer-Tsai*, P. Ström*, A. Kjellin*, E. Johnson†, T. Wredmark*Center for Surgical Sciences CFSS, at KarolinskaInstitutet, Stockholm, †Tema T Linköping University,SwedenAdvanced simulator training within medicine andhealth care is a rapidly growing field. Virtual Realitysimulators are being introduced as cost-saving educa-tional tools, which also lead to increased patientsafety. This paper presents the findings of a study inwhich the use of the Procedicus KSA (Key SurgicalActivities) simulator was tested as an educational toolto train medical students at Huddinge UniversityHospital. It is claimed that these simulators will beable to reduce educational costs, circumvent theethics issues tied to training new surgeons on animalspecimens, and improve patient safety. The improve-ment of patient safety is a key element in the discus-sions being carried out, stemming both from aconcern for patients’ well-being and a recognitionthat correctly performed surgical procedures are lesscostly for the healthcare institution. There is alsospeculation that VR simulators can eventually beused to introduce standardised skill evaluation.Methods: Ten medical students (3 female, 7 male)were included in the study. Performance was moni-tored in 2 endoscopic simulators (Procedicus withhaptic feedback and MIST without haptic feed-back)before and after 1 h of training in the Procedicussimulator. Time, movement economy and total scorewere registered. Long-term learning curves were alsoanalysed in one individual performing more than300 tests.Results: There was a significant improvement after1 h of training regarding, time, movement economyand total score. Results in the Procedicus simulatorwere highly correlated to performance in the MISTsimulator. The students mentioned that they felt thevalue in simulator training lay in the ability to prac-tise procedures without having to worry about injur-ing a real patient.Conclusions: Our results show that the use of sur-gical simulators as a pedagogical tool in medical stu-dent training is encouraging. It shows rapid learningcurves and emphasises the importance of patientsafety.

Abstracts 7


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SANTANDER-02-10

Difficult airway – a suggestion of simulationtraining. Anaesthetists in practice versusASA standardsA. Lukaszewska, M. Czaplinska, M. Symonides, J. Jarosz, P. SowinskiSimulation Training Centre, Dept of Anaesthesia. The Maria Sklodowska-Curie Memorial Cancer Center – Institute of Oncology, Warsaw, PolandIn cases of situations requiring fast decision making,simulation training may provide a method of testingwhether practice conforms to standards. By analyz-ing questionnaires designed to evaluate the actions oftrained anaesthesiologists faced with difficult intuba-tion situations we have discovered the need to providesimulation training for difficult airway. In the Simu-lation Training Centre of the Maria Sklodowska-Curie Memorial Cancer Center in Warsaw we havealready held a number of courses on difficult airwaymanagement. They were designed to acquire skillswith new equipment (fibreoptic intubation, Trach-Lite®). However, we have not yet held simulationtraining designed to assess the doctors themselves.The aim of the study was to find out whether thebehaviour of anaesthesiologists in face of a difficultintubation remains in unison with ASA standards.

Twelve anaesthesia consultants employed at theInstitute took part. In the simulation training roomthe mannequin had been arranged for a difficult airway case and a team formed by a doctor and ananaesthetic nurse was informed that it was to dealwith a case of spinal injury and severe trauma to themaxillo-facial area. The patient was semiconscious,on the verge of respiratory insufficiency and beingprepared for urgent laparotomy. The objective was tosecure the airway as fast as possible. The equipmentfound in the simulation room was identical withthat in an ordinary operating theatre. During thesimulation programme we were able to presentdesaturation, tachycardia and hypotension.

In order to assess anaesthetic practice a form con-taining ASA standard procedures was prepared.After analysis we concluded that nobody behavedaccording to standards. Serious omissions included –‘call for help’ – neither for another anaesthesiologistor the surgeon, no saline suction, removal of theSchantz collar, head manipulations, too long a reac-tion time before the decision to intubate.

None of the observed anaesthesiologists made use ofadditional equipment; one person decided to performtracheostomy by himself. Some administered steroids(due to spinal trauma). One person decided to admin-ister catecholamines. A majority forgot about Sellick’smanoeuvre. None achieved 100% correct answers. A majority of trainees ended up with one or two

flaws in their questionnaires, although in 30% ofquestionnaires replies there were at least three flaws.

The results emphasize the need to prepare aneffective scenario concerning difficult intubation.Constant training in such cases is vital, as well astraining anaesthesiologists in the use of additionalequipment designed to secure the difficult airway.

SANTANDER-02-11

Comparison of action density patternsbetween simulator and clinical settingsT. Manser*, M. Rall†, B. Schaedle†, P. Dieckmann*,T. Wehner*, K. Unertl†

*Institute of Work and Organisational Psychology, Swiss Federal Institute of Technology (ETH), Zürich,Switzerland, †Center for Patient Safety and Simulation,Department of Anaesthesiology, University HospitalTübingen, GermanyThe question of whether simulator settings repre-sent the salient characteristics of real work situationsremains unanswered. This study aims to assess theecological validity of simulator settings on an empir-ical basis by analysing action sequences across vari-ous settings. In our research on action sequences inclinical practice we focus on the ways in which com-plexity and unexpected events (i.e. disturbances, inter-ruptions etc.) are handled by the anaesthetists [1].Methods: After obtaining informed consent, 6 anaes-thetists (3 first year and 3 third year residents) tookpart in the study. All participants were observedduring 2 cases with patients and 3 simulator casesinvolving laparoscopic surgery. In the simulator setting the participants were exposed to 1 routinecase (control scenario) followed by 1 case with acutehaemorrhage and 1 with anaphylactic shock. A trainedobserver familiar with the operating theatre and theprocedures recorded the anaesthetist’s interventions(i.e. elements of actions) throughout the entire caseapplying a new observation method, sensitive tooverlapping operations in action sequences. In a previous study the methodological problem ofrecording and interpreting overlapping operations[2] could be overcome by applying a new computer-based observation method [3]. In order to describeaction sequences, we generated quantitative mea-sures of action density that serve as an indicator ofthe relative amount of overlapping operations. Thesemeasures help to analyse the extent to which totalactivity and particular operations fluctuate during aspecific anaesthesia case.Results: The results of our process-oriented caseanalysis show that action density exhibits a character-istic and distinct distribution during the conduction

8 Abstracts


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of anaesthesia. For example, periods characterized by increased action density are the induction of andthe emergence from anaesthesia. These variations inaction density during the course of anaesthesia can beobserved in clinical as well as in simulator cases.Moreover, in all simulator cases involving unexpectedevents an increase in action density can be observedduring this event.Discussion: As described in literature on theorganisation of multiple actions on an individual orgroup level, concurrent actions may occur due toincreased task complexity. By drawing an analogyoverlapping operations in action sequences may beinterpreted as an indicator for coping with complex-ity varying during different phases of an anaesthesiacase. The comparison of clinical and simulator casesempirically supports the assumption that there aresimilar action sequences on this level of analysis.Moreover, overlapping operations seem to have acentral position when dealing with the variousrequirements related to the occurrence of unex-pected events in a simulator scenario.Conclusions: The results of this study can be inter-preted as an indication of the huge potential of simu-lators as research instruments when striving for animproved understanding of the anaesthetists’ practicein the management of unexpected events. A researchstrategy integrating clinical and simulator settingshas the potential to contribute to the evaluation ofsimulator settings (e.g. its ecological validity) andthereby lead to improvements in the design of set-tings for research and training. This will be crucial toassure the quality of education and medical practicein an increasingly complex health care system.

References

1. Manser T, et al. Analysing action sequences: Variations inaction density in the administration of anaesthesia.Cognition, Technology & Work 2002; 4: 71–81.

2. Weinger MB, et al. An objective methodology for taskanalysis and workload assessment in anesthesia providers.Anesthesiology 1994; 80: 77–92.

3. Manser T, et al. Analysing action sequences in anaesthesia.Eur J Anaesthesiol, 2000; 17: 526.

SANTANDER-02-12

Do anaesthesiologists feel alone in theoperating room?M. A. Rodríguez-Caballero, I. Del Moral, J. C. Díaz de Terán, J. M. Rabanal, A. M. GonzálezSantander Simulation Centre. H.U.M. Valdecilla, SpainAnaesthetists work in dynamic and complex envi-ronments. Teamwork is required and team error can

be defined as action or inaction leading to devia-tion from team of organizational intentions [1].Effective teamwork is an error-management tech-nique, and communication also has several positiveside effects, such as fewer and shorter delays, andincreases efficiency [2]. Leadership is an essentialingredient of success in the search for safety, as it isthroughout the enterprise of quality [3]. The aim ofthis study is to assess the self-perception of anaes-thetist about their teamwork and team organization.We are showing preliminary data of a projectedbroader study.Methods and Results: 14 staff anaesthesiologistswho attended an ACRM course at SantanderSimulation Centre were surveyed before and after thecourse to study their self-perception on teamworkand team organization.

The survey prior to the course was:

The survey after the course was:

Score

Questions Yes No

Has the course recognised teamwork as 14 (100%) 0 (0%)a tool of patient safety?

Has the course improved your skills 14 (100%) 0 (0%)of communication?

Has the course expanded your 14 (100%) 0 (0%)leadership skills?

Comments• Speak with surgeons frequently;• Surgeons are members of the team! (2 comments);• Leadership is a tool for managing the team;• Sessions previous to surgery with the team.

Score

Questions Yes No

Do you think you work alone in the OR? 5 (35%) 9 (65%)Do you think you perform your job as 5 (35%) 9 (65%)teamwork?

Do you warn everybody in the OR when 11 (78%) 3 (22%)a crisis occurs?

I usually call for help when I face an 14 (100%) 0 (0%)anaesthesia crisis.

Have you any sessions with surgeons 1 (7%) 13 (97%)and nurses?

Do you ask surgeons for information of 9 (64%) 5 (36%)surgery previous to the procedure?

Do you usually communicate with 6 (43%) 8 (57%)surgeons during the procedure?

Do you think your job performed as 14 (100%) 0 (0%)teamwork may improve the outcome?

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Conclusions: The anaesthesiologists surveyed havea poor self-perception about team organization, team-work during their job. Anaesthetists have developeda deficient skill in communication. Simulator train-ing may improve the patient safety by emphasizingthe significance of team organization and enhancingcommunication among the team. From their writtenand verbal comments, most believed they learned agreat deal about teamwork. Because these results aresubjective thoughts, it would be necessary to developan objective measurement instrument, which avoidssome of the limitations of traditional approaches tomeasuring teamwork attributes. It is desirable thatsimulator training involves complete operating roomteams to achieve their better performance [4].

References

1. Helmreich RL. On error management: lessons from avia-tion. BMJ 2000; 320: 781–785.

2. Sexton, BJ, et al. Error, stress, and teamwork in medicineand aviation: cross sectional study. BMJ 2000; 320:745–749.

3. Leape LL, et al. Safe health care: are we up to it? BMJ 2000;320: 725–726.

4. Marsch SCU, et al. Training complete operating room teamsin the simulator enhances team performance in the real oper-ating room. Anesthesiology 1999; Suppl. 1: A-1115.

SANTANDER-02-13

Which scenarios should be included insimulator training? Empirical decision treespredict crises during anaesthesiaJ. Vollmer, S. Mönk, T. Uthmann, W. HeinrichsSimulationszentrum der Klinik für Anästhesiologie,Johannes Gutenberg-Universität, Mainz, GermanyWe have developed a model for prediction of crisisduring anaesthesia using empirical decision treemethods. Interpretation of such models can help inchoosing scenarios for simulation on a statisticalbase.Motivation: Anaesthesia is a safe discipline.Experienced anaesthetists know combinations of a patient’s state, operation, anaesthesia technique andcircumstances, which increase the risk for a crisisduring anaesthesia. Training with simulators isaimed to reduce the risks of such crises. For a rationalselection of scenarios and standardization of simula-tor trainings a statistical founding is a prerequisite.Empirical tree methods may help to developschemes for simulator trainings.Methods: An empirical tree represents a segmenta-tion of data that is created by applying a series of

simple rules. Each rule assigns an observation to a segment based on the value of the target criteria.Such trees enable the user to classify observationsand interpret them through the applied logic state-ments of the segmenting rules. The segmentation canbe used as a prediction model of the target criteria.We applied the method to a database of 334 000incidents of anaesthesia use from 24 hospitals inGermany during 2000. The database structure isbased on a proposition for quality management bythe German Society for Anaesthesia and IntensiveCare Medicine (DGAI) [1] and it codes adminis-trative data, diagnosis, times of anaesthesia andoperation, and critical incidents (AnästhesiologischeVerlaufsbeobachtung, AVB). We chose the occur-rence of relevant AVB as the target criteria for ourstudy, which was carried out using SAS EnterpriseMiner V 4.0 [2].Results: We observed the occurrence of relevantAVB (rAVB) in 1.8% of the cases. The segmentsfound by tree methods showed relative frequenciesfrom 0.4% to 21% for rAVB. The segments can becharacterized by the applied segmentation rules.Examples of 2 segments: (a) Patients less than 60 yrold with ASA classification of I or II, non-emergencyoperation, and duration of the operation less than3 h, showed an occurrence of rAVB with a relativefrequency of only 0.4%. About 15% of the patientsfulfilled these criteria. (b) Patients older than 60 yr,ASA III, IV, or V in emergency situation showed arelative frequency of 12% of occurrence of relevantAVB. This applied to 2% of the patients. 75% of therAVB, which occurred for this group apply to thecardiovascular system, including 12% with lethaloutcome.Conclusions: For choosing the contents and scenar-ios of simulation classes, empirical decision treesmay give a statistical basis. This corresponds to anapproach to include knowledge and techniques ofquality management into medical simulation. ‘Safeanaesthesia’, i.e., patients and operations that show a low relative frequency of rAVB do not need to betrained. Anaesthesia cases that show a high occur-rence of rAVB should be included in simulator train-ing. These patients and operations can be detectedwith the means of empirical trees, and correspond-ing scenarios can be created and justified. The exam-ined case gives reason for training scenarios in thefield of cardiovascular problems for the elderly.

References

1. Benson H, et al. DGAI Kerndatensatz Anästhesie Version2.0, 1999. Anästhesiologie und Intensivmedizin 1999; 9:649–660.

2. http://www.sas.com

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SANTANDER-02-14

How do anaesthesiologists experience a simulator setting in comparison withclinical settings? Results from an interview studyP. Dieckmann*, T. Manser*, B. Schaedle†, M. Rall†*Institute of Work Psychology, Swiss Federal Institute ofTechnology (ETH), Zürich, Switzerland, †Centre forPatient Safety and Simulation, Department ofAnaesthesiology, University Hospital Tübingen,GermanyOur project investigates the ecological validity ofsimulator settings by using several sources of data.Besides action sequences we focus on the partici-pants’ experience of the simulator setting. Thisapproach acknowledges that actions may be experi-enced differently, depending on their dynamic con-text. Both objective and subjective data have to beconsidered to improve the ecological validity of sim-ulator settings.Methods: After 18 simulator sessions semi-structuredinterviews were conducted focussing on setting ele-ments making it feel ‘real’ or ‘simulated/fictional’.Informed consent was obtained from 6 anaesthesiolo-gists (3 first year and 3 third year residents) each taking part in 3 simulator scenarios (1 routine caseand 2 containing critical events). The interviews wereanalysed by extracting ‘reality signs’ and ‘fictionsigns’ [2].Results: In the following we focus on reality andfiction signs concerning actions of participants. Allparticipants pointed out that their actions werenearly the same in the simulator setting as in the OR (e.g. cross checking between different sources of information). However, the participants weresometimes uncertain whether to perform certainactions in the simulator setting or not (e.g. using thetelephone). Thus emphasizing the formerly statedimportance of thorough briefings before simulatorsessions [3]. The most prominent fiction sign was the participants’ feeling that they were more carefulin their clinical decision making (e.g. reading thepatient chart several times). Inconsistencies betweendifferent sources of information due to not optimallysynchronized elements of the simulator setting wereparticularly difficult in the decision process. Thenecessity to communicate with other team membersor the patient was experienced either as a reality or afiction sign depending on communication style andcontent. Some elements – e.g. inability to completethe anaesthesia record during the scenario – wereexperienced completely different by some partici-pants. While one person thought this to be a fictionsign (the scenario was too short to complete therecord) one other person said that he had reacted to

the time pressure like in the OR (set priorities: skipthe protocol).Discussion: Our results highlight the value of dia-logue and consensus oriented research striving forecological validity of simulator settings. The insightgained by interview data is essential for derivingdesign implications such as the importance to syn-chronise all elements of the simulator setting verycarefully. Nevertheless we need an improved under-standing of the processes leading to different experi-ences of the same elements of simulator settings.

References

1. Manser T, et al. Comparison of action density patternsbetween simulator and clinical settings. Eur J Anaesthesiol2003; 20: xxx–xxx <<=SANTANDER-02-11>>.

2. Schreier M, et al. ‘Perceived Reality’ als Teilbereich von Realitäts-Fiktions-Unterscheidungen: ein integrativesModell. In: Silbereisen R K, Reitzle M. Bericht über den 42.Kongreß der Deutschen Gesellschaft für Psychologie in Jena2000. Lengerich, Germany: Pabst, 2000.

3. Rall M, et al. Key elements of debriefing for simulatortraining. Eur J Anaesthesiol 2000; 17: 516–517.

SANTANDER-02-15

Simulator training for medical emergenciesin dental practiceR. J. Glavin, N. J. MaranScottish Clinical Simulation Centre, Stirling RoyalInfirmary, Scotland, UKPrompt recognition and appropriate management of medical emergencies occurring in the dental chairis now regarded as a core competence in the trainingof general dental practitioners. This study sought to look at the impact of a simulator based course on both theoretical and clinical performance. Pre-liminary findings from 2 scenarios (scenarios 1 and4) involving cardiac arrest in the dental chair arereported.Methods: Ten core medical emergencies weregrouped into 5 clinical scenarios, which also formedthe basis of a short answer written paper. Seventy-nine final year dental students attended our centre for2 half-day visits in groups of 8–10. On each visit theywere presented with the written examination, thenfollowing an introduction and orientation took partin clinical scenarios. Each scenario was followed bydebriefing, aided with a video-recording of the sce-nario, and on the first visit this was in turn followedby some further instruction in the clinical area. Onthe first visit each group participated in 2 scenariosand on the second visit 4 scenarios. A structured

Abstracts 11


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marking system based on specimen answers was usedto score the written examination and a marking system derived from these was used to mark the technical performance of the students in the clinicalscenarios. Related t-tests were used to analyse thewritten scores and independent t-tests for the clinicalscores. For this study the written scores for the ques-tions relating to scenarios 1 and 4 were analysedrather than the written paper as a whole.Results: Analysis of the written scores for each ofthe two scenarios showed no significant differencebetween the first and second visit scores. In contrastthere was a significant improvement in the clinicalscores of the second visit (Table 1).Discussion: The improvement in scores in clinicalperformance suggests that the brief period of simula-tor training does have a positive impact on clinicalperformance, as scores in both groups improved sig-nificantly. However, the initial scores on both visitswere very low and so it should not surprise that animprovement was seen. The lack of a difference ofscores in the written examination does suggest thatthere is a gap between ‘knows how’ and ‘shows how’to manage a clinical emergency and this raises issuesworthy of further exploration.

SANTANDER-02-16

Incorporation of simulation in a newlydeveloped medical curriculumC. Grube, Y. Zausig, T. Boeker, B. GrafDepartment of Anesthesia, Heidelberg University,GermanyThe traditional medical curriculum for German med-ical students is mainly knowledge-based instead ofskill-based. So most of the time medical studentsspend at university they are educated in theory sit-ting in the lecture theatre. The intermediate and finalexaminations are also conventionally Multiple ChoiceQuestion style. For the last 2 yr the Heidelberg med-ical faculty took measures to develop a completelydifferent medical curriculum. Based on the experi-ences of Harvard Medical School, Boston, this new

curriculum should be directed much more to skill-based teaching and interactive learning for the studentsthan before. It is labelled ‘Heidelberg CurriculumMedicinale’ (HeiCuMed). The only department atHeidelberg University presently running a full-scalepatient simulator is the Department of Anesthesia.So our department decided to incorporate this simu-lator into HeiCuMed. During each year of theirmedical studies our students stay for 2 weeks in theDepartment of Anesthesia. The schedule for the firstweek includes: pharmacology of anaesthesia drugs,principles of anaesthesia, intensive care, and paintherapy. In the second week the students are edu-cated in emergency medicine.

The schedule for the first week starts with aninteractive seminar with 30 participating studentsand 2 teachers in the morning. The teachers give lectures using sandwich techniques to offer the students a chance of interacting with each other andthe teachers. After a lunch break the students aredivided into 3 groups of 10 students each. While 2 of these groups spent 1 h on a case study under faculty supervision there is always 1 group of 10 students at the simulator. Rotation of the stu-dents through different departments allows us toteach 150 students within a period of 10 weeks. The2 case studies are intended for better comprehensionand retention of the relevant learning objectives ofthe morning seminars. During the simulator timethe students have to actively solve problems byusing the theoretical knowledge they have beentaught in the morning. The teacher’s role at the sim-ulator is to facilitate this transfer of knowledge intopractice.

The concept of this curriculum is the combinationof theory, case study, and active treatment of a simu-lated patient to achieve the given learning objec-tives. According to current learning theory the bestway to achieve these aims is to activate the studentduring the learning process. By the 1 day schedule ofinteractive lectures followed by a case study and sim-ulator training we intend to facilitate the students’acquisition of knowledge and skills necessary for animproved performance as a physician. The concept ofa whole day curriculum allows a limited use of theexpensive simulator time as a kind of ‘top of theteaching line’ instrument. Preliminary results ofevaluating students’ experience of simulator trainingshow that this kind of training is highly activatingand motivating for students.

As the anaesthesia department is by now the onlydepartment using a simulator for student educationfor HeiCuMed other departments e.g., InternalMedicine, Pharmacology, and Physiology are highlyinterested in making use of our full scale simulatorfor their purposes.

12 Abstracts


Table 1.

Written Clinical test (%) performance (%)

Scenario 1 Visit 1 87 34Visit 2 85 46 (P � 0.01)

Scenario 4 Visit 1 61 42Visit 2 67 54 (P � 0.01)

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SANTANDER-02-17

A study of General Practitioner refreshercoursesA. K. McIndoe, A. J. JonesBristol Medical Simulation Centre, UKThe Bristol Medical Simulation Centre (BMSC) has undertaken 7 General Practitioner (GP) half-dayrefresher courses between January 2001 and February2002 (Table 1).Setting the scene: The adult METI HumanPatient Simulator was positioned lying face-up fit-ted with a cannulation arm on a couch reading abook in front of a television to set the scene for ahome visit or doctor’s surgery. The GPs were briefedwith some patient details before each scenario andwere equipped with a ‘black bag’ (Table 2).Course content: The programme comprised fourscenarios interspersed with debriefing.Scenario 1. After climbing the stairs at home, thepatient develops a myocardial infarction leading tocardiac arrest.Scenario 2. The patient falls in his home and developsan intra-abdominal bleed and simple pneumothorax,which progresses to a tension pneumothorax.Scenario 3. The doctor is called by the practice nurseto the treatment room to assess a patient who hasdeveloped a systemic reaction to a routine inocula-tion, which results in anaphylactic shock.Scenario 4. The patient is rushed to the surgery aftereating a chocolate covered peanut developing ana-phylaxis leading to a ‘can’t intubate can’t ventilate’scenario.Course feedback: From 50 attendees 32 GPs com-pleted standard BMSC questionnaires. Results wereas follows (Table 3).A selection of comments:‘An enjoyable and extremely useful afternoon. Veryrealistic scenarios and well acted’;‘Excellent, unthreatening atmosphere. Very clear,relevant explanations’;‘Much better way of remembering. Staff non-threatening. Thanks’;

‘Very good. Not as frightening as I thought it would be’;‘Useful as both an individual and a group observer’;‘Excellent method of teaching, made more aware ofwhat is available to the average GP’.

Abstracts 13


Table 1. Courses completed (*denotes no feedback for this course).

Date of course GPs in attendance

11/01/01 5*

25/04/01 703/07/01 603/09/01 805/09/01 920/11/01 822/02/02 7*

Total 50

Table 3. Column ‘All’ denotes all delegates (GPs, medicalstudents, SHOs, SpRs, dentists, nurses) who have completedquestionnaires at the BMSC (Excluding national/industrysponsored courses) since opening.

GPs All Questions (%) (%)

Q 1. Do you think the simulator has a role to play 100 100in teaching?

Q 2. Has it improved:(a) Your practical skills? 90 77(b) Your clinical knowledge? 100 93(c) Your understanding of basic sciences? 63 64(d) Your confidence in dealing with 94 65

patients?(e) Your familiarity with equipment? 78 77(f) Your understanding of principles of 19 66

anaesthesia?

Q 3. Would this session have been best covered in:(a) A lecture format? 0 8(b) A ward round about the bedside? 7 10(c) A classical tutorial? 4 15(d) A problem based simulation approach? 94 94

Q 4. Score in terms on a value of 0–3 spent in:(a) Simulation theatre (GP avg 2.8) 93 90(b) With cannulation arm (GP average 2.3) 77 73(c) Lecture room (GP average 2.5) 83 70

Table 2. Contents of ‘black bag’.

Content Quantity

Mini-Trach II® Minitracheotomy Kit 1A selection of Venflon® cannulae 8A selection of hypodermic needles 6A selection of syringes 3Vecafix i.v. dressingsA pocket mask 1Glyceryl trinitrate pumpspray 1Laryngoscope 1Guedel airways 2Endotracheal tubes 2Glucose Minijet® injection 11 mg in 1 mL epinephrine ampoule 1Epinephrine 1:10 000 Minijets® 2Frusosemide Minijet® injection 1Isoproterenol Minijet® injection 1Inhalers 21 mL hydrocortisone injection 5 ampoules1 mL chlorpheniramine injection 5 ampoulesAtropine sulphate injection 1Diamorphine injection 1Stethoscope 1Assorted adhesive tape 2 rolls

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Conclusions: General practitioners unanimouslythink: there is a role for the simulator in teaching andthat it greatly improved their practical skills (more sothan other groups of delegates); confidence in dealingwith patients (in critical situations; more so thanother groups of delegate); familiarity with equipment(such as tracheostomy kits) and understanding ofbasic sciences (using the latest BLS/ALS protocols).

94% of GPs thought that the session was bestcovered in the simulation centre environment andindicated it as the most useful method of teaching.Comments: The BMSC has diversified this courseby piloting two variations in the GP refresher coursefor (a) Cardiac GPs and (b) drug specific courses suchas a ketamine GP course for BASICS trauma GPs(trauma first responders).

SANTANDER-02-18

Assessment of a full patient simulator forteaching decision making in emergencymedicineA. Quesada, J. C. Rodríguez-Borragán, I. Del Moral, J. M. RabanalSantander Simulation Centre, H.U.M. Valdecilla,Santander, SpainWe have developed a 5 day and 40 h long course onteaching emergency medical techniques for physicians.For the last 4 yr we have organized 4 courses and 320trainees have passed through the course. The courseconsists of 20 h of lectures and 10 of practicals, eachlasting 2 h. Each course was attended by 8 students.Practicals were: mechanical ventilation, airway man-agement, drugs, ACLS in animal laboratory, manage-ment of acute coronary syndromes, dysrhythmias, useof abdominal echography, troubleshooting workshop,managing a poisoned patient, and decision-making inemergency medicine. This last workshop took place inSantander Simulation Centre, using a full-scale patientsimulator to create a realistic environment. The aim ofthis practice was to evaluate and teach dynamic deci-sion making during highly complex clinical scenarios.A short analysis of the case followed each scenario. Atthe end of the course, all participants completed aquestionnaire to assess all aspects of the course (ratingscale 1 to 5; 1 minimum and 5 maximum).Results: Questionnaire results are shown in Table 1.Conclusions: This course is being well received byparticipants, as a useful course for their job. Thiscourse combines lectures and workshops, whichseems to be useful for the trainees. The full patientsimulator workshop is the most highly attendedpractice by students among 11 different workshops.Teaching decision making with a full patient simu-lator improves the educational value of these courses.

SANTANDER-02-19

Patient simulator as test bed for mobiletelemedicine applications for medicalemergencies – The Guardian-Angel-SystemM. Rall, J. Zieger, B. Schaedle, A. Wengert, K. UnertlCenter for Patient Safety and Simulation, Department of Anaesthesiology, University Hospital Tübingen,GermanyThe implementation of new technical systems inhealth care always bears the risk of inadvertentlyendangering patients [1,2]. This may be due to theuse of the system itself or due to distraction of atten-tion. This effect may even be pronounced while estab-lishing a new safety system in emergency patientcare. Until now, the use of telemedical systems toprovide help in acute life-threatening situations hasbeen very limited. A realistic simulation environmentwas used to develop and test the new ‘Guardian-Angel-System’ (GANS) intended to improve patientsafety in medical crisis situations.Methods: In the 6WINIT (Ipv6-Wireless InternetInitiative) project (www.6winit.org), funded by theEuropean Commission, we developed a real-time,mobile and wireless telemedicine system to provideacute medical help to health care professionals outside the hospital in collaboration with the Uni-versity of Stuttgart Computing Centre and EricssonResearch. The system transmits vital data and videostreams via Java and Java Media Framework pro-grams using JDK 1.4 in a Linux environment. Allapplications are enabled for the future IPv6 (Internetprotocol 6) and allow multi-access and seamless hand-over. The system is designed to improve patientsafety by instantly transferring expert knowledge to the emergency scene. As a result of realistic sce-narios with the simulator and variable modes of data transmission we qualitatively derived technical

14 Abstracts


Table 1. Results of the questionnaires.

Topic Score

Usefulness of the course 4.52Lectures 3.81Workshops 4.35Decision-making with a FPS 4.57Mechanical ventilation 4.55Airway management 4.43Troubleshooting workshop 4.37Drugs 4.36Abdominal echography 4.28Acute coronary syndrome 4.20ACLS in animal lab 4.19Dysrhythmias 4.01Managing a poisoned patient 3.44

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specifications from the needs of the experts in theGANS centre and the remote doctors.Results: To support the physician at the scene it isnecessary to transmit all vital data streams, such asblood pressure, oxygen saturation and ECG in real-time to the GANS centre. Otherwise the expertwould have to ask repeated questions regarding thevital signs, thus unduly distracting the attention ofcolleagues. Also, it would be very difficult for theexpert to develop a mental model of the patient’s condition without continuously monitoring the vitalsigns. In order to contribute positively to the crisisresource management of a case it proved to be veryhelpful to have at least one live video stream includ-ing audio from the treatment scene. This enables theexpert (a) to assess the people involved, (b) to recom-mend to call for help, (c) to perceive the stress level ofthe situation, and (d) to decide when to talk to theremote colleague and when to be quiet (e.g. it is dis-turbing trying to talk to a colleague when he is aboutto auscultate the chest). The colleague at the scenemust be able to start the GANS system by ‘one-button-activation’ and needs a wireless full-duplexheadset for effective communication.Conclusions: The use of the realistic simulator as a test bed for the new telemedical Guardian-Angel-System led to the specification of several technicalrequirements, which are otherwise difficult to obtainwithout endangering patients. In our opinion thisinnovative use of simulators to develop technical sys-tems for patient safety is a very promising conceptfor the future [3].

References

1. Lin L, et al. Patient safety, potential adverse drug events,and medical device design: a human factors engineeringapproach. J Biomed Inform 2001; 34: 274–284.

2. Feigal DW, et al. Ensuring safe and effective medicaldevices. N Engl J Med 2003; 348: 191–192.

3. Bates DW, et al. Reducing the frequency of errors in med-icine using information technology. J Am Med Inform Assoc2001; 8: 299–308.

SANTANDER-02-19

The role of debriefing in simulator trainingcourses for medical studentsB. Schaedle*, P. Dieckmann†, A. Wengert*, J. Zieger*, M. Rall**Center for Patient Safety and Simulation, Departmentof Anaesthesiology, University Hospital Tübingen,Germany, †Institute of Work Psychology, Swiss FederalInstitute of Technology (ETH), Zürich, SwitzerlandCase management and ‘hands-on’ training is impor-tant for the education of medical students to increase

their performance ability in the real world [1].Simulators provide a means to making critical inci-dents ‘available’ for regular training courses [2].However, to use the full potential of simulator train-ing a real sense of ‘hands-on’ experience is essential.This is usually achieved in debriefing sessions, whichare widely regarded as important [3]. This study wasperformed to assess the role of debriefing in trainingcourses for medical students.Methods: Over 2 yr, 88 medical students took partin a 1 week simulator training course. The maxi-mum course size was 10 students. Each participanttook part in three to four scenarios each followed by an intensive debriefing session. Subsequently stu-dents provided feedback by a standardized question-naire containing 40 closed questions. Each questionwas answered by marking one out of four answerpossibilities (rating scale 1–4).Results: Participants indicated the experience ofthe course in whole as intense (94.3% marked ‘veryintense’ or ‘intense’). The scenarios itself were ratedas stressful (97.7% marked ‘very high’ or ‘high’).Despite this perceived stress, most participants didnot suffer from it (58.6% marked ‘no suffering’;24.1% marked ‘little suffering’). The debriefingswere not rated as intimidating as 81.8% rated ‘no’ tothe question whether the debriefing was ‘compro-mising or attacking’. 94.3% indicated the debrief-ing to be ‘indispensable for a simulator course’. Thelearning experience during the debriefing was ratedas very valuable. 67.5% of the participants marked‘yes’ or ‘rather yes’ to the question whether theylearned more during debriefing than during scenar-ios. Overall, 83.0 % of students indicated that thiswas the best course during medical school so far.Conclusions: Students seem to like intense andstressful courses when they provide an unparalleledlearning experience. The results indicate two mainobjectives of debriefing. Firstly, the widely acceptedfacilitation and transfer of learning from the sce-nario, and secondly, the modulation and reflection ofthe experienced stress to prevent it to harm thetrainees.

References

1. Rall M, et al. Live-Telementoring für die Ausbildung vonMedizinstudenten. Verbesserung der Handlungsfähigkeit.Telemedizinführer Deutschland 2002: 128–133.

2. Larbuisson R, et al. Use of anaesthesia simulator: initialimpressions of its use in two Belgian University Centers.Acta Anaesthesiol Belg 1999; 50: 87–93.

3. Rall M, et al. Key elements of debriefing for simulatortraining. Eur J Anaesthesiol 2000; 17: 516–517.

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