the gordon center for research in medical education effective uses of simulation in bls & acls...

Simulation The Gordon Center for Research in Medical Education

Effective Uses of Simulation in BLS & ACLS Training

Improving Efficiencies in Simulation Education, Blended Learning in Basic and Advanced

Cardiac Life Support TrainingGeoffrey T. Miller

Associate Director, Research and Curriculum Development

Division of Prehospital and Emergency HealthcareGordon Center for Research in Medical Education

University of Miami Miller School of Medicine



Session aims

In the context of BLS and ACLS training:◦Review the fundamental benefits of simulation ◦Discuss various examples of simulation◦Discuss key questions surrounding blended learning◦Explore practical applications of simulation◦Participate in simulation activities for BLS and ACLS

training (Part 2)



What’s new in medical simulation…



What is medical simulation?

“In general, medical simulations aim to imitate real patients, anatomic regions, or clinical tasks, or to mirror real-life situations in which medical services are rendered.”

“simulation refers broadly to any device or set of conditions… that attempts to present patient problems authentically, whereas a simulator, more narrowly defined, is a simulation device.”

Issenberg, SB, Scalese, RJ. Simulation in Healthcare Education. Perspectives in Biology and Medicine. Vol. 51, No. 1: 31-46.



Why use simulation?

Benefits of medical simulation◦ Safe environment, mistake forgiving◦ Trainee focused vs. patient focused◦ Controlled, structured, proactive clinical exposure◦ Reproducible, standardized, objective◦ Debriefing as a norm in everyday practice◦ public trust in profession◦ Deliberate and repetitive practice



Why use simulation?

Assessment of professional competence◦Patient care◦Medical knowledge◦Practice-based learning & improvement◦Communication skills◦Professionalism◦Systems-based practice



Why use simulation?

What does the science say…◦Overwhelmingly positive and favors use of simulation

Examples:2. A longitudinal study of

internal medicine residents’ retention of advanced cardiac life support skills – Wayne DB, et. al. Academic Medicine, 2006.

“ACLS skill improved significantly… cohort followed for 14 months and the skills did not decay”

3. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study – Wayne DB, et. al. Chest, 2008.

“Simulation-based educational program significantly improved the quality of care during actual events”

1. Written evaluation is not a predictor for skills performance in Advanced Cardiovascular Life Support course – Rodgers DL, et. al. Resuscitation 2010

“The ACLS written evaluation was not a predictor of participant skills in managing a simulated cardiac arrest event”



Food for thought… and discussion

"Excellence is an art won by training and habituation. We are what we repeatedly do. Excellence, then, is not an act but a habit."

Aristotle



Another interesting thought…

How could learning style affect awareness,pattern recognition and “habits”?



A quick case study



Inattentional blindness

Inattentional blindness is the phenomenon of not being able to perceive things that are in plain sight◦Can result from:

no internal frame of reference, or mental focus or attention which

cause mental distractions



‘Right conditions’ for learning in simulation

Feedback should be provided during the learning experience Learners should engage in repetitive practice Simulation should be integrated into the overall curriculum Learners should practice with increasing levels of difficulty Multiple learning strategies should be employed Simulations should represent clinical variation The simulation environment should be controlled Simulations should foster individualized learning Outcomes must be clearly defined and measured The simulator should be valid as a representation of a human or

situation

Issenberg SB,McGaghie WC, Petrusa ER, Gordon D, Scalese RJ (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher 27(1): 10–28.



Fidelity

The degree of realism

Types:◦Environmental◦Physical◦Technical◦Psychological

Key Question: Is the simulation activity “realistic” enough to accomplish the desired outcomes.



Fidelity and technology

Low fidelityHigh technology

Low fidelityHigh technology

Low fidelityLow technology

Low fidelityLow technology

High fidelityHigh technology

High fidelityHigh technology

High fidelityLow technology

High fidelityLow technology

FidelityFidelity

Tech

nolo

gyTe

chno

logy



“Realism versus relevance”

Key Question: ◦Which concept is more important in choosing and

developing the learning activity?

Realism Relevance



Fidelity (realism)

Adapted from: Alessi S. Design of Instructional Simulations. J Computer-based Instruction. 1988. 40-7.

Realism and relevancePri

or

Learn

ing

Relevance

Novice

Experienced

Expert

Most cost-effective

Best learning

Low High

None

Hig

h



Learning ladder

BEME: multiple learning strategies andclinical variation



The ultimate goal?



Where does simulation fit?



The ‘big picture”

Attitude

Knowledge

Skill



Miller’s Pyramid of Competence

Knows

Knows how

Shows

Does

George E. Miller MD. The Assessment of Clinical Skills/Competence/Performance.Academic Medicine. 1990. Vol. 65 No. 9: S63-67.



Knows

Knows how

Shows

Does

“Knows”Assessment opportunities:• Multiple-choice

question• Essay / Short answer• Oral interview

LearningOpportunities:• Reading /

Independent study• Lecture• Computer-based• Colleagues / Peers



Knows

Knows how

Shows

Does

Clinical ContextBased Tests• Multiple-choice

question• Essay / Short answer• Oral interview

“Knows how”LearningOpportunity• Problem-based Ex.• Tabletop exercises• Direct observation• Mentors



Knows

Knows how

Shows

Does

“Shows”PerformanceAssessment• Objective Structured

Clinical Examination (OSCE)

• Standardized Patient-based

LearningOpportunity• Skill-based Exercises

• Repetitive practice• Small group• Role playing



Knows

Knows how

Shows

Does

“Does”PerformanceAssessment• Undercover / Stealth

standardized patient-based

• Video

LearningOpportunity• Experience



Key questions regardingblended learning models



Who are our Learners?

Key Questions:◦Who are our learners?◦Why do they Learn?◦What are their Motivations?



Blended learning

Key Questions:◦What is “blended learning?◦Where does it happen?◦What does this mean to me as a healthcare educator?



Simulation methods



Simulation technologies

Low-tech simulation modalities:◦Patient management problems◦3D Models◦Basic plastic manikin and simple skills trainers◦Simulated or standardized patients

High-tech simulation modalities:◦Screen-based simulations◦Intelligent gaming ◦Realistic high-tech interactive patient simulators



3D models basic plastic manikins

Heart and lung models



Basic plastic manikins

BLS manikins (Rescusi Anne)Simple simulators for teaching basic interventions and/or

physical examination skills



Standardized PatientsRepresent ultimate alternative to live patients

◦Standardized role play of psychological and physiological aspects of patients

Student examines patient

Facilitator & peers evaluate student performance

Facilitator & SP provide feedback & training



Screen-based simulations

Software driven systems that include multimedia and VR components.◦Ranges from simple non-

interactive to fully interactive teaching programs.

◦Enhance cognitive knowledge, clinical reasoning and decision making.



Intelligent/Serious gaming



Realistic high-tech interactive patient simulators

Realistic full-sized manikin, computer, and interface devices that operate manikin physiology and drive monitors◦Can be used in a variety of

settings (low to high fidelity)



“Testing force feedback virtual reality products for dogs”



Learning and assessment opportunities



Large group instructor ledReach many learners at once

◦Additional equipment: cameras/projectors/AVInstructor needs practiceAudience response system



Small group instructor led

Focused teachingAbility to assess

individuals’ skillsHands-on,

interactiveInterest up to 2 hrs



Individual self-directed learning

Important for skills acquisition (deliberate practice)

Ability to work at own pace

Responsible for own learning



Independent small group learning

Less “hands-on” time

Opportunity to exchange ideas & problem solve

Practice team work

Peer to peer



Assessments

Should include assessment of:◦Knowledge – not only factual recall, but

comprehension, application, analysis, synthesis and evaluation of cognitive knowledge

◦Skills – communication, physical exam, basic life support skills, airway management, IV therapy, defibrillation, time management, problem-solving

◦Attitudes – behavior, teamwork, delivering “bad news”



AssessmentAssessment should be educational and formative

◦Learning through testing◦Feedback to build knowledge and skill

Reflection - error correction – refinement

“Assessment drives learning”



A case study in developing a blended learning curriculum



Blended learning – model program

Emergency Response to Terrorism Training

◦Multiple healthcare professionals◦Many learner levels◦Methods of delivery

Lecture – case based Psychomotor skill exercises

◦ Small group◦ Individual / independent learner

Large group exercises Integration exercises – SPE-OSCEs



Templates and blueprints

Key features:◦Maps out:

session/course objectives learning opportunities and objects assessment opportunities and

objects Provides instructor support

materials and objects◦Allows assessment of omissions

& redundancies◦Provides a common

understanding



UM Course DesignDay 1

◦Didactic Response Concepts Operations PPE Decontamination ICS / IMS

◦Psychomotor PPE Medical Management Ambulatory DECON Incapacitated DECON

Day 2◦ Didactic

Chemical Agents Biological Agents Radiological and Explosive

Agents◦ Large Group Exercises

Triage – computer-based Tabletop

◦ Integration Exercises OSCEs



Case –Based Lecture• Open-air concert• 18,000 people

• Temp: 84° F • Wind: ENE 12 knots• Chemical weapon from a boat on shoreline



• Plume throughout concert area

• Initially mistaken as smoke machine (part of show)

• Hundreds with symptoms within minutes

ConcertArea

Wind

Plume

Case –Based Lecture



Individual Self-learning



Small group instructor teaching



Large group exercise (student directed)



Web/eLearning integration



Assessment and feedback



The final result

Course reduced to 8 hours, focused on hands on simulation based activities

Enduring materials allow for on-time, on-demand access by learners for maintenance of knowledge and skill (to a lesser degree)

Faculty time reduced and opportunity for training increased

Student assessment scores increased



Summary

Simulation offers a wide array of learning and assessment opportunities for BLS and ACLS training

Variation of learning methods and clinical difficulty is key to a successful learning ladder

The greatest effect on sustained learning is developed through the application of a blended learning environment



Questions and discussion



For additional information:

Geoffrey T. [email protected]

the gordon center for research in medical education effective uses of simulation in bls & acls...

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