Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Improving Efficiencies in Simulation Education, Blended Learning in Basic and Advanced Cardiac Life Support Training Geoffrey T. Miller Associate Director, Research and Curriculum Development Division of Prehospital and Emergency Healthcare Gordon Center for Research in Medical Education University of Miami Miller School of Medicine Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education 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) Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education What’s new in medical simulation… Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education 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. Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education 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 Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Why use simulation? Assessment of professional competence ◦ Patient care ◦ Medical knowledge ◦ Practice-based learning & improvement ◦ Communication skills ◦ Professionalism ◦ Systems-based practice Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Why use simulation? What does the science say… ◦ Overwhelmingly positive and favors use of simulation 1. Examples: 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” 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 casecontrol study – Wayne DB, et. al. Chest, 2008. “Simulation-based educational program significantly improved the quality of care during actual events” Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education 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 Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Another interesting thought… How could learning style affect awareness, pattern recognition and “habits”? Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education A quick case study Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education 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 Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education ‘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. Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Fidelity The degree of realism Types: ◦ Environmental ◦ Physical ◦ Technical ◦ Psychological Key Question: Is the simulation activity “realistic” enough to accomplish the desired outcomes. Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Fidelity and technology High fidelity High technology Low fidelity Low technology High fidelity Low technology Technology Low fidelity High technology Fidelity Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education “Realism versus relevance” Key Question: ◦ Which concept is more important in choosing and developing the learning activity? Realism Relevance Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Realism and relevance Most cost-effective Prior Learning None High Best learning Expert Experienced Novice Low High Fidelity Relevance (realism) Adapted from: Alessi S. Design of Instructional Simulations. J Computer-based Instruction. 1988. 40-7. Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Learning ladder BEME: multiple learning strategies and clinical variation Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education The ultimate goal? Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Where does simulation fit? Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education The ‘big picture” Knowledge Attitude Skill Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Miller’s Pyramid of Competence Does Shows Knows how Knows George E. Miller MD. The Assessment of Clinical Skills/Competence/Performance. Academic Medicine. 1990. Vol. 65 No. 9: S63-67. Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education “Knows” Learning Opportunities: • Reading / Independent study • Lecture • Computer-based • Colleagues / Peers Assessment opportunities: Does Shows Knows how Knows • Multiple-choice question • Essay / Short answer • Oral interview Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education “Knows how” Learning Opportunity Clinical Context Based Tests • Problem-based Ex. • Tabletop exercises • Direct observation • Mentors • Multiple-choice question • Essay / Short answer • Oral interview Does Shows Knows how Knows Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education “Shows” Learning Opportunity Performance Assessment • Skill-based Exercises •Repetitive practice • Small group • Role playing Does Shows Knows how Knows • Objective Structured Clinical Examination (OSCE) • Standardized Patient-based Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education “Does” Performance Assessment Learning Opportunity • Experience Does Shows Knows how Knows • Undercover / Stealth standardized patientbased • Video Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Key questions regarding blended learning models Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Who are our Learners? Key Questions: ◦ Who are our learners? ◦ Why do they Learn? ◦ What are their Motivations? Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Blended learning Key Questions: ◦ What is “blended learning? ◦ Where does it happen? ◦ What does this mean to me as a healthcare educator? Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Simulation methods Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education 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 Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education 3D models basic plastic manikins Heart and lung models Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Basic plastic manikins BLS manikins (Rescusi Anne) Simple simulators for teaching basic interventions and/or physical examination skills Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Standardized Patients Represent ultimate alternative to live patients ◦ Standardized role play of psychological and physiological aspects of patients Facilitator & peers evaluate student performance Student examines patient Facilitator & SP provide feedback & training Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Screen-based simulations Software driven systems that include multimedia and VR components. ◦ Ranges from simple noninteractive to fully interactive teaching programs. ◦ Enhance cognitive knowledge, clinical reasoning and decision making. Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Intelligent/Serious gaming Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education 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) Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education “Testing force feedback virtual reality products for dogs” Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Learning and assessment opportunities Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Large group instructor led Reach many learners at once ◦ Additional equipment: cameras/projectors/AV Instructor needs practice Audience response system Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Small group instructor led Focused teaching Ability to assess individuals’ skills Hands-on, interactive Interest up to 2 hrs Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Individual self-directed learning Important for skills acquisition (deliberate practice) Ability to work at own pace Responsible for own learning Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Independent small group learning Less “hands-on” time Opportunity to exchange ideas & problem solve Practice team work Peer to peer Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education 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” Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Assessment Assessment should be educational and formative ◦ Learning through testing ◦ Feedback to build knowledge and skill Reflection - error correction – refinement “Assessment drives learning” Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education A case study in developing a blended learning curriculum Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education 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 Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education 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 Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education UM Course Design Day 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 Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Case –Based Lecture • Open-air concert • 18,000 people • Temp: 84° F • Wind: ENE 12 knots • Chemical weapon from a boat on shoreline Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Case –Based Lecture • Plume throughout concert area • Initially mistaken as smoke machine (part of show) • Hundreds with symptoms within minutes Concert Area Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Individual Self-learning Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Small group instructor teaching Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Large group exercise (student directed) Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Web/eLearning integration Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Web/eLearning integration Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Assessment and feedback Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education 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 Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education 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 Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education Questions and discussion Simulation Effective Uses of Simulation in BLS & ACLS Training The Gordon Center for Research in Medical Education For additional information: Geoffrey T. Miller gmiller@med.miami.edu
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