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?

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◦
◦
◦
◦
◦
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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

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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
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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
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Day 1
◦ Didactic
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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