Автор неизвестен - Mededworld and amee 2013 conference connect - страница 54

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Conclusions: There was measureable improvement in the simulator between the first and second prototypes. Faculty and resident evaluations of the simulator indicate that it is a valuable training device, with minor improvements.

Take-home messages: High-fidelity simulators can be valuable training tools in neurosurgical education.


Human Patient Simulation Training in End of Life Care

Lisa Redgrave (Lancashire Teaching Hospitals NHS Trust, Lancashire Simulation Centre, Sharoe Green Lane, Fulwood, Preston PR2 9HT, United Kingdom) Kathryn Gaunt (Lancashire Teaching Hospitals NHS Trust, Lancashire Simulation Centre, Preston, United Kingdom)

Mike Dickinson (Lancashire Teaching Hospitals NHS Trust, Lancashire Simulation Centre, Preston, United Kingdom)

Mark Pimblett (Lancashire Teaching Hospitals NHS Trust, Lancashire Simulation Centre, Preston, United Kingdom) Lorna Lees (Lancashire Teaching Hospitals NHS Trust, Lancashire Simulation Centre, Preston, United Kingdom) Jackie Hanson (Lancashire Teaching Hospitals NHS Trust, Lancashire Simulation Centre, Preston, United Kingdom)

Background: All health professionals are involved in the care of dying patients at some stage in their careers. The delivery of end of life care is challenging due to the interplay of emotional, ethical and clinical considerations. Despite this, most staff do not receive formal training in this field (Sullivan 2003). The use of human patient simulation (HPS) for palliative care training is a new concept (Pease 2007). By using clinical scenarios, reproduced safely and run in real time, we aim to show the effectiveness of HPS in addressing this educational challenge.

Summary of work: Mannequins and simulated patients were used in 'end of life' scenarios, for health professionals in palliative care and elderly medicine. Scenarios: Opioid toxicity in palliative care; Time pressured decisions at end of life; Family communication regarding the care of dying pathway; Artificial nutrition for patient with dementia. All participants completed post course reflective statements and feedback, assessed by thematic analysis. Summary of results: Key benefits of HPS training: Advanced feedback on performance; Improved understanding and awareness of facilitative aids / barriers to communication; Highlighted the impact of a stressful working environment on clinical encounters; Allowed colleagues to learn from each other's experience.

Conclusions: The use of HPS for palliative care training received strongly positive feedback, developing skills transferable to clinical practice. In view of the current public interest (Dept Health UK Jan 2013), such training is justified to ensure professional competency and optimise patient care.

Take-home messages: HPS is an effective educational tool for palliative care training.


Measuring Cognitive Load in Hybrid Simulations of Venous Catheter Insertion

Rodrigo B Cavalcanti (University of Toronto, Department of Medicine, Toronto Western Hospital - East Wing 8­420, 399 Bathurst Street, Toronto M5T 2S8, Canada)

Luke Devine (University of Toronto, Department of

Medicine, Toronto, Canada)

Christie Lee (University of Toronto, Department of

Medicine, Toronto, Canada)

Lynfa Stroud (University of Toronto, Department of

Medicine, Toronto, Canada)

Background: Learning can be enhanced by manipulating cognitive load. Hybrid simulation (HS) is useful in training for complex procedural skills, however data is lacking on how to asses cognitive load in hybrid simulation.

Summary of work: Ten senior residents in General Internal Medicine participated in two HS scenarios in ultrasound-guided central venous catheter (CVC) insertion. Simulations required insertion of a CVC into a rubber part task trainer affixed to a standardized patient (SP), while interacting with the SP and a standardized nurse, and monitoring the patient's clinical status and


ECG. Two scenarios with increasing complexity were designed. Scenario 1 included a minor arrhythmia during CVC insertion. Scenario 2 required addressing severe hypotension and an arrhythmia. Workload was measured with the NASA-TLX tool, and clinical performance was graded using validated checklists. Summary of results: NASA-TLX workload results ranged from 27-87 (max 120), increasing on average 16 points (range 5-35) between scenarios 1 and 2. Differences were similar regardless of scenario sequence. Major sources of CL were mental demand, temporal demand, effort and frustration. As in prior studies, NASA-TLX workload and procedural performance did not correlate


Conclusions: Retrospective analysis of workload using NASA-TLX correlates with scenario complexity in this hybrid simulation exercise. Sources of workload were similar to previous clinical studies using NASA-TLX. Take-home messages: Measuring CL can help tailor simulation exercises, by adjusting scenario difficulty to individual trainees' proficiency. NASA-TLX appears to capture workload appropriately in HS.


The Tools, the process and the training - a three pronged approach to improving the management of the difficult airway

CA Boynton (Royal Brompton Hospital, Anaesthetics, London, United Kingdom)

A Shonfeld (St George's Hospital, Anaesthetics, London, United Kingdom)

L Boss (Northwick Park Hospital, Anaesthetics, London, United Kingdom)

N Mehta (Northwick Park Hospital, ENT, London, United Kingdom)

T Tatla (Northwick Park Hospital, ENT, London, United Kingdom)

H Morris (Northwick Park hospital, Anaesthetics, London, United Kingdom)

Background: Over two years we have developed a unique multidisciplinary training day in difficult airway management. A workshop is followed by in-situ high-fidelity simulation involving theatre staff and anaesthetic and surgical trainees. We are conscious of Martin Bromiley's words asking for tools, process AND training 'so we can make quantum leaps in safe practice'.

Summary of work: The morning consisted of skills stations: the tools recommended by the Difficult Airway Society (DAS) for management of the difficult airway, with discussion of DAS guidelines, i.e. the process. An afternoon of multi-disciplinary workplace-based simulation with ENT surgeons, theatre staff and anaesthetists followed. The simulation covered 3-4 difficult airway simulations requiring all members of the team to become involved as the scenario progressed. In-depth structured de-brief followed each scenario. Candidates completed a questionnaire rating confidence with a full range of airway equipment before and after

the workshop and post simulation questionnaire evaluating the simulation, using a Likert scale (1-6). Summary of results: All 78 candidates felt that the simulation replicated the stress of "live" situations (Mean =4.8), addressed training needs (mean=5.5), improved clinical knowledge, teamwork, leadership and non technical skills (mean =5.6). There was an increase in confidence with all airway equipment. Conclusions: Simulation is an effective tool for teaching difficult airway management. A single workshop followed by in-situ simulation improves staff confidence with the tools and process necessary to improve outcome. We recommend a combined approach to teaching with an emphasis on multi-disciplinary participation.

Take-home messages: This course demonstrates success with multi-disciplinary training using in-situ high fidelity simulation and workshop-based teaching.


Sequential Simulation: An innovative approach to exploring the patient journey

Polly Hirons (Imperial College London, Department of Surgery and Cancer, London, United Kingdom) Dilip Bassi (Imperial College London, Department of Surgery and Cancer, London, United Kingdom) Elisabeth Paice (Elisabeth Paice Ltd, North West London Integrated Care Pilot, London, United Kingdom) Sara Hamilton (Imperial College Healthcare NHS Trust, Paediatrics, London, United Kingdom) Roger Kneebone (Imperial College London, Department of Surgery and Cancer, London, United Kingdom) Fernando Bello (Imperial College London, Department of Surgery and Cancer, London, United Kingdom)

Background: With a call for better Integrated Care within medicine, Sequential Simulation (SqS) recognises the importance of a temporal context, where a sequence of clinical events unfolds during each patient's journey. Recreating such events through simulation complements the training needs of medical staff, allowing participants and audience members to visualise the journey of a patient through the healthcare system. This process highlights key 'crunch points' in the journey - most commonly hand-over or transition points where communication between teams is paramount. Summary of work: Following Stroke and Myocardial Infarction projects, our current work focuses on paediatric asthma and elderly diabetic patients. We use a range of different simulated settings (for example A+E, GP surgery, hospital ward) to provide the physical context. Sequential Simulations have been run for both pathways, with the involvement of a multidisciplinary team, at a number of different public engagement and professionals' events.

Summary of results: SqS has received positive feedback from health professionals. They felt it was a valuable learning tool, which allowed them to think about patient journeys and their role in a more holistic way. It also stimulated much discussion amongst patient groups about how to improve their journey.


Conclusions: SqS is an innovative way of looking at the patient journey and learning about Integrated Care. It is highly versatile and is rated favourably by participants. Further work is needed to establish its feasibility and cost-effectiveness.

Take-home messages: At a time when Integrated Care is very much in the spotlight, SqS provides an exciting and innovative modality to educate trainees and help improve patient care.


Peer-assisted simulation teaching

Lydia Hanna (Maidstone and Tunbridge Wells, Surgery, Kent, United Kingdom)

Terry Collingwood (Maidstone and Tunbridge Wells,

Anaesthetics, Kent, United Kingdom)

Emma Moran (Maidstone and Tunbridge Wells,

Postgraduate Centre, Kent, United Kingdom)

Paul Moran (Maidstone and Tunbridge Wells,

Anaesthetics, Kent, United Kingdom)

Simon Bailey (MTW, Surgery, Kent, United Kingdom)

Background: The EWTD and ever-changing shift patterns have meant that foundation doctors (FD) are increasingly spending less time in the hospital with reduced opportunity to safely learn key practical skills. The busy working environment presents a challenge to seniors in finding time for teaching and supervision in performing procedures. Core trainees (CT) and the use of simulation techniques may provide a solution to these issues.

Summary of work: A simulated practical skills weekend was set up to provide theoretical and hands-on teaching. It was delivered through simulation by appropriately trained surgical, anaesthetic and medical CTs. A total of 8 procedures were taught based on the Foundation Programme curriculum objectives and was centred around candidates being able to describe the indication for the procedure, relevant anatomy, complications during and after the procedure and post-procedure care. A pre and post-course questionnaire was distributed to assess learning. Summary of results: Comparison of pre and post-course questionnaires demonstrated increased levels of confidence in performing all procedures with a reduction in the learners' perception of procedural complexity. Confidence in managing post-procedure complications was also improved. Conclusions: Core trainees are well positioned within the training system to provide peer-assisted learning to Foundation trainees due to their accessibility and approachability. The use of simulation provides a safe environment to learn and become confident with procedural skills and their care without compromising patient safety.

Take-home messages: Simulation training delivered through peer-assisted learning by core trainees is valuable teaching modality for foundation doctors.


"Post factum"-What if you could change the terms? Initial experiences of U/S guided lines

Briseida Mema (Hospital for Sick Children, Critical Care Medicine, 555 University Ave, Toronto -ON M5G 1X8, Canada)

Ilene Harris (University of Illinois at Chicago, Department of Medical Education, Chicago, United States)

Background: Ultrasound (U/S) guided Central Venous Line (CVL) insertion is currently the standard of care. Randomized Controlled Trials show that simulation is superior to apprenticeship training. Summary of work: We explored from the perspectives of participants in a U/S guided CVL simulation program the role of simulation training and other factors that impact real life performance. Purposeful sampling with 7 novice trainees and theoretical sampling with 6 faculty was used to investigate the experience of novice learners, after they had completed simulation training and then performed real life procedures. Semi structured interviews were used as the data source. In the constructivist grounded theory tradition, constant comparative analysis was conducted to identify emerging themes.

Summary of results: The novices had no prior knowledge or skills related to U/S guided CVL insertion. The transfer of skills from simulation to the actual bedside was not the only determinant of their performance. There were supportive factors (supervision, further real life experiences) and challenging factors (concern for patient welfare, complexity of the case, inability to troubleshoot) present at the bedside that further impacted the outcome. While some of those challenges could have been anticipated and taught using simulation, some could not. Novices also made suggestions for improving the simulation program (right refreshers, increasing the fidelity and complexity of scenarios with time). Conclusions: Reflections of learners and faculty on real life experiences gave insight into utility and improvement of simulation training. Take-home messages: As we strive to perfect our simulation training, we should also aim to perfect the clinical learning environment to appropriately support and challenge the learner.


Hybrid simulation: Bringing motivation to the art of teamwork training in the operation room

A Kjellin (CLINTEC, Surgery, Karolinska University

Hospital Huddinge, K53, Stockholm SE-14186, Sweden)

L Hedman (CLINTEC, Stockholm, Sweden)

C Escher (CLINTEC, Anesthesiology, Stockholm, Sweden)

L Fellander-Tsai (Clintec, Orthopedics, Stockholm,


Background: Crew Resource Management (CRM) based operating room team training will be an evident part of future surgical training. Hybrid simulation in the


operating room enables the opportunity for trainees to perform higher fidelity training of technical and non­technical skills in a realistic context. Summary of work: Intact and authentic OR-teams consisting of residents in anesthesia (2), anesthesia nurses (3), residents in surgery (2) and scrub nurses (6). During a one-day course they were exposed to four different scenarios and their self-efficacy and motivation were measured at the start and end of the day. Training was performed in a mock up operating theater equipped with a hybrid patient simulator (SimMan 3G Laerdal and a laparoscopic simulator, Simbionix LapMentor Express). The functionality of the systematic hybrid procedure simulation scenario was also analyzed in an exit questionnaire and the overall evaluation (1-5, disagree entirely- agree completely).

Summary of results: Exit questionnaire showed very good result with a median grading of 5. Self efficacy (graded from 1-7) among the team-members improved significantly from 4 to 6 (median). Conclusions: We conclude that hybrid-simulation is feasible and has the possibility to train an authentic operating team in order to improve individual confidence (self-efficacy and motivation). Take-home messages: Hybrid simulation is a method to bring motivation to the art of teamwork training in the operation room.


Advanced emergency skills training for first-year medical students using manifold simulation-based approaches

LP Mileder (Medical University of Graz, Clinical Skills Center, Auenbruggerplatz 33, Graz 8036, Austria) T Wegscheider (Medical University of Graz, Department of Anaesthesiology and Intensive Care Medicine, Graz, Austria)

A Schmidt (Medical University of Graz, Department of Internal Medicine, Graz, Austria)

HP Dimai (Medical University of Graz, Vice-Rectorate for Teaching and Studies, Graz, Austria)

Background: Basic and advanced life support (ALS) are extensively taught during the clinical period of medical study. Yet, the practical ALS competence of graduating students is still insufficient. A possible solution may be to implement advanced emergency skills training in the pre-clinical period of study. Summary of work: A two-hour course teaching cardiopulmonary resuscitation, airway management procedures (e.g. oropharyngeal suctioning, use of supraglottic airway devices) and structured emergency assessment was implemented. Central components are thorough theoretical pre-course preparation, peer-teaching, small teaching groups, and a hands-on concept. Simulation technology is used throughout the entire course: part-task trainers and static manikins for procedural training, a simulation software for the practice of patient assessment, and high-fidelity patient simulators for emergency simulations.

Summary of results: Between November 2011 and February 2013, 398 students have successfully completed the course. Initial student satisfaction is very high: 51 students have participated in a voluntary online-evaluation, with 45 students (88.2%) strongly agreeing/agreeing that they were satisfied with the course (mean grade of 1.4±1.0 on a six-point Likert scale).

Conclusions: Despite high student satisfaction, students' post-course competence and the long-term impact of this single training have to be assessed objectively. By using an innovative simulation-based course design, advanced practical aspects of emergency medicine can be implemented successfully in pre-clinical student education.

Take-home messages: Pre-clinical students are highly satisfied with advanced emergency skills training. Manifold simulation-based approaches are valuable in teaching first-year students emergency skills.


Does the Nasopharyngeal Box Model Help Medical Students Improve Mirror Examination


Watanaporn Vorasilapa (Chonburi Medical Education Center, Otolaryngology, Chonburi Hospital, Tambol Bansuan, Sukhumvit Rd, Amphur Maung, Chonburi

20000, Thailand)

Background: Medical students are unfamiliar with nasopharyngeal mirror examination. The anatomy of nasopharynx from mirror is different from the textbooks. The nasopharyngeal box model may help them illustrate anatomy before examining the patient. Summary of work: Nasopharyngeal box, size 3.5x 4x 1.2 cms., made of printed paper, was used as teaching and learning model. The 27 fifth- year medical students in academic year 2012 were divided into two groups. The first group, 13 students, used this model for practising nasopharyngeal examination. The teacher clearly identified 4 structures including: posterior nares, eustachian tubes opening, nasopharynx and posterior pharyngeal wall. The second group, 14 students, learned nasopharyngeal anatomy from textbooks. Both groups were assessed by describing pathological findings from the other model. Then the scores of both groups were compared.

Summary of results: The mean score of nasopharyngeal box model group (11.77±3.22) was significantly higher than the other group (9.07±1.64,p<.05). Conclusions: Nasopharyngeal box models help the students to be familiar with nasopharyngeal anatomy and enhance students' skill in nasopharyngeal mirror examination.

Take-home messages: Nasopharyngeal box model is cheap, simple and practical for practising nasopharyngeal mirror.



Comparing laparoscopic skill acquisition between at-home and in-Lab training, a randomised controlled trial

Ali N Bahsoun (King's College London, Urology, London, United Kingdom)

Michael Michael (King's College London, Surgery, London, United Kingdom)

Saied Froghi (Guy's Hospital, Urology, London, United Kingdom)

Kamran Ahmed (Guy's Hospital, Urology, London, United Kingdom)

Prokar Dasgupta (Guy's Hospital, Urology, London, United Kingdom)

Background: Opportunities to acquire laparoscopic skills can be difficult to access and costly. At home, training may prove to be an innovative solution. Summary of work: Our aim was to directly compare the skill acquisition between an 'At-Home' training device, an iPad tablet trainer (TT), and an 'In-Lab' laparoscopic box trainer (BT).

Summary of results: Over the repetitions of each task the OSATS improved significantly for Group A (p<0.05). Similarly, over the repetitions of each task the OSATS improved significantly for Group B (p<0.05) except in task 2 (p=0.322). For task 1, both groups demonstrated a Significant improvement in time taken (p<0.002), but in task 2 (p=0.096) and task 3 (p=0.47) there was no significant improvement in both groups. Conclusions: Both simulators proved useful at teaching basic laparoscopic skills to novices. Additionally, the TT has similar acquisition of basic laparoscopic skills to the BT. This is important as the TT is more portable and cost effective than the BT. Therefore, 'shifting' laparoscopic training from 'In-Lab' to 'At-Home' is a convenient way of training.

Take-home message: 'At-Home' laparoscopic training with its added benefits of convenience for both the trainees and the trainers is ideal for learning accessible tasks due to it being equally as useful as 'in-Lab' training. With the adoption of home training lab, time can become more focused on assessment and procedural skills making lab simulation time more productive for both trainees and trainers. The next few steps will be to design a home curriculum and build a library of tools and tasks.

SESSION 5: Simultaneous Sessions

Monday 26 August: 1600-1730

5A Symposium: Dialogue in medical education: Clinical education

transformation as a means to social repair

Location: Congress Hall, PCC

David Hirsh (Harvard Medical School, USA)

Paul Worley (Flinders University School of Medicine,


Brian Hodges (The Wilson Centre, University of Toronto, Canada) (Moderator)

David Hirsh and Paul Worley will present their deliberations on the topic of clinical education transformation and its capacity to foster individual benefits (to learners and patients) and societal benefits (to institutions and communities). They will explore the learning sciences and the case for change that drives clinical educational reform. Further, they will consider the degree to which health professional education can advance community engagement, social justice, and humanism. Both have been engaged in the development and scholarly exploration of Longitudinal Integrated Clerkships and will use that as one platform from which to discuss their current thinking about advancing clinical learning, health systems change, justice, and social capital.

Note: In the Dialogue series, published in Medical Education1, pairs of scholars who do not ordinarily work with one another, but share a common interest in a current issue, are asked to correspond over the course of two months about the thoughts and challenges with which they are currently grappling. The goal is explicitly not to force sides in a debate, but rather to work through divergent perspectives to determine what new ideas might emerge.

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