- Email: [email protected]
High-Fidelity Simulation—Emergency Medicine
High-Fidelity Simulation—Emergency Medicine Shekhar Menon, MD, Morris Kharasch, MD, FACEP, and Ernest E. Wang, MD, FACEP Background High-fidelity simulation (HFS) has become an essential tool for training many health care providers in virtually every field of medicine. The primary benefit of using HFS as an educational and evaluative tool is that learners can practice medical decision-making and procedural skills on simulated patients in an environment where the risk of error will not harm an actual patient.1 These technologies and the educational constructs designed around their use were developed to practice skills without incurring risk. Medicine followed precedents set by model high reliability organizations such the military with its war games exercises, the aerospace industry with flight training of pilots and astronauts, and the nuclear power industry to train personnel to deal effectively and resiliently in crises situations.2 Bridging the gap between other industries and medicine, Gaba and DeAnda pioneered the use of simulation in anesthesia to train anesthesiologists.3 Their report described the creation of a comprehensive anesthesia simulation environment that re-created an operating room. Appropriate monitoring equipment was included as was a realistic intubation/thorax mannequin, which allowed for the formulation of realistic problems within the operating room. Built on Gaba’s work in the 1980s, the subspecialty of anesthesia was the first to adopt it as an educational tool within the field of medicine.4 The first study regarding training in emergency medicine occurred in 1999 and emphasized airway training.5 This advanced airway course used simulation to teach rapid sequence intubation skills as well as how to manage problems during rapid sequence intubation. The idea of using HFS to limit human error and improve safety was initially introduced by the airlines and National Aeronautics and Space Administration as a Crew Resource Management (CRM) Curriculum.4 It was then used to create an Anesthesia Crisis Resource Management Dis Mon 2011;57:734-743 0011-5029/2011 $36.00 ⫹ 0 doi:10.1016/j.disamonth.2011.08.011 734
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(ACRM) program that emphasized teamwork and responses to medical crises.6 Based in the ACRM principle, an additional study was published in 1999 that began to design and establish an HFS course to “improve EM clinician performance, increase patient safety, and decrease liability.”7 This course used simulators and patient-actors to teach these ideas while using ACRM as a basis. Finally, a formal CRM course was established for emergency medicine in 2002, entitled “EMCRM.”8 This course used didactics, simulation, and debriefing to teach principles on human error and crisis management, was rated very favorably by the participants, and helped establish the idea of HFS as an effected teaching tool in emergency medicine training. Simulation has also received favorable reviews as an effective model for teaching medicine.9,10 In addition to its ability to allow learners of all levels to “practice” medicine in an environment without risk to actual patients, simulation can bridge basic science and clinical medicine.1,11 Competency training can be effectively performed using simulated patient encounters.12 The idea is that simulation education acts as a practical model on which to build real-life skills before using these skills on real patients. However, the greatest strength of effective simulation is that participants experience a heightened emotional response during the event. Gordon et al writes, “Consider the issue of patient safety, and imagine a practitioner who makes a clinical mistake; immediately after realizing the error, he or she will experience an emotional reaction that is powerfully instructive— but only for the next patient. What if educators could . . . [allow] trainees to ‘live through’ a compendium of important cases in a fraction of real-time?”11 Emotional involvement allows students to integrate and understand information at a deeper cognitive level. As “learning by doing” becomes less acceptable to the public, simulation exercises, done well, provide learners with meaningful repetition, reinforcement of concepts in the debriefing session, and self-reflection that is critical to improved learning so that residents may “. . .see one, simulate many, do one competently, and teach everyone.”13 Currently, the American College of Surgeons has created a multilevel certification for simulation centers.14 The American Society of Anesthesiologists Workgroup on Simulation Education has begun to characterize simulation centers for the purposes of “approval” as a site to provide continuing medical education certification.15 The Accreditation Council for Graduate Medical Education ACGME Residency Review Committee for Emergency Medicine has determined that simulation can serve as an adjunct for the documentation of competencies.16 Use of HFS is becomDM, November 2011
735
ing increasingly integrated into undergraduate and graduate medical educational curricula.17 As HFS has become more popular within emergency medicine, formal interest groups within different emergency medicine societies have formed and fellowship training in medical simulation is being established.18 The first Simulation Academy was created by the simulation interest group of the Society for Academic Emergency Medicine in 2009 and has one of the largest constituencies of simulation-based experts in emergency medicine.
Current Use of Simulation in Emergency Medicine There is a growing body of emergency medicine literature describing the use of HFS in undergraduate and graduate medical education curricula. Its adaptability to a wide array of educational needs makes it a particularly useful tool for meeting educational objectives. Educators are documenting their applications of HFS to address core competencies,12,19 high-stakes—low-frequency procedures,20 crisis resource management,8 team training,7,21,22 venous access,23 resident professionalism in ethical dilemmas,24 cognitive forcing strategies,25 comparative evaluation of resident performance,26,27 systems-based modular residency curriculum,19 and medical student education.28-31 The significant literature and successful implementation around the country are driving the demand for HFS training and proliferation of training facilities has followed. Between 2003 and 2008, there was an increase in the use of HFS within emergency medicine residency programs from 29% to 85%. Additionally, 91% of emergency medicine training programs report using some form of simulation.32 The use of HFS has been extended to address and evaluate the 6 core competencies that are emphasized during emergency medicine (EM) training. Bond et al identified that HFS was most useful for addressing the following core competencies: patient care (disease management and procedures), system-based practice (knowing resources available and structuring the team), and interpersonal skills (communication and acting as a team leader).12 Wagner et al studied the application of the medical knowledge competency to EM training, indicating the simulation is an effective means to assess procedural skills, critical care, and less common, high-acuity clinical scenarios.33 In 2005, Wang et al described a simulation-based curriculum specifically designed to address the Systems-Based Practice (SBP) core competency, which focuses on the residents’ abilities to “understand the 736
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relationship of their individual medical practice to the context of the health care system as a whole. . . [as well as]. . . how to practice cost-effective health care, how to efficiently allocate resources, and how to deal with system complexities such that the quality of patient care is not compromised.”19 The importance of developing a strong SBP skill set in emergency medicine cannot be overemphasized. The scope of emergency medicine is broad, with respect to the variety of medical conditions treated, the specialists with which emergency physicians interact, and the social conditions of patients who present to the emergency department. An HFS-based curriculum provides a “hands-on” experience that attempts to reproduce not just an emergent case, but also the systems-based issues unique to that case within an emergency department. A simulation with properly executed SBP learning objectives forces the resident not only to manage the medical aspects of the case but also to provoke the resident to think critically about how to manage the specific circumstances of the case to optimize care with the available resources at that time. A few examples of SBP-related skills that can be incorporated into the case include requiring the resident to obtain more history from an Emergency medical services (EMS) provider or family member, problem solving in situations where a consultant is not available or occupied (a patient presents with an acute ST-elevation myocardial infarction, but the cardiologist is in the cath laboratory at another hospital performing a procedure), and understanding necessary elements of patient transfer. Other cases could involve end-of-life management in the peri-arrest period or devising alternative therapy for a patient who does not have insurance. This article provided a curriculum that incorporated both attending and peer observation, checklist evaluation of competency criteria, and videotape-based debriefing to reinforce key principles to both the participating and the observing residents. Crisis resource management training was patterned after the aviation industry based CRM concept and was initially developed by anesthesiologists.4,6 First mentioned in 1998, a course based on ACRM training was formed that provided the basis for Emergency Crisis Resource Management (ECRM).7 In 2003, Reznek et al published a pilot study that established a structured crisis management curriculum for teaching and assessing the ability of resident emergency physicians to perform the following behaviors: planning, communication, leadership, resource awareness and use, workload distribution, re-evaluation of the situation, and awareness and use of all available information.8 In addition, the following behaviors were added: appropriate triage, management of DM, November 2011
737
multiple patients, coping with disruptions. The curriculum involved didactics, simulated crisis scenarios, and debriefing. In 2008, Hicks et al surveyed attitudes of EM personnel toward CRM training, recognizing that EM resuscitations often require additional skills beyond medical knowledge.34 A coordinated effort is often required to maximize patient care in the setting of crisis. This study emphasized the participants’ desire for further CRM training, with communication between team members being identified as an area for improvement. HFS training has thus been used to improve team building. Shapiro et al demonstrated that simulation-based teamwork training is an effective way to enhance didactic teamwork training.22 Two emergency department (ED) groups received didactic training at baseline and then were observed in the simulation setting or in the ED by blinded, independent observers. These observers measured the teamwork via a previously validated scale. There was no difference in the didactic or the simulation groups at baseline. An experimental group was provided 8 hours of simulator-based training involving 3 HFS scenarios focused on teamwork training. The groups were then observed again in the ED clinical setting after the intervention. There was a greater tendency toward quality of team behavior in the simulator group, while the comparison group demonstrated no change.22 The use of standardized patients to assess professionalism has been mentioned in the literature frequently.35 HFS has been used to assess professionalism in EM residents.24 An ethical dilemma was introduced in a simulated case that focused on (1) patient confidentiality, (2) informed consent, (3) withdrawal of care, (4) practicing procedures on the recently decreased, (5) the use of do-not-attempt resuscitation orders. Each of the residents who participated was evaluated with a predefined checklist. Senior residents demonstrated better overall performance, but what the HFS course revealed was that there was more work necessary in professionalism education, specifically in areas such as patient confidentiality and informed consent. HFS has been used to teach the concepts of metacognition and error avoidance to educate residents.25 Cases were designed so residents would make a particular error and subsequently learn from the mistake. A renal failure patient with respiratory distress was simulated and 2 cognitive traps were created. The first trap was making the resident believe that the respiratory distress was secondary to a cardiac condition and giving succinylcholine to the patient erroneously. The second error was created after the resident witnessed a wide-complex tachycardia (WCT) on the monitor. Shocking and antiarrhythmics would be the incorrect treatment 738
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options, while recognizing that the WCT was secondary to hyperkalemia and subsequent treatment. Residents would be led into the second error regardless of whether they gave succinylcholine, with the WCT being delayed if succinylcholine is not given. Afterward, a debrief session was performed that highlighted succinylcholine and cognitive forcing strategies. “Residents ranked this second only to direct patient care for educational effectiveness.” Residents indicated that they felt more knowledgeable about succinylcholine, treating hyperkalemia, and cognitive forcing strategies as a teaching tool. HFS has tremendous potential as a resident evaluation tool. A study by Gordon et al demonstrated that an oral objective-structured clinical examination based performance evaluation tool was equally valid in the simulation setting, thereby making HFS a viable alternative to objectivestructured clinical examination for resident evaluation.27 Girzadas et al demonstrated that HFS could be used to differentiate junior level from senior level residents.36 In an anaphylaxis case, novice residents took longer to establish a surgical airway, to start the surgical airway, to complete the case, and to use epinephrine as an initial action. HFS proved to be an effective assessment tool that differentiated between different levels with respect to the patient care general competency. With the increased use of HFS in residency, its use has been implemented more and more as a part of the residency curriculum. A study by Wang et al in 2008 determined that emergency medicine residents rated simulation-based training sessions higher than traditional lectures.37 Residents scored simulation higher than lectures with respect to addressing goals and objectives, increasing knowledge and understanding of the topic of the session, and following the subject matter presented. A simulation model has been created to make an effective simulation training session, involving 5 different stations: a manikin-based HFS scenario followed by debriefing, a standardized patient encounter with family members, partial task trainers for procedural proficiency, and small-group interactive sessions.38 This model has been used at multiple resident conferences, including ones at our institution. Simulation education has been used as a novel method for conducting morbidity and mortality conferences. Patient encounters were re-created and resident input was obtained with audience response systems that allowed for evaluation of the case in “real-time.” This method allowed a more realistic interpretation of the case and understanding of why mistakes were made.39 Simulation is now being used in residency training programs to promote resident-as-teachers curricula. Learning effective teaching skills in emerDM, November 2011
739
gency medicine residency can now be accomplished by having resident physicians assume educator roles for medical student simulation training sessions.18 HFS training has even been extended to medical student teaching and has been shown to be as effective, if not more, than standard didactics, with 27 of 28 subjects performing better on high-risk/lowfrequency cases with HFS rather than standard didactics.40 In addition, more critical actions were performed with HFS rather than didactics (93% vs 71%).
Future Directions in Emergency Medicine As HFS training has become a more effective and accepted means of education within emergency medicine, future exciting directions are forming. As more emergency medicine residencies implement HFS, the formation of HFS centers is increasing as well, with up to 85% of EM residency programs use HFS.32,41 Simulation education has extended to postresidency training in the form of simulation education fellowships.41 As the number of these fellowships grows, accreditation status may be considered, thereby further solidifying the status of HFS within emergency medicine education. Fellowship opportunities could create a larger research base with increased funding. HFS has proven utility within the domains of medical knowledge acquisition, procedural competency, and professionalism. Its use has now been extended to death notification and family conferences.35,42 Although a simulation setting can never approximate the emotions and gravity of notifying a family member of the death or complication regarding a loved one, the SPIKES protocol (Set the stage, Perception, Inform, Knowledge, Empathy, and Summarize) was implemented using lectures and roleplaying, and a HFS case and the simulation aspect was found to be most useful by EM residents (43%) vs role play (14%) and lecture (7%). Finally, HFS-based Continuing Medial Education and maintenance of certification may not be far off for emergency medicine practitioners, as it would allow for improved documentation and opportunity to demonstrate competency with procedures that are not frequently performed. Opportunities for this type of life-long learning will become increasingly more feasible as simulation centers within close proximity of the primary employment site become more widespread.41 The field of simulation in emergency medicine is rapidly changing. Technological improvement and innovation in simulation instruction will lead to new applications for simulation, improved realism that will allow a more powerful experience, and increased transference of the lessons learned to the clinical setting. It seems certain that HFS will remain an 740
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integral part of how we train and maintain the skills of emergency practitioners as we head into the 21st century.
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Gordon JA, Oriol NE, Cooper JB. Bringing good teaching cases “to life”: a simulator-based medical education service. Acad Med 2004;79(1):23-7. Issenberg SB, McGaghie WC, Hart IR, et al. Simulation technology for health care professional skills training and assessment. JAMA 1999;282(9):861-6. Gaba DM, DeAnda A. A comprehensive anesthesia simulation environment: re-creating the operating room for research and training. Anesthesiology 1988;69(3):387-94. Reznek M, Harter P, Krummel T. Virtual reality and simulation: training the future emergency physician. Acad Emerg Med 2002;9(1):78-87. Ellis C, Hughes G. Use of human patient simulator to teach emergency medicine trainees advanced airway skills. Acad Emerg Med 1999;16(6):395-9. Howard SK, Gaba DM, Fish KJ, et al. Anesthesia crisis resource management training: Teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 1992;63(9):763-70. Small SD, Wuerz RC, Simon R, et al. Demonstration of high-fidelity simulation team training for emergency medicine. Acad Emerg Med 1999;6(4):312-23. Reznek M, Smith-Coggins R, Howard S, et al. Emergency Medicine Crisis Resource Management (EMCRM): pilot study of a simulation-based crisis management course for emergency medicine. Acad Emerg Med 2003;10(4):386-9. Weller JM. Simulation in undergraduate medical education: bridging the gap between theory and practice. Med Educ 2004;38(1):32-8. Steadman RH, Coates WC, Huang YM, et al. Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills. Crit Care Med 2006;34(1):151-7. Gordon JA, Wilkerson WM, Shaffer DW, et al. “Practicing” medicine without risk: students’ and educators’ responses to high-fidelity patient simulation. Acad Med 2001;76(5):469-72. Bond WF, Spillane L. The use of simulation for emergency medicine resident assessment. Acad Emerg Med 2002;9(11):1295-9. Vozenilek J, Huff JS, Reznek M, et al. See one, do one, teach one: advanced technology in medical education. Acad Emerg Med 2004;11(11):1149-54. Sachdeva AK, Pellegrini CA, Johnson KA. Support for simulation-based surgical education through American College of Surgeons—accredited education institutes. World J Surg 2008;32(2):196-207. ASA. ASA Approval of anesthesiology Simulation Programs, A.B.o.S. Education, Editor. 2006, American Society of Anesthesiologists. Available at: http://www. asahq.org/For-Members/Education-and-Events/Simulation-Education/WhitePaper-on-ASA-Approval-of-Anesthesiology-Simulation-Programs.aspx. Accessed March 14, 2011. Accreditation Council for Graduate Medical Education, American Board of Medical Specialties. Assessing resident performance: examples from the field. Available at: http://www.acgme.org/outcome/assess/asses_residentPerf.pdf. Accessed March 14, 2011.
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McLaughlin SA, Bond W, Promes S, et al. The status of human simulation training in emergency medicine residency programs. Simul Healthc 2006;(1 Spec no.): 18-21. McLaughlin S, Fitch MT, Goyal DG, et al. Simulation in graduate medical education 2008: a review for emergency medicine. Acad Emerg Med 2008; 15(11):1117-29. Wang EE, Vozenilek JA. Addressing the systems-based practice core competency: a simulation-based curriculum. Acad Emerg Med 2005;12(12):1191-4. Schaefer JJ. Simulators and difficult airway management skills. Paediatr Anaesth 2004;14(1):28-37. Jay GD, Small SD, Langford V, et al. Teamwork training supported by high fidelity simulation training improves emergency department team behaviors. Acad Emerg Med 2000;7(5):519 [Abstract]. Shapiro MJ, Morey JC, Small SD, et al. Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? Qual Saf Health Care 2004;13(6):417-21. Reznek MA, Rawn CL, Krummel TM. Evaluation of the educational effectiveness of a virtual reality intravenous insertion simulator. Acad Emerg Med 2002;9(11):1319-25. Gisondi MA, Smith-Coggins R, Harter PM, et al. Assessment of resident professionalism using high-fidelity simulation of ethical dilemmas. Acad Emerg Med 2004;11(9):931-7. Bond WF, Deitrick LM, Arnold DC, et al. Using simulation to instruct emergency medicine residents in cognitive forcing strategies. Acad Med 2004;79(5):438-46. Clyne B, Gutman DC, Sutton E, et al. Oral board vs. high-fidelity simulation for competency assessment: senior emergency medicine resident management of an acute coronary syndrome. Acad Emerg Med 2004;11(5):500 [Abstract]. Gordon JA, Tancredi D, Binder W, et al. Assessing global performance in emergency medicine using a high-fidelity patient simulator: a pilot study. Acad Emerg Med 2003;10(5):472. Takayesu JK, Gordon JA, Farrell SE, et al. Learning emergency and critical care medicine: what does high-fidelity patient simulation teach? Acad Emerg Med 2002;9(5):476-7. Shapiro M, Morchi R. High-fidelity medical simulation and teamwork training to enhance medical student performance in cardiac resuscitation. Acad Emerg Med 2002;9(10):1055-6. Vozenilek J, Handler J, Kontrick A. Augmentation of the medical student rotation with high-fidelity simulation: learning by the numbers. Acad Emerg Med 2004;11(8):898. Coates WC, Steadman RH, Huang YM, et al. Full-scale high fidelity human patient simulation vs problem based learning: comparing two interactive educational modalities. Acad Emerg Med 2003;10(5):489. Okuda Y, Bond W, Bonfante G, et al. National growth in simulation training within emergency medicine residency programs, 2003-2008. Acad Emerg Med 2008; 15(11):1113-16. DM, November 2011
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Wagner MJ, Thomas Jr. HA Application of the medical knowledge general competency to emergency medicine. Acad Emerg Med 2002;9(11):1236-41. Hicks CM, Bandiera GW, Denny CJ. Building a simulation-based crisis resource management course for emergency medicine, phase 1: Results from an interdisciplinary needs assessment survey. Acad Emerg Med 2008;15(11):1136-43. Quest TE, Otsuki JA, Banja J, et al. The use of standardized patients within a procedural competency model to teach death disclosure. Acad Emerg Med 2002;9(11):1326-33. Girzadas Jr, DV, Clay L, Caris J, et al. High fidelity simulation can discriminate between novice and experienced residents when assessing competency in patient care. Med Teach 2007;29(5):472-6. Wang EE, Beaumont J, Kharasch M, et al. Resident response to integration of simulation-based education into emergency medicine conference. Acad Emerg Med 2008;15(11):1207-10. Noeller TP, Smith MD, Holmes L, et al. A theme-based hybrid simulation model to train and evaluate emergency medicine residents. Acad Emerg Med 2008;15(11):1199-206. Vozenilek J, Wang E, Kharasch M, et al. Simulation-based morbidity and mortality conference: new technologies augmenting traditional case-based presentations. Acad Emerg Med 2006;13:48-53. McCoy CE, Menchine M, Anderson C, et al. Prospective randomized crossover study of simulation vs. didactics for teaching medical students the assessment and management of critically ill patients. J Emerg Med 2011;40(4):448-55. Vozenilek JA, Gordon JA. Future directions: a simulation-based continuing medical education network in emergency medicine. Acad Emerg Med 2008; 15(11):978-81. Park I, Gupta A, Mandani K, et al. Breaking bad news education for emergency medicine residents: A novel training module using simulation with the SPIKES protocol. J Emerg Trauma Shock 2010;3(4):385-8.
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(ACRM) program that emphasized teamwork and responses to medical crises.6 Based in the ACRM principle, an additional study was published in 1999 that began to design and establish an HFS course to “improve EM clinician performance, increase patient safety, and decrease liability.”7 This course used simulators and patient-actors to teach these ideas while using ACRM as a basis. Finally, a formal CRM course was established for emergency medicine in 2002, entitled “EMCRM.”8 This course used didactics, simulation, and debriefing to teach principles on human error and crisis management, was rated very favorably by the participants, and helped establish the idea of HFS as an effected teaching tool in emergency medicine training. Simulation has also received favorable reviews as an effective model for teaching medicine.9,10 In addition to its ability to allow learners of all levels to “practice” medicine in an environment without risk to actual patients, simulation can bridge basic science and clinical medicine.1,11 Competency training can be effectively performed using simulated patient encounters.12 The idea is that simulation education acts as a practical model on which to build real-life skills before using these skills on real patients. However, the greatest strength of effective simulation is that participants experience a heightened emotional response during the event. Gordon et al writes, “Consider the issue of patient safety, and imagine a practitioner who makes a clinical mistake; immediately after realizing the error, he or she will experience an emotional reaction that is powerfully instructive— but only for the next patient. What if educators could . . . [allow] trainees to ‘live through’ a compendium of important cases in a fraction of real-time?”11 Emotional involvement allows students to integrate and understand information at a deeper cognitive level. As “learning by doing” becomes less acceptable to the public, simulation exercises, done well, provide learners with meaningful repetition, reinforcement of concepts in the debriefing session, and self-reflection that is critical to improved learning so that residents may “. . .see one, simulate many, do one competently, and teach everyone.”13 Currently, the American College of Surgeons has created a multilevel certification for simulation centers.14 The American Society of Anesthesiologists Workgroup on Simulation Education has begun to characterize simulation centers for the purposes of “approval” as a site to provide continuing medical education certification.15 The Accreditation Council for Graduate Medical Education ACGME Residency Review Committee for Emergency Medicine has determined that simulation can serve as an adjunct for the documentation of competencies.16 Use of HFS is becomDM, November 2011
735
ing increasingly integrated into undergraduate and graduate medical educational curricula.17 As HFS has become more popular within emergency medicine, formal interest groups within different emergency medicine societies have formed and fellowship training in medical simulation is being established.18 The first Simulation Academy was created by the simulation interest group of the Society for Academic Emergency Medicine in 2009 and has one of the largest constituencies of simulation-based experts in emergency medicine.
Current Use of Simulation in Emergency Medicine There is a growing body of emergency medicine literature describing the use of HFS in undergraduate and graduate medical education curricula. Its adaptability to a wide array of educational needs makes it a particularly useful tool for meeting educational objectives. Educators are documenting their applications of HFS to address core competencies,12,19 high-stakes—low-frequency procedures,20 crisis resource management,8 team training,7,21,22 venous access,23 resident professionalism in ethical dilemmas,24 cognitive forcing strategies,25 comparative evaluation of resident performance,26,27 systems-based modular residency curriculum,19 and medical student education.28-31 The significant literature and successful implementation around the country are driving the demand for HFS training and proliferation of training facilities has followed. Between 2003 and 2008, there was an increase in the use of HFS within emergency medicine residency programs from 29% to 85%. Additionally, 91% of emergency medicine training programs report using some form of simulation.32 The use of HFS has been extended to address and evaluate the 6 core competencies that are emphasized during emergency medicine (EM) training. Bond et al identified that HFS was most useful for addressing the following core competencies: patient care (disease management and procedures), system-based practice (knowing resources available and structuring the team), and interpersonal skills (communication and acting as a team leader).12 Wagner et al studied the application of the medical knowledge competency to EM training, indicating the simulation is an effective means to assess procedural skills, critical care, and less common, high-acuity clinical scenarios.33 In 2005, Wang et al described a simulation-based curriculum specifically designed to address the Systems-Based Practice (SBP) core competency, which focuses on the residents’ abilities to “understand the 736
DM, November 2011
relationship of their individual medical practice to the context of the health care system as a whole. . . [as well as]. . . how to practice cost-effective health care, how to efficiently allocate resources, and how to deal with system complexities such that the quality of patient care is not compromised.”19 The importance of developing a strong SBP skill set in emergency medicine cannot be overemphasized. The scope of emergency medicine is broad, with respect to the variety of medical conditions treated, the specialists with which emergency physicians interact, and the social conditions of patients who present to the emergency department. An HFS-based curriculum provides a “hands-on” experience that attempts to reproduce not just an emergent case, but also the systems-based issues unique to that case within an emergency department. A simulation with properly executed SBP learning objectives forces the resident not only to manage the medical aspects of the case but also to provoke the resident to think critically about how to manage the specific circumstances of the case to optimize care with the available resources at that time. A few examples of SBP-related skills that can be incorporated into the case include requiring the resident to obtain more history from an Emergency medical services (EMS) provider or family member, problem solving in situations where a consultant is not available or occupied (a patient presents with an acute ST-elevation myocardial infarction, but the cardiologist is in the cath laboratory at another hospital performing a procedure), and understanding necessary elements of patient transfer. Other cases could involve end-of-life management in the peri-arrest period or devising alternative therapy for a patient who does not have insurance. This article provided a curriculum that incorporated both attending and peer observation, checklist evaluation of competency criteria, and videotape-based debriefing to reinforce key principles to both the participating and the observing residents. Crisis resource management training was patterned after the aviation industry based CRM concept and was initially developed by anesthesiologists.4,6 First mentioned in 1998, a course based on ACRM training was formed that provided the basis for Emergency Crisis Resource Management (ECRM).7 In 2003, Reznek et al published a pilot study that established a structured crisis management curriculum for teaching and assessing the ability of resident emergency physicians to perform the following behaviors: planning, communication, leadership, resource awareness and use, workload distribution, re-evaluation of the situation, and awareness and use of all available information.8 In addition, the following behaviors were added: appropriate triage, management of DM, November 2011
737
multiple patients, coping with disruptions. The curriculum involved didactics, simulated crisis scenarios, and debriefing. In 2008, Hicks et al surveyed attitudes of EM personnel toward CRM training, recognizing that EM resuscitations often require additional skills beyond medical knowledge.34 A coordinated effort is often required to maximize patient care in the setting of crisis. This study emphasized the participants’ desire for further CRM training, with communication between team members being identified as an area for improvement. HFS training has thus been used to improve team building. Shapiro et al demonstrated that simulation-based teamwork training is an effective way to enhance didactic teamwork training.22 Two emergency department (ED) groups received didactic training at baseline and then were observed in the simulation setting or in the ED by blinded, independent observers. These observers measured the teamwork via a previously validated scale. There was no difference in the didactic or the simulation groups at baseline. An experimental group was provided 8 hours of simulator-based training involving 3 HFS scenarios focused on teamwork training. The groups were then observed again in the ED clinical setting after the intervention. There was a greater tendency toward quality of team behavior in the simulator group, while the comparison group demonstrated no change.22 The use of standardized patients to assess professionalism has been mentioned in the literature frequently.35 HFS has been used to assess professionalism in EM residents.24 An ethical dilemma was introduced in a simulated case that focused on (1) patient confidentiality, (2) informed consent, (3) withdrawal of care, (4) practicing procedures on the recently decreased, (5) the use of do-not-attempt resuscitation orders. Each of the residents who participated was evaluated with a predefined checklist. Senior residents demonstrated better overall performance, but what the HFS course revealed was that there was more work necessary in professionalism education, specifically in areas such as patient confidentiality and informed consent. HFS has been used to teach the concepts of metacognition and error avoidance to educate residents.25 Cases were designed so residents would make a particular error and subsequently learn from the mistake. A renal failure patient with respiratory distress was simulated and 2 cognitive traps were created. The first trap was making the resident believe that the respiratory distress was secondary to a cardiac condition and giving succinylcholine to the patient erroneously. The second error was created after the resident witnessed a wide-complex tachycardia (WCT) on the monitor. Shocking and antiarrhythmics would be the incorrect treatment 738
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options, while recognizing that the WCT was secondary to hyperkalemia and subsequent treatment. Residents would be led into the second error regardless of whether they gave succinylcholine, with the WCT being delayed if succinylcholine is not given. Afterward, a debrief session was performed that highlighted succinylcholine and cognitive forcing strategies. “Residents ranked this second only to direct patient care for educational effectiveness.” Residents indicated that they felt more knowledgeable about succinylcholine, treating hyperkalemia, and cognitive forcing strategies as a teaching tool. HFS has tremendous potential as a resident evaluation tool. A study by Gordon et al demonstrated that an oral objective-structured clinical examination based performance evaluation tool was equally valid in the simulation setting, thereby making HFS a viable alternative to objectivestructured clinical examination for resident evaluation.27 Girzadas et al demonstrated that HFS could be used to differentiate junior level from senior level residents.36 In an anaphylaxis case, novice residents took longer to establish a surgical airway, to start the surgical airway, to complete the case, and to use epinephrine as an initial action. HFS proved to be an effective assessment tool that differentiated between different levels with respect to the patient care general competency. With the increased use of HFS in residency, its use has been implemented more and more as a part of the residency curriculum. A study by Wang et al in 2008 determined that emergency medicine residents rated simulation-based training sessions higher than traditional lectures.37 Residents scored simulation higher than lectures with respect to addressing goals and objectives, increasing knowledge and understanding of the topic of the session, and following the subject matter presented. A simulation model has been created to make an effective simulation training session, involving 5 different stations: a manikin-based HFS scenario followed by debriefing, a standardized patient encounter with family members, partial task trainers for procedural proficiency, and small-group interactive sessions.38 This model has been used at multiple resident conferences, including ones at our institution. Simulation education has been used as a novel method for conducting morbidity and mortality conferences. Patient encounters were re-created and resident input was obtained with audience response systems that allowed for evaluation of the case in “real-time.” This method allowed a more realistic interpretation of the case and understanding of why mistakes were made.39 Simulation is now being used in residency training programs to promote resident-as-teachers curricula. Learning effective teaching skills in emerDM, November 2011
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gency medicine residency can now be accomplished by having resident physicians assume educator roles for medical student simulation training sessions.18 HFS training has even been extended to medical student teaching and has been shown to be as effective, if not more, than standard didactics, with 27 of 28 subjects performing better on high-risk/lowfrequency cases with HFS rather than standard didactics.40 In addition, more critical actions were performed with HFS rather than didactics (93% vs 71%).
Future Directions in Emergency Medicine As HFS training has become a more effective and accepted means of education within emergency medicine, future exciting directions are forming. As more emergency medicine residencies implement HFS, the formation of HFS centers is increasing as well, with up to 85% of EM residency programs use HFS.32,41 Simulation education has extended to postresidency training in the form of simulation education fellowships.41 As the number of these fellowships grows, accreditation status may be considered, thereby further solidifying the status of HFS within emergency medicine education. Fellowship opportunities could create a larger research base with increased funding. HFS has proven utility within the domains of medical knowledge acquisition, procedural competency, and professionalism. Its use has now been extended to death notification and family conferences.35,42 Although a simulation setting can never approximate the emotions and gravity of notifying a family member of the death or complication regarding a loved one, the SPIKES protocol (Set the stage, Perception, Inform, Knowledge, Empathy, and Summarize) was implemented using lectures and roleplaying, and a HFS case and the simulation aspect was found to be most useful by EM residents (43%) vs role play (14%) and lecture (7%). Finally, HFS-based Continuing Medial Education and maintenance of certification may not be far off for emergency medicine practitioners, as it would allow for improved documentation and opportunity to demonstrate competency with procedures that are not frequently performed. Opportunities for this type of life-long learning will become increasingly more feasible as simulation centers within close proximity of the primary employment site become more widespread.41 The field of simulation in emergency medicine is rapidly changing. Technological improvement and innovation in simulation instruction will lead to new applications for simulation, improved realism that will allow a more powerful experience, and increased transference of the lessons learned to the clinical setting. It seems certain that HFS will remain an 740
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integral part of how we train and maintain the skills of emergency practitioners as we head into the 21st century.
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