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From APLS courses to advanced simulation training: A tale of our
journeyJos Draaisma & Ester Coolen
Outline• To start with APLS• Teaching pediatric emergencies:
Why do we need simulation as an educational tool?• Prerequisites for transfer of training:
How can we enhance tranfer of skills into daily clinical practice?• The importance of teaching team skills: How can we train and asses teamskills? - Situational leadership – Followership- Situational awareness• Challanges for our future training program
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What is the purpose of APLS courses?• To improve the acute medical care by individual physicians and / or nurses
of severly ill or traumatized children by improving
• primary assessment / survey• resuscitation
• secondary assessment• (sometimes) emergency treatment
• definitive treatment
•
What is the effect of APLS courses?Kirkpatrick’s Levels of Learning
• Level 1: Reaction• Level 2: Learning• Level 3: Behavioural change• Level 4: Organisational performance
Level 1: Self-efficacy Turner et al
Mean self-efficacy (SE) per task for doctors according to APLS group
0
10
20
30
40
50
60
70
80
Resuscitationglobally
Cardiac Massage Bag and MaskVentilation
EndotrachealIntubation
Insertion of anI.O. device
SE
(1
00
mm
VA
S)
NO APLS (n = 31)
APLS (n = 18)*
*
*
Level 3: Behavioural change Turner et alAPLS (n= 18 ) No-APLS n = 31 P
Global resuscitation score (mean (sd))
5.6 (1.8) 4.0 (1.7 0.003
Time to staring chest compressions (median (IQR))
125.3 (149.2) 57.9 (57.0) 0.001
Number (%) failing to perform chest compressions
0 6 0.046
Adequately resuscitated 12 (67%) 10 (32%) 0.020
Open the airway 16 19 0.038
Open the airway adequately 9 7 0.048
Check the rhythm adequately 11 9 0.028
Coordinate chest compressions with ventilations adequately
13 12 0.024
Insert an IV 5 18 0.041
Insert an IO 13 17
Insert an IO adequately 8 6 0.013
Intubate adequately 8 4 0.013
Administered second dose of adrenaline
16 19 0.038
From a team of experts to an expert team
• Members of pediatric teams are expected to share a common goal, also called a “shared mental model “
• Although team members are sufficiently trained individually; team work skills have traditionally been less emphasized in medical training
Features of high fidelity medical simulation Providing feedback Repetitive practice Curriculum integration Variety of clinical conditions Controlled safe environment Individualised learning (range of difficulty levels) Defined outcomes Simulator validity
Conclusion:High fidelity medical simulations are effective andcomplement medical education in patient care settings (Issenberg et al 2000)
However it’s an expensive learning tool and little evidence comparing simulator based training to traditional educational models for pediatric emergencies
“It’s OK, this is a teaching hospital. Some people just have to learn the hard way”
Additional value of VARS model over traditional educational models
PBL EPLS VARS
Effectiveness of high fidelity video-assisted real-time simulation: a comparison of three training methods for acute pediatric emergencies.Coolen EH & Draaisma JM, et al.
-Scores on the post-intervention scenarios were significantly higher for all groups-The VARS-group showed significantly (p<0.05) higher scores on both post-intervention scenario’s in structure and timely achievement of critial actions
Technique
Task Environment
Organization
SEIPS-model / Systems Engineering Initiave for Patient Safety
Prof. Pascale Carayon / University of Winconsin – Madison - USA
Human Factor Competencies
ABCD algorithmsBasic Life SupportCrew Resource Management (CRM)VMS 1:Recognition and treatement of critically ill patientVMS 2:Recognition and treatement of painVMS 3:Prevention and treatement of sepsisVMS 4: High-risk medication: preparing and administering intravenous medication and parental nutrition.VMS 5: Medication verification
Debriefing
ABCD PBLS Break
8.00LectureE-learning
8.15SkillE-learning
9.00
Introductie simulator
9.30skill
VMS 1simulation
11.45simulation
VMS 1workshop
12.30workshop
Break
11.00
CRMsimulation
9.45Lecture
CRMworkshop
10.15simulation
Lunch
13.00
VMS 3simulation
15.00simulation
VMS 3workshop
15.45workshop
VMS 2simulation
13.30simulation
VMS 2workshop
14.15workshop
16.15
CRMprincipes
11.15workshop
Break
14.45
End
16.30
Our Video Assisted Real Time Team Training Program
Klik op het pictogram als u een afbeelding wilt toevoegen
Prerequisites for training: Realism
- The perspective of realism depends strongly on setting and learning goals (technical vs non-technical).
- During STT team assembly and role playing can become more important to participants, while physical aspects become less important (semantical vs physical).
Most important Least important
1. Scenario Content (56.9%) 1. Simulation room(60.9%)
2. Real time performance of actions(36.1%)
2. Physical appearance (58.1%)
3. Monitoring vital parameters(30.0%) 3. Communication with manikin (22.6%)
Prerequisites for training:Self-efficacy
Leadership skills
Skog et al, Teaching and Learning Medicine 2012
Leadership style
1 2 3 4 5 60%
10%
20%
30%
40%
50%
60%
70%
CoachingDirectingParticipatingDelegating
Postgraduate year
Perc
enta
ge o
f tot
al
Manage problems by predicting them instead of waiting for them to happen
Risk Profile for Clinical Deterioration
-Elevated PEWS-High risk therapy-Family expresses concern-Communication breakdown-Gut feeling not expressed: “watcher”
• A simulation is frozen at randomly selected times and all professionals are queried as to their
perceptions of the simulation at that time
• Scenario setting• Subacute deteriorating clinical patient• The scenario is stopped for 3 minutes and the monitor blanked• All professionals are asked to answer multiple choice questions about their current
perceptions of the situation, including perception of data, perception of the problem and
what they would like to do• Debriefing with video and SAGAT input
Situation Awareness Global Assessment In VARS training
Experiences with SAGA• The disturbance by “freeze” is minimal: time-out can increase individual SA
• Complementary SA of nurses may lead to miscommunication
• Perception of leadership differs between nusrses and physicians
• The mark for teamwork is mainly given as a consequence of the perception of importance of everybody’s own task
For effective team work:• Explicitely improve speak-up
• Leadership may be composed of two tasks: hands-on (management) and hands-off (overview)
• Leadership is not only the allocation of tasks, but also the evaluation and correction of individual and teamtasks
• Share alternatives with the team
Challenges for our future training program• Measuring Situational Awareness during Clinical Practice
• Training inter-professional teams: e.g. gynecologists, emergency physicians, pediatric surgeons
• Competition with other patient safety programs / government obligations
• Time and Money
Thank you for your attention
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