Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Improving Efficiencies in Simulation Education, Blended Learning in Basic and Advanced
Cardiac Life Support TrainingGeoffrey T. Miller
Associate Director, Research and Curriculum Development
Division of Prehospital and Emergency HealthcareGordon Center for Research in Medical Education
University of Miami Miller School of Medicine
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
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 The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
What’s new in medical simulation…
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
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 The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Why use simulation?
Benefits of medical simulation◦ Safe environment, mistake forgiving◦ Trainee focused vs. patient focused◦ Controlled, structured, proactive clinical exposure◦ Reproducible, standardized, objective◦ Debriefing as a norm in everyday practice◦ public trust in profession◦ Deliberate and repetitive practice
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Why use simulation?
Assessment of professional competence◦Patient care◦Medical knowledge◦Practice-based learning & improvement◦Communication skills◦Professionalism◦Systems-based practice
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Why use simulation?
What does the science say…◦Overwhelmingly positive and favors use of simulation
Examples: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 case-control study – Wayne DB, et. al. Chest, 2008.
“Simulation-based educational program significantly improved the quality of care during actual events”
1. 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”
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
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 The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Another interesting thought…
How could learning style affect awareness,pattern recognition and “habits”?
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
A quick case study
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
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 The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
‘Right conditions’ for learning in simulation
Feedback should be provided during the learning experience Learners should engage in repetitive practice Simulation should be integrated into the overall curriculum Learners should practice with increasing levels of difficulty Multiple learning strategies should be employed Simulations should represent clinical variation The simulation environment should be controlled Simulations should foster individualized learning Outcomes must be clearly defined and measured The simulator should be valid as a representation of a human or
situation
Issenberg SB,McGaghie WC, Petrusa ER, Gordon D, Scalese RJ (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher 27(1): 10–28.
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Fidelity
The degree of realism
Types:◦Environmental◦Physical◦Technical◦Psychological
Key Question: Is the simulation activity “realistic” enough to accomplish the desired outcomes.
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Fidelity and technology
Low fidelityHigh technology
Low fidelityHigh technology
Low fidelityLow technology
Low fidelityLow technology
High fidelityHigh technology
High fidelityHigh technology
High fidelityLow technology
High fidelityLow technology
FidelityFidelity
Tech
nolo
gyTe
chno
logy
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
“Realism versus relevance”
Key Question: ◦Which concept is more important in choosing and
developing the learning activity?
Realism Relevance
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Fidelity (realism)
Adapted from: Alessi S. Design of Instructional Simulations. J Computer-based Instruction. 1988. 40-7.
Realism and relevancePri
or
Learn
ing
Relevance
Novice
Experienced
Expert
Most cost-effective
Best learning
Low High
None
Hig
h
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Learning ladder
BEME: multiple learning strategies andclinical variation
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
The ultimate goal?
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Where does simulation fit?
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
The ‘big picture”
Attitude
Knowledge
Skill
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Miller’s Pyramid of Competence
Knows
Knows how
Shows
Does
George E. Miller MD. The Assessment of Clinical Skills/Competence/Performance.Academic Medicine. 1990. Vol. 65 No. 9: S63-67.
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Knows
Knows how
Shows
Does
“Knows”Assessment opportunities:• Multiple-choice
question• Essay / Short answer• Oral interview
LearningOpportunities:• Reading /
Independent study• Lecture• Computer-based• Colleagues / Peers
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Knows
Knows how
Shows
Does
Clinical ContextBased Tests• Multiple-choice
question• Essay / Short answer• Oral interview
“Knows how”LearningOpportunity• Problem-based Ex.• Tabletop exercises• Direct observation• Mentors
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Knows
Knows how
Shows
Does
“Shows”PerformanceAssessment• Objective Structured
Clinical Examination (OSCE)
• Standardized Patient-based
LearningOpportunity• Skill-based Exercises
• Repetitive practice• Small group• Role playing
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Knows
Knows how
Shows
Does
“Does”PerformanceAssessment• Undercover / Stealth
standardized patient-based
• Video
LearningOpportunity• Experience
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Key questions regardingblended learning models
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Who are our Learners?
Key Questions:◦Who are our learners?◦Why do they Learn?◦What are their Motivations?
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Blended learning
Key Questions:◦What is “blended learning?◦Where does it happen?◦What does this mean to me as a healthcare educator?
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Simulation methods
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
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 The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
3D models basic plastic manikins
Heart and lung models
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Basic plastic manikins
BLS manikins (Rescusi Anne)Simple simulators for teaching basic interventions and/or
physical examination skills
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Standardized PatientsRepresent ultimate alternative to live patients
◦Standardized role play of psychological and physiological aspects of patients
Student examines patient
Facilitator & peers evaluate student performance
Facilitator & SP provide feedback & training
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Screen-based simulations
Software driven systems that include multimedia and VR components.◦Ranges from simple non-
interactive to fully interactive teaching programs.
◦Enhance cognitive knowledge, clinical reasoning and decision making.
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Intelligent/Serious gaming
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
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 The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
“Testing force feedback virtual reality products for dogs”
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Learning and assessment opportunities
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Large group instructor ledReach many learners at once
◦Additional equipment: cameras/projectors/AVInstructor needs practiceAudience response system
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Small group instructor led
Focused teachingAbility to assess
individuals’ skillsHands-on,
interactiveInterest up to 2 hrs
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Individual self-directed learning
Important for skills acquisition (deliberate practice)
Ability to work at own pace
Responsible for own learning
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Independent small group learning
Less “hands-on” time
Opportunity to exchange ideas & problem solve
Practice team work
Peer to peer
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
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 The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
AssessmentAssessment should be educational and formative
◦Learning through testing◦Feedback to build knowledge and skill
Reflection - error correction – refinement
“Assessment drives learning”
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
A case study in developing a blended learning curriculum
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
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 The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
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 The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
UM Course DesignDay 1
◦Didactic Response Concepts Operations PPE Decontamination ICS / IMS
◦Psychomotor PPE Medical Management Ambulatory DECON Incapacitated DECON
Day 2◦ Didactic
Chemical Agents Biological Agents Radiological and Explosive
Agents◦ Large Group Exercises
Triage – computer-based Tabletop
◦ Integration Exercises OSCEs
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Case –Based Lecture• Open-air concert• 18,000 people
• Temp: 84° F • Wind: ENE 12 knots• Chemical weapon from a boat on shoreline
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
• Plume throughout concert area
• Initially mistaken as smoke machine (part of show)
• Hundreds with symptoms within minutes
ConcertArea
Wind
Plume
Case –Based Lecture
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Individual Self-learning
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Small group instructor teaching
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Large group exercise (student directed)
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Web/eLearning integration
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Web/eLearning integration
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Assessment and feedback
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
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 The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
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 The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
Questions and discussion
Simulation The Gordon Center for Research in Medical Education
Effective Uses of Simulation in BLS & ACLS Training
For additional information:
Geoffrey T. [email protected]
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