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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