Portal de Periódicos da CAPES

Simulation Tools in the Research and Delivery of Competency-Based Medical Education and Health Care: Evolving Considerations in the Contemporary COVID-19 Era

2021; Elsevier BV; Volume: 37; Issue: 3 Linguagem: Inglês

10.1016/j.cjca.2020.10.003

1916-7075

Eric C. Wong, Daniel Negreanu, Najah Adreak, Katherine S. Allan, Nicolas Thibodeau-Jarry, Dimitrios N. Tsirigotis, Karim Qayumi, Christopher B. Fordyce, Varinder K. Randhawa,

Clinical Reasoning and Diagnostic Skills

Adapted from its use in the aviation industry, simulation is increasingly applied as an educational tool for training health care professionals. This can range in spectrum (Fig. 1A )1Escudero E. Silva M. Corvetto M. Simulation: A Training Resource for Quality Care and Improving Patient Safety.https://www.intechopen.com/online-first/simulation-a-training-resource-for-quality-care-and-improving-patient-safetyGoogle Scholar from low-fidelity modes such as standardized patients to acquire basic communication or technical skills, to high-fidelity modes using advanced simulators to practice teamwork within emergent scenarios. Simulation allows for trainees to learn in a low-stakes, high-fidelity standardized environment, in which potential mistakes are not translated into actual patient harm.2Brunette V. Thibodeau-Jarry N. Simulation as a tool to ensure competency and quality of care in the cardiac critical care unit.Can J Cardiol. 2017; 33: 119-127Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar For health care trainees, this can facilitate a learner-centred, rather than patient-centred educational experience. The design of a simulation program should be on the basis of learning theories (Fig. 1B)1Escudero E. Silva M. Corvetto M. Simulation: A Training Resource for Quality Care and Improving Patient Safety.https://www.intechopen.com/online-first/simulation-a-training-resource-for-quality-care-and-improving-patient-safetyGoogle Scholar and requires the consideration of certain programmatic components: learning objectives, mode type, target participants, implementation, feedback, and debriefing (Fig. 1C).1Escudero E. Silva M. Corvetto M. Simulation: A Training Resource for Quality Care and Improving Patient Safety.https://www.intechopen.com/online-first/simulation-a-training-resource-for-quality-care-and-improving-patient-safetyGoogle Scholar These design elements are extensively discussed elsewhere.1Escudero E. Silva M. Corvetto M. Simulation: A Training Resource for Quality Care and Improving Patient Safety.https://www.intechopen.com/online-first/simulation-a-training-resource-for-quality-care-and-improving-patient-safetyGoogle Scholar Herein, we focus on the specific use of simulation for cardiovascular training within the newly instituted model of competency-based medical education (CBME), and review the research on the use of such simulation-based programs. We also discuss the implications of the current COVID-19 pandemic on the use of simulation tools in these scenarios. The use of simulation tools for cardiovascular training to facilitate important clinical skills is well established. Critically ill patients in the cardiac intensive care unit require a cohesive, well trained interprofessional team to provide optimal care, and cardiovascular trainees often require acquisition of specialized technical skills.2Brunette V. Thibodeau-Jarry N. Simulation as a tool to ensure competency and quality of care in the cardiac critical care unit.Can J Cardiol. 2017; 33: 119-127Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar In a recent American College of Cardiology survey of practicing cardiologists, more than two-thirds agree that simulation-based educational experiences are effective for learning.3American College of CardiologySimulation-Based Education: A Popular Tactile Learning Technique.https://www.acc.org/latest-in-cardiology/articles/2016/11/29/16/31/simulation-based-educationGoogle Scholar Several options exist for simulation-based tools for cardiovascular training (Table 1). This includes for the clinical case management, and the performance of diagnostic, therapeutic, or surgical procedures. Simulation has shown improved performance in crisis resource management during team-based resuscitation, communication, and leadership skills. In terms of technical skills, transesophageal echocardiography (TEE), for example, is a complex task reliant on 3D spatial awareness of cardiac anatomy and dexterity to manipulate the transducer probe. Cardiology fellows who underwent an augmented simulation-based TEE teaching outperformed those in the nonsimulation group in terms of proficiency in obtaining appropriate TEE views.4Damp J. Anthony R. Davidson M.A. Mendes L. Effects of transesophageal echocardiography simulation training on learning and performance in cardiovascular medicine fellows.J Am Soc Echocardiogr. 2013; 26 (1450.e2)Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar Similarly, simulation for femoral artery access and percutaneous coronary intervention has shown a reduction in time to achieve a standard number of successful femoral artery access procedures, and a reduction in patient complications during cardiac catheterization.5Harrison C.M. Gosai J.N. Simulation-based training for cardiology procedures: Are we any further forward in evidencing real-world benefits?.Trends Cardiovasc Med. 2017; 27: 163-170Crossref PubMed Scopus (15) Google Scholar Furthermore, simulated training within electrophysiology for trans-septal puncture to access the left heart has shown improved procedural ability and reduced errors overall.5Harrison C.M. Gosai J.N. Simulation-based training for cardiology procedures: Are we any further forward in evidencing real-world benefits?.Trends Cardiovasc Med. 2017; 27: 163-170Crossref PubMed Scopus (15) Google Scholar Among cardiac surgery training, there is also a growing trend for increased use of simulation. Overall performance in component tasks and complete cardiac surgical procedures has shown improvement after simulation-based training modules in coronary artery bypass grafting, aortic valve replacement, and the management of intraoperative aortic dissection (a complication of aortic cannulation) among first-year cardiothoracic surgical residents across various institutions.6Feins R.H. Burkhart H.M. Conte J.V. et al.Simulation-based training in cardiac surgery.Ann Thorac Surg. 2017; 103: 312-321Abstract Full Text Full Text PDF PubMed Scopus (105) Google ScholarTable 1Examples of simulation use in clinical training and research in cardiovascular medicine and surgery1Escudero E. Silva M. Corvetto M. Simulation: A Training Resource for Quality Care and Improving Patient Safety.https://www.intechopen.com/online-first/simulation-a-training-resource-for-quality-care-and-improving-patient-safetyGoogle ScholarExampleCardiovascular medicineCardiovascular surgeryClinical trainingVirtual interactive scenariosVirtual interactive scenarios•CyberPatient•CyberPatient•Standardized patients•Standardized patientsHands-on procedural trainingHands-on procedural training•Task trainers (venous or arterial puncture, pericardiocentesis, intercostal drainage, line insertion, intubation)•Task trainers (suturing, chest tube insertion)•CPR manikin, critical events drills, pacemaker insertion simulators•Simulated intraoperative emergency scenario training•Harvey cardiovascular physical exam simulator•Touch on surgery (phone application)•Endovascular procedure simulators (coronary angioplasty, pacing, EP studies, transcatheter valve placement, peripheral vascular interventions)•3D-printing simulation (eg, valve deployment in valve surgeries)•3D-printing simulation•Simple bench model (Chamberlain Group Heart Case)•Echo simulators•Virtual reality cardiac surgery and lobectomy simulators•Human performance simulatorsEducation and research•Curriculum assessment•CyberPatient•Skills retention (eg, basic life support, advanced cardiac life support)•Skills retention (eg, operating room emergencies)•Competency assessment (eg, observed standardized competency evaluations)•Assessment of skill metrics•Models for patient or learner education•Models for patient or learner educationThe Harvey cardiovascular physical exam simulator is from Laerdal Medical (Toronto, ON).CPR, cardiopulmonary resuscitation; EP, electrophysiology. Open table in a new tab The Harvey cardiovascular physical exam simulator is from Laerdal Medical (Toronto, ON). CPR, cardiopulmonary resuscitation; EP, electrophysiology. Current evaluation methods within postgraduate medical education have recently shifted from a time-based to a competency-based approach to assessment. This focus on CBME is meant to allow for trainees to graduate with the necessary competencies to meet the health care needs of patients. This transition highlights a greater need for novel and more standardized assessment systems within CBME, away from traditional postgraduate assessment methods. Within a CBME framework, a simulation-based training curriculum can play a role in developing and evaluating competence for each learning stage. An important element of CBME is the concept of mastery learning, with a goal to ensure learners accomplish all educational objectives with minimal or no variation in clinical outcome.7McGaghie W.C. Isssenberg S.B. Barsuk J.H. Wayne D.B. A critical review of simulation-based mastery learning with translational outcomes.Med Educ. 2014; 48: 375-385Crossref PubMed Scopus (391) Google Scholar Instead of the traditional time-based approach, this type of training focuses on predetermined levels of mastery that the learners need to reach before completing the training. Simulation-based medical education can be used for mastery learning and can serve as a powerful educational model within the context of CBME, to evaluate a range of learners' interpersonal to technical and procedural skills, as part of set learning outcomes.7McGaghie W.C. Isssenberg S.B. Barsuk J.H. Wayne D.B. A critical review of simulation-based mastery learning with translational outcomes.Med Educ. 2014; 48: 375-385Crossref PubMed Scopus (391) Google Scholar Simulation training can be integrated into training by linking it with standard entrustable professional activities, elements that are used to assess the competence of trainees. Rotations for cardiovascular trainees that require mastery of technical skills (eg, echocardiography, cardiac catheterization, electrophysiology, cardiac surgery), would benefit from starting with simulation sessions to decrease the cognitive load of learners, to reduce the risk to patients, and to ensure that all trainees achieve the same predetermined mastery level before starting their rotation. Furthermore, simulation-based education as part of an overall introductory curriculum (eg, resident bootcamp), using simulated manikins within a team-based model, can help standardize training among learners in the effective management of common acute cardiovascular presentations, as well as rare presentations with a potential for serious complications that they might encounter during their calls. Institutions moving toward simulation training within CBME must also consider the availability of resources such as time, equipment, and appropriate faculty training, along with other advantages or disadvantages (Table 2).Table 2Advantages and disadvantages of simulation as an educational tool1Escudero E. Silva M. Corvetto M. Simulation: A Training Resource for Quality Care and Improving Patient Safety.https://www.intechopen.com/online-first/simulation-a-training-resource-for-quality-care-and-improving-patient-safetyGoogle ScholarAdvantagesDisadvantages•Case library, including of complex or rare cases•Cost factor: expensive to build and conduct, resource intensive•Decreases the training time•Time factor: logistics of team coordination difficult, especially if multidisciplinary•Helps with transfer of theoretical knowledge to practical concept•Failure to mimic real-life scenarios: lack of human interaction•Assesses procedural metrics: total time, radiation time, contrast used, suturing efficiency or speed•Poor design can lend itself to negative and/or ineffective learning•No radiation exposure•Can compromise learner attitude to become overly cautious or cavalier•Haptic (sensory) feedback•Knowledge retention and/or transfer not always complete•Learner centric: can adjust to different skill levels•Need maintenance and updates•Risk-free environment to make mistakes and learn from errors•Technical and/or programming difficulties•Potential to improve learner skill performance•Limited assessment tools•Preparation for infrequent health problems or disaster management such as pandemic planning•Safety for learners: the psychological effect of immersion experience•Increases the learner's confidence and satisfaction•Adopting habitual unsafe behaviours or ignoring patient consent•Asynchronous learning option•Communication issue•Potential to increase patient safety: decreases rate of procedural complications•Identify areas for quality improvement•Potential for cost savings from improved outcomes Open table in a new tab Recent advances in technology, coupled with the pursuit of improved health care quality and patient safety have resulted in rapid developments within medical simulation. This growth has resulted in a greater need for simulation-based research to demonstrate improved health care delivery to patients with consideration of the cost of simulation and the time required to build and run simulation sessions. There are 2 broad areas of simulation research that have consequently emerged: (1) assessing the simulation program as a clinical or technical skills training tool; and (2) using simulation to investigate efficacy among health care workers within health care systems.8Littlewood K.E. High fidelity simulation as a research tool.Best Pract Res Clin Anaesthesiol. 2011; 25: 473-487Crossref PubMed Scopus (26) Google Scholar Specifically, simulation-based research can be conducted to explore multiple fronts, ranging from the analysis of device or technical skills performance, to the exploration of team dynamics and crisis resource management in a simulated environment. Evaluative processes can focus on a number of elements, including explicit and implicit assessment (Fig. 1D).1Escudero E. Silva M. Corvetto M. Simulation: A Training Resource for Quality Care and Improving Patient Safety.https://www.intechopen.com/online-first/simulation-a-training-resource-for-quality-care-and-improving-patient-safetyGoogle Scholar Despite increased use, there remains a need for a coordinated approach to simulation-based research. It is important for this to show translation of skills within a CBME model to improved patient outcomes. Currently, a major pitfall of simulation tools and research is that these assess technical skills or behavioural changes, rather than more global competencies.8Littlewood K.E. High fidelity simulation as a research tool.Best Pract Res Clin Anaesthesiol. 2011; 25: 473-487Crossref PubMed Scopus (26) Google Scholar As cardiovascular training programs increasingly adopt simulation into their training curricula, research in simulation education must also strive to demonstrate knowledge transfer and improved patient care. For example, the longitudinal effect of simulation on the achievement of prespecified CBME competencies and real-world patient outcomes (eg, procedural complications related to technical skills or mortality associated with code resuscitations) can be evaluated. As the Royal College of Physicians and Surgeons of Canada began to phase in its integration of CBME into the cardiovascular curricula, educational and training institutions were affected by the COVID-19 global pandemic. This has affected many aspects of cardiovascular training, such as the provision of patient care in various settings, learner education, and research. For cardiovascular trainees, there has been an even greater transition toward simulated or virtual learning, because many trainees were reallocated from ambulatory, elective subspecialty, or operating room settings. Because of the high infectivity of COVID-19 from asymptomatic SARS-CoV-2 carriers, care algorithms were reconfigured to account for protocol changes. For example, simulation has been helpful to educate health care teams on modified cardiac arrest protocols that centred on minimizing exposure to infected patients. This included the need to intubate patients to prevent aerosolization during resuscitation efforts before chest compressions and/or defibrillation could be administered, limiting the number of personnel tending to a "code" scenario at the patient's bedside to only the most essential and experienced, and ensuring appropriate personal protective equipment. Simulation has also been used to teach other critical care management skills, including intubation and ventilator mechanics. Despite these advantages, there are inherent challenges with in-person simulation because of the need for physical distancing and personnel limits arising from COVID-19 restrictions. Simulation-based education and research will continue to evolve in the future, with the increasing use of novel modalities (eg, virtual platforms) that can provide safer learning environments for health care personnel. Digital health technology (eg, CyberPatient [Interactive Health International Ltd., Vancouver, BC with the University of British Columbia/Vancouver Coastal Health], a digitally enhanced online simulation platform proven useful for teaching history-taking skills to medical students with a computer avatar) is ripe for advancing individual or team-based simulation learning or research. Individualized low-fidelity simulations (eg, surgical knot-tying, online case-based modules) or innovative high-fidelity virtual reality environments (eg, haptics) are also opportunities for future growth. The use of simulation in health care is rapidly increasing and has a role in cardiovascular training within CBME and cardiovascular research. In the context of the current COVID-19 pandemic posing challenges to the delivery of traditional educational and research methods, the role for simulation-based training and research has become even more essential. High-quality simulation can complement other aspects of cardiovascular training, to educate trainees in fundamental technical and nontechnical skills, to help maintain overall competency. This is central to helping facilitate a learner-centred educational experience and build confidence toward patient-centred care.