Dale S. Vincent

Teaching mass casualty triage skills using immersive three-dimensional virtual reality.

OBJECTIVES Virtual reality (VR) environments offer potential advantages over traditional paper methods, manikin simulation, and live drills for mass casualty training and assessment. The authors measured the acquisition of triage skills by novice learners after exposing them to three sequential scenarios (A, B, and C) of five simulated patients each in a fully immersed three-dimensional VR environment. The hypothesis was that learners would improve in speed, accuracy, and self-efficacy. METHODS Twenty-four medical students were taught principles of mass casualty triage using three short podcasts, followed by an immersive VR exercise in which learners donned a head-mounted display (HMD) and three motion tracking sensors, one for their head and one for each hand. They used a gesture-based command system to interact with multiple VR casualties. For triage score, one point was awarded for each correctly identified main problem, required intervention, and triage category. For intervention score, one point was awarded for each correct VR intervention. Scores were analyzed using one-way analysis of variance (ANOVA) for each student. Before and after surveys were used to measure self-efficacy and reaction to the training. RESULTS Four students were excluded from analysis due to participation in a recent triage research program. Results from 20 students were analyzed. Triage scores and intervention scores improved significantly during Scenario B (p < 0.001). Time to complete each scenario decreased significantly from A (8:10 minutes) to B (5:14 minutes; p < 0.001) and from B to C (3:58 minutes; p < 0.001). Self-efficacy improved significantly in the areas of prioritizing treatment, prioritizing resources, identifying high-risk patients, and beliefs about learning to be an effective first responder. CONCLUSIONS Novice learners demonstrated improved triage and intervention scores, speed, and self-efficacy during an iterative, fully immersed VR triage experience.

Technology-enabled interprofessional education for nursing and medical students: A pilot study.

The US Joint Commission, a non-profit healthcare accreditation organization, identified miscommunication as the main cause of serious, unexpected patient injuries (The Joint Commission, 2007), and improving the effectiveness of communication among healthcare providers as a 2009 US National Patient Safety Goal (The Joint Commission, 2009). One strategy for improving interprofessional communication is the Situation-BackgroundAssessment-Recommendation (SBAR) communication tool (Haig, Sutton, & Whittington, 2006). This tool has four components: situation (a description of the clinical event), background (circumstances surrounding the event), assessment (possible causes), and recommendation (possible corrective actions). Medical and nursing students have demonstrated improved information transfer when using the SBAR method during manikin-based simulations within their own professional schools (Krautscheid, 2008; Marshall et al., 2007). Medical simulation may be resource intensive in terms of equipment and trained faculty, and distance education technologies have the potential to leverage limited resources (Berg, Wong, & Vincent, 2007). This paper reports on a study that assessed the feasibility of conducting interprofessional SBAR training with nursing and medical students using remote technologies coupled with manikin simulation. The feasibility of using a university-based faculty nurse experienced in simulation-based education as a manikin operator, student evaluator, and mentor at a site distant from the students and simulation was also assessed.

Mass-casualty triage training for international healthcare workers in the Asia-Pacific Region using manikin-based simulations.

INTRODUCTION More than half of the worlds disasters occur in the Asia-Pacific region. A simulation-based exercise to teach healthcare workers prehospital triage, tagging, and treatment methods was used to link disaster management theory to practice with a student-centered, hands-on educational activity. Various strategies for teaching disaster health education have been advocated, and best-practice disaster education models continue to be sought. METHODS A manikin-based, primary triage and treatment course was adapted for international healthcare providers in the Asia-Pacific region using symbolic representations of triage categories and physical findings. The pedagogical construct that was used was an interactive, formative assessment in which faculty members mediated learner information gathering and interpretation during four simulation scenarios. After establishing a multi-casualty disaster context, a wireless, audience response system anonymously collected learner responses to four clinical situations: (1) leg wound (hemorrhagic shock/immediate); (2) chest wound (tension pneumothorax/immediate); (3) head wound (traumatic brain injury/expectant); and (4) limb trauma (leg fracture/delayed). RESULTS There were 182 healthcare providers from eight Asia-Pacific countries (including the US) that participated in four simulation seminars. The simulation sessions were successfully tailored to groups of learners that varied in size and professional composition. Expectant and delayed triage categories posed the greatest challenge to learners. In one of two groups that were queried, learner self-confidence in applying principles of triage and treatment improved significantly. At the conclusion of the simulation sessions, learners strongly agreed that manikin-based simulation improved their understanding of triage, and should be used to teach principles of primary triage and treatment. CONCLUSIONS Simulation training represents an opportunity to engage learners regardless of language and cultural barriers. Simulation-based training can be effective in introducing healthcare professionals to principles of primary triage and treatment in an effective and culturally sensitive manner. The characteristics of the course with respect to planned formative assessment and culturally competent scholarship were reviewed.

Teaching mass casualty triage skills using iterative multimanikin simulations.

Objective. Effective mass casualty triage requires rapid andaccurate decision making. First responders need to be trained, but opportunities to practice triage andreceive individualized feedback during traditional mass casualty (MC) exercises are uncommon. It was hypothesized that novice learners would improve in speed, accuracy, andself-efficacy after deliberate practice triaging multiple simulated casualties in a MC exercise using high-fidelity manikins. Methods. Learners initially developed baseline knowledge of MC triage by listening to four short podcasts andpassing a written examination. They then experienced three sequential MC scenarios (A, B, andC) consisting of five manikin simulations each, coupled with individual feedback after each scenario. Students served as their own controls. A triage score (TS) andintervention score (IS) were recorded. For the TS, one point was awarded for each correctly identified main problem, required intervention, andtriage category. For the IS, one point was awarded for each correctly applied intervention. Before-and-after surveys measured self-efficacy andreaction to the training. Results. Twenty-one medical students were enrolled and20 students passed the examination. The TS andIS improved significantly during scenario B (p < 0.001). Time to complete each scenario decreased significantly from scenario A (8 min 27 sec) to scenario B (6 min 19 sec) (p < 0.001), but not from scenario B to scenario C (5 min 40 sec). Self-efficacy improved significantly after scenario C for prioritizing treatment andresources, identifying high-risk casualties, andlearning to be an effective first responder. Conclusion. Novice learners demonstrated improved triage andintervention scores, speed, andself-efficacy during an iterative, multimanikin MC training experience

Standardized patient interviewing with remote interactive technologies

Standardized patients (SPs), people who have been trained to simulate or represent a medical condition in a standardized way, are commonly used in medical education. However, considerable effort is required to maintain a panel of SPs and trained evaluators. We conducted a study using the Access Grid advanced videoconferencing system and the Internet2 high performance research and education network at a hospital in Hawaii with medical residents and a medical school in New Mexico with an SP programme. After receiving one didactic presentation and written material about smoking cessation, three residents in Hawaii each counselled an SP in New Mexico via the Access Grid. One evaluator was located in New Mexico at an Access Grid node. Two evaluators were located in Hawaii, one in the same room as the residents, and one connected via the Access Grid. Evaluators scored the learners using 11 criteria. Student and SP feedback and inter-rater reliability among evaluators were good. Teaching and evaluating interviewing skills appear to be feasible using the Access Grid. Wider implementation of the technique will require considerable technical, logistical and curriculum coordination among participating sites.

Videolaryngoscopy for intubation skills training of novice military airway managers.

An estimated 10% of preventable battlefield deaths are due to Airway obstruction. Improved airway rescue strategies are needed with new tools for airway management by less experienced providers. Airway management and training are improved using video laryngoscopy (VL) compared to direct laryngoscopy (DL). We evaluated if novices could rapidly acquire fundamental skills and compared intubation time and laryngeal visualization using VL compared to DL in a manikin model of normal laryngeal anatomy. For 43 subjects mean intubation time did not differ for DL (25.9 +/- 24.5 seconds) vs. VL (26.4 +/- 31.5 seconds) {p = 0.94 paired t-test}. Self reported novice intubation time was 6.82 +/- 31.0 seconds greater with VL (31.6 +/- 34.6 seconds) vs. DL (24.8 +/- 18.5 seconds) {p = 0.255 paired t-test}. VL vs. DL time difference was not different between self-reported novice and non-novice groups. Mean Cormack-Lehane airway visualization grades (range 1-4) were higher with VL (1.95 +/- 0.97) vs. DL (1.02 +/- 0.15) {Students t-test p < 0.0001}. VL (69.7%) was preferred to DL (18.6%); no preference was indicated by 11.6%.

Teaching nursing skills at a distance using a remotely controlled human patient simulator

We investigated the feasibility of using a nurse educator to control a human patient simulator and provide skills training for student nurses while located remotely from the students. Eight student nurses and a patient simulator were stationed at a site 8 km from the School of Nursing. The manikin was controlled over a private virtual local area network. Using videoconferencing at 400kbit/s, students were taught how to obtain peripheral and apical pulses on the manikin while exposed to rhythm disturbances initiated and controlled by the instructor. Students agreed that the simulation made understanding irregular rhythms easier and increased their interest in the course. On-site and remotely located nursing instructors agreed in their assessments of student performance. We conclude that a remotely located nurse educator can successfully instruct and control a manikin-based skills session in a manner that is acceptable to the nursing students.