From APLS courses to advanced
simulation training: A tale of our
journey
Jos 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?
o
• The importance of teaching team skills:
How can we train and asses teamskills?
- Situational leadership – Followership
45
- Situational awareness
• Challanges for our future training program
45
30
30
15
15
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
80
*
70
NO APLS (n = 31)
APLS (n = 18)
*
SE (100 mm VAS)
60
*
50
40
30
20
10
0
Resuscitation
globally
Cardiac Massage
Bag and Mask
Ventilation
Endotracheal
Intubation
Insertion of an
I.O. device
Level 3: Behavioural change Turner et al
APLS (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
“It’s OK, this is a teaching hospital.
Some people just have to learn the hard way”
Conclusion:
High fidelity medical simulations are effective and
complement 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
Additional value of VARS model over traditional educational models
PBL
EPLS
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
VARS
Human Factor Competencies
Organization
Technique
Environment
Task
SEIPS-model / Systems Engineering
Initiave for Patient Safety
Prof. Pascale Carayon / University of
Winconsin – Madison - USA
Our Video Assisted Real Time Team Training Program
ABCD
PBLS
8.00
Lecture
E-learning
8.15
Skill
E-learning
VMS 2
simulation
13.30
simulation
Break
9.00
VMS 2
workshop
14.15
workshop
Introductie
simulator
9.30
skill
Break
14.45
CRM
principes
9.45
Lecture
VMS 3
simulation
15.00
simulation
CRM
simulation
10.15
simulation
VMS 3
workshop
15.45
workshop
Break
11.00
Debriefing
16.15
CRM
workshop
11.15
workshop
VMS 1
simulation
11.45
simulation
End
16.30
ABCD algorithms
Basic Life Support
Crew Resource Management (CRM)
VMS 1:Recognition and treatement of critically ill patient
VMS 2:Recognition and treatement of pain
VMS 3:Prevention and treatement of sepsis
VMS 4: High-risk medication: preparing and administering intravenous medication and parental nutrition.
VMS 5: Medication verification
VMS 1
workshop
12.30
workshop
Lunch
13.00
Prerequisites for training: Realism
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%)
- 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).
Prerequisites for training:Self-efficacy
Leadership skills
Skog et al, Teaching and Learning Medicine 2012
Leadership style
Percentage of total
70%
60%
50%
40%
Coaching
30%
Directing
Participating
20%
Delegating
10%
0%
1
2
3
4
5
6
Postgraduate year
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”
Situation Awareness Global Assessment
In VARS training
•
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
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
o
15
45
45
15
30
30