1. Improving Efficiencies in Simulation Education, Blended Learning in Basic and Advanced Cardiac Life Support Training
Geoffrey T. Miller Associate Director, Research and Curriculum Development Division of Prehospital and Emergency Healthcare Gordon Center for Research in Medical Education University of Miami Miller School of Medicine

2. 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)

3. What’s new in medical simulation…

4. 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:

5. 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

6. Why use simulation? Assessment of professional competence Patient care
Medical knowledge
Practice-based learning & improvement
Communication skills
Professionalism
Systems-based practice

7. Why use simulation? What does the science say… Examples:
Overwhelmingly positive and favors use of simulation
Examples:
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”
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”

8. 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

9. Another interesting thought… How could learning style affect awareness, pattern recognition and “habits”?

10. A quick case study

11. 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

12. ‘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
Metaanalysis not possible due to lack of homogeneity in the literature. Thematic review of 109 articles
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.

13. Fidelity The degree of realism Types: Environmental Physical Technical
Psychological
Key Question: Is the simulation activity “realistic” enough to accomplish the desired outcomes.

14. Fidelity and technology
Low fidelity
High technology
High fidelity
High technology
Technology
Low fidelity
Low technology
High fidelity
Low technology
Fidelity

15. “Realism versus relevance”
Key Question:
Which concept is more important in choosing and developing the learning activity?
Realism
Relevance

16. Realism and relevance Most cost-effective Best learning High Expert
Prior Learning
Experienced
None
Novice
Low
High
Fidelity (realism)
Relevance
Adapted from: Alessi S. Design of Instructional Simulations. J Computer-based Instruction

17. BEME: multiple learning strategies and clinical variation
Learning ladder
BEME: multiple learning strategies and
clinical variation
Emphasis on multiple learning strategies. From bottom to up. People work with objects, and models like a heart or cutaway model of the airway.
High-fidelity will have thorough scenario. Wouldn’t start student here.

18. The ultimate goal?

19. Where does simulation fit?

20. The ‘big picture”
Knowledge
Attitude
Skill

21. Miller’s Pyramid of Competence
Knows
Knows how
Shows
Does
George E. Miller MD. The Assessment of Clinical Skills/Competence/Performance.
Academic Medicine Vol. 65 No. 9: S63-67.

22. “Knows” Learning Assessment opportunities: Opportunities: Does Shows
Reading / Independent study
Lecture
Computer-based
Colleagues / Peers
Assessment opportunities:
Multiple-choice question
Essay / Short answer
Oral interview
Knows
Knows how
Shows
Does

23. “Knows how” Learning Opportunity Clinical Context Based Tests Does
Problem-based Ex.
Tabletop exercises
Direct observation
Mentors
Clinical Context
Based Tests
Multiple-choice question
Essay / Short answer
Oral interview
Knows
Knows how
Shows
Does

24. “Shows” Learning Performance Opportunity Assessment Does Shows
Skill-based Exercises
Repetitive practice
Small group
Role playing
Performance
Assessment
Objective Structured Clinical Examination (OSCE)
Standardized Patient-based
Knows
Knows how
Shows
Does

25. “Does” Performance Learning Assessment Opportunity Does Shows
Undercover / Stealth standardized patient-based
Video
Learning
Opportunity
Experience
Knows
Knows how
Shows
Does

26. Key questions regarding blended learning models

27. Who are our Learners? Key Questions: Who are our learners?
Why do they Learn?
What are their Motivations?
Social relationships: to make new friends, to meet a need for associations and friendships.
External expectations: to comply with instructions from someone else; to fulfill the expectations or recommendations of someone with formal authority.
Social welfare: to improve ability to serve mankind, prepare for service to the community, and improve ability to participate in community work.
Personal advancement: to achieve higher status in a job, secure professional advancement, and stay abreast of competitors.
Escape/Stimulation: to relieve boredom, provide a break in the routine of home or work, and provide a contrast to other exacting details of life.
Cognitive interest: to learn for the sake of learning, seek knowledge for its own sake, and to satisfy an inquiring mind.

28. Blended learning Key Questions: What is “blended learning?
Where does it happen?
What does this mean to me as a healthcare educator?

29. Simulation methods

30. 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

31. 3D models basic plastic manikins
Heart and lung models

32. Basic plastic manikins
BLS manikins (Rescusi Anne)
Simple simulators for teaching basic interventions and/or physical examination skills

33. Standardized Patients
Represent ultimate alternative to live patients
Standardized role play of psychological and physiological aspects of patients
Facilitator & peers evaluate student performance
Facilitator & SP provide feedback & training
Student examines patient

34. 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.

35. Intelligent/Serious gaming

36. 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)

37. “Testing force feedback virtual reality products for dogs”

38. Learning and assessment opportunities

39. Large group instructor led
Reach many learners at once
Additional equipment: cameras/projectors/AV
Instructor needs practice
Audience response system

40. Small group instructor led
Focused teaching
Ability to assess individuals’ skills
Hands-on, interactive
Interest up to 2 hrs

41. Individual self-directed learning
Important for skills acquisition (deliberate practice)
Ability to work at own pace
Responsible for own learning

42. Independent small group learning
Less “hands-on” time
Opportunity to exchange ideas & problem solve
Practice team work
Peer to peer

43. 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”

44. “Assessment drives learning”
Assessment should be educational and formative
Learning through testing
Feedback to build knowledge and skill
Reflection - error correction – refinement
“Assessment drives learning”

45. A case study in developing a blended learning curriculum

46. 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

47. 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

48. UM Course Design Day 1 Didactic Psychomotor Day 2 Didactic
Response Concepts
Operations
PPE
Decontamination
ICS / IMS
Psychomotor
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

49. Case –Based Lecture concert 18,000 people Wind: ENE 12 knots
Open-air
concert
18,000 people
Temp: 84° F
Wind: ENE 12 knots
Chemical weapon from a
boat on shoreline

50. Case –Based Lecture Plume throughout concert area
Initially mistaken as smoke machine (part of show)
Hundreds with symptoms within minutes
Concert
Area
Wind
Plume

51. Individual Self-learning

52. Small group instructor teaching

53. Large group exercise (student directed)

54. Web/eLearning integration

55. Web/eLearning integration

56. Assessment and feedback

57. 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

58. 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

59. Questions and discussion

60. For additional information: Geoffrey T. Miller gmiller@med.miami.edu