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Improving Efficiencies in Simulation Education, Blended Learning in Basic and Advanced Cardiac Life Support Training Geoffrey T. Miller Associate Director,

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Presentation on theme: "Improving Efficiencies in Simulation Education, Blended Learning in Basic and Advanced Cardiac Life Support Training Geoffrey T. Miller Associate Director,"— Presentation transcript:

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

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