Acute Care: A Simulator Based Experience

1. Acute Care: A Simulator Based Experience Dr. Vedantashankar Sean Sarma MBBS v.s.sarma@ncl.ac.uk Lecturer in Anatomy and Clinical Skills Newcastle University Dr. Guy McNulty MBBS guy.mcnulty@doctors.org.uk Specialist Trainee 2 Acute Care Common Stem Pinderfields General Hospital Mid-Yorkshire NHS Trust

2. Reacting To The Acutely Unwell Patient

3. Acute Care • Core competency of the Foundation Programme • Generally feared by junior doctors • new doctors → organisation, communication, immediate emergency management • Difficult to teach practical skills • Patient simulators offer a solution to this

4. Patient Simulation • Broad term • Role-play • Online resources • Mannequins (CPR etc) • More recently → advanced, interactive mannequins

5. Laerdal Sim Man • Safe environment • Standardised teaching

6. Aim – Pilot Study Simulator Session ↑ Effectiveness + ↑ Confidence +

7. 3 cohorts final year students from Tyne Base Unit → 3 separate weekend sessions • 43 students in total (W1 = 12, W2 = 15, W3 = 17) • Random allocation into test & control groups • Confidence questionnaire + 10 minute skills assessment both mornings → GI bleed • Test group → 3 hour teaching session between skills assessments (Saturday afternoon) • Students invited into focus groups after the weekend Method - Overview

8. Students selected from Critical Care rotation in Tyne Base Unit during Hospital-Based Practice • Voluntary basis • Course held on the last weekend of the rotation (except cohort 1 → held on following weekend due to MPS revision course!) Recruitment

9. Confidence Questionnaire • 14 statements relating to ABCDE • 6-point Likert scale responses • e.g. I feel confident assessing the airway (A) • 1 2 3 4 5 6 • Given before skills assessment on both days Strongly Disagree Disagree Mildly Disagree Mildly Agree Agree Strongly Agree

10. 10 minute station • “You have been called to the ward to see . . . ” • GI bleed both days • Peptic ulcer disease on Saturday • Oesophageal varices on Sunday • Same mark scheme for both scenarios • One “inexperienced nurse” to help (VSS) • All necessary equipment & fluids + distracters (e.g. nasal cannulae, nebuliser) • Video recordings marked by independent, blind assessor (GM) Skills Assessments

11. Case-based approach → highly structured ABCDE assessment and initial management discussed and practised by students • No more than 4 students per session (session repeated each afternoon to facilitate this) • Scenarios were as follows: • Airway obstruction (caused by tongue) secondary to hypoglycaemic coma (A+D) • Acute pulmonary oedema (B) • Post-op bleed (C) • Teaching session repeated for the control group after all results collected to • avoid civil unrest within the student community! Teaching Session

12. Results

13. Results • Confidence Questionnaires • Skills Assessments • Focus Groups

14. I feel confident assessing the airway (A) • I feel confident managing the airway, including use of simple airway manoeuvres, adjuncts and suction • I feel confident assessing breathing (B) • I feel confident prescribing oxygen, including choice of delivery system and flow rate • I feel confident assessing circulatory status (C) • I feel confident prescribing a fluid challenge • I feel confident assessing the response to a fluid challenge • I feel confident assessing neurological status (D) • I feel confident completing my examination and identifying relevant signs to aid my diagnosis (E) • I feel confident ordering appropriate investigations for an acutely unwell patient • I feel confident seeking senior help where appropriate • Overall I am confident making an immediate assessment of an acutely unwell patient • Overall I feel confident starting initial management of an acutely unwell patient • Overall I am concerned I would do the wrong thing if I were called to see an acutely unwell patient Confidence Questionnaire

18. Results • Confidence Questionnaires • Skills Assessments • Focus Groups

19. Skills Assessments • Mean total percentages • Mean percentages for individual sections of assessment • Initial haematemesis → A-D • Then repeat haematemesis → Reassess ABCDE from A • Further management

22. Results • Confidence Questionnaires • Skills Assessments • Focus Groups

23. Focus Groups • Themes split into: • Those regarding acute care teaching so far • Those regarding use of the simulator

24. Focus Groups - Themes • Regarding Acute Care Teaching: • Theory has been covered well; very little practical teaching • “We’ve all gone through it on paper, talked through it, but we haven’t actually been put through a situation where we have to put it all together and had to think what we’re doing next by ourselves”

25. Focus Groups - Themes • Regarding Acute Care Teaching: • 2. Practical teaching can be “luck of the draw” • Opportunism • Students given access to courses variably • “I have put myself out there quite a lot, but it really does depend on what happens. I’ve done nights on call where nothing’s happened” • “I think it should be baseline taught. It’s too important to just rely on you getting it sorted. And confidence about this is absolutely paramount”

26. Focus Groups - Themes Regarding Acute Care Teaching: 3. Arrest algorithms are taught well, as is the ABC mantra “We’ve had good sessions going through the ALS algorithm. So we’re OK once they’ve already arrested” But . . . “Everybody always tells you to ‘do ABC’, but you never really go through what that actually means. It’s kind of this assumed thing”

27. Focus Groups • Themes split into: • Those regarding acute care teaching so far • Those regarding use of the simulator

28. Focus Groups - Themes Regarding Use Of The Simulator: 1. The monitor on the simulator and need to measure vital signs make it more realistic “On a mannequin, when you’re listening for breath sounds, you’re not actually listening, but here I really had to listen because if you wanted to you could have programmed something in”

29. Focus Groups - Themes Regarding Use Of The Simulator: 2. The assessments form an integral part of the learning experience “It’s all very well talking things through slowly but that’s not actually how it’s going to be in real life, so it’s nice to have the pressure put on you to see how you’d put everything together”

30. Focus Groups - Themes Regarding Use Of The Simulator: 3. Seeing and discussing equipment was of extreme value “Just to talk through the equipment and get more confidence in giving people instructions. I know it sounds silly, but you feel like a wally when you’re supposed to be directing everyone else but you have no idea which oxygen mask is which”.

31. Limiting Factors • Lots! • Students enlisted on a voluntary basis • Varying levels of previous acute care teaching/experience • Skills assessment used only one scenario • Skills assessment needs to be more rigid • Mark scheme unvalidated • Sometimes ↑ knowledge → ↓ confidence! • System of assessment can be treated too dogmatically • And many more . . .

32. Conclusions • Small pilot study on an extremely important topic • Results in confidence and ability are promising • Extremely positive student response

33. So what now, Sean? More robust study with senior support & supervision Consider incorporating into curriculum? Major issues – time required by teachers, reproducibility and equipment

34. Thank-you! Any Questions?