Simulation Best Practices

Must-haves for successful simulation in prehospital care

 

 
 
 

Paul E. Phrampus, MD | From the Making It Real Issue

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Simulation Best Practices

This photo gallery illustrates the proper level of environmental fidelity, which is needed to accomplish the learning objectives during simulation training.
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Simulation as a means of training healthcare providers is rapidly becoming the standard in EMS education. It has been integrated into entry-level training programs for students as well as continuing education programs for practicing professionals.

But whether you’re just getting started with simulation or running a seasoned program and want to take it to the next level, there are some basic principles you must consider to ensure the program’s success.

Planning Ahead
Although determining training and learning objectives doesn’t have to be a long, formal process, it’s essential, because clearly defined objectives help facilitate planning of other aspects of the simulation, such as equipment, instructors, facilities and necessary resources.

Instructors new to simulation-based education often mistakenly assume that they can watch a simulation exercise, capture every decision, thought process and procedure that occurs during the scenario, and then adequately debrief on it. After conducting a few simulation exercises, it becomes painfully clear that this isn’t possible. Clearly defined objectives focus the exercise and provide it with a needed level of consistency.

Simulations that aren’t properly planned often leave trainees sitting around and waiting while the necessary equipment and support is hastily arranged. And nothing annoys students more than waiting an excessive amount of time to participate in simulation.

To avoid this problem when developing your solution-based education activities, provide other creative activities that contribute to student education, in addition to the time spent at the simulator. Examples include rotating and running concurrent workshops, such as those that can be achieved with a simple partial task trainer. Other alternative activities include assigning specific groups of students to watch other students during the simulation and then involving them in the debriefing or assessment process.

Important: Some programs spend a significant amount of time and money on environmental situations, i.e., re-creating the inside of an ambulance or moulage of patients and simulators. But often, high levels of environmental fidelity aren’t needed to accomplish the learning objectives, and in some cases can be a distraction.

If the learning objectives focus on the care of a difficult airway while in the confines of an aircraft, then it makes sense to attempt to recreate the environmental confines and perhaps the noise that occurs in a helicopter.

However, if the learning objectives are aimed at merely establishing competence at following a protocol of difficult airway management, then the time, money and effort are not necessary and the simulation can be carried out in a hotel room.

Instructor Training
Conducting a debriefing, or after-action report, involves having trainee(s) reflect on what occurred during the simulation. This is thought by many experts in the field to be the time when the most learning transfer occurs. As such, it should not be left to chance.

Instructors involved in simulation programs should be well trained in debriefing techniques and realize that during simulations, trainees feel vulnerable, because their every action is being critically analyzed. It’s tempting for new instructors to focus on areas that need improvement during a debriefing, but they must also remember to comment on the things that went well. For more on debriefing, read “Performance Review: An overview of student debriefing,” p. 8.

Instructors must be trained not only in the debriefing aspect of simulation, but the entire simulation process. It’s commonly misperceived that those who are effective traditional instructors will easily transition to the world of simulation.

Competent simulation-based instructors realize the capabilities and limitations of the simulation environment, and they understand the importance of keeping the simulation-based activity and debriefing confined to the original learning objectives. This is particularly important because many different topics arise during simulation that could be debriefed, if needed.

Many simulations are also part of a bigger program that requires the debriefing of specific subject areas to ensure that the learning objectives are followed. Understanding different methods of debriefing will help the instructor develop a higher level of competence when using simulation for education and/or assessment.

Simulation technology is becoming easier to operate, but the time to figure out how it functions is not while training students. So faculty members should never operate a simulator during a simulation program that they aren’t familiar with or haven’t been trained on.

And although simulation equipment is fairly durable, instructors must be familiar with its limitations so they can avoid damaging it.

Expanding Simulation
Simulation in prehospital care has been used successfully in many ways; however, many programs around the world have expanded their use of simulation into continuing education and competency assessment-based programs for practicing providers; retraining or remediation for specific events or personnel; pre-hire skill assessments; and many other innovative uses.

Expansion also assists agencies and training programs in maximizing the number of programs that use the simulation equipment, which helps them remain cost-effective. This often requires you to be creative and collaborate with other departments or agencies.

Technical &
Manufacturer Support

Depending on the size of your program, dedicating an individual to its technical operations could be crucial to its success. Someone who can operate the simulation-based equipment, as well as the accompanying audio-visual equipment, and who understands the storage, stocking and deployment procedures of equipment can increase program efficiency and effectiveness.

But be careful not to assign someone the task who doesn’t have a strong understanding of technology. As a program becomes more heavily reliant upon highly technological solutions, the demand for an expert technician/operator increases. This type of support will also allow the instructors’ knowledge base, as well as the program as a whole, to grow.

But what do you do if/when you experience difficulties that prevent your simulation-based courses from proceeding, particularly when the problem(s) escalates above and beyond the capabilities of the on-site technician? Answer: Establish relationships with product manufacturers.

To lay the groundwork for a good relationship, purchase equipment from a single vendor, as this will help you build trust, show your loyalty and may lead to your becoming a “preferred customer,” which often comes with significant benefits, such as real-time support and the use of loaner equipment.

Program Funding
Many program organizers have been able to acquire robust funding sources to purchase equipment, but fail to plan for the expenses needed to actually run the program. Without the proper financial support, a room full of simulation equipment won’t get you or your program very far.

And although obtaining the funding for hardware may be relatively easy via grants and one-time budget allocations, securing ongoing funding needed to carry out the program’s mission may be overlooked or not available. Remember that the equipment can’t plan scenarios on its own, schedule simulation times and operate itself, so your challenge is to earmark funds that support staff for your simulation program and conduct structured faculty development programs that will allow the program to more easily achieve its stated mission.

One way to help ensure program funding is to establish relationships with and provide information to administration and community leaders. In addition, consider holding outreach and community events, and inviting dignitaries and other potential donors to witness and support your simulation education efforts

Simulation has significant face value because it offers a realistic, common-sense approach to training healthcare providers. So to help secure ongoing funding and support, continually remind all community leaders, program leaders, operational directors, etc., of the importance of the program, as well as its unique approach to teaching future providers.

Summary
Simulation is an extraordinarily powerful learning and assessment tool, but for any program to be successful, you must focus on priorities and best practices. Some of the most fundamental priorities are organizational; however, they are often overlooked or minimized because of the mistaken belief that when the simulator arrives, the work is done.

If you focus on developing and adhering to learning objectives, hiring (and maintaining) quality instructors, monitoring the technical aspects of the program, as well as making a concerted effort to sustain ongoing funding and support, your program will enjoy long-lasting success.

Disclosure: The author has reported no conflicts of interest with the sponsor of this supplement.

Resources

  • Boyle M, Williams B, Burgess S. Contemporary simulation education for undergraduate paramedic students. Emergency Medicine Journal. 2007;24:854–857.
  • Cone DC, O’Connor RE, Fowler RL. (Eds.). Emergency medical services: Clinical practice and systems oversight. 2009; Kendall/Hunt: Dubuque, Iowa.
  • Kory PD, Eisen LA, Adachi M, et al. Initial airway management skills of senior residents: simulation training compared with traditional training. Chest. 2007;132:1927–1931.
  • Kyle RR, Murray WB. Clinical simulation: Operations, engineering, and management. 2008; Elsevier Inc.: Oxford.
  • Lammers RL, Byrwa MJ, Fales WD, Hale RA. Simulation-based assessment of paramedic pediatric resuscitation skills. Prehospital Emergency Care. 2009;13:345–356.
  • Lloyd GE, Lake CL, Greenburg RB. (Eds.). Practical health care simulations. 2004; Elsevier Mosby: Philadelphia.
  • Riley RH. (Ed). Manual of simulation in healthcare. 2008; Oxford University Press Inc.: New York.
  • von Wyl T, Zuercher M, Amsler F, et al. Technical and non-technical skills can be reliably assessed during paramedic simulation training. Acta Anaesthesiologica Scandinavica. 2009;53(1):121–127.
  • Wilkerson W, Avstreih D, Gruppen L, et al. Using immersive simulation for training first responders for mass casualty incidents. Academic Emergency Medicine. 2008;15:1152–1159.


This article originally appeared in an editorial supplement to the September 2010 issue of JEMS as “Simulation Best Practices: Must-haves for successful simulation in prehospital care.”



Simulation Best Practices

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Training Standard

Simulation is rapidly becoming the training standard in EMS education. To ensure program success, focus on specific priorities and best practices, such as learning objectives, hiring quality instructors, monitoring the technical aspects of the program, and ensuring ongoing funding and support. Photo Julie Macie/WakeMed Health & Hospitals


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Environmental Fidelity: Aicraft

If the learning objectives focus on the care of a difficult airway while in the confines of an aircraft, then it makes sense to attempt to recreate the environmental confines and perhaps the noise that occurs in a helicopter. Photo Julie Macie/ WakeMed Health & Hospitals


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Environmental Fidelity: Hotel room

If the learning objectives are aimed at merely establishing competence at following a protocol of difficult airway management, then the simulation can be carried out in a hotel room. Photo Paul E. Phrampus MD


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Simulation Debriefing

Conducting a debriefing involves having trainee(s) reflect on what occurred during the simulation. This is thought by many experts to be the time when the most learning transfer occurs. As such, instructors involved in simulation programs should be well trained in debriefing techniques. Photo Laerdal


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Simulation Equipment

Simulation equipment, such as the fully stocked, high-tech ambulance mock-up shown here, is becoming much more technologically advanced. Dedicating someone to technical support who understands and can operate the simulation-based equipment, as well as the accompanying audio-visual equipment, can increase program efficiency and effectiveness. Photo Paul E. Phrampus MD



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Related Topics: Paul Phrampus, simulations, EMS training, manikin, mannequin, simulation equipment, simulation funding

 

Paul E. Phrampus, MDis an associate professor in the departments of emergency medicine and anesthesiology at the University of Pittsburgh School of Medicine. He’s the director of the Winter Institute for Simulation, Education and Research (WISER). He’s also a former paramedic and remains an EMS educator. He can be reached at paul@phrampus.com.

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