Jeremy Huang, BS1; Caitlin Cook, MD, MS2; Adam Oplinger, BS, RN, CEN, EMT-P (Ret.)3; Becky Chatt, RN, MS3; Kate Dellonte, RN, BSN, MBA3; Jeremy T. Cushman MD, MS, EMT-P4; Mark Gestring, MD3,5; Michael A Vella, MD, MBA3,5
- University of Rochester School of Medicine and Dentistry
- Department of Surgery, University of Rochester Medical Center
- Kessler Trauma Center, University of Rochester Medical Center
- Department of Emergency Medicine, Division of Prehospital Medicine, University of Rochester Medical Center
- Department of Surgery, Division of Acute Care Surgery and Trauma, University of Rochester Medical Center
Introduction
To maintain verification as a level one trauma center, hospitals must follow a set of standards for Optimal Care of the Injured Patient established by the American College of Surgeons (ACS), most recently updated in December 2023. A key component of these standards includes professional and community outreach and education for residents, nurses, prehospital personnel (including EMS and other first responders), and the public.1 As these educational standards evolve, advanced medical simulation to assist in training and education is utilized by our program.
Of particular interest is the use of high-fidelity simulation equipment, defined as equipment which relies heavily on digital technology such as computer interfaced mannequins or computer-based audio-visual technology. While in-hospital simulations for hospital providers have been previously described, the availability of this technology for prehospital providers is limited. The use of mobile simulation-based education to supplement prehospital provider education may be especially valuable.
New simulation equipment was acquired by our trauma program in November 2022. This included advanced trauma simulation mannequins, Stop the BleedTM kits for demonstration of hemorrhage control, intraosseous access devices, and pelvic orthotic devices. These educational tools are transported to various locations in a fully functional, refurbished ambulance, allowing for realistic simulated patient encounters. Experienced trauma center personnel supplemented with these training aids comprise our trauma education mobile simulation unit (MSU)2, which provides mobile skills training to prehospital organizations in the region.
This mobile education program includes both basic life support (BLS) and advanced life support (ALS) skills training, and provides hands-on, supervised practice with advanced airway management, needle decompression, and intraosseous insertion. The program has allowed EMS agencies and first responders to have access to training equipment and experienced instructors at a location of their choosing that was previously unavailable.
We sought to evaluate the effectiveness and perception of simulation-based training for prehospital providers implemented as part of our mobile simulation unit.
Methods
A series of educational sessions using high-fidelity simulation equipment were conducted over a six-month period from March to August 2023. The sessions were conducted by a consistent educational team including trained nurses and physicians from the Kessler Trauma Center. The target audience included suburban and rural prehospital providers employed by several emergency medical services, fire departments, and other first responder organizations. The Kessler Trauma Center at the University of Rochester is the only ACS-verified Level 1 trauma center serving the Finger Lakes region of New York state, which includes nine counties, over 6,000 square miles, and over one million people across urban, suburban and rural areas.
More than one hundred EMS and fire agencies and three helicopter service agencies provide prehospital care. Mobile simulation education was provided and arranged at the request of the outside organizations and provided at no cost to the agencies or providers. The specific educational content of the sessions was tailored to individual organizations’ needs; however, all sessions included the use of high-fidelity simulation equipment for demonstration and training scenarios.
Following IRB approval, a voluntary pre- and post- questionnaire was administered to course attendees to gain insight on course attitudes and utility using a Likert scale where 1 indicated strong disagreement with posed questions and five indicated strong agreement. The pre-course questionnaire included non-identifying demographic information. At the conclusion of each session, attendees were asked to complete an identical post-intervention questionnaire with additional questions tailored to course perception. Changes in responses were analyzed using Mann-Whitney U/Wilcoxon Rank Sum test using R Statistical Software. Statistical significance was defined as p-value < 0.05.
Results
Forty-three responses were captured and one participant was removed from the study due to an incomplete post-survey. Study participants had an average of 10.1 years of post-training work experience (range: 0-35 years). Respondent credentials varied as follows: one registered nurse, four paramedics, thirty-seven emergency medical technicians. A total of 35.7% of respondents had previously attended a training event of any kind held by the Kessler Trauma Center; 28.6% of respondents had previously attended a mobile simulation event (Table 1).
Learners reported statistically significant increases in all measures, including comfort level in managing adult, pediatric, and geriatric trauma, airway trauma, traumatic brain injury (TBI), and hemorrhage. Participants also reported improvements in hospital handoffs, receptiveness to needs of prehospital providers, and amount of prehospital education provided by the trauma program (Table 2). No difference in perception of the importance of collaboration was identified.
Post course survey feedback was largely positive. Medians of Likert responses indicate that most participants agreed or strongly agreed that the course was valuable for their education and would improve patient care, that simulations were realistic, and that teamwork was enhanced. Participants agreed or strongly agreed with recommending this course to other prehospital providers and found it helpful to have the trauma team travel to their location for the course.
Table 1. Table describing characteristics of respondents captured in the study. KTC = Kessler Trauma Center; MSU = Mobile Simulation Unit.
| Total: 42 Respondents | ||||
| Role | (1/42) Registered Nurse | (4/42) Paramedic | (37/42) Emergency Medical Technician | |
| Previous years of Experience | Average: 10.1 ± 10.5 years of experience, range 0-35 years | |||
| Previous Attendance, KTC Training | 35.7% (15/42) Yes | 64.3% (27/42) No | ||
| Previous Attendance, MSU Event | 28.6% (12/42) Yes | 71.4% (30/42) No | ||
Table 2. Prehospital care skills, management topics and course opinion questions with median of pre- and post-intervention response values. Nonparametric analysis conducted and P-values calculated with Mann Whitney U test.
| Question | Pre-Session Likert Median | Post-Session Likert Median | P value (* denotes statistical significance) |
| Comfort with Adult Trauma Management | 4 | 5 | 0.003* |
| Comfort with Pediatric Trauma Management | 4 | 4 | <0.001* |
| Comfort with Geriatric Trauma Management | 4 | 4 | <0.001* |
| Comfort with Hemorrhagic Trauma Management | 4 | 5 | <0.001* |
| Comfort with Airway Trauma Management | 4 | 5 | <0.001* |
| Comfort With Traumatic Brain Injury Management | 4 | 4 | 0.009* |
| Comfort With Patient Handoff at Trauma Center | 4 | 4 | 0.003* |
| Trauma Center meets Provider Needs | 4 | 5 | <0.001* |
| Trauma Center provides adequate Provider Education | 4 | 5 | 0.003* |
| Importance of Collaboration with Trauma Center | 5 | 5 |
Discussion
Advantages of mobile simulation education include the ability to provide education in varied settings (e.g., EMS base, ambulance bay, community locations), increased flexibility in learner accessibility, capacity for interdisciplinary training, strengthening of the critical relationship between local trauma centers and partnering organizations, and providing resources and personnel that the agency may not normally have access to. Disadvantages may include a limited didactic component, greater funding needs, and a reliance on host institutions for instructor staffing.3
Outside of urban settings, one of the challenges of providing safe and reliable healthcare over a large geographic area is ensuring that the healthcare workforce has equal access to effective evidence-based training.4 The need for trauma centers to provide additional training for prehospital emergency providers, particularly rural providers, is well described. First, trauma is an extremely significant driver of mortality in the rural setting, especially when compared to the urban setting; rural residents have been found to be 14% more likely to die after traumatic injury.5
While the main contributor to this disparity is most likely geographic, enhancements in prehospital interventions such as bleeding control strategies and prehospital transport protocols have been shown to have favorable impacts on post-traumatic outcomes.6 Mobile simulation-based training therefore provides an opportunity to address the unique needs of rural trauma providers, who may require more emphasis on training at point-of-care and who lack access to high fidelity simulation that might currently be more widely available in urban centers.6
Multifaceted trauma education outreach programs have played a critical role in allowing rural trauma providers to maintain their trauma certifications.7 A needs assessment for simulation-based training for rural emergency medicine providers, including prehospital providers was recently conducted which found that the modular basis of simulation-based training made it easily adaptable to specific educational needs, including management of cardiovascular or respiratory emergencies or pediatric and infant care.8 By leveraging the resources of a larger trauma center, outreach programs such as the one described here can provide the communication and networking necessary to improve working relationships between local emergency medical services and large trauma centers, even in spite of challenges such as geographic distance.
Although no change in prehospital provider perception of collaboration was identified, the consistently high value placed on it demonstrates the importance of trauma center collaboration with these providers, whether through mobile simulation or other forms of outreach. The mobile simulation component of this outreach program is unique, and at the time of writing, is the first of its kind in New York to our knowledge.
Simulation-based training has been characterized as a valuable opportunity for emergency medical professionals to perform hands-on, realistic clinical activities that fall under their scope of practice in an informed, encouraging, and supportive learning environment.9 Specifically identified advantages included the ability to standardize the assessment and the ability to evaluate performance metrics based on specific steps of the procedure. Simulation-based training was also found to be effective in the development of non-clinical skills in emergency services, such as teamwork, communication, task management, and situational awareness.10
We believe that mobile simulation-based training represents the next step in addressing the educational needs of diverse groups of providers as educational standards evolve. As the use of mobile simulation-based education becomes more widespread, learned experiences from pilot programs such as the one captured here can be used to inform development of future programs for prehospital care.
Conclusion
Our mobile, high-fidelity, simulation-based trauma education program was well received by prehospital providers. The unique advantages of this program make it particularly valuable for rural prehospital providers, who often represent some of the most under-resourced components of the healthcare network. This program was characterized by participants as a valuable opportunity for emergency medical professionals to perform hands-on, realistic clinical activities that fall under their scope of practice in an informed, encouraging and supportive learning environment.
Trauma centers may find integration of mobile simulation into new or existing prehospital provider education outreach programs to be effective not just to improve care outcomes but also to build working relationships with frontline healthcare providers. To our knowledge, this is the first evaluation of the utility of a mobile, high-fidelity trauma simulation program targeting prehospital providers.
About the Authors
Jeremy Huang, BS
Jeremy Huang, BS, is a second-year medical student at the University of Rochester School of Medicine and Dentistry in Rochester NY. He is interested in trauma surgery and medical education.
Caitlin Cook, MD, MS
Caitlin A. Cook, MD, MS, is a second-year general surgery resident at the University of Rochester in Rochester, NY. She is interested in the fields of trauma and acute care surgery.
Adam Oplinger, BS, RN, CEN, EMT-P (Ret.)
Adam Oplinger, BS, RN, CEN, TCRN, EMT-P (Ret.) is the pediatric trauma program manager at the University of Rochester Medical Center Golisano Children’s Hospital in Rochester, NY. He has extensive experience in EMS, emergency nursing, critical care transport and trauma.
Becky Chatt, RN, MS
Becky Chatt, MS, RN, is the trauma program dducator at the University of Rochester Medical Center in Rochester, NY. She has been a nurse for 14 years, 10 of which were spent in the adult Emergency Department at Strong Memorial Hospital as an assistant nurse manager overseeing the critical care bay, specifically related to the education and orientation of nursing staff.
Kate Dellonte, RN, BSN, MBA
Kate Dellonte, RN, MBA, BSN, is the Trauma Program manager at the American College of Surgeon’s Verified Adult Level 1 Kessler Trauma Center at University of Rochester Medical Center (NY). Kate has been with the Trauma Program for 6.5 years, serving as performance improvement coordinator prior to transitioning into her current role. Prior to joining the Trauma Program, Kate was an adult emergency department nurse where she continues to work clinically on a per diem basis.
Jeremy T Cushman, MD, MS, EMT-P
Professor of Emergency Medicine and Chief of the Division of Prehospital Medicine at the University of Rochester, Dr. Cushman remains a certified paramedic and is medical director for the Monroe-Livingston Region, Monroe County, City of Rochester, and dozens of fire and EMS agencies. In addition to administrative medical direction, he provides medical support and scene response for all law enforcement, fire department, and special operations teams in the City of Rochester and Monroe County.
Mark Gestring, MD
Mark Gestring, MD, FACS, is chief of Acute Care Surgery at the University of Rochester in Rochester New York. Dr. Gestring serves as an appointed member of the National EMS Advisory Council (NEMSAC) and is past chair of the EMS subcommittee of the ACS- Committee on Trauma.
Michael A Vella, MD, MBA
Michael A. Vella, MD, MBA, FACS, is a trauma surgeon in Rochester, NY and the trauma medical director of the Kessler Level I Trauma Center at the University of Rochester. He was previously an emergency medical technician in Pennsylvania and currently serves as an associate medical director for a helicopter emergency medical services agency in New York.
References
1. Surgeons ACo. Resources for Optimal Care of the Injured Patient. American College of Surgeons; 2022.
2. Baker A, Hardie L, Somerville S, Ker J. Analysis of the use of a mobile simulation unit using the principles of a managed educational network. Rural Remote Health. Mar 2021;21(1):5670. doi:10.22605/rrh5670
3. Kobayashi L, Patterson MD, Overly FL, Shapiro MJ, Williams KA, Jay GD. Educational and research implications of portable human patient simulation in acute care medicine. Acad Emerg Med. Nov 2008;15(11):1166-74. doi:10.1111/j.1553-2712.2008.00179.x
4. Premkumar K, Umaefulam V, O’Brien JM. Mobile medical simulation for rural anesthesia providers: A feasibility study. Can Med Educ J. Dec 2020;11(6):e60-e71. doi:10.36834/cmej.69572
5. Jarman MP, Castillo RC, Carlini AR, Kodadek LM, Haider AH. Rural risk: Geographic disparities in trauma mortality. Surgery. Dec 2016;160(6):1551-1559. doi:10.1016/j.surg.2016.06.020
6. Jarman MP, Hashmi Z, Zerhouni Y, et al. Quantifying geographic barriers to trauma care: Urban-rural variation in prehospital mortality. J Trauma Acute Care Surg. Jul 2019;87(1):173-180. doi:10.1097/ta.0000000000002335
7. Archuleta M, McGraw C, D’Huyvetter C, Mains CW. An Educational Outreach Program: A Trauma System’s 5-Year Experience. J Trauma Nurs. May-Jun 01 2022;29(3):152-157. doi:10.1097/jtn.0000000000000653
8. Wehbi NK, Wani R, Yang Y, et al. A needs assessment for simulation-based training of emergency medical providers in Nebraska, USA. Adv Simul (Lond). 2018;3:22. doi:10.1186/s41077-018-0081-6
9. Amiel I, Simon D, Merin O, Ziv A. Mobile in Situ Simulation as a Tool for Evaluation and Improvement of Trauma Treatment in the Emergency Department. J Surg Educ. Jan-Feb 2016;73(1):121-8. doi:10.1016/j.jsurg.2015.08.013
10. Mather C, Jensen S, Cummings E. Clinical Simulation: A Protocol for Evaluation of Mobile Technology. Stud Health Technol Inform. 2017;241:179-184.
