Acute Care: A Simulator Based Experience

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Acute Care A Simulator Based Experience

• Dr. Vedantashankar Sean Sarma MBBS
• v.s.sarma_at_ncl.ac.uk
• Lecturer in Anatomy and Clinical Skills
• Newcastle University

Dr. Guy McNulty MBBS guy.mcnulty_at_doctors.org.uk S
pecialist Trainee 2 Acute Care Common
Stem Pinderfields General Hospital Mid-Yorkshire
NHS Trust
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Reacting To The Acutely Unwell Patient
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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

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Patient Simulation

• Broad term
• Role-play
• Online resources
• Mannequins (CPR etc)
• More recently ? advanced, interactive mannequins

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Laerdal Sim Man

• Safe environment
• Standardised teaching

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Aim Pilot Study
Simulator Session
? Effectiveness ? Confidence
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Method - Overview

• 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

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Recruitment

• 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!)

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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
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Skills Assessments

• 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)

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Teaching Session

• 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 (AD)
• 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!

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Results
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Results

• Confidence Questionnaires
• Skills Assessments
• Focus Groups

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Confidence Questionnaire

• 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

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Results

• Confidence Questionnaires
• Skills Assessments
• Focus Groups

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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

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Results

• Confidence Questionnaires
• Skills Assessments
• Focus Groups

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Focus Groups

• Themes split into
• Those regarding acute care teaching so far
• Those regarding use of the simulator

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Focus Groups - Themes

• Regarding Acute Care Teaching
• Theory has been covered well very little
  practical teaching
• Weve all gone through it on paper, talked
  through it, but we havent actually been put
  through a situation where we have to put it all
  together and had to think what were doing next
  by ourselves

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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. Ive done
  nights on call where nothings happened
• I think it should be baseline taught. Its too
  important to just rely on you getting it sorted.
  And confidence about this is absolutely
  paramount

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Focus Groups - Themes
Regarding Acute Care Teaching 3. Arrest
algorithms are taught well, as is the ABC
mantra Weve had good sessions going through the
ALS algorithm. So were OK once theyve already
arrested But . . . Everybody always tells you
to do ABC, but you never really go through what
that actually means. Its kind of this assumed
thing
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Focus Groups

• Themes split into
• Those regarding acute care teaching so far
• Those regarding use of the simulator

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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
youre listening for breath sounds, youre not
actually listening, but here I really had to
listen because if you wanted to you could have
programmed something in
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Focus Groups - Themes
Regarding Use Of The Simulator 2. The
assessments form an integral part of the learning
experience Its all very well talking things
through slowly but thats not actually how its
going to be in real life, so its nice to have
the pressure put on you to see how youd put
everything together
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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
youre supposed to be directing everyone else but
you have no idea which oxygen mask is which.
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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 . . .

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Conclusions

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

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So what now, Sean?

• More robust study with senior support
  supervision
• Consider incorporating into curriculum?
• Major issues time required by teachers,
  reproducibility and equipment

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Thank-you!
Any Questions?