Geoffrey T. Miller Associate Director, Research and Curriculum Development

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: 31-46.

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… • Overwhelmingly positive and favors use of simulation • Examples: 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” 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”

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 IssenbergSB,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. 1988. 40-7.

17. Learning ladder BEME: multiple learning strategies and clinical variation

18. The ultimate goal?

19. Where does simulation fit?

20. The ‘big picture” Knowledge Attitude Skill

21. Does Shows Knows how Knows Miller’s Pyramid of Competence George E. Miller MD. The Assessment of Clinical Skills/Competence/Performance. Academic Medicine. 1990. Vol. 65 No. 9: S63-67.

22. Does Shows Knows how Knows “Knows” • Learning • Opportunities: • Reading / Independent study • Lecture • Computer-based • Colleagues / Peers • Assessment opportunities: • Multiple-choice question • Essay / Short answer • Oral interview

23. Does Shows Knows how Knows “Knows how” • Learning • Opportunity • Problem-based Ex. • Tabletop exercises • Direct observation • Mentors • Clinical Context • Based Tests • Multiple-choice question • Essay / Short answer • Oral interview

24. Does Shows Knows how Knows “Shows” • Learning • Opportunity • Skill-based Exercises • Repetitive practice • Small group • Role playing • Performance • Assessment • Objective Structured Clinical Examination (OSCE) • Standardized Patient-based

25. Does Shows Knows how Knows “Does” • Performance • Assessment • Undercover / Stealth standardized patient-based • Video • Learning • Opportunity • Experience

26. Key questions regardingblended learning models

27. Who are our Learners? • Key Questions: • Who are our learners? • Why do they Learn? • What are their Motivations?

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 • 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. Day 2 Didactic Chemical Agents Biological Agents Radiological and Explosive Agents Large Group Exercises Triage – computer-based Tabletop Integration Exercises OSCEs UM Course Design • Day 1 • Didactic • Response Concepts • Operations • PPE • Decontamination • ICS / IMS • Psychomotor • PPE • Medical Management • Ambulatory DECON • Incapacitated DECON

49. Case –Based Lecture • Open-air • concert • 18,000 people • Temp: 84° F • Wind: ENE 12 knots • Chemical weapon from a • boat on shoreline

50. Wind Concert Area Plume Case –Based Lecture • Plume throughout concert area • Initially mistaken as smoke machine (part of show) • Hundreds with symptoms within minutes