Arielle Levy, Dominic Allain, Afrothite Kotsakis and Terry Varshney
© Springer International Publishing Switzerland 2016
V. J. Grant, A. Cheng (eds.), Comprehensive Healthcare Simulation: Pediatrics, Comprehensive Healthcare Simulation, DOI 10.1007/978-3-319-24187-6_10 A. Levy ()
Department of Pediatric Emergency, Department of Pediatrics, University of Montreal, Sainte-Justine Hospital University Centre, Montreal, Quebec, Canada
e-mail: [email protected] D. Allain
Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
e-mail: [email protected] A. Kotsakis
Department of Pediatrics, Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
e-mail: [email protected] T. Varshney
Department of Pediatric Emergency, Children Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
e-mail: [email protected]
Simulation Pearls
1. Level of fidelity should target the educational needs guid- ed by the training objectives of the program. Ask yourself three questions: (1) What are your educational needs? (2) How does the fidelity relate to the needs? (3) What is the optimal combination of simulation tools and technologies to meet these needs?
2. Part task trainers can be used to teach novices basic psy- chomotor skills and can allow experts to maintain more advanced skills.
3. Having a case facilitator and/or having visual cues pre- pared to prompt the learners can help overcome limita- tions inherent to all mannequins.
4. Although extremely effective, hybrid models are time- and cost-consuming, thus should only be used if they will enhance the learners’ educational objectives.
Introduction
Mannequin-based simulators were first developed in the 1960s [1]. Over the past few decades, their design has un- dergone tremendous change and the models available today, including pediatric models, offer specialized functions with compact control systems and increasingly smaller physical footprints with greater flexibility. Compared to desktop or screen-based simulations, these computerized, mannequin- based simulators offer the advantage of recreating a realis- tic patient for use within a realistic simulated environment.
Also referred to as high-fidelity simulators, they are capable of recreating a wide variety of human functions. These in- clude physical examination findings such as heart and lung sounds, as well as physiological parameters, such as changes in respiratory rate or heart rate. Mannequin-based simulators offer both instructors and participants real-time display of electronically monitored physiological parameters. Opera- tors have the capacity to pre-program simulation scenarios and modify a range of parameters in response to changes in the patient’s clinical condition as well as participant inter- ventions. By programming effectively and adjusting the in- puts to the mannequin and to the environment, the operator is able to maximize the realism of the interaction, and contrib- ute positively to the learner experience, as well as optimize the simulator’s use as a research and assessment tool. Inva- sive procedures, such as inserting a catheter for intravenous access, performing endotracheal intubation, or defibrillating a patient in cardiac arrest, can all be practiced, depending on the type of mannequin. Mannequin-based simulators can be used in a dedicated simulation facility or transported to a specific clinical setting, such as a clinic, a ward, or an emer- gency department room, based on the resource availability and learner needs and numbers.
Key differences exist between pediatric and adult man- nequin, reflecting the real-life distinctions seen between pediatric and adult patients. Some of these differences are
anatomical, some are physiological and based on underlying medical conditions, while others are based on responses to treatments. This chapter will explore, compare and contrast (where possible) the various task trainers and whole body mannequins available in the market today. Finally, the chap- ter will explore the programming of whole body mannequins and highlight how the understanding of both the features and limitations of the current generation of simulation manne- quins is essential to create and deliver clinically authentic and realistic scenarios that will help with simulation educa- tion delivery.
Fidelity/Realism
In simulation-based education, fidelity can be classified into three types: semantical (or conceptual), emotional (or phenomenal), and physical [2]. Semantical or conceptual fidelity concerns concepts such as information presented via text, pictures, sounds, or progression in clinical events.
For example, a scenario can be conceptually realistic if the information given is interpretable regardless if it is lacking physical realism and if the clinical progression is consistent with what would be experienced with a real patient (e.g., in a patient with hypovolemic shock, the heart rate improves after a fluid bolus is given). Emotional or phenomenal fidel- ity includes emotions or beliefs that learners directly experi- ence when emerged in a situation. This is an important issue in simulation because it describes the different elements of the experience such as complex real-time situation and an educational experience resembling a real situation [2].
Physical fidelity classically refers to the degree to which a simulator looks, feels, and acts like a human patient. The definition of physical fidelity has a tendency to emphasize technical and physical advances over pedagogical principles and objectives. Although some studies report that training with realistic mannequins improves clinical performance [3, 4], several studies have demonstrated that the degree of physical fidelity is independent of educational effectiveness [5, 6]. Nevertheless, trainees do report increased satisfaction with more realistic high physical fidelity mannequins [7].
However, fidelity should not just refer to the physical resem- blance of the simulator but should consider the functional aspect of fidelity, that is, the degree to which learners are required to use the same performance strategies and compe- tencies in the simulation and in the real clinical environment [8]. As such, simulation should not be simply considered high or low fidelity.
It is not uncommon for practitioners to simplify fidelity into a one-dimensional construct that results in categoriza- tion on a continuum from low to high. However, a one-di- mensional conceptualization of fidelity can be misleading
when trying to select appropriate simulators for a given train- ing need. A simulation that has the look and feel of the real world is often considered high fidelity, when in fact only one dimension of overall fidelity (i.e., physical fidelity) is high.
A simulation can replicate the outward appearance of the op- erational environment (e.g., an operating room, OR) quite effectively yet still be ineffective at helping learners meet the training goals. Ultimately, the focus should be to match the various types of simulation fidelity to best meet educational targets (Fig. 10.1). For example, team training involves high emotional, high conceptual, and high physical fidelity. Pa- tient assessment will target high conceptual and physical fi- delity. In communication training, the focus will be on high conceptual and emotional fidelity. Keeping in mind the fol- lowing questions is mandatory when considering fidelity op- tions for a simulation: What are the educational needs of the learner group, and what are the educational objectives of the session? What level of fidelity is required to best meet those needs? What is the best combination of simulation tools and technologies available to achieve that level of fidelity and meet the aforementioned needs [9]? Figures 10.2 and 10.3 illustrate an example of the choice of simulation modalities according to educational objectives.
The term Human Factors (HF) represents a set of physical and psychological characteristics that are needed to success- fully match humans to equipment and systems. It integrates technology, policies, processes and environment, training, skills, and experiences of the personnel involved in the simulation. HF tools originating in aviation and other safety critical industries have been proven effective [11]. The latter are currently being applied effectively in health care because they may support fidelity decisions and design. Incorpo- rating HF techniques into simulation-based education may lead to better decisions on appropriate use of fidelity. Many frameworks have been suggested to classify and understand elements of fidelity. A simple and common framework of HF called the PTE (Patient-Task-Environment; Fig. 10.4) is one example where after determining the learning objectives, educators can choose simulation elements within the PTE dimension for each stage of the scenario and match the ap- propriate level of fidelity to target specific objectives within each stage. Systematically reviewing the training objective relevant to the simulation element and matching the element fidelity against the training objective will further guide edu- cators to select the most appropriate level of fidelity to target educational needs.
A recent review examining key concepts and assumptions surrounding the topic of fidelity in simulation suggests that concepts such as transfer of learning, learner engagement, and suspension of disbelief are not only useful in explain- ing educational effectiveness but also directly influence properties of the learning experience. The authors suggest
Fig. 10.2 Choosing a 3D training program best used to train knowledge of endotracheal intubation. (Photo courtesy of CAE Healthcare [10])
Fig. 10.1 Matching simulation fidelity to educational needs. (Photo courtesy of CAE Healthcare [10])
abandoning the term fidelity in simulation-based education and replacing it with terms reflecting the underlying physi- cal resemblance and functional task alignment. They also suggest shifting away from the current emphasis on physi- cal resemblance to a focus on functional link between the simulator and the desired educational context. Finally, they recommend that educators focus on methods to enhance edu- cational effectiveness such as principles of transfer of learn- ing, learner engagement, and suspension of disbelief [12].
Pediatric Partial Task Trainers
When teaching a particular procedural skill, it may only be necessary to reproduce specific portions of the patient or task. Partialtask physical trainers replicate only a portion of a complete process or system [13], provide key elements of the procedure being learned, and allow learners to acquire the basic skills needed to accomplish the same task on real
Fig. 10.4 PTE framework to choose simulation elements. PTE patient-task-environment. (Photo courtesy of CAE Healthcare [10])
Fig. 10.3 High-intensity team training best used to train for team skills during trauma intuba- tion. (Photo courtesy of CAE Healthcare [10])
patients (see Chap. 11). Some examples of homemade task trainers include using oranges to learn injection techniques or chicken bones to learn intraosseous line placement [14], among others. Commercially produced pediatric partial task trainers (PTTs), usually composed of plastic and rub- ber allow the same procedural practice, albeit in a safe (and cleaner) environment. In contrast to whole body manne- quins, they incorporate only the anatomical section required for a particular procedural skill. Hybrid simulations involve combining a PTT with a live standardized patient (SP) actor to help enhance the physical fidelity of the overall educa- tional experience. Examples include partial task trainers for suturing lacerations consisting of a pad with a wound cut on the surface. Such a pad can be strapped onto the arm of an SP and then draped appropriately. The learner not only has to perform the elements of suturing the wound but also has to do so while speaking to the patient, thus emulating a real-life situation (Fig. 10.5).
PTTs are a commonly utilized modality due to cost and size. They can be effectively used to teach novices the basics of psychomotor skills [15] and can allow experts to maintain and practice more advanced skills. Currently, a significant amount of PTTs are available or are in development. The fol- lowing section will focus on various PTTs that are currently available on the market, divided into five categories:
1. Airway trainers
2. Vascular and intraosseous (IO) access trainers
3. Invasive torso-based task trainers (including lumbar puncture (LP) trainers, chest tube, and pericardiocentesis trainers)
4. Surgical task trainers 5. Miscellaneous trainers
Airway Trainers Airway Management
Airway management skills demand a significant amount of practice in order to achieve competency standards [16–20].
Infant and child PTTs that realistically reproduce different parts of an anatomic airway allow for practicing basic and advanced airway management skills. They permit skill de- velopment in bag-valve mask ventilation, placement of na- sopharyngeal and oropharyngeal airways, and placement of endotracheal tubes (Fig. 10.6). Many studies have shown that trainees can develop responses to and skill in manage- ment of emergency airway situations when practicing with airway trainers [16]. Furthermore, studies have also demon- strated that recent tracheal intubation training is associated with immediate refresher training effectiveness and trainer outcome [17–20].
Airway trainers may have certain mechanical and visual limitations. For example, not all trainers allow for a good seal to practice effective bagging during ventilation. In other models, the tongue and the epiglottis may be semirigid in structure and are distinctly separated from the posterior phar- ynx. The epiglottis is suspended anteriorly and superiorly away from the laryngeal inlet. Identifying laryngeal struc- tures and controlling the tongue and epiglottis on an airway trainer may not represent a realistic clinical challenge. Along with the mechanical and visual limitations of airway trainers, most institutions provide trainees with practice on only one type of intubation trainer. This fosters a very limited under- standing of anatomy and mechanical variation encountered in actual patients. Studies support the use of several types of airway trainers to enhance learning. [21, 22]
Fig. 10.6 Infant Airway Management Trainer. (Image used courtesy of Laerdal Medical [23])
Fig. 10.5 Partial task trainers for suturing lacerations.(From https://
web.mail.comcast.net/service/home/~/?id=176615&part=2.2&auth=co
&disp=i)
Adolescent, Child, and Infant Choking Mannequins Some airway PTTs also offer opportunities to practice for- eign body removal (Fig. 10.7). Some adolescent, child, and infant choking mannequins include a rib cage, xiphoid process, and jugular notch to provide anatomical reference points for the demonstration of proper hand placement for the technique inherent to the clearing of impacted airway foreign bodies. Each life-size head and upper torso allows practice of abdominal thrusts, chests thrusts, and back blows for clearing foreign body obstruction. When correct clear- ing procedures are performed, the mannequin will expel the object causing the blockage. The choking objects provided make excellent practice of obstructions.
Cricothyrotomy and Tracheotomy Insertion and Care
PTTs have been developed for training in rescue airway skills such as cricothyrotomy and tracheotomy. Infant tra- cheostomy trainers also provide an opportunity to teach basic tracheostomy care skills to patients and caregivers (Fig. 10.8). Procedures such as dressing changes, stoma cleansing, changing of tracheostomy tube, and tracheos- tomy ties as well as cuff inflation can be performed on this infant trainer. These trainers have the advantage of filling lungs and stomach with fluid for realistic practice of tra- cheostomy care and tracheal suctioning. They also allow for practice of various steps for tracheostomy insertion and care. However, they are limited in their ability to mimic human anatomy and tissues, but may be used to gain famil- iarity with the different equipment available for percutane- ous tracheostomy.
Cricothyrotomy trainers are designed for learning and practicing the technique of emergency cricothyrotomy. Pal- pable landmarks include both the cricoid and thyroid car- tilage. All landmarks are accurately placed and allow for a rapid procedure. As the airway passes completely through from top to bottom, the trachea in this simulator is replace- able. This allows checking the stylet and obturator placement once the stab has been made. Complete with a full-size neck, ties can be used to hold the obturator in a secure position (Fig. 10.9). Advantages include the opportunities for trainees to practice various steps of a high-stakes procedure such as this one, as well as preparing necessary equipment manda- tory to ensure a successful procedure. However, disadvan- tages include variable realism and fixed anatomy specific to the model. Models cannot bleed and certain tissues may not feel realistic. In addition, because most emergent airways are done in patients who have altered anatomy (e.g., a patient with an expanding hematoma after undergoing branchial cyst resection, a teenager with massive trauma to the face or neck, a syndromic child with a short, fat, thick neck, etc.), these fixed models may not be the ideal method for training [26].
Vascular Access and Intraosseous Trainers Venipuncture and Intravenous Catheter Insertion Venipuncture PTTs are commonly used for training health- care providers. Intravenous access arms come in differ- ent colors, sizes, and depths of veins (Fig. 10.10). Not only do they allow for the procedures of venipuncture and
Fig. 10.8 Infant tracheostomy trainer. (Photo courtesy of North Ameri- can Strategy for Competitiveness (NASCO) [25])
Fig. 10.7 Adolescent, Child, and Infant Choking Mannequins. (Photo courtesy of Simulaids [24] Corporation)
intravenous catheter insertion, they also permit learners to practice the ancillary procedures of preparation, wearing gloves, and respecting sterility. Proper needle placement can be confirmed on these models by a flashback of simulated blood, as well as the possibility of infusing fluids and with- drawing blood. These trainers allow for review of principles, skills and tools necessary for insertion, assessment, dressing care, securement and maintenance of vascular access devices in children. Disadvantages include minimal adhesion when placing dressings on certain models due to the nonstaining properties of the tissuelike material. Studies have shown improvements in peripheral intravenous vein placement and higher scores on knowledge examinations of pediatric house staff after simulated procedural skill training [27].
Central Venous Catheter Insertion
Central line PTTs are widely available, with some of the newer models allowing for the use of ultrasound in ultra- sound-guided central venous catheter insertion. Pediatric
models that are currently available include subclavian, inter- nal jugular, and femoral veins (Fig. 10.11). Anatomic land- marks can be palpated and identified. There is good evidence to support the positive impact of practicing these skills be- fore experiencing similar procedures in clinical settings [28].
Studies have shown higher confidence levels and knowledge gain, and improved clinical performances of trainees after
Fig. 10.9 Life/form® Cricothy- rotomy Simulator Kit. (Photo courtesy of NASCO [25])
Fig. 10.11 VascularAccessChild. (Photo courtesy of Simulab Corpora- tion [32])
Fig. 10.10 Pediatric Multi-Venous IV Training Arm Kits (a, b). (Im- ages courtesy of Laerdal Medical [23])
simulated training with these task trainers [29, 30]. A recent study demonstrated how dissemination of a simulation- based mastery learning intervention reduced central-line- associated bloodstream infections [31].
Umbilical Venous Catheter Insertion
Neonatal trainers are available for the practice of umbilical venous and arterial line catherization (Fig. 10.12). These trainers offer an opportunity to practice blood withdrawal and fluid infusion. The lifelike umbilicus allows the repeat- ed accessing of the umbilical vein, with proper placement verified by blood return. Advantages include flashback of simulated blood, and certain models can mimic the curves of the umbilical vein after it enters the body, making placement more realistic. However, in some models, the cord is secured poorly and thus does not adequately mimic placement in a newborn. Other models are limited in their ability to mimic the curves of the umbilical vein after it enters the body, rep- resenting a more unrealistic placement.
Intraosseous Access Trainers
IO trainers are designed for teaching infant intraosseous in- fusion techniques and permit both intraosseous needle inser- tion and aspiration of simulated bone marrow (Fig. 10.13).
IO access trainers can be used to train to competency as assessed by validated assessment instruments [33]. Advan- tages include the ability to use either manual IO introducers or powered IO insertion devices such as guns or drills. How- ever, some models offer only one size and do not provide flashback. In addition, current models do not allow external rotation of the hip to permit proper positioning. Most models do not allow practicing insertion in other sites other than the proximal tibia, such as proximal humerus, distal femur, and malleola.
Invasive Torso-Based Task Trainers
Chest Tube Placement (Tube Thoracostomy) and Pericardiocentesis
Many high-fidelity full-body mannequins offer the possibili- ty of performing needle thoracostomy, chest tube placement, paracentesis, and even pericardiocentesis. However, there is the potential for increased wear and tear on the mannequins and likely an earlier need to replace the mannequin. Because of the high costs associated with high-fidelity full-body mannequins, specific PTTs are available to acquire neces- sary skill and experience in performing the same procedures, as well as the ancillary concepts of setting up and maintain- ing closed water-seal drainage systems. Many programs use torso-based surgical PTTs as part of pediatric emergency medicine, critical care, and surgery procedural skills training programs for needle and tube thoracostomy as well as peri- cardiocentesis (Fig. 10.14). A recent study developed and validated an assessment tool for chest tube insertion compe- tency (Tool for Assessing Chest Tube Insertion Competency;
TACTIC) in children and identified areas where training is required for pediatric emergency physicians. They dem- onstrated significant improvement in scores after targeted training, providing a way to document acquisition of skill, guide individualized teaching, and assist with the assessment of the adequacy of clinician training [34].
Limitations in using torso-based surgical PTTs for chest tube insertion (CTI) include gaps in the procedural fidelity of current training models and their insufficiency to support training of procedural mastery potentially leading to iatro- genic complications associated with these procedures. A re- cent study developed, piloted, and implemented a novel CTI bench model for usability by volunteer pediatric residents
Fig. 10.13 Laerdal Intraosseous Trainer. (Image used courtesy of Laerdal Medical [23])
Fig. 10.12 Baby Umbi. (Photo courtesy of Laerdal Medical [23])