We read the Park et al. Manifesto for healthcare simulation practice1 with great interest and present this commentary to prompt continued discussion.
The effects of the pandemic are widespread throughout healthcare and health professions education. In the Manifesto, the authors implore simulationists to “adopt a commitment to comprehensive safety, to advocate collaboratively and to lead ethically.” They emphasize working remotely and fear that some simulationists’ “calls for safety are overlooked or even disregarded by their own institutions.” We emphatically agree that healthcare simulationists should inform clinical and educational leaders about safety, collaborative advocacy, and ethics during the current pandemic and in its aftermath.
The article suggests that standardized patients (SPs) may not have an empowered voice to speak up if they feel unsafe in the learning environment and that SPs should have the same psychological safety as learners and patients. We agree with the authors that psychological safety for all simulationists, learners, and clinicians is imperative to the health and wellbeing of learners and patients.
The Quadruple Aim of healthcare suggests a thriving, well-trained, and fulfilled workforce provides better care for patients.2 In this unusual time, there is an essential tension among the competing priorities of professional safety, service, duty, and satisfaction. We simulationists have spent decades demonstrating how rigo...
We read the Park et al. Manifesto for healthcare simulation practice1 with great interest and present this commentary to prompt continued discussion.
The effects of the pandemic are widespread throughout healthcare and health professions education. In the Manifesto, the authors implore simulationists to “adopt a commitment to comprehensive safety, to advocate collaboratively and to lead ethically.” They emphasize working remotely and fear that some simulationists’ “calls for safety are overlooked or even disregarded by their own institutions.” We emphatically agree that healthcare simulationists should inform clinical and educational leaders about safety, collaborative advocacy, and ethics during the current pandemic and in its aftermath.
The article suggests that standardized patients (SPs) may not have an empowered voice to speak up if they feel unsafe in the learning environment and that SPs should have the same psychological safety as learners and patients. We agree with the authors that psychological safety for all simulationists, learners, and clinicians is imperative to the health and wellbeing of learners and patients.
The Quadruple Aim of healthcare suggests a thriving, well-trained, and fulfilled workforce provides better care for patients.2 In this unusual time, there is an essential tension among the competing priorities of professional safety, service, duty, and satisfaction. We simulationists have spent decades demonstrating how rigorous experiential education improves patient care outcomes. Our leadership actions and advocacy statements affect the health and wellbeing of the healthcare workforce and the patients we serve.
We acknowledge that psychological safety does not exist in either the clinical setting or in educational environments simply because we deem it so. The COVID-19 pandemic makes plain that frontline workers are not guaranteed psychological safety when reporting concerns. In fact, healthcare providers and public health officials have often been muzzled or experienced retaliation when voicing concerns3
At the onset of the pandemic, clinicians who spoke out about the lack of personal protective equipment (PPE) in hospitals across the world were silenced. Dr. Li Wenliang as the Wuhan whistleblower who expressed fears about the public health threat was initially silenced, then celebrated for his courage and sacrifice. Following public outcry, authorities apologized for silencing Dr. Li’s concerns recanting claims that he was “making untrue comments” and “severely disturbing social order” after his death from COVID-19.
We respectfully challenge the authors’ Manifesto position on two key points. First, that SPs are non-essential to experiential healthcare education. The challenge of how to move ahead in our new paradigm has many questions about safety and autonomy. Educational leaders across the continuum, from kindergarten to higher education, face the same ethical challenge. We must abide by policies and protections of local institutions and public health organizations. We believe SPs should have decision-making autonomy. In fact, simulationists, learners, and clinicians should all have agency to weigh the risks and benefits of participating in simulation activities with adequate PPE and safety precautions.
Second, we offer that PPE, social distancing, and effective hand hygiene are essential tools to improve safety for the population, healthcare providers, and learners. Accumulating evidence shows that precautions improve safety and that PPE works. Social distancing—keeping six feet apart, wearing high-quality medical masks, or face shields when distancing is not possible—minimizes the spread of SARS-CoV-2.4 Mandating face mask use in public is credited with a decline in daily COVID-19 incidence and has averted greater than 200,000 estimated COVID-19 cases in the U.S. since May 22, 2020.5
At the onset of the pandemic, healthcare leaders worked to preserve scarce PPE for frontline patient care providers. Now, however, restaurants, hair salons, professional sports teams, and public spaces worldwide are operating with safety protocols in place. Clinical and simulation-based education is obviously more essential than these activities because healthcare education is necessary to maintain a well-trained workforce that can provide optimal patient care. Safe healthcare education is particularly important during a pandemic.
PPE should be reserved for direct patient care activities in places that have shortages. However, organizations with adequate PPE supplies can deploy resources to protect simulation educators and trainees to provide essential health care services.
This is a pivotal time in healthcare and healthcare simulation history. Our greatest concern is that, in its present form, the Manifesto may produce the unintended consequence of limiting the autonomy of SPs and other critical simulation personnel suggesting their face-to-face presence is non-essential. Simulation leaders must simultaneously ensure that simulation experiences are delivered safely, providing transparency and choice about potential hazards that cannot be eliminated.1
Our work as simulationists provides a foundation to improve the health and wellbeing of society as we use education to advance patient care quality. During this pandemic, and in the future, as clinical leaders in simulation, we need to endorse and utilize scientific, evidence-based approaches including social distancing and PPE.
Calls for personal, physical, or patient safety should never be disregarded or met with retaliation. Everyone’s voice and safety are important. We know that psychological safety to report concerns has been promoted in other high-risk industries as an essential element to ensure safety. Yet, in healthcare, psychological safety is not routinely measured, quantified, or reported. We agree that SP, learner, and clinician voices must be heard and valued as we move ahead. Psychological safety of all members of the healthcare team to report concerns must be a priority.
We thank the diverse group of Manifesto authors for their work and commitment to simulation education. We agree that safety, advocacy, and leadership are core tenets of healthcare simulation. We affirm the importance of active stakeholder collaboration to achieve consensus and invite productive discourse and difficult conversations that increase the physical and psychological safety of all who contribute to improving the care of the patients we serve.
REFERENCES
1. Park CS, Clark L, Gephardt G, et al. Manifesto for healthcare simulation practice. BMJ Simulation and Technology Enhanced Learning Published Online First: 04 September 2020. doi: 10.1136/bmjstel-2020-000712.
2. Morrow E, Call M, Marcus R, Locke A. Focus on the Quadruple Aim: Development of a Resiliency Center to Promote Faculty and Staff Wellness Initiatives. The Joint Commission Journal on Quality and Patient Safety. 2018;44(5):293-298.
3. Health officials are quitting or getting fired amid outbreak, Associated Press. Modern Healthcare. 2020. https://www.modernhealthcare.com/policy/health-officials-are-quitting-or.... Accessed 25 October 2020.
4. Klompas M, Baker MA, Rhee C. Airborne Transmission of SARS-CoV-2: Theoretical Considerations and Available Evidence. JAMA. 2020;324(5):441–442. doi:10.1001/jama.2020.12458.
5. Desai AN, Aronoff DM. Masks and Coronavirus Disease 2019 (COVID-19). JAMA. 2020;323(20):2103. doi:10.1001/jama.2020.6437.
CORRESPONDING AUTHOR
Sharon Griswold, MD, MPH, Professor of Emergency Medicine, Department of Emergency Medicine, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, P.O. Box 850, M.C. H043, Hershey, PA 17033, USA; sgriswold@pennstatehealth.psu.edu https://orcid.org/0000-0001-6978-0541
We were interested to read about your use of a Web-OSCE to enhance clinical skills training via Zoom for third year medical students in Qatar. In the UK, medical schools have also been forced to change teaching and assessment practices due to Covid-19 and at University of Buckingham we have held a summative OSCE online for three final year medical students.
The main cohort of final year students was able to take a shortened, amended OSCE in March 2020 before lockdown with the transfer to a non-clinical site and the use of simulated patients instead of real patients. However three students needed to take the resit OSCE at the end of May and due to the social distancing and the fact students had in some cases returned to their home countries and could not fly back to the UK, we decided to convert this to a remote OSCE (rOSCE).
We used Microsoft Teams as the online platform due to its versatility and availability; it is free to download and works on most computer hardware. Each student was assigned a ‘channel’ on the Team and allocated an invigilator. Unlike the experience in Qatar, the students remained in the channel and the assessors and simulated patients circulated and we were able to run eight 15-minute stations in this way. As in Qatar and other settings (1) it was not possible to test practical procedures or clinical skills however these had been assessed at other points in the course. We were able to assess high level skills in these final year students...
We were interested to read about your use of a Web-OSCE to enhance clinical skills training via Zoom for third year medical students in Qatar. In the UK, medical schools have also been forced to change teaching and assessment practices due to Covid-19 and at University of Buckingham we have held a summative OSCE online for three final year medical students.
The main cohort of final year students was able to take a shortened, amended OSCE in March 2020 before lockdown with the transfer to a non-clinical site and the use of simulated patients instead of real patients. However three students needed to take the resit OSCE at the end of May and due to the social distancing and the fact students had in some cases returned to their home countries and could not fly back to the UK, we decided to convert this to a remote OSCE (rOSCE).
We used Microsoft Teams as the online platform due to its versatility and availability; it is free to download and works on most computer hardware. Each student was assigned a ‘channel’ on the Team and allocated an invigilator. Unlike the experience in Qatar, the students remained in the channel and the assessors and simulated patients circulated and we were able to run eight 15-minute stations in this way. As in Qatar and other settings (1) it was not possible to test practical procedures or clinical skills however these had been assessed at other points in the course. We were able to assess high level skills in these final year students in addition to history taking from simulated patients. The students also used evidence-based medicine skills to discuss a clinical paper with a patient, performed a handover to a senior colleague and used simulation findings presented on slides to discuss the acute management of a case.
The rOSCE was highly acceptable to both students and assessors and unlike the WebOSCE in Pittsburgh we did not find the students achieved lower marks than expected. Training was required for assessors, invigilators, simulated patients and students and we held a pilot rOSCE as well as a full mock rOSCE for the students to ensure they were familiar with the process. As with Qatar, the largest resource in terms of running the rOSCE was the numbers of staff involved and the training time of approximately 4 hours per assessor and simulated patient. However, this was offset by the lack of physical space requirements and increased availability of assessors.
The effects of Covid-19 may be with us for some time and the Medical School Council in the UK has advised that medical students will need to expect different assessment methods in the future (2). Although more research is required in larger cohorts to ascertain the reliability of the rOSCE, we have shown that it is possible to perform a remote assessment of the clinical skills of final year medical students. With the ability to have up to 200 channels in an MS Team and run multiple concurrent circuits we believe we can run a rOSCE for larger cohorts of students using similar staffing requirements to those needed in a face to face OSCE.
Despite the limitations caused by Covid -19 we still need to ensure that we can reliably assess the clinical skills of medical students to ensure patient safety whilst allowing them to graduate to join the cohorts of new junior doctors.
1 Novack DH, Cohen D, Peitzman SJ, et al. A pilot test of WebOSCE: a system for assessing trainees’ clinical skills via teleconference. Med Teach 2002; 24:483–7.
2. Medical Schools Council Returning to clinical placements: An update for medical students. May 2020 https://www.medschools.ac.uk/studying-medicine/covid-19/information-for-...
We read with interest the article by Ahmed O et al1 regarding simulation training during the coronavirus pandemic. We would like to congratulate the authors for the same. The time since simulation training has been introduced for learning anaesthesia skills, it has increased the success rates when the procedures are performed on patients after practicing on simulators. We would like to stress on the point that although simulation training improves the success rate for all procedures, but special recommendations which have been specially added for anaesthesia management during the present pandemic needs extra attention like donning doffing of the PPE kit and clamping to unclamping of the ETT (points 17-20)
It is a well known fact that clamping of the ETT increases airway resistance and changes the dynamic compliance of the lung.2 If the total process of clamping till unclamping is prolonged, it can lead to adverse effect on the lung dynamics, in an already compromised COVID 19 patient, showing ARDS type features. If the total time of clamping is increased the cuff needs to be deflated prevent the increase in airway resistance, thereby increasing the chances of secretion drooling and hampering the whole purpose of clamping. It is essentially important to complete the whole procedure within a short time span. In present COVID situation the results may not be as anticipated as number of assistants will be limited, and anxiety of operator will be high. Simulation will be...
We read with interest the article by Ahmed O et al1 regarding simulation training during the coronavirus pandemic. We would like to congratulate the authors for the same. The time since simulation training has been introduced for learning anaesthesia skills, it has increased the success rates when the procedures are performed on patients after practicing on simulators. We would like to stress on the point that although simulation training improves the success rate for all procedures, but special recommendations which have been specially added for anaesthesia management during the present pandemic needs extra attention like donning doffing of the PPE kit and clamping to unclamping of the ETT (points 17-20)
It is a well known fact that clamping of the ETT increases airway resistance and changes the dynamic compliance of the lung.2 If the total process of clamping till unclamping is prolonged, it can lead to adverse effect on the lung dynamics, in an already compromised COVID 19 patient, showing ARDS type features. If the total time of clamping is increased the cuff needs to be deflated prevent the increase in airway resistance, thereby increasing the chances of secretion drooling and hampering the whole purpose of clamping. It is essentially important to complete the whole procedure within a short time span. In present COVID situation the results may not be as anticipated as number of assistants will be limited, and anxiety of operator will be high. Simulation will be the only way to practice and limit the duration required. The operator as well as the assistant be fully prepared in coordination to use clamp as well as the ventilator tubing. So we would like to focus that although the whole procedure should be practiced by simulation but if the resources and time is limited for training, the procedures which are recently recommended should be seriously practiced on simulators before doing real time.
References
1. Ahmed OMA, Belkhair AOM, Ganaw AEA, et al Anaesthesia simulation training during coronavirus pandemic: an experience to share BMJ Simulation and Technology Enhanced Learning Published Online First: 30 April 2020. doi: 10.1136/bmjstel-2020-000643
2. Stenqvist O (2003) Practical assessment of respiratory mechanics. Br J Anaesth 91(1):92–105
We read with interest the report by Ahmed et al1. "Anaesthesia simulation training during coronavirus pandemic: an experience to share". The authors developed A metric-based checklist steps of induction of GA, tracheal intubation, intraoperative management, tracheal extubation and patient recovery in the context of treating patient with covid-19. A supplemental video was used as learning method for the involved health workers. Although the investigators initiate that their clinicians improved their performance during simulation training, they could not consistently addressing all concerns. 1) it is not clear at what flow rate O2/min that preoxygenation should be delivered. Defining such flow is crucial to minimize viral transmission2. 2) the preparation/management between two cases of COVID19, ( e.g soda-lime canister changes; the necessary time pause between cases…),was not notified in their training sessions. Adding such guidance to the checklist would ensure more supplementary protective measures.
On the other hand, the video showed nicely all training steps, including the using of the glidescope as videolarungoscope (GVL) tool for endotrachel intubation. It is well known that due to the curvature of the GVL blade, a stylet must be used to position the endotrachel tube (ETT) tip at the glottic opening especially in suspected difficult airway3,4. The using of stylet facilitate a quick-pass first-attempt tracheal instrumentation5 .However, in the record...
We read with interest the report by Ahmed et al1. "Anaesthesia simulation training during coronavirus pandemic: an experience to share". The authors developed A metric-based checklist steps of induction of GA, tracheal intubation, intraoperative management, tracheal extubation and patient recovery in the context of treating patient with covid-19. A supplemental video was used as learning method for the involved health workers. Although the investigators initiate that their clinicians improved their performance during simulation training, they could not consistently addressing all concerns. 1) it is not clear at what flow rate O2/min that preoxygenation should be delivered. Defining such flow is crucial to minimize viral transmission2. 2) the preparation/management between two cases of COVID19, ( e.g soda-lime canister changes; the necessary time pause between cases…),was not notified in their training sessions. Adding such guidance to the checklist would ensure more supplementary protective measures.
On the other hand, the video showed nicely all training steps, including the using of the glidescope as videolarungoscope (GVL) tool for endotrachel intubation. It is well known that due to the curvature of the GVL blade, a stylet must be used to position the endotrachel tube (ETT) tip at the glottic opening especially in suspected difficult airway3,4. The using of stylet facilitate a quick-pass first-attempt tracheal instrumentation5 .However, in the recorded video the HME filter was used to sealed the ETT that indicated the non-use of stylet. Hence, the authors did not show us the ability of intubation without stylet. In addition, some recommend care when removing the stylet or bougie to avoid spreading contamination.
References
1. Ahmed OMA, Belkhair AOM, Adel E Ahmed Ganaw AEA et al. Anaesthesia simulation training during coronavirus pandemic: an experience to share. BMJ Stel .(2020-04-30).10.1136/bmjstel-2020-000643.
2. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020 Mar 27. doi: 10.1111/anae.15054. [Epub ahead of print].
3. DJ. The GlideScope video laryngoscope. Anaesthesia. 2005;60 :414-5.
4. Turkstra TP, Harle CC, Armstrong KP et al. The GlideScope-specific rigid stylet and standard malleable stylet are equally effective for GlideScope use. Can J Anaesth. 2007 ;54:891-6.
5. van Zundert A, Maassen R, Lee R, Willems R, Timmerman M, Siemonsma M, Buise M, Wiepking M. A Macintosh laryngoscope blade for videolaryngoscopy reduces stylet use in patients with normal airways. Anesth Analg. 2009;109:825-31.
We read with interest the article, Preparing and responding to 2019 novel coronavirus with simulation and technology-enhanced learning for healthcare professionals: challenges and opportunities in China (1) echoing the old adage ‘necessity is the mother of invention’ in relation to remote-site clinical education. Disruption to all levels of education have sparked initiatives as described by Li et al and have exposed the stark lack of a global coordinated mitigation plan. Lessons learned during the current crisis will re-shape our view of traditional clinical teaching theory and delivery. Distance learning is likely to become the norm in the post Covid-19 era and innovative simulation tools are set to enhance these platforms (2).
Our experiences in ophthalmology reinforce the notion that pedagogy follows technology in producing robust, validated and clinically relevant higher level education in the surgical specialties (3). We foresee a growing global imperative to ensure continued development of cost-effective, accessible, high quality alternatives to on-campus face to face clinical learning to supplement, and in some cases supplant current programmes. These are likely to include asynchronous discussion boards, reflective e-portfolios, remote site assessments and developing home microsurgical simulators (personal communication, Brennan P). Covid-19 has revealed, on a global scale, both our human frailties and resilience.
We read with interest the article, Preparing and responding to 2019 novel coronavirus with simulation and technology-enhanced learning for healthcare professionals: challenges and opportunities in China (1) echoing the old adage ‘necessity is the mother of invention’ in relation to remote-site clinical education. Disruption to all levels of education have sparked initiatives as described by Li et al and have exposed the stark lack of a global coordinated mitigation plan. Lessons learned during the current crisis will re-shape our view of traditional clinical teaching theory and delivery. Distance learning is likely to become the norm in the post Covid-19 era and innovative simulation tools are set to enhance these platforms (2).
Our experiences in ophthalmology reinforce the notion that pedagogy follows technology in producing robust, validated and clinically relevant higher level education in the surgical specialties (3). We foresee a growing global imperative to ensure continued development of cost-effective, accessible, high quality alternatives to on-campus face to face clinical learning to supplement, and in some cases supplant current programmes. These are likely to include asynchronous discussion boards, reflective e-portfolios, remote site assessments and developing home microsurgical simulators (personal communication, Brennan P). Covid-19 has revealed, on a global scale, both our human frailties and resilience.
Notwithstanding the tragic human toll of Covid-19, necessity can give birth to invention. Harnessing new teaching and assessment tools borne out of this crisis have the capability to both save lives and sustain the educational needs of students worldwide.
References
1. Li L, Lin M, Wang X, et al. Preparing and responding to 2019 novel coronavirus with simulation and technology-enhanced learning for healthcare professionals: challenges and opportunities in China. BMJ Simulation and Technology Enhanced Learning Published Online First: 11 March 2020. doi: 10.1136/bmjstel-2020-000609
2. Pottle J1. Virtual reality and the transformation of medical education. Future Healthc J. 2019;6(3):181-185.
3. Smith P, Wigmore S, Paisley A et al. Distance Learning Improves Attainment of Professional Milestones in the Early Years of Surgical Training Ann Surg. 2013; 258(5): 838–843.
We congratulate Kim et al on developing a shoulder dystocia training program that included video instruction, a didactic portion and a simulation training session including force measurement, followed by a study aimed at evaluating the impact of the training on actual clinical outcomes.1 Their observed two-fold increase in shoulder dystocia incidence is consistent with some other studies,2, 3 and more in line with prospective clinical studies that report an incidence of ~ 4% among term vaginal deliveries.4, 5 It further suggests improved recognition of shoulder impaction in the final stages of delivery in the clinical setting following simulation-based training.
Ultimately, the patient safety goal of shoulder dystocia simulation training for should be the reduction in shoulder dystocia-associated brachial plexus injuries. We would be interested to learn if there was a higher correlation between brachial plexus injuries and shoulder dystocia after training than before.
Compared to other force training studies, Kim et al did not find a similar decrease in brachial plexus injuries.6-8 We offer a hypothesis as to why that might be.
We believe that demonstrating what 100 N feels during simulation, even with admonishing the trainee not to use that much traction, is not effective at reducing injury. One reason is that memory of that much traction once experienced is short-lived, and clinicians tend to underestimate the traction they apply during a difficu...
We congratulate Kim et al on developing a shoulder dystocia training program that included video instruction, a didactic portion and a simulation training session including force measurement, followed by a study aimed at evaluating the impact of the training on actual clinical outcomes.1 Their observed two-fold increase in shoulder dystocia incidence is consistent with some other studies,2, 3 and more in line with prospective clinical studies that report an incidence of ~ 4% among term vaginal deliveries.4, 5 It further suggests improved recognition of shoulder impaction in the final stages of delivery in the clinical setting following simulation-based training.
Ultimately, the patient safety goal of shoulder dystocia simulation training for should be the reduction in shoulder dystocia-associated brachial plexus injuries. We would be interested to learn if there was a higher correlation between brachial plexus injuries and shoulder dystocia after training than before.
Compared to other force training studies, Kim et al did not find a similar decrease in brachial plexus injuries.6-8 We offer a hypothesis as to why that might be.
We believe that demonstrating what 100 N feels during simulation, even with admonishing the trainee not to use that much traction, is not effective at reducing injury. One reason is that memory of that much traction once experienced is short-lived, and clinicians tend to underestimate the traction they apply during a difficult delivery.9 In force training studies that demonstrate a clinical impact on shoulder dystocia-associated brachial plexus injury, providers were allowed to proceed with the delivery and were critiqued afterward. Often they went far beyond 100 N of traction. Gurewitsch Allen et al allowed trainees to prospectively estimate increasing levels of traction using a fetal head attached to a force measuring system; the trainees became better at estimating their own traction with repeated rehearsals.8
In still other studies where a decrease in brachial plexus injury incidence was observed after introducing a simulation-based intervention, a specific protocol was taught. Inglis et al. reduced their brachial plexus injury incidence by 2/3 after introducing a mandatory protocol (Code D) for all shoulder dystocia deliveries that began with a hands off period, a call for help, identifying fetal shoulder position and a rotation of the shoulders into the oblique pelvic diameter.10 These initial steps were considered mandatory before allowing for clinical judgement to be used concerning which additional shoulder dystocia maneuvers to employ. We previously demonstrated that rotation of fetal shoulders is mechanically advantageous over McRoberts;11 this is likely why Inglis et al were successful. Grobman, et al. was able to reduce brachial plexus incidence by a more than 80% introducing a team-based shoulder dystocia protocol, utilizing low-fidelity simulation (i.e., without force-training) and requiring prospective tracking of time elapsed during the head-to-body delivery interval.12
A systematic review of simulation-based training for shoulder dystocia identifies strengths and gaps in curricular content of differing training programs.13 We believe variation in clinical outcomes associated shoulder dystocia training programs is likely reflective of the differences in the curricular elements of each simulation program. The key is finding the simulation program that is most cost-effective and provides the best clinical outcome.
We again congratulate the important gains achieved by Kim et al in creating a training system that raises awareness of shoulder dystocia and recognition of the complication. Their lack of favorable impact on brachial plexus injuries should not discourage their continuing efforts.
References
1. Kim T, Vogel RI, Das K. Simulation in shoulder dystocia: does it change outcomes?. BMJ Simulation and Technology Enhanced Learning. 2018 Mar 29:bmjstel-2017.
2. van de Ven J, van Deursen FJ, van Runnard Heimel PJ, Mol BW, Oei SG. Effectiveness of team training in managing shoulder dystocia: a retrospective study. The Journal of Maternal-Fetal & Neonatal Medicine. 2016 Oct 1;29(19):3167-71.
3. Nguyen T, Fox NS, Friedman Jr F, Sandler R, Rebarber A. The sequential effect of computerized delivery charting and simulation training on shoulder dystocia documentation. The Journal of Maternal-Fetal & Neonatal Medicine. 2011 Nov 1;24(11):1357-61
4. Spong CY, Beall M, Rodrigues D, Ross MG. An objective definition of shoulder dystocia: Prolonged head-to-body delivery intervals and/or the use of ancillary obstetric maneuvers. Obstet Gynecol. 1995 September 01;86(3):433-6
5. Beall MH, Spong C, McKay J, Ross MG. Objective definition of shoulder dystocia: A prospective evaluation. Obstet Gynecol. 1998 October 01;179(4):934-7.
6. Draycott TJ, Crofts JF, Ash JP, Wilson LV, Yard E, Sibanda T, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol. 2008;112(1):14-20.
7. Crofts JF, Lenguerrand E, Bentham GL, Tawfik S, Claireaux HA, Odd D, et al. Prevention of brachial plexus injury-12 years of shoulder dystocia training: An interrupted time-series study. Brit J Obstet Gynaec. 2015;123(1):111-8.
8. Gurewitsch Allen ED, Brown Will SE. Improving shoulder dystocia management and outcomes with a targeted quality assurance program. Am J Perinatol. 2017;34:1088-96.
9. Creasy RK, Resnik R, Iams JD. Maternal-fetal medicine: Principles and practice. In: 5th ed. Philadelphia: W.B. Saunders Company; 2004. p.671,677, 678.
10 Gurewitsch ED, Kim EJ, Yang JH, Outland KE, McDonald MK, Allen RH. Comparing McRoberts' and Rubin's maneuvers for initial management of shoulder dystocia: an objective evaluation. Am J Obstet Gynecol. 2005 Jan 1;192(1):153-60.
11. Inglis SR, Feier N, Chetiyaar JB, Naylor MH, Sumersille M, Cervellione KL, Predanic M. Effects of shoulder dystocia training on the incidence of brachial plexus injury. American journal of obstetrics and gynecology. 2011 Apr 1;204(4):322-e1.
12. Grobman WA, Miller D, Burke C, Hornbogen A, Tam K, Costello R. Outcomes associated with introduction of a shoulder dystocia protocol. Obstet Gynecol. 2011;205(6):513-7.
13. Gurewitsch Allen ED. Simulation of Shoulder Dystocia for Skill Acquisition and Competency Assessment: A Systematic Review and Gap Analysis. Simulat Healthc. 2018 Aug 1;13(4):268-83.
We read the Park et al. Manifesto for healthcare simulation practice1 with great interest and present this commentary to prompt continued discussion.
The effects of the pandemic are widespread throughout healthcare and health professions education. In the Manifesto, the authors implore simulationists to “adopt a commitment to comprehensive safety, to advocate collaboratively and to lead ethically.” They emphasize working remotely and fear that some simulationists’ “calls for safety are overlooked or even disregarded by their own institutions.” We emphatically agree that healthcare simulationists should inform clinical and educational leaders about safety, collaborative advocacy, and ethics during the current pandemic and in its aftermath.
The article suggests that standardized patients (SPs) may not have an empowered voice to speak up if they feel unsafe in the learning environment and that SPs should have the same psychological safety as learners and patients. We agree with the authors that psychological safety for all simulationists, learners, and clinicians is imperative to the health and wellbeing of learners and patients.
The Quadruple Aim of healthcare suggests a thriving, well-trained, and fulfilled workforce provides better care for patients.2 In this unusual time, there is an essential tension among the competing priorities of professional safety, service, duty, and satisfaction. We simulationists have spent decades demonstrating how rigo...
Show MoreWe were interested to read about your use of a Web-OSCE to enhance clinical skills training via Zoom for third year medical students in Qatar. In the UK, medical schools have also been forced to change teaching and assessment practices due to Covid-19 and at University of Buckingham we have held a summative OSCE online for three final year medical students.
Show MoreThe main cohort of final year students was able to take a shortened, amended OSCE in March 2020 before lockdown with the transfer to a non-clinical site and the use of simulated patients instead of real patients. However three students needed to take the resit OSCE at the end of May and due to the social distancing and the fact students had in some cases returned to their home countries and could not fly back to the UK, we decided to convert this to a remote OSCE (rOSCE).
We used Microsoft Teams as the online platform due to its versatility and availability; it is free to download and works on most computer hardware. Each student was assigned a ‘channel’ on the Team and allocated an invigilator. Unlike the experience in Qatar, the students remained in the channel and the assessors and simulated patients circulated and we were able to run eight 15-minute stations in this way. As in Qatar and other settings (1) it was not possible to test practical procedures or clinical skills however these had been assessed at other points in the course. We were able to assess high level skills in these final year students...
We read with interest the article by Ahmed O et al1 regarding simulation training during the coronavirus pandemic. We would like to congratulate the authors for the same. The time since simulation training has been introduced for learning anaesthesia skills, it has increased the success rates when the procedures are performed on patients after practicing on simulators. We would like to stress on the point that although simulation training improves the success rate for all procedures, but special recommendations which have been specially added for anaesthesia management during the present pandemic needs extra attention like donning doffing of the PPE kit and clamping to unclamping of the ETT (points 17-20)
Show MoreIt is a well known fact that clamping of the ETT increases airway resistance and changes the dynamic compliance of the lung.2 If the total process of clamping till unclamping is prolonged, it can lead to adverse effect on the lung dynamics, in an already compromised COVID 19 patient, showing ARDS type features. If the total time of clamping is increased the cuff needs to be deflated prevent the increase in airway resistance, thereby increasing the chances of secretion drooling and hampering the whole purpose of clamping. It is essentially important to complete the whole procedure within a short time span. In present COVID situation the results may not be as anticipated as number of assistants will be limited, and anxiety of operator will be high. Simulation will be...
We read with interest the report by Ahmed et al1. "Anaesthesia simulation training during coronavirus pandemic: an experience to share". The authors developed A metric-based checklist steps of induction of GA, tracheal intubation, intraoperative management, tracheal extubation and patient recovery in the context of treating patient with covid-19. A supplemental video was used as learning method for the involved health workers. Although the investigators initiate that their clinicians improved their performance during simulation training, they could not consistently addressing all concerns. 1) it is not clear at what flow rate O2/min that preoxygenation should be delivered. Defining such flow is crucial to minimize viral transmission2. 2) the preparation/management between two cases of COVID19, ( e.g soda-lime canister changes; the necessary time pause between cases…),was not notified in their training sessions. Adding such guidance to the checklist would ensure more supplementary protective measures.
Show MoreOn the other hand, the video showed nicely all training steps, including the using of the glidescope as videolarungoscope (GVL) tool for endotrachel intubation. It is well known that due to the curvature of the GVL blade, a stylet must be used to position the endotrachel tube (ETT) tip at the glottic opening especially in suspected difficult airway3,4. The using of stylet facilitate a quick-pass first-attempt tracheal instrumentation5 .However, in the record...
We read with interest the article, Preparing and responding to 2019 novel coronavirus with simulation and technology-enhanced learning for healthcare professionals: challenges and opportunities in China (1) echoing the old adage ‘necessity is the mother of invention’ in relation to remote-site clinical education. Disruption to all levels of education have sparked initiatives as described by Li et al and have exposed the stark lack of a global coordinated mitigation plan. Lessons learned during the current crisis will re-shape our view of traditional clinical teaching theory and delivery. Distance learning is likely to become the norm in the post Covid-19 era and innovative simulation tools are set to enhance these platforms (2).
Our experiences in ophthalmology reinforce the notion that pedagogy follows technology in producing robust, validated and clinically relevant higher level education in the surgical specialties (3). We foresee a growing global imperative to ensure continued development of cost-effective, accessible, high quality alternatives to on-campus face to face clinical learning to supplement, and in some cases supplant current programmes. These are likely to include asynchronous discussion boards, reflective e-portfolios, remote site assessments and developing home microsurgical simulators (personal communication, Brennan P). Covid-19 has revealed, on a global scale, both our human frailties and resilience.
Notwithstanding the tragic human tol...
Show MoreWe congratulate Kim et al on developing a shoulder dystocia training program that included video instruction, a didactic portion and a simulation training session including force measurement, followed by a study aimed at evaluating the impact of the training on actual clinical outcomes.1 Their observed two-fold increase in shoulder dystocia incidence is consistent with some other studies,2, 3 and more in line with prospective clinical studies that report an incidence of ~ 4% among term vaginal deliveries.4, 5 It further suggests improved recognition of shoulder impaction in the final stages of delivery in the clinical setting following simulation-based training.
Ultimately, the patient safety goal of shoulder dystocia simulation training for should be the reduction in shoulder dystocia-associated brachial plexus injuries. We would be interested to learn if there was a higher correlation between brachial plexus injuries and shoulder dystocia after training than before.
Compared to other force training studies, Kim et al did not find a similar decrease in brachial plexus injuries.6-8 We offer a hypothesis as to why that might be.
We believe that demonstrating what 100 N feels during simulation, even with admonishing the trainee not to use that much traction, is not effective at reducing injury. One reason is that memory of that much traction once experienced is short-lived, and clinicians tend to underestimate the traction they apply during a difficu...
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