Elsevier

Resuscitation

Volume 80, Issue 8, August 2009, Pages 919-924
Resuscitation

Simulation and education
Excellence in performance and stress reduction during two different full scale simulator training courses: A pilot study,☆☆

https://doi.org/10.1016/j.resuscitation.2009.04.027Get rights and content

Abstract

Background

Simulator training is well established to improve technical and non-technical skills in critical situations. Few data exist about stress experienced during simulator training. This study aims to evaluate performance and stress in intensivists before and after two different simulator-based training approaches.

Methods

Thirty-two intensivists took part in one of six 1-day simulator courses. The courses were randomised to either crew resource management (CRM) training, which contains psychological teaching and simulator scenarios, or classic simulator training (MED). Before and after the course each participant took part in a 10-min test scenario. Before (T1) and after (T2) the scenario, and then again 15 min later (T3), saliva samples were taken, and amylase and cortisol were measured. Non-technical skills were evaluated using the Anaesthetist's Non-Technical Skills (ANTS) assessment tool. Clinical performance of the participants in the test scenarios was rated using a checklist.

Results

Twenty-nine participants completed the course (17—CRM, 12—MED). ANTS scores as well as clinical performances were significantly better in the post-intervention scenario, with no differences between the groups. Both cortisol concentration and amylase activity showed a significant increase during the test scenarios. In the post-intervention scenario, the increase in amylase but not cortisol was significantly smaller. There were no differences between the CRM and MED group.

Conclusions

High fidelity patient simulation produces significant stress. After a 1-day simulator training, stress response measured by salivary alpha-amylase was reduced. Clinical performance and non-technical skills improved after 1 day of simulator training. Neither stress nor performance differed between the groups.

Introduction

High fidelity patient simulation is increasingly used for undergraduate and postgraduate medical education. A simulator placed in a clinical environment facilitates the training of clinical teams in the management of critical situations under realistic conditions. It is assumed that a high psychological fidelity of the simulator setting creates realistic psychological challenges and thus produces similar problems for human performance as in real situations.1 Teams in critical care medicine frequently experience crisis situations, which are highly dynamic and complex. This can cause significant stress in the team members. Although there are different explanations for stress, one model explains stress as divergence between perceived demands and capabilities.2 The factors leading to stress and the reactions of the individual can vary broadly. However, we know from previous research that stress modifies human performance.3 Furthermore, stress also leads to reduced team perspective, which can influence the management of crises in an intensive care medicine setting.4

Several cases have been reported where life threatening complications have been recognised early because the involved physician had experienced the same symptoms in a simulator training prior to the real case.5 However, it is not feasible to present all possible complications to all physicians to ensure the best performance in all situations. Furthermore, we know that poor performance in non-technical skills contribute to 64–83% of critical incidents in medicine.6

The first simulator-based courses focusing on non-technical skills were established in the early 1990s.7 Structured teaching of these skills may improve patient safety, especially in high-risk environments such as critical care medicine. We previously published a simulator-based crew resource management (CRM) curriculum, which addresses situation awareness, teamwork, task management, and decision making.8 In a CRM course no medical content is taught, and during the debriefing of the scenarios there is no discussion about the medical background (diagnosis and treatment of the specific problem). The instructors facilitate discussion about non-technical skills which are needed in the crisis scenarios. We strongly believe that this curriculum improves the participants’ performance in critical situations although the teaching content is “only” psychological in nature.

Furthermore, we hypothesised that simulator training may decrease the stress response in critical situations. Medical simulator training aims to improve medical performance so that participants may handle critical situations more routinely, resulting in a lower stress load. In CRM courses the participants learn how to utilise all available resources effectively. This may, for example, result in better allocation of tasks among team members. Although there is no technical training, CRM training may be more appropriate to reduce stress in crisis situations as compared to medical simulator training.

The primary aim of our study was to compare the effects of a simulator-based CRM curriculum and medical simulator training on stress and performance. We measured salivary cortisol and amylase concentrations as markers for stress and used scores for non-technical skills and medical performance. Our secondary aim was to study whether a high fidelity simulator scenario produces significant changes in salivary amylase and cortisol concentrations.

Section snippets

Methods

This randomised prospective controlled study (ClinicalTrails NCT00704470) was approved by the local institutional ethics board. Out of all physicians working at the five intensive care units at Dresden University Hospital, 32 were randomly chosen and asked to participate in this study. Physicians who denied participation or who had previously taken part in a simulator training were replaced. The participants were assigned to one of two different simulator course concepts by lot. Participants

Results

Twenty-nine participants completed the course, 17 in the CRM group and 12 in the MED group. Three participants had to cancel participation due to an unscheduled on-call shift. In the CRM group, eight participants were male and nine female, whereas the MED group consisted of six male and six female participants. Mean age was 31 ± 4 years (CRM) and 34 ± 6 years (MED), respectively. Our study participants were physicians being trained in internal medicine, general surgery, paediatrics, neurology, and

Discussion

In 1999, the Institute of Medicine published a book summarising epidemiological studies on patient safety. The authors estimate the number of patients who die as a result of medical errors in the United States at up to 98,000 per year.12 Intensive care medicine represents a high-risk working environment where errors may be even more hazardous to our patients. Among others, CRM seminars and simulator training are two approaches to increase patient safety.

This study compares the effects of two

Conclusions

Our data suggest that a 1-day simulator training course improves clinical and non-technical performance of ICU physicians in simulated crisis scenarios. However, we found no significant outcome differences following the two distinct interventional course curricula (CRM and MED). Furthermore, our study shows that a high fidelity simulated scenario produces a significant stress response. Post-course rise of alpha-amylase activity was significantly decreased. Further studies are needed to confirm

Conflict of interest

All authors declare that they have no conflict of interest.

Acknowledgements

We thank Kathrin Zimmermann and Kristin Seele who played the nurses’ roles during the simulator scenarios for their excellent support. Furthermore we are indebted to Ursula Nagy for the development of the adapted German ANTS score.

Funding sources: This study was solely funded by the Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Dresden.

References (21)

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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.04.027.

☆☆

This study has been presented at the 8th Annual International Meeting on Simulation in Healthcare, San Diego, CA, January 13–16, 2008 (3rd prize research abstract award, category patient safety).

1

Both authors contributed equally.

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