Simulation-based education is thought to be more effective than traditional teaching and recent studies have described its benefits on physician performance in several clinical areas. Despite this, not many studies have researched the benefits of simulation training in teaching mechanical ventilation. With that said, this study was composed to assess the approach of mannequin simulation-based training as a method to provide an interactive learning experience for residents and respiratory therapists, which could translate into better ventilator management performance.
Residents and respiratory therapists were randomized into 10 groups of 4 participants and each group was presented with the clinical scenarios of ARDS and COPD using the mannequin-based ventilator simulator. A 20 question multiple choice assessment which highlighted the principles of mechanical ventilation was administered before and after the simulation training.
The data from the combined 40 participants was analyzed using a two-tailed paired t-test. The results demonstrated a significant improvement in scores (p-value 0.019) after mannequin based training supporting the proposed hypothesis.
Mannequin based simulation training on mechanical ventilation can be a vital addition to traditional learning methods as demonstrated in this study. Mannequin based training does provide a more interactive learning experience which could translate into better performance.
Simulation training is more likely to be superior to traditional lecture based format in teaching mechanical ventilation to medical trainees (resident physicians) and respiratory therapists. Simulation can also be used to assess competency on an ongoing basis. Further studies are needed to assess how improvements in the simulation setting translates to the bedside performance and outcome measures.
Simulation-based training has been shown to be a beneficial compared to traditional didactic medical education [1]. Simulation-based education is thought to be more effective than traditional teaching methods, therefore it is proposed that simulation could provide added benefits that traditional teaching methods cannot. Recent studies have described the benefits of simulation-based training on physician performance in several clinical areas, but few have researched the benefits of simulation training in teaching mechanical ventilation to clinicians using lifelike mannequin-based simulation [2].
With this in mind, this study was performed to assess the approach of mannequin simulation-based training as a method to learn mechanical ventilation strategies with the proposed hypothesis of 'introducing mannequin based simulation training would lead to more adequate learning with quicker recognition of the clinical problem when compared to traditional lecture based education' [3,4].
Different clinical scenarios were developed which targeted specific mechanical ventilation problems, such as patients on mechanical ventilation with acute exacerbation of chronic obstructive pulmonary disease (COPD) and adult respiratory distress syndrome (ARDS). A twenty question pretest and post-test assessment related to the simulation training was administered to twenty resident physicians and twenty respiratory therapists, who were further evaluated by key actions and overall problem solving skills of each simulation scenario.
Resident physicians and respiratory therapist participated in a short didactic lecture session on respiratory pathology as it applied to mechanical ventilation which provided a baseline foundational learning base for all participants at which time objectives were discussed prior to the administration of the pretest. No further learning objectives were given prior to the final assessment compared with the beginning to avoid influence by solo studying of the residents and respiratory therapists. Residents and respiratory therapists were randomized into 10 groups of 4 participants who were trained using the mannequin-based simulator. During the simulation, the instructor (Respiratory therapy director) assessed the skills of each participant (via training assessment) and each session was followed by a debriefing session of each group to discuss the correct actions and best approaches to solving each scenario along with the administration of the post-test. All participants were challenged on the same ARDS and COPD exacerbation scenarios (see Appendix 1, which contains all scenarios explained in detail).
20 Resident physicians from the Internal Medicine Residency program and 20 practicing Respiratory therapists.
A signed consent form was obtained from each participant by the non-clinician instructor prior to participating in the mechanical ventilation scenario. The consent form described the purpose of the study, the procedures to be followed, and the risks and benefits of participation. A copy was given to each participant and documented in the participant's record (see Appendix 2, which contains a copy of the consent form).
After the didactic lecture, but before simulation training, a pretest was administered to each group in order to assess whether the groups had equal distributions of knowledge and training. The test consisted of 20 multiple choice questions that covered the principles of mechanical ventilation (see Appendix 3, which contains the complete questionnaire).
The mechanical ventilation simulation allowed residents and respiratory therapists to set up the ventilator in presence of various diseases (ARDS, COPD) and to modify the parameters of respiratory mechanics including resistance, compliance, tidal volume, respiratory rate, and inspiratory and expiratory pause. Any changes in the respiratory variables were displayed on the computer screen and participants were then able to make adjustments to optimally decide on the treatment course. Simulation training was performed using a mannequin and a high fidelity ASL 5000 breathing ventilator simulator connected to a GE ventilator (Siemens-Elena, Solna, Sweden). The ASL 5000 is a digitally controlled, high fidelity breathing simulator able to simulate spontaneously or passively breathing patients from neonate to adult.
Performances in management of the training scenarios were evaluated by one instructor (respiratory therapy director) who presented the scenarios to each group in random order. Fifteen minutes were allotted for completion of each scenario. A 15-minute debriefing session followed completion of both scenarios [5]. The performance of each participant during the training was assessed by a standard scoring/rating tool. The scoring system reflected the number of correct actions performed (diagnosis, initial treatment, and final treatment) for successful patient management. In addition, the scoring scale used assesses the overall performance (both technical and nontechnical skills) by the instructor using a 1-4 scale (1 = Poor: Problem not identified; 2 = Marginal: Problem identified but not solved; 3 = Acceptable: Problem identified and partially solved; and 4 = Good: Problem identified and completely solved) [6].
Demographic scoring characteristics of participants pre-test knowledge are summarized in Table 1. Both groups average scores were within reasonable limits of each other to deem them equivocal. Initial comparison of data showed no significant difference between the two groups (p = 0.49) which indicates that neither group had an advantage prior to beginning the ventilation simulator.
Table 1: Pre-test scoring. View Table 1
The combined results of the 40 participants, as well as the separate groups of 20 Respiratory therapist & 20 internal medicine residents, were analyzed using a two-tailed paired t-test and p < 0.05. The combined data between pre and posttest scoring demonstrated a statistical difference (p = 0.02) which supports our hypothesis that Mannequin based training would lead to improved learning. Table 2 shows the raw data collected showed an average score improvement of 9% after mannequin based training which further supports the hypothesis. Table 3 shows the post-test mean scoring comparison between both groups.
Table 2: Combined raw scoring data. View Table 2
Table 3: Post-test mean scoring comparison between both groups. View Table 3
Our results support the hypothesis that simulation training contributes toward strengthening skills in mechanical ventilation [7]. The Internal Medicine resident participants had much less experience but when placed in real life scenarios with mannequin-based training demonstrated a much improved outcome on scoring. The outcome of our study may imply better understanding of ventilation management in particular events. Continued mannequin based training may also translate to improved resident training and information retention due to the hands on nature of the learning experience.
The Pulmonary Critical care specialist constructed the assessment questions that reflected fundamental knowledge to the decision making necessary to manage ventilators.
This study included residents and respiratory therapists with different levels of experience which likely lead to differing levels of improvement [7]. As demonstrated by the results, respiratory therapist did not see any significant change in scoring likely due to their familiarity with the material and experience with the ventilator. Internal Medicine residents demonstrated rudimentary familiarity with each scenario but greatly improved with training made evident by raw data and posttest analysis.
We chose COPD exacerbation and ARDS complex scenarios which were also tested on in the pre- and post-test assessments. The mannequin connected lung simulator to create a realistic clinical environment which allowed the improvement or decompensation of the mannequin according to the participant's treatment decision.
This study did experience some limitations. First, the sample size was small which negatively affects the data results. In addition, the pre- and post-tests did not perfectly mirror what was being presented in the mannequin-simulated training sessions. There was also some variation pertaining to the teaching of each group as the moderator did not follow a strict guide. The moderator was only following a loose footprint during each teaching course which allowed for a more liberal approach to each training session (i.e. some groups may have been given deeper explanation during each simulation than others.) Other limitations were recognized with the post-test questionnaire; certain questions in the quiz were not reflected during the staged scenarios which may have negatively skewed results.
Our results show that simulation training can be a vital addition to traditional learning methods in teaching mechanical ventilation as demonstrated in this study likely because mannequin-based high fidelity simulation training does provide a more interactive learning experience which could translate into better bedside management of the mechanical ventilator.