Simulation training for dental foundation in oral and maxillofacial surgery a new benchmark

Transcription

1 Simulation training for dental foundation in oral and maxillofacial surgery a new benchmark A. S. Kalsi,* 1 H. Higham, 2 M. McKnight 3 and D. K. Dhariwal 4 IN BRIEF Explains simulation training for critically ill patients. Discusses the uses of simulation training in foundation dentistry. Suggests novel approaches to training maxillofacial surgery trainees. EDUCATION Simulation training involves reproducing the management of real patients in a risk-free environment. This study aims to assess the use of simulation training in the management of acutely ill patients for those in second year oral and maxillofacial surgery dental foundation training (DF2s). DF2s attended four full day courses on the recognition and treatment of acutely ill patients. These incorporated an acute life-threatening events: recognition and treatment (ALERT ) course, simulations of medical emergencies and case-based discussions on management of surgical inpatients. Pre- and post-course questionnaires were completed by all candidates. A maximum of 11 DF2s attended the course. The questionnaires comprised 1 10 rating scales and Likert scores. All trainees strongly agreed that they would recommend this course to colleagues and all agreed or strongly agreed that it met their learning requirements. All DF2s perceived an improvement in personal limitations, recognition of critical illness, communication, assessing acutely ill patients and initiating treatment. All participants felt their basic resuscitation skills had improved and that they had learned new skills to improve delivery of safety-critical messages. These techniques could be implemented nationwide to address the more complex educational needs for DF2s in secondary care. A new benchmark for simulation training for DF2 has been established. INTRODUCTION Simulation training (ST) involves reproducing the management of real patients in a risk-free environment. A number of teaching methods have evolved in medicine and dentistry including the examples of role plays, objective structured clinical examinations (OSCE) and other work-based assessments (WBA). There have been rapid advancements in the field of technology enhanced learning to support medical education in recent years. ST has been an established part of undergraduate dental teaching to develop clinical dental skills for many years through the use of a phantom head. More recently in medicine, 1 Career Development Trainee in Restorative Dentistry, Department of Restorative Dentistry, Eastman Dental Hospital, 256 Grays Inn Road, London WC1X 8LD; 2 Consultant Anaesthetist, Department of Anaesthetics, 3 Consultant Orthodontist, Orthodontics Department, 4 Consultant in Oral and Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU. *Correspondence to: Amardip Kalsi askbms@hotmail.co.uk Refereed Paper Accepted 16 July 2013 DOI: /sj.bdj British Dental Journal 2013; 215: Table 1 Committee of Postgraduate Dental Deans and Directors and the British Association of Oral and Maxillofacial Surgeons Joint Position Statement Summary Relevant to DF2 ST Ideally DF2s should not be on call throughout the night, however, without an alternative provision of out of hours care the removal of DF2s from overnight duties will have a negative impact on patient care Training should include involvement with the management of patients with complex co-morbidities Training should include exposure to emergency care, including appropriately supervised on-call Training should include exposure to patients on the surgical ward and in the emergency department Training should be progressive and include experiential learning in an environment that permits the development of patient management and surgical skills Training within OMFS departments aims to build the confidence of new dental graduates ST has included the use of computer controlled hi-fidelity models. 1 These simulate with remarkable accuracy the physiology of acutely ill patients to create crisis situations on-demand to facilitate the development of technical and non-technical management skills. 2 Acutely ill patients are those whose health suddenly deteriorates and these situations can be life threatening. These simulators have mock upper airways, show chest movement, variable cardiac and chest sounds, and a palpable pulse. They can be ventilated, intubated, cannulated, given fluids and medications, and defibrillated. The Committee of Postgraduate Dental Deans and Directors and the British Association of Oral and Maxillofacial Surgeons in 2011 published a statement on DF2 training which is summarised in Table 1. 3 These statements echo the foundation doctor curriculum. This highlights the value of providing emergency and inpatient care and managing patients with complex comorbidities. DF2 roles in oral and maxillofacial surgery (OMFS) departments often involve care of surgical inpatients with significant co-morbidities. These are roles that the DF2 feels unprepared for and so we sought to meet this training need by devising a new course incorporating medical simulation. To BRITISH DENTAL JOURNAL VOLUME 215 NO. 11 DEC

2 provide a high level of care and develop as a professional, experiential learning in an environment safe to patients is ideal. This is a dilemma common to all medical training as clinicians require experience to provide the best care; however, patients should be able to expect to be managed by competent staff. This issue has been tackled by ST across the world in over 150 simulation centres, including training medical undergraduates in urology, paediatrics, orthopaedics and anaesthesia. 4 8 To our knowledge this is the first time ST for acutely ill patients has been implemented in foundation training for dentists. We present an evaluation of its use. METHODS Subjects Groups of between 9 to 11 DF2s attended the ST. The DF2s were aged 24 26, two males and nine females. Each DF2 had previously attended a preparatory dentist on the ward course. Two had previously worked for one year in different hospitals and specialties while the rest had worked for one to two years in general dental practice before working as DF2s in OMFS. The DF2 roles included on-call shifts during working hours, overnight and weekends covering trauma, oncology and deformity inpatients and the emergency department. However, two of the DF2s were based in the salaried service in a primary care setting. In setting the learning objectives of this study, detailed mapping and alignment of the DF2 curriculum was undertaken. Intervention DF2s attended four full-day courses on the recognition and treatment of acutely ill patients. One day involved acute life-threatening events: recognition and treatment (ALERT ) training. This involved interactive seminars built around practical patient-based scenarios along with a comprehensive reference manual. The course utilised a structured and prioritised system of patient assessment and management to enable a pre-emptive approach to critical illness. The ALERT and Oxford Simulation, Teaching and Research Centre (OxSTaR) programmes have been specifically redesigned for DF2 and are separate to the existing medical Foundation Year two (FY2) programmes. Three other full-day courses took place at the OxSTaR centre in the Nuffield Department of Anaesthetics based at the John Radcliffe Hospital, Oxford. Groups were split into two and each day involved a half-day of ST and a half-day of casebased learning (CBL) with the groups swapping over halfway through the day. ST involved pairs of DF2s managing a hi-fidelity simulation of an acutely ill inpatient in the simulation centre (Fig. 1). Monitors displayed representations of blood pressure, ECG, oxygen saturation and expired carbon dioxide where appropriate. OxSTaR faculty controlled the mannequins physiological signs (Fig. 2) and a member was always in the simulation room acting as a ward nurse. The scenarios were carefully designed to align with the learning objectives (Appendix 1) and lasted seven to 10 minutes. Table 2 summarises the ST scenarios. Consent was obtained at the beginning of the course to film DF2s actions and these were streamed into the seminar room for use in the debriefing after every scenario (Fig. 3). All faculty involved in providing feedback in OxSTaR have been carefully trained to do so using the video as supporting evidence. The focus is very much on adhering to specific, measurable, attainable, realistic and timedependent (SMART) goals and delivering useful feedback in a supportive manner. Only one member of faculty gave the feedback. DF2s were encouraged to reflect on their performance. CBL was designed to avoid didactic teaching practice and involved presentation and open discussion of a number of clinical scenarios (Table 3) by a consultant in OMFS. Each topic covered the initial presentation of a clinical problem and moved on to management and complications. DF2s were encouraged to make management decisions as the case unfolded. This allowed for discussion among the group enhancing learning in a group working environment. Data collection DF2s completed questionnaires before and after the training (Fig. 4). These consisted of Likert and 1 10 rating scales. Five key areas were assessed including personal limitations, recognition of the acutely ill patient, safety-critical communication, initiating treatment in Fig. 1 The OxSTaR Simulation Centre showing the hi-fidelity clinical mannequin, medical equipment and one-way mirror Fig. 2 OxSTaR faculty member controlling the mannequin s physiological signs from behind a one-way mirror. The member also spoke as the patient to DF2s via a microphone Table 2 Simulation training scenarios Opioid overdose Acute coronary syndrome Acute severe asthma Pulmonary embolism Anaphylaxis Left ventricular failure Pre-eclampsia Fig. 3 Debriefing taking place in the seminar room with audiovisual cues acutely ill patients and airway, breathing and circulation (ABCs). The third and fourth days of the course utilised a final questionnaire to record feedback more relevant to the ST and CBL rather than assessing DF2s confidence (Fig. 5). The second questionnaire also allowed free 572 BRITISH DENTAL JOURNAL VOLUME 215 NO. 11 DEC

3 Table 3 Case-based learning scenarios Head and neck oncology including initial history, diagnosis, work up for surgery and inpatient management of the treatment of a patient with oral cancer The management of a patient taking warfarin, who presents with a persistently bleeding socket following dental extraction The clinical assessment and work up for a patient requiring bimaxillary orthognathic surgery, the potential complications of osteotomy and management in the postoperative period Salivary gland surgery including postoperative management and complications The management of an OMFS patient on intensive care The early management of a patient who has suffered major trauma with facial injuries including multidisciplinary team working The recognition of severe odontogenic infection involving deep space neck infections, immediate management and monitoring The recognition and urgent treatment of retrobulbar haemorrhage Recognition and management of patients with head injury and facial trauma Fig. 5 OxSTaR Simulation Centre feedback form text comments. The questionnaires were collected and the data analysed. RESULTS The feedback for the course was all positive. All the DF2s strongly agreed that they would recommend this course to colleagues and all agreed or strongly agreed that it met their learning requirements. The DF2s showed an improvement in confidence of five key areas measured by 1 10 rating scales (Fig. 6). All DF2s recorded an improvement in all key areas except one whose scored stayed the same in personal limitations. Free text comments were also all positive (Table 4). Fig. 4 Simulation training feedback form DISCUSSION The results of this study replicate those found in other disciplines. The learning points taken from ST and CBL are directly relevant to DF2s. Medical errors have been shown to be common and often preventable. 9 There is growing evidence from high risk organisations and healthcare that training in a real time environment away from the patient can have an impact on safety. ST presents an opportunity to experience and be prepared for rare clinical emergencies without a risk to patients and allows a systematic exposure to a range of critical situations compared with traditional ad hoc exposure. ST allows DF2s the opportunities to see one, simulate many, do one competently, and BRITISH DENTAL JOURNAL VOLUME 215 NO. 11 DEC

4 teach everyone. 10 Why should this kind of training be mandated for foundation doctors and not DF2s when their roles are comparable? Deficiencies in non-technical skills such as communication, teamwork and awareness have been shown to cause errors; 2,11 ST helps to address the development of these skills, and hopefully to decrease the number of these errors. Certainly our results show an improvement in a surrogate marker, that of DF2s confidence (Fig. 6). ST has the benefit of assessing trainees attitudes and approaches to patient care and team working and has potential to help develop their culture and ethics. The DF2s worked in teams in the scenarios and reviewed each other s work as a group. Mistakes made during the scenarios were visible to all present and the whole group were involved in feedback this encouraged a supportive but questioning environment. This has the potential to improve clinical incident reporting and may be one step on the way to the development of a just culture where incident reporting will lead to learning from errors. ST fits in well with the four clinical domains of the DF2 curriculum (Fig. 7). Within the clinical domain, medical and dental emergency competencies are raised to a standard not experienced by postgraduate DF2 previously. Good communication with the clinical team, peers and other professionals within the communication domain lends itself well to simulation training in a non-threatening environment. ST allows easier development of a professional approach and can help trainees recognise areas of weakness via self-assessment, reflection and feedback. Figure 8 shows a summary of the flow of experiential learning relevant to ST. It involves education, medical assessment, research, communication, ethics, multiprofessional team working, media, education and risk management. 12 The analysis of patient safety incidents and developments of strategies is seen in the final domain of management and leadership. ST can be used to allow human errors to occur and their effect seen without patient harm. It facilitates DF2 reflection, encourages understanding and aids prevention of the same mistakes in clinical practice. Mean improvement out of 10 Fig. 6 Average improvement in five key areas Table 4 Free text comments Very constructive criticism given throughout It is easier than ever to implement ST due to improvements in technology and a gradual decrease in costs. ST could help reduce the time taken to train DF2s to manage an acutely unwell patient safely. ST can be useful to assess a clinician s understanding of best practice, management of patients, use of instruments and materials and overall competence. 13 It is already being used in examination and is being offered as a tool to assess surgical competence. ST allows trainees to manage clinical patients with the context of having gained experience of critical situations. 14 Trainee autonomy has been shown to develop better students with a more humanistic approach to Key areas Should have more of these sessions throughout the year Really useful, very friendly staff This course was excellent and something that should be done earlier and more often Perfect sort of training - would love some more of it Excellent day again Very useful session; v good speakers- whole day The case studies we went over were very helpful and the session interactive and fun Very useful - might be better earlier in the year Excellent day - very enjoyable and learned loads Please could we have more? More teaching of different maxillofacial scenarios please CLINICAL PROFESSIONALISM COMMUNICATION LEADERSHIP & MANAGEMENT Fig. 7 Domains for DF training competencies (COPDEND) patient care. 15 ST allows DF2s to practice clinical skills at their own pace to achieve competence. ST does have some limitations, one of which is cost, however, this should be weighed against the benefits of learning in a real time environment to enhance clinical competence, patient safety and help reduce errors. 574 BRITISH DENTAL JOURNAL VOLUME 215 NO. 11 DEC

5 Concrete experience (an event) and evidence obtained, the combination of simulation training and case-base learning offers a new benchmark in dental foundation training in secondary care. Active experimentation (what is done differently) Planning for implementation (what will be done differently) Fig. 8 Flow chart of experiential learning Methods to improve these teaching methods include simulation of the OMFS specific scenarios with models or mannequins so that rather than a casebased learning model, we could introduce an OxSTaR type model with which the trainee can interact and make decisions on management. Other potential areas include the use of DVDs and e learning materials that would enhance the learning skills, for example taking trainees through the decision making tree in relation to the OMFS specific areas. The results of this study are qualitative and express views of individual perceptions of the value of the training. It is difficult to prove that this one-year course has made any tangible difference to patient safety. However, ongoing research will need to show clear evidence that fewer errors are Abstract conceptualisation (what was learned, future implications) being made to prove the value of this training for DF2. CONCLUSIONS Reflective observation (what happened) Our data show that all candidates felt that their basic resuscitation skills had improved and that they had learned new skills to improve delivery of safety-critical messages. A second cohort of DF2s is now in post and will be undertaking this training. Further recommendations will be made in a future paper. In conclusion, we describe a new approach to training using the latest medical education techniques for DF2s, which has not been previously reported in this group. The authors believe it could be implemented nationwide to address the more complex educational needs for DF2s in secondary care. With the feedback The authors would like to thank the OxSTaR and anaesthetic teams for providing their time and expertise into initiating this training. They would also like to thank OMFS Consultants at Oxford. Thanks are also noted for the financial support from the Oxford Deanery. There are no conflicts of interest. 1. Issenberg S B, McGaghie W C, Petrusa E R, Lee Gordon D, Scalese R J. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005; 27: Murphy J G, Cremonini F, Kane G C, Dunn W. Is simulation based medicine training the future of clinical medicine? Eur Rev Med Pharmacol Sci 2007; 11: British Association of Oral and Maxillofacial Surgeons, Committee of Postgraduate Dental Deans and Directors. Joint position statement British Association of Oral and Maxillofacial Surgeons (BAOMS) and the Committee of Postgraduate Dental Deans and Directors (COPDEND) on hospital dental foundation training in OMFS units Weller J M. Simulation in undergraduate medical education: bridging the gap between theory and practice. Med Educ 2004; 38: Le C Q, Lightner D J, VanderLei L, Segura J W, Gettman M T. The current role of medical simulation in american urological residency training programmes: an assessment by programme directors. J Urol 2007; 177: Overly F L, Sudikoff S N, Shapiro M J. High-fidelity medical simulation as an assessment tool for paediatric residents airway management skills. Pediatr Emerg Care 2007; 23: Blyth P, Anderson I A, Stott N S. Virtual reality simulators in orthopedic surgery: what do the surgeons think? J Surg Res 2006; 131: ; discussion Morgan P J, Cleave-Hogg D. A worldwide survey of the use of simulation in anaesthesia. Can J Anaesth 2002; 49: Berwick D M, Leape L L. Reducing errors in medicine. BMJ 1999; 319: Vozenilek J, Huff J S, Reznek M, Gordon J A. See one, do one, teach one: advanced technology in medical education. Acad Emerg Med 2004; 11: Risser D. T, Rice M M, Salisbury M L, Simon R, Jay G D, Berns S D. The potential for improved teamwork to reduce medical errors in the emergency department. The MedTeams Research Consortium. Ann Emerg Med 1999; 34: Ziv A, Ben-David S, Ziv M. Simulation based medical education: an opportunity to learn from errors. Med Teach 2005; 27: Kunkler K. The role of medical simulation: an overview. Int J Med Robot 2006; 2: Ziv A, Wolpe P R, Small S D, Glick S. Simulationbased medical education: an ethical imperative. Acad Med 2003; 78: Williams G C, Deci E L. The importance of supporting autonomy in medical education. Ann Intern Med 1998; 129: BRITISH DENTAL JOURNAL VOLUME 215 NO. 11 DEC

6 APPENDIX Guideline for Faculty: Scenario 2 ACS DF2s Scenario summary and main learning outcomes: Improve confidence in use of ABC assessment Develop communication skills in emergency setting Institute appropriate medical management of an acute myocardial infarction Practice advanced life support management for VF. Mrs Dorothy Walker is a 63-year-old lady in the specialist surgery inpatient ward. She underwent a four hour resection of a parotid tumour the previous afternoon and complained of chest pain in the recovery ward, which settled with sublingual GTN. She will go on to develop severe chest pain on SSIP and suffer a VF arrest requiring the candidate to provide CPR and DC cardioversion. PMH: IHD and HT Meds: nifedipine, bendroflumethiazide GTN spray PRN Smokes 5/day Clinical situation Sim Man Settings Expected candidate actions Central chest pain radiating to L arm and jaw Feels like angina Very frightened Results: Troponins normal 12 lead from last night SR no evidence ischaemia Hb U+E all normal Stops responding If successfully resuscitated wakes slowly responds to voice Initial A clear B RR 30 BS quiet scattered wheeze C HR 120 SR ischaemic BP 100/55 SaO2 93 on room air (when monitoring applied) Mid-scenario A clear B RR 0 C VF BP 0/0 SaO2 unrecordable End-scenario A clear B RR 10 C HR 95 SR ischaemic BP 80/40 SaO2 96 Introduction Take history while: A apply O2 (non rebreathe) B C cardiac monitoring/bp / oximetry/ insert IV access Should ask for appropriate assistance early MONA Crash call BVM/ CPR ALS protocol Apply O2 via non-rebreathe mask Think of appropriate site for continuing care Clear handover to medical team OMFS DF2 simulation scenarios 2011 Scenario Number: 2 Name: Mrs Dorothy Walker Age: 63 Hospital Number: 441,082 Location: SSIP Student brief: You are about to manage a clinical scenario in a training environment. Please consider this a real life case and manage the clinical case as you would see fit. The following information is made available to you before you go to see the patient. A nurse is with the patient and is there to assist you. Clinical case: History: You are called by a nurse on SSIP to write up TTO s for Mrs Walker who had a parotidectomy yesterday. The nurse tells you that after the surgery she complained of chest pain but she has had a settled night. Exam: Mrs Walker is available to be examined in the cubicle Investigations: Any appropriate investigations can be sent off and results of recent tests will be provided if you request them. Instructions for helper: You are another DF2 doctor working on the ward. You are available to help your colleague when requested. Please wait outside the cubicle. The nurse will come and find you if your help is needed. If your assistance is requested please act as you would in a normal clinical environment. 576 BRITISH DENTAL JOURNAL VOLUME 215 NO. 11 DEC