Chest
Volume 156, Issue 6, December 2019, Pages 1223-1233
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Contemporary Reviews in Critical Care Medicine
Simulation Training in the ICU

https://doi.org/10.1016/j.chest.2019.07.011Get rights and content

Because of an emphasis on patient safety and recognition of the effectiveness of simulation as an educational modality across multiple medical specialties, use of health-care simulation (HCS) for medical education has become more prevalent. In this article, the effectiveness of simulation for areas important to the practice of critical care is reviewed. We examine the evidence base related to domains of procedural mastery, development of communication skills, and interprofessional team performance, with specific examples from the literature in which simulation has been used successfully in these domains in critical care training. We also review the data assessing the value of simulation in other areas highly relevant to critical care practice, including assessment of performance, integration of HCS in decision science, and critical care quality improvement, with attention to the areas of system support and high-risk, low-volume events in contemporary health-care systems. When possible, we report data evaluating effectiveness of HCS in critical care training based on high-level learning outcomes resulting from the training, rather than lower level outcomes such as learner confidence or posttest score immediately after training. Finally, obstacles to the implementation of HCS, such as cost and logistics, are examined and current and future strategies to evaluate best use of simulation in critical care training are discussed.

Section snippets

History of Medical Simulation

Simulators were introduced in the aviation industry in the 1920s so pilots could receive standardized flight training without putting people’s lives at risk.6 The first documented use of HCS did not occur until 1960, when a group of anesthesiologists led by Peter Safar in the United States and Bjørn Lind in Norway collaborated with Norwegian toy manufacturer Åsmund Lærdal to develop Resusci Anne, a full-size manikin simulator of a pulseless dying victim.6 Soon thereafter, Sim One, a

Procedural Training

With the current emphasis on patient safety, the traditional “See one, do one, teach one” approach to procedural training has come under scrutiny. The empirical cognitive science evidence suggests that skill acquisition requires deliberate practice, a planned series of activities of increased complexity with opportunities for repetition that are guided by specific feedback to improve in a particular domain.12 Developing expertise in performing procedures requires three-dimensional understanding

Debriefing to Learn

A discussion of HCS is incomplete without emphasizing the importance of debriefing. Simulation training is based on the constructivist learning theory, which suggests learners gain knowledge and meaning on the basis of their experiences. In high-fidelity simulation scenarios with multiple learners, each participant gains different knowledge, based on their experience. This knowledge acquisition occurs not only during the simulation case but also during debriefing with feedback, which has been

Milestones in Critical Care Training

The current Accreditation Council for Graduate Medical Education (ACGME) accreditation system incorporates entrustable professional activities (EPAs) and milestones to provide meaningful trainee assessment to learners.47 EPAs are tasks that trainees are expected to perform independently on graduation while milestones are competency-based development outcomes that can be demonstrated progressively from beginning of residency or fellowship to graduation.48

Milestones and EPAs exist for all ACGME

Simulation for Health-Care System Support

A highly reliable health-care system requires a culture of safety, and leadership committed to process improvement.59 Effective QI processes for health-care systems include having clinical team members practice together, with simulation serving as an effective way to learn and rehearse so teams can prevent adverse events, or improve after their occurrence. Communication errors during handoffs between teams or at shift change are common and an area of QI focus. Simulation has successfully been

Simulation in Decision Science

Simulation has also been used in decision science to assess biases in provider choices. Serious games, simulations of real-world events, or processes designed for the purpose of solving a problem, have been used to both teach and assess provider decision-making, which can be negatively influenced by cognitive load inherent to caring for critically ill patients. Physicians randomized to different types of active serious games with structured feedback demonstrated reduction of undertriage of

Areas of Uncertainty and Future Directions

We have highlighted many benefits of simulation to ICU training (Table 4). However, the cost of the educational or performance improvements gained from simulation must be acknowledged. High-fidelity simulators are expensive and require maintenance. Dedicated simulation staff must schedule, set up, and run scenarios and aid educators who require assistance throughout the simulation process. Hiring SPs for communication programs or examinations can also be costly. Additional costs may be incurred

Acknowledgments

Financial/nonfinancial disclosures: None declared.

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

Other contributions: The authors thank Kelly Byrne for technical assistance with editing and formatting.

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    FUNDING/SUPPORT: This work was supported in part by the National Institutes of Health Intramural Program.

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