All simulation training is not created equal

Simulation Training in EMS

January 15th 2023?

Introduction

Among healthcare disciplines, Emergency Medical Services (EMS) is unique in that the appropriate resources and approach to care may vary widely based on patient location, and paramedics must contend with uncontrolled environments and environmental factors, in addition to patient condition-a factor not typically seen by other healthcare providers.?As well, EMS personnel infrequently encounter certain cohorts of seriously ill and injured patients, and medical skills once learned in the classroom, may be forgotten once working on “the street”. Therefore, a broad skill set is demanded of a paramedic, which requires a more intense onboarding and bespoke education process.?To add to the complexity of the EMS education process, retention and knowledge of medical skills by EMS providers have been correlated with frequency of use.?Skill retention may decrease precipitously within six months after completing a course where the skills learned are not used(1). To counter these challenges, simulation training is an increasingly important strategy in EMS education.?

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The use of simulation training to educate paramedics is a well-established training modality that stems from the armed forces. Regardless of pathway through to registration, EMS personnel spend a substantial portion of their education undergoing simulation-based training. These simulations have a variety of intended outcomes, dependent on the skills or lessons taught.?At a lower cognitive level, simulation is used to develop simple motor skills, and at a higher cognitive level, it is used to challenge the practitioner’s ability to problem-solve and adapt to patient presentation. The term simulation can be interpreted in a variety of ways, but in this context, it is used to describe techniques that imitate prehospital patient situations and are “designed to demonstrate procedures, decision-making, and critical thinking”.?

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Benefits of Simulated-Based Training

The increasing trend in simulation use in EMS can be attributed to its many benefits.?Notably, simulation allows standardization and consistent replication of patient conditions, it can provide a solution for overcoming limitations of clinical opportunities (e.g. low-frequency encounters), and it provides an opportunity for students to develop their skills without subjecting actual patients to risk.?Evidence from several healthcare disciplines has shown that simulation can improve knowledge and skill performance, and continuing paramedic education, using simulated environments, is considered the most effective remedy for skill atrophy. Indeed, EMS has learned much from professions that are successfully using simulation for training, such as aviation, the military and space exploration.?The increasing availability of quality resources is helping to make sophisticated simulation technologies more accessible than in the past.?In support of this approach to EMS training, a recent NAESME vision paper, projects continued increased demands for simulation as the increasing emphasis on education outcomes and broad competency-based assessment grows(2).

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The advantages of simulation-based education can likely be attributed to the reality that traditional clinical learning experiences often rely on chance encounters with rarely occurring clinical conditions, such as pediatrics, geriatrics, abuse, assault, airway management and patients with special needs. Simulation can support better knowledge translation around this low frequency, but highly-impactful, patient interactions.?

Barriers to Implementing Simulation

Finite personnel and financial resources limit the amount of time EMS agencies can dedicate to continuing education and simulation training.?Competition for clinical sites, limited patient encounters, and focus on patient safety have led to new ways of thinking about EMS education, increasingly involving technology and innovative ways to provide a standardized curriculum.?

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The solutions to the barriers of effective simulation-based learning approaches are confounded by the lack of existing knowledge regarding the skills set of instructors, the level of fidelity and frequent funding challenges.?As well, the availability and use of simulation equipment and resources among paramedic education programs varies.?Over the past decade, simulations have become an integral part of medical education at all levels, including EMS training.?Findings from Simulation Use in Paramedic Education Research (SUPER): A Descriptive Study, indicated that most accredited programs (91%) have or have access to, advanced, fully programmable manikins.?Over three-fourths (78%) of respondents called for expanded use of simulation in their programs.?Yet just 71% of programs with access to advanced manikins actually use them(2).?Clearly a disconnect exists between simulation resource acquisition and implementation.

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Faculty Training

Further complicating the matter of simulation use in EMS education is the reality that effective instruction using technology requires that educators have adequate knowledge about content, methods of teaching and learning, when to select a particular method to teach specific content, and the technology being used. In order to attain this knowledge, appropriate faculty training is an essential element to the development of an effective simulation program.?There is little evidence in the literature describing simulation resources, how simulation is used, EMS-educator training, or educator-perceptions about simulations in EMS programs.?Simulation is not necessarily used effectively by all educators and may see inconsistent results in the level of skilled application.

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Psychological Fidelity

Fidelity in EMS training is essential for real-patient encounters. The loftiest goal of simulation is to provide highly realistic experiences in which students can safely apply knowledge and practice skills without endangering a live patient.?Conversely, poorly designed experiences can introduce and reinforce bad habits.?Research shows that it is imperative that simulation in EMS education be conducted in a manner that realistically represents the dynamic EMS environment so that the overall experience of a student taking part in a simulation is one that builds a believable experience in their mind, which they may later call upon, much like an experienced clinician reflecting on past patient care experiences during present moment clinical decision making (2).?

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Inadequate Funding

A significant number of EMS educators report having inadequate budget funding specifically allocated to simulation.?Evidence shows that pre-hospital, high-fidelity equipment is lacking, primarily due to cost.?Although at a higher cost, re-creating “real” scenarios can pay off by transferring knowledge and skills onto students, allowing them to have more preparation for their patients and healthcare roles in the real world.?Educators and administrators must become more adept at making the business case to justify increased funding to support effective use of simulation.

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Simulation in the EMS Classroom

While the evidence and benefits of learning enhancement through simulation provides sufficient justification to support the use of simulation in paramedic education, there is also a growing body of evidence that supports the use of simulation as a substitute for selected clinical experiences.?Evidence increasingly shows that simulation-based healthcare education with deliberate practice leads to improved results compared with traditional clinical education. Several studies have reported that replacing a portion of clinical requirements with simulation is equal to, or in some cases, more effective than an equivalent clinical experience(3).?This evidence is of crucial importance for EMS educators, given the documented challenges of achieving targeted clinical and field skills and assessments among paramedic students and the limited number of opportunities to perform for example, advanced airway management on live patients.?Consequently, it is important that EMS education stakeholders consider if and when it is appropriate to substitute simulation for skills, clinical hours, or field hours in paramedic programs.?

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The Future of Simulation-Based Training

Simulation training in EMS is poised to expand.?The increasing availability of quality resources is helping to make sophisticated simulation technologies more accessible than in the past.??For example, a growing and evolving area of simulation is virtual reality, which is having an increasing application to all fields of healthcare. Sight, sound, and new functions such as haptics (creation of the experience of touch by applying forces, vibrations or motions) provide an immersive world for learners to develop clinical skills. For years, simulation-based training in EMS focused solely on the use of mannequins.?Adding an immersive experience through the use of augmented reality projects life-like holographic patients into physical environments, allows participants and students to view realistic patient simulations for a variety of clinical presentations, improving and strengthening critical thinking, decision-making and assessment skills.

Conclusion

Simulation-based training as a learning modality and performance-improvement tool in EMS has garnered significant attention and research over the past two decades.?The use of increasingly-sophisticated simulation to educate paramedics is a more-frequently used modality to teach psycho-motor skills, acquire new knowledge and gain competence in practice. While more traditional learning mechanisms continue to provide students the foundation knowledge, research shows the benefits of simulation-based training, and its benefits to students and professionals at all levels of the health care delivery system, and particularly within EMS. As well, the sophistication of simulation-based training has significantly increased over the past decades revolutionizing EMS education and competency.?Looking ahead, it is imperative that EMS educators and those looking to the future of EMS, strategize towards a collective vision that incorporates sophisticated, simulated training at all levels of EMS.

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References

1.????????Lammers RL, Byrwa MJ, Fales WD, Hale RA. Simulation-based Assessment of Paramedic Pediatric Resuscitation Skills. Prehospital Emergency Care. 2009;13(3):345-56.

2.????????NAESME. Simulation in EMS Education: Charting the Future 2021 [Available from: https://cdn.ymaws.com/naemse.org/resource/resmgr/naemse_vision_paper_final_11.pdf.

3.????????McKenna KD, Carhart E, Bercher D, Spain A, Todaro J, Freel J. Simulation Use in Paramedic Education Research (SUPER): A Descriptive Study. Prehospital Emergency Care. 2015;19(3):432-40.

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Written by Jennie Helmer, ACP, MEd for MedCognition.