SCCM Resource Library-Pro/Con: Telesimulation in Critical Care: Lessons Learned

Video Transcription

Hello, I would like to thank you for tuning into this virtual presentation and to thank the Society of Critical Care Medicine for inviting me to speak.  My name is Robert Finkelstein and I work at Weill Cornell Medicine, New York Presbyterian Hospital in New York City.  Today I'll be looking at a project that colleagues of mine from Emergency Medicine and Critical  Care and I collaborated on in order to teach ventilator management during the beginning of the COVID-19 pandemic. I have no relevant financial disclosures.  I would like to share an example of how we used telesimulation with both asynchronous and synchronous learning to teach non-ICU physicians to manage ventilators at the start  of the COVID-19 pandemic. We'll also review some of the benefits and challenges of such a project and other opportunities for the use of telesimulation.  This is a graphic I found on the internet to which I added some modifications. I imagine most people would agree that this is an appropriate rating for 2020.  Unfortunately, I know some would feel the same way about 2021 and 2022 I guess it remains to be seen, but we still have some hope.  Of course, 2020 brought us into a situation where help really was wanted and needed, particularly at the beginning of the pandemic when New York City was the epicenter in the United  States. We needed clinicians for ICU patients. We were offering wonderful pandemic hours, and we had to say that ventilator experience was not necessary and that we would train.  And who would do that training? Well, we had a multidisciplinary group of simulation experts, both from pediatrics and  the medical critical care divisions, as well as from general emergency medicine and pediatric emergency medicine.  And this training would be for any interested non-critical care providers. The subject matter, of course, would focus on ventilator management in COVID-19 respiratory  failure with some basic principles of ARDS, as well as cardiopulmonary interactions on positive pressure ventilation.  What we did is record a video that we put on the internet for the asynchronous didactics, and we will be showing you some clips of that as we go on in the presentation.  And that learning was meant to be reinforced by a synchronous simulation, but of course the simulation had to be remote since we had to remain socially distant.  The asynchronous learning was done at home at the provider's convenience, and this was followed by a synchronous simulation, also done from home, but with other providers on  as well. And those telesimulation sessions were about 40 minutes long. In order to make people aware of this opportunity, invitations were sent out via departmental leadership.  We wanted to include all different types of providers. It certainly was encouraged amongst the emergency medicine and pediatric emergency medicine  staff, and medicine shared it with their hospitalists, several of whom were instrumental in helping us work in the ICU.  The following video is made up of an amalgamation of sniplets from the longer, more deliberate teaching video that providers would watch prior to engaging in the telesimulation.  Note that the version I'm showing for this presentation really jumps around and would not be intended for a new learner to follow.  It is merely to give a broad overview to show you which topics were covered, which included basic pathophysiology of ARDS and respiratory failure, basic vent settings in the volume  control mode, and some appendices at the end, the one that included the types of ventilators that we were likely to see, predominantly it was the LTV ventilators, and also some  information on alternative modes of ventilation. This is a pretty classic x-ray. This is what happens in different lung regions in ARDS.  This lung CT scan represents the heterogeneity. This high peep, low tidal volume strategy is considered open lung ventilation.  The goal is to try to stay in this safe window, which is a nice balance between volume and pressure, the optimal point to balance the pulmonary vascular resistance with the lung  volume and get optimal blood flow with optimal gas exchange. We want to keep pressure from getting too high, so a plateau pressure of less than 30  centimeters of water and a peak inspiratory pressure of less than 35. It is measured at the end of an inspiration with an inspiratory hold maneuver.  This is easily done on most ventilators as there is a push button. The first thing that you'll be choosing is the mode.  It's recommended that you begin with assist control, volume control. You can have identical volumes, but different pressures that will reflect how compliant the lungs are.  Assist control usually is a fairly comfortable mode. Increasing your mean airway pressure improves oxygenation.  We spend a longer time in expiration than we do in inspiration, thus if you increase your peep, you will increase the amount of time seeing a higher pressure.  You can also increase your mean airway pressure by increasing your inspiratory time. Since the inspiratory pressures tend to be higher, even though it's shorter, you can  increase that time seeing that higher pressure. This graph represents breast stacking when a new inspiration begins before exhalation is completed.  There are situations where you will try to increase the respiratory rate or the inspiratory time. Expiratory time is shorter and thus increase the risk of air trapping.  To increase oxygenation, we want to increase the mean airway pressure. Something that must be considered is the interaction between the respiratory system  and the cardiovascular system. Ventilation refers to getting rid of carbon dioxide rate times the tidal volume.  That is how much gas are you exchanging with each breath and how many times in a minute is that happening.  The use of PACO2 doesn't necessarily force you to increase your tidal volume or rate in the interest of protecting the lungs. There are several signs of distress.  I'll have the features that we discussed and that are reviewed thus far. The first one we'll look at is the servo ventilators.  Down to the right is the inspiratory hold button, which you would use to check a plateau pressure.  At the bottom of the main screen, you see the four most common want-to-know settings. The LTV ventilators don't have the fancy graphics, but do have all the necessary controls.  You see the plateau pressure. The inspiratory hold button is there at the bottom in the middle. Another ventilator you might be using is the Puritan Bennett.  You will be able to participate in a 30-minute remote simulation. In this case, the tidal volume varies depending on lung compliance and the volume is not guaranteed.  As you may have noticed at the end of that video, there was information on how they could build on what they had learned from the video. One of which, of course,  is the telesimulation that we had, which was based on an actual case in our ICU in the early days of the pandemic. A 23-year-old female who came in with  hypoxemic respiratory failure due to COVID, initial stats were 73 percent on room air, was intubated, and now needs ventilatory management. The simulation started after  the intubation and upon arrival to the ICU. There were three main learning objectives. One was to come up with initial settings. The other was to understand concepts  of lung protective ventilation, and then some common alarms and complications that one might encounter. Additional objectives were to show adequate communication and teamwork with  the added difficulty, if you will, of communicating effectively over a virtual platform. The hardware needed included a main computer with a video conference platform.  We used Zoom, but anyone will do. We had a ventilator. We chose the LTV because due to ventilator shortages, that was most likely the one our participants would be using.  We had a monitor for vital signs hooked up to our high-fidelity mannequin. Despite this mannequin being high-fidelity, we found that the visuals and teaching worked better when we  had test lungs that were propped on the mannequin's chest under a gown. The test lungs were such that if you reach eight mLs per kilogram of tidal volume,  the pressures on the ventilator would be higher than the desired pressures. To display all this different information, we had three webcams, one on the mannequin and on those lungs,  one focusing on the monitor to give them feedback on their changes and decisions, and one on the ventilator so they could see how it worked and indicate to  one of the telesimulationists changes that they wanted made.  In terms of personnel, at least two facilitators are needed. One to be the lead and the person who communicates with the people who are participating in the telesimulation,  and the other one to manage the equipment. It actually probably would be easier if you had three to sort of split those equipment duties, but it can be done with two.  Each group consisted of about four to five participants who consented to being recorded. The next two slides show the script of the simulation and some of the expected actions.  You can see this patient, as we said, had just been intubated. The SATs went from the 70s to 84. We have immediate acceptable actions of choosing the mode of ventilation.  Again, highlighting that we want a lung protective tidal volume, how to manage the FiO2, where to start with the PEEP and the plateau pressures.  Following that, there's transfer to the ICU. There are vital sign changes on the monitor based on their initial settings. Looking at cardiopulmonary interactions,  for instance, the blood pressure will drop if the pressures are very high. Some discussion on PEEP. They're expected to discuss the concepts and use the concepts of  permissive hypercapnia and targeting the correct pressures and some other strategies including prone ventilation if needed. The following video is an edited version of  one of our actual telesimulation sessions. Dr. Joy Howell was the facilitator in that session and debriefer and graciously allowed us to use this clip. I would just ask,  please focus on some of the parallels between the didactic video and the simulation. Also, you will note that the participants do refer back to  the video during the simulation indicating that they did have some background and baseline that they got from the asynchronous portion that helped  them during this synchronous portion. Vegas rules apply. What happens in sim stays in sim. Our patient here is made of plastic and you couldn't hurt him even if you tried.  The more you invest and engage, the richer the learning opportunity will be. You are part of a remote management team establishing  baseline and then making adjustments to the ventilator. The first view will be that of your patient, the patient's monitor or ventilator.  These are the ventilators that are in most abundant availability. For a 23-year-old, for SATs we're in the 70s on room air. Talk amongst yourselves and identify what mode,  what tidal volume, what respiratory rate, what PEEP, what FIO2, what inspiratory time. We can go by 85 kilos, right? We need her ideal body weight.  I'm looking at the chart they sent us. About 65 kilos. Okay. 390 could be the tidal volume. PEEP of 10 and the eye time maybe one. The respiratory rate, what, 12 or so?  I think we could start higher. I think it would, yeah, like 16. And then we need a mode. So we're going to do volume control, right? I'll go to 100 for now.  Yeah, I would start at 100 as well. You guys asked for a rate of 16. Yeah. The button on the left is breast rate. I toggle the dial to 16 and then I press  the button underneath it to accept. So what are you guys interested in knowing? What's the blood pressure? What's the PAO2 for the pH?  And what you would do is you would press this button, it's an inspiratory hold, and then you press and hold it. 720 for the pH, the PCO2 is 70, and the PO2 is 60.  Increase the minimum ventilation, we could do volume or rate, right? Or both. You could do a little bit of both. Go up like 450 on the title volume  and then go a little bit up on the respiratory rate, 18. Sure, yeah, that sounds good to me. Did I hear correctly, 450 for the title volume and 18 for the rate? Correct.  We can also increase the PEEP and decrease the FIO2. Well, that's a good point, yes. Well, can somebody summarize what we ended up doing? It just increased the title volume to 450  and the respiratory rate to 18. Is everyone in consensus with that? Let's start with that. Can we also check another plateau pressure? So our plateau pressure is now 26.  Has a big number 63, that's end title, correct? Yes, you're correct. Go up on the title volume more. How about we increase the respiratory rate  since the plateau pressure is reaching that maximum of 30? Tell me where you want to take the PEEP. You want to take it to 12? I think we can increase it to 15.  The pH, 730, the PCO2 was 58. The CO2 was 70. Our pH is kind of more in the range that we want. Still retaining CO2. We care how much CO2 they're retaining.  I mean, long as their pH is stable, like this doesn't have to be perfect. Degree of hypercapnia is permissive hypercapnia. Permissible hypercapnia, yeah.  Do we want to get a plateau pressure after all of our change? Yeah, we can. Sure. And our peak inspiratory pressure is 39.  And our plateau pressure is 37.  And we want it below 30. Tommy is not getting enough expiratory time, right? The title volume might be a little high and we could try cloning to increase recruitment.  I'm being called to the next room. So I need you guys to let me know what you need me to do. We're going to pause here and transition to our debrief.  You guys engaged some beautiful teamwork. We want to use generous PEEP,  but we want to limit title volumes so that we don't overstretch. There was an initial discussion of basing the title volume on the absolute weight,  but a member of the team appropriately identified we should use ideal body weight. Oxygenation is always going to be a function of mean airway pressure and FIO2.  Ventilation is a by-product of title volume and respiratory rate. Because we spend most of our time in exhalation, increasing the PEEP is the single most efficient way  to increase the mean airway pressure. The next way to increase the mean airway pressure is to increase the inspiratory time. And the higher the inflation  and the longer you spend at that inflated state, the higher the mean airway pressure. Increasing the title volume or increasing the inspiratory pressure  will also increase mean airway pressure, but at the expense of inviting more volume trauma or barotrauma. Tell me what you know about goal peak inspiratory pressures  and goal plateau pressures. The goal for peak inspiratory pressure is less than 35. Correct. And the goal for plateau is less than 30. Correct.  You guys came to a point of the concept of permissive hypercapnia. What is permissive hypercapnia? You allow the patient to have a higher CO2.  As long as the pH is greater than 7.25. Second blood gas with 7.2562, that's a perfectly acceptable pCO2 and a perfectly acceptable pH. Tell me about the goals for oxygenation.  So you want to try to get the FiO2 less than 60%. I think the goal is 88 to 92 and the PaO2 50s to 80s. So those two things are tethered.  If you remember the oxygen hemoglobin dissociation curve, you guys identified that when the pO2 was 60 on a peak with 10 and 100% oxygen,  that the appropriate thing to do was to go up on the peak. When you guys saw that the PIP went to 39 and the plateau went to 34, appropriately you lower your tidal volume.  The two functions of mechanical ventilation are to accomplish oxygenation and ventilation. But of the two, which is the more important?  As part of the teaching during the debriefing, we would show participants the wizard behind the curtain, if you will. Lift up the gown, allow them to see the test lungs  and do things to change lung compliance, such as I'm doing here, just putting a little bit of pressure on the lung so they could see changes in pressures and volume.  This was also useful in teaching the concept of breath stacking, altering the respiratory rate and or inspiratory time to obtain breath stacking  for them to see the effect on the lungs and also to get a look at the flow waveform on the ventilator to know what that would look like.  It was helpful to demonstrate the concept of PEEP. We could actually set the PEEP to zero and see the lungs fully collapse and we could set it to different levels,  including the highest we might use in ARDS, the typical we might use and have them really take a look at what that PEEP was doing and describe the physiology behind it.  Challenges included that early in 2020, as hard as it is to believe now, learners were not as familiar with the different video conferencing platforms  and not as adept with remote learning.  There are fewer nonverbal cues, not being there in person and that definitely diminishes the emotional realism.  It's also hard to assign roles  whereas one might assign someone to the airway and someone to vascular access and someone to be the leader. In this case, they were all focused on the same role,  which was managing the oxygenation and ventilation. It is resource intense. We are certainly lucky in the setting where we were that we had access to the Sim Center,  to the necessary equipment, to the three cameras. And so it may not be possible in different settings, but there are also workarounds.  We found that it was very important to remember to pre-brief and to perhaps extend that a bit beyond the typical simulation pre-brief to allow them time to acclimate  to what was a new type of situation and different camera angles and ways of communicating. We also noticed that the tele-simulation seems to be conducive to concept  and knowledge-based scenarios. It would be like when we were in the lab  and it would be likely more difficult when it came to procedural skills and task performance, although people have done that.  If you would like more information, we were fortunate enough to have a paper published in Simulation and Gaming about this experience and anyone can contact me directly.  Dr. Neil Nayak and I were also able to present this concept  at the first annual Tele-Simulation and Healthcare Conference. It was interesting because we were using tele-learning to demonstrate how to do tele-simulation and learning.  So those sort of one concept on top of the other made for very interesting discussions.  And these are just the obligatory institution pictures at the end of a talk. This is New York Presbyterian Hospital while Cornell Medicine.  You can see the main entrance top to the left and at the bottom right, you can see how we're right there along the East River. Very interesting views from many of the patient rooms  and from the ambulance bay.  Thank you so much for taking the time to listen to this. And again, thank you to the Society of Critical Care Medicine for the invitation to present.  Welcome to the 51st Society of Critical Care Medicine Annual Congress. And I would like to thank the SCCM for this opportunity to present our work at the meeting.  The title of my talk is what was new is even more new again. My name is Pooja Nawate and I'm a Pediatric Cardiac Intensivist by background along with being the Medical Director  of Simulation and Pediatrics at Cedars-Sinai Medical Center, Los Angeles, California. This assigned title really encouraged me to explore the past and present concepts,  frameworks that have existed in critical care, simulation and education methodologies that needed innovation and adaptability during the trying times of the pandemic  and so that we could meet the learner needs.  I do not have any financial disclosures with any of the software that will be merely examples mentioned in this talk. The examples I've mentioned to provide some structure  to the construct of these simulation methodologies.  As we focus on the learning objectives of this concurrent session, I'm going to demonstrate some examples of successful tele-simulation and critical care we have used,  how we identify frameworks for successful faculty and team development and technology support. Lastly, suggest areas for continued growth in the field of critical care simulation.  I will be starting with the last two objectives followed by examples of successful tele-simulations at our institution  and areas for collaboration and growth. The whole fabric of medical education has been ripped apart. This turmoil has also led to widespread innovation,  albeit not as visible to the public and the media. As with telemedicine, the potential of web-based education has been touted for years, but uptake amongst educational institution  has widely varied. Some massive open online courses that have had global impact  are the Maintenance Certification, Khan Academy, and the Human Diagnosis Project.  Many simulation programs have recently shifted towards providing remote simulations with virtual debriefings. Such innovations present an opportunity  for medical educators to leverage technology to develop courseware that incorporates empirically derived insights into how adults learn. A strong sense of community contributes  to effective virtual learning environments. Originally developed for asynchronous, text-based online learning, the COI, or the Community of Inquiries Framework,  has since been studied and applied extensively with literature also supporting its applicability for synchronous online learning. The COI framework describes three core elements,  educator presence, cognitive presence, and social presence required to create successful virtual learning environments. These three elements conceptualize  how online learning spaces are jointly created by the ways educators plan and facilitate their sessions, how learners think and solve problems together, the cognitive presence,  and the ways in which all parties connect socially with an online learning environment. Educator presence relates to how educators design and implement educational activities,  facilitate discourse to build understanding, and provide instructions to clarify misconceptions and consolidate learning. Educators must provide appropriate structure  and deliver content, define topics, and guide discussions, share personal meaning, seek consensus, and summarize key learning points. How learners think together  represents their cognitive presence, defined as the extent to which learners critically reflect and construct meaning through reflective discourse. Indicators of cognitive presence  include learners who identify problems, exchange and connect ideas, brainstorm solutions, and apply new concepts to existing practice. Educators must provide appropriate structure  and apply new concepts to existing practice. Lastly, social and emotional connections represent social presence, which refers to how learners project personal characteristics.  As depicted in the figure, these three elements intersect other domains of psychological safety that, if insufficient, will hinder open communication, emotional expression,  and ultimately learning with negative effects of achieving the objectives. A psychologically safe environment facilitates these social connections  that promote the authentic reflective discourse vital to effective virtual debriefings. In the pre-briefing, take an opportunity to encourage learners  to engage in this social context with technology-induced barriers to build a collaborative environment. What lies in the center of this Venn diagram  is debriefing, the quintessential element to make the telesimulation experience effective. I'm going to suggest some strategies to debriefing technique.  Some of these are really technical etiquette-related, which a lot of us are familiar with as far as virtual meetings happen. A lot of them are applicable to virtual debriefings  and telesimulations, too. Co-facilitating with a second educator, applying existing debriefing techniques, optimizing educator visibility, testing sound quality,  using the gallery grid function during debriefing because, unlike in-person debriefing, virtual debriefings, there is not a selection of seating, et cetera,  which has been described in the debriefing literature that you can choose. Educators must explicitly clarify and advance the rules of engagement for virtual debriefings,  such as turn-taking during the conversation, using technical features such as hand-raising to indicate a desire to speak, ensuring attentiveness,  and minimizing interruptions while others are speaking. Frequent testing with feedback, that is a retrieval practice effect, space learning, interleaving,  which is alternating between learning points that may be unrelated, a focus on threshold concepts, scaffolding, minimization of cognitive overload,  and self-paced learning are all among the potential advantages presented by electronic educational materials and virtual courses.  Indeed, some professional organizations have already responded to the outpouring of innovative ideas emanating by creating repositories that will allow for agile sharing  and disseminating of these educational approaches.  Let us talk about technologies. Zoom, for example, is a company that started in 2011. Microsoft Teams, WebEx, BlueJeans,  all of these are examples of internet communication platforms that have existed over years but are being leveraged now to their fullest potential.  However, this technology-mediated teaching requires new skills and instructional infrastructure. It is time and labor intensive,  requires more than simply recording a lecture and posting slides?  Might medical educators benefit from technology, entertainment and design, or TED Talk experts,  from marketing professionals, or from developing serious games? All these questions remain unanswered in the field of professional development for telesimulation.  So what are the tips for domains specific to telesimulation?  In a needs assessment, we need to consider technology available to the learners, their internet speed limitations, institutional firewalls, audiovisual capabilities, and privacy  policies. In the learning outcomes, if there is no hands-on component, we should develop the  learning outcomes that focus on why actions are performed rather than the technical know-how.  For equipment, consider whether a low-fidelity, less costly setup would serve our needs just as  well as a more expensive version, and then opt for the former if the latter is not needed.  Higher technology does not make the telesimulation experience a better one.  Practice. Practice ahead of time to troubleshoot technical problems. Pre-brief. Spend time at the beginning of the session emphasizing suspension of disbelief,  assign roles to learners, and clarify who will speak when.  How does one facilitate the simulation? Moderating the simulation, operating the equipment, and conducting the debrief is difficult for one instructor to manage alone.  Consider recruiting other staff to fill these roles.  Sometimes not feasible, so then the cognitive load on the single facilitator is a real issue.  Debrief. Very critical to the success of simulation. Encouraging remote participants  to keep their videos on during the debrief to maximize engagement. Make this clear in  Make this clear in the ground rules when the pre-brief is done.  Feedback. Obtain immediate feedback after the simulation on the educational value of the experience and or any technical or logistical issues. Leave the link in the chat box for the  evaluation or display the QR code on the screen.  The next slide is going to demonstrate what a hybrid simulation means.  And what it does. So a hybrid simulation is where there is distance learning or tele-simulation along with either an inside to simulation or a simulation center session  happening at the same time. What do we need for it to be set up? And then I'll show you examples of hybrid simulations we have done at our institutions during the pandemic.  And actually continue to do them now because we don't want to go back to the status quo. So what we need is a mannequin, an in-room monitor, a video capture of the scenario,  as well as video capture of the in-room monitor. And there are softwares available who can do that.  Video streaming with a recording system is applicable if your team uses video assisted debriefing. Video streaming interface running on the educator or facilitator's computer.  Educator or facilitator screen sharing capability with remote learners.  I'm going to share an example of a COVID-19 airway simulation at the beginning of the pandemic  where we had a total of 24 participants. Seven at the bedside including the educators and operations specialists and 17 on the internet communication platform.  The learning objectives were around systems issues, communication with PPE,  number of personnel identified to be in the room for the team to effectively perform.  This is an example of a COVID-19 airway hybrid simulation we did with participants inside the  room. This display was achieved using a video capturing device within the room that was being  streamed on my computer live. I was sharing that live streaming screen with the participants at  home to an internet communication platform. This image depicts the communication happening  outside the room amongst the anesthesiologist, the pharmacist with me as the educator in the background. The top of the screen shows the distance learners. As you see the gallery  grid view tip is most applicable during the debriefing section rather than with the live  streaming. This is another example of an extubation scenario happening in situ with identifying the  equipment needed, understanding the ergonomics to minimize viral particulate dissemination.  The in-room monitor and the in-room scenario are being recorded and streamed live to the distance learners attending. Augmented and virtual reality are the next frontier in  educational program development. Already available for teaching anatomy and surgical procedures,  might this technology be leveraged to replace at least in part what year four trainees learned  on clinical rotations? Is that possible? Is that the future or is that something that we all aspire  to do? Problem specific patient interviewing, disease presentations, and team training are but  a few of the potential applications of augmented and virtual reality educational programs.  To fully capitalize on these, medical educators need to partner with video game developers,  the military, and others who are working at the forefront of augmented and virtual reality.  I will be presenting an example of the virtual reality we used in the development of our vascular access team that was a specialized interprofessional team of anesthesiologists,  interventional cardiologists, pediatric intensivists, and internal medicine procedure  specialists who came together during the pandemic at our institution to provide emergent vascular  access to adult and pediatric COVID-19 patients. This tele-simulation, unlike education for trainees,  was for practicing professionals who had to adapt a procedure they performed frequently  with the learning points of donning and doffing, minimizing time and room to minimize exposure, etc.  We had a multimodal approach to this educational curriculum. Initially, we did tele-simulation  sessions in a similar manner as described in the earlier slides, but streaming of the process to  the team members. Then we recorded virtual reality videos as the team expanded, presented in the  subsequent slides. Lastly, as the team dissolved and the primary fellows performed the procedures, we did in-person proctoring as deemed necessary by the program directors.  This slide shows the 360-degrees view virtual reality videos recorded for the sessions.  We had questions and hot spots with instructions integrated into the virtual reality videos  demonstrating retrieval practice effect with feedback. Our center is one of the 10 special  pathogen centers for disaster preparedness in the country. In collaboration with the CDC and the  National Emerging Special Pathogens Training Center, or NETEC, we have had tele-simulations  as a part of our routine simulation in critical care before the pandemic. We pivoted as the pandemic started, but the common themes identified during the special pathogens training  to subsequently adapt to tele-simulation in the present circumstances. Will faculties and leaders of regulatory and accrediting agencies embrace the innovations  that this crisis necessitates? Will we make them permanent, accepting changes that in some cases,  I would argue, have been long overdue? Or will we simply endure for now and then return to the  pre-COVID-19 status quo? By recognizing that we will grieve the loss of what was, I urge all of  us to continue to unleash the innovative power of our teams and transform our critical care  learning for the good of our students, patients, and community. Thank you so much for your attention and enjoy the rest of the Congress.  Thank you so much for logging in and choosing to listen to this presentation.  My name is Christina Yurinimakis. I'm a bedside critical care nurse and the lead tele-critical  care nurse at Madigan Army Medical Center. And I'm absolutely honored to be presenting to you  today about the interface of tele-critical care and tele-simulation. I have no conflicts of  interest to disclose, and since I work for the U.S. government, the information presented are  my views and not that of my employer. Before the pandemic, it's estimated that 15% of all adult  ICU beds had hardwired tele-critical care support in the United States. The pandemic has changed  our delivery of tele-critical care to novel solutions such as mobile cards and smartphone  applications. Initially, we used this technology to help address staffing shortages, either from  attrition or from patient surges, but the benefits of tele-critical care remains unchanged. Through  the adherence to evidence-based practices and clinical practice guidelines, we have  an increasing improvement in compliance to standards of care with reductions in morbidity and mortality.  The military provides 24-7 tele-critical care support through a collaboration between the Army  and the Navy known as the Joint Tele-Critical Care Network. Through our three hub sites, we offer  both physician and nursing support to 16 military treatment facilities with plans to expand to all  of our adult ICU beds. But unlike our civilian counterparts, we need to be prepared to expand our  focus based on a range of needs from national defense conflicts to the pandemic. The military  has leveraged this technology to provide expert consultation to soldiers with battlefield injuries  and during simulated field training exercises. The Jetson has been tasked with disaster  responses which include COVID relief missions.  The big question is how can we prepare for these potential threats while simultaneously testing our network function and effectiveness?  There are some challenges that we really need to keep in mind, and the first is that during peacetime, preparation is dependent on the ability to perform training exercises,  and two, military who have deployed may have limited exposure to tele-critical care. And the most important point is that each disaster and conflict is unique. So how do we feasibly  offer different iterations of training events to be prepared for the unpredictable?  The answer lies in tele-simulation. Tele-simulation has demonstrated to be a feasible way to maintain medical readiness skills. Tele-simulation can be defined as  the ability to provide education, training, and assessment to learners at an off-site location.  The pandemic has shown us that training normally done in person can be facilitated remotely  because one of the most important parts of simulation occurs at the end with the debriefing, which helps the learner to reinforce the objectives through honest self-reflection  and direct feedback from the instructor. I'm going to break up my talk about tele-simulation into two different categories, procedural and non-procedural skills.  I will start by going over procedural skills to address topics such as broad knowledge assessment,  surgical procedures, and device implementation. An example from over 20 years ago highlights a  transcontinental tele-simulation. In this scenario, the human patient simulator was located at the  distant learner site of a Puerto Rico Naval Hospital, but operated by remote instructors in Ann Arbor, Michigan. The emergency medical personnel in Puerto Rico volunteered to being  what I would describe as a speed-dating tele-simulation. There were five scenarios carried out over five minutes, followed by a five-minute debriefing. The objective was to  assess the perceived preparedness of the following medical emergencies. We had near-drowning,  ventricular fibrillation, blunt trauma with pneumothorax, rapid sequence intubation, and shock.  The participants reported that they felt better prepared to medically manage these emergencies  because of their tele-simulation experience. The goal of damage control resuscitation is to limit the amount of blood loss and prevent coagulopathy through permissive hypotension  and minimal fluid administration, and to give blood product with a ratio of one to one to one,  that is one RBC to one FFP to one platelet. The last component of damage control resuscitation  is damage control surgery, which is to temporize the bleeding until stabilization can be achieved  at a higher level of care. In this example of procedurals field development using tele-simulation,  we have surgically naive first responders performing damage control laparotomies with wound packing due to exsanguinating liver injuries that mimic battlefield injuries.  Volunteers were randomized into two groups. The first was the remote tele-mentored group that wore  a two-way headset and head-mounted camera that communicated and displayed images to an off-site instructor, and the second was the non-tele-mentored group. The simulated surgery  was performed using a high-fidelity cut suit that was modified to measure both volume and velocity  of fluid loss. The results indicate that the remote tele-mentored group reported the use of  tele-simulation and damage control surgeries improved the operator's confidence and enhanced  their learning experience. In our last example, there was a collaboration with the early medics  were able to test the application of a novel wound clamp to stop extremity exsanguination. The innovative technology or IT clamp is a single-use disposable self-locking clamp  that seals the wound using mechanically assisted direct pressure. The volunteers were broken up into two groups. The first group was taught how to use the clamp before the training,  and the second group learned how to use the device during the tele-simulation by being  tele-mentored by instructors in Calgary. Although both groups were able to apply the IT clamp and  stop extremity exsanguination, it's important that I reinforce the point that one group received the  training during the exercise. This is important for the military because new devices and technology  may be released during an act of conflict, and that using video telecommunication, we can train remote end-users for immediate use of the device or technology.  Tele-simulation is a feasible way for performing MassCal training exercises using state-of-the-art technology. The individual pictured on the left is wearing  the Google Glass device and has the application EyeSight to create a virtual reality of MassCal  training events. In a transcontinental study, students in an EMS course from Irvine, California,  and English-speaking healthcare personnel from two universities in Saudi Arabia participated.  The objective was to offer a transcontinental MassCasualty training course and assess the  feasibility and effectiveness of performing this training. This scenario is using virtual reality  technology to immerse learners directly as if they were in person. As they demonstrated in providing  the same experience in person, it could be done by experts over 100 miles away or to a broader  audience to increase the access to this education, thus eliminating geographic barriers to learning  and experiential knowledge. As in-person learning transitioned to remote learning during the  pandemic, we've been able to utilize tele-simulation to develop non-procedural skills. For example,  teamwork. Bandura's social cognitive theory states that teams that train together perform better together, and tele-simulation is a team-building experience or exercise. So whether  you are performing these scenarios as a team off-site or in individual locations, you're still  working and collaborating for the same objective. We're also able to utilize tele-simulation to  develop leadership skills. In our own anecdote at Madigan, we had a very shy active duty soldier with  very strong informal leadership skills, and we used a tele-simulation event to highlight her  formal leadership skills and capabilities. Due to the fact that we're performing medical procedures,  it requires critical thinking as we decide what our next choice of action is going to be and intervention, as well as time-sensitive decision making. Our medical interventions and  patient management and care needs to be performed on a timely manner because failure to respond can  result in the patient or human patient simulator deteriorating. Military efforts are expanding the  use of tele-critical care beyond the bedside to include meeting the diverse needs for our military  medical readiness. In the following slides, I'm going to demonstrate to you how we integrate a  tele-critical care with tele-simulation to train tomorrow's soldiers today. We were able to  successfully demonstrate the utilization of tele-critical care. In the 2019 joint warfighter  assessment, a simulated traumatic brain injury patient was received at the battalion aid station  after sustaining a head injury in the battlefield. Here, the general surgeons needed guidance with  performing a decompressive craniectomy, but the trauma surgeon was over 50 miles away in the  combat support hospital. Communications was available between the two aid stations and the  expert trauma surgeon was able to tele-mentor the surgical residents using synchronous video  telecommunication capabilities. As you can see on the picture on the left, he was able to talk the  surgical residents on performing this procedure. There was a tele-critical care physician and nurse  at the main hospital over 100 miles away on standby for additional consultation during the  procedure and for medical and nursing management of the patient after the cranie. In a simulated  remote area of Africa, an active duty soldier comes to the clinic complaining of shortness  of breath and quickly develops increasing oxygen needs. The inexperienced nurses are still providing  care within their scope of practice stateside and they recognize that this patient needs to be  medically evacuated, but cannot because of increased enemy activity in the area. So these  nurses reach out to critical care physicians using the National Emergency Telecritical Care Network  app, also known as Omnicare. The critical care physicians help with securing a definitive airway  and after the patient develops a pneumothorax, providing procedural tele-mentoring of a needle  decompression with subsequent chest duplacement. The interventions, the needle decompression and  the chest duplacement, those instructions were actually sent by Omnicare just in case communication  was lost between the remote users and the distant or off-site instructors. In this case, we're  thinking of the critical care physicians. One of the things to think about is that the far forward  environment is incredibly challenging. We have limited resources, we have limited knowledge  skills and abilities of the caregivers who are providing these interventions, that having an  on-demand resource is an invaluable asset to the safe medical management of high acuity traumatic  injuries. The most recent example of the military utilizing telecritical care occurred in the 2021  Pacific Defender Army Training Exercise, which was designed to operationalize the National Defense  Strategy. Here we tested the feasibility of a deployable physiological monitoring device  with a two-way audio communication and one-way video transmission. Think battlefield to stateside.  With the anticipated loss of the golden hour in future conflicts, today's deployable units, which  are smaller and more geographically dispersed, need to be prepared for providing prolonged field  care with limited resources. The Tempest Pro pictured on the right has 12 lead EKG capabilities,  invasive and non-invasive blood pressure ports, SpO2 monitoring, respiratory rate monitoring, as  well as ultrasound and laryngoscopy capabilities. To demonstrate the utility of such technology,  nurses deployed to Indonesia were not only able to communicate with providers in San Diego,  but they were also able to display images to the virtual medical operations center as well.  This technology is changing the delivery of care in deployable settings to increase the accuracy and efficacy of battlefield interventions.  Telecritical care improves patient outcomes through the adherence of evidence-based practices  as well as clinical practice guidelines, overall reducing the ICU length of stay and risk of  morbidity and mortality. Telesimulation can be an extension of telecritical care to improve the  knowledge, skills, and abilities of our deployable caregivers. We can integrate telesimulation with our telecritical care technology to train our soldiers, whether they're in the  battlefield or at higher levels of care, for skill development, for new devices, or even in real time  for procedural tele-mentoring of surgical interventions. We're working to leverage these  remote technologies to advance our critical care training without any regards to our geographical  barriers. Thank you so much for your time. I sincerely hope that you enjoyed this presentation. Please feel free to email me if you have any questions.

Video Summary

The speaker, Robert Finkelstein, discusses a project that used tele-simulation to teach non-ICU physicians how to manage ventilators during the beginning of the COVID-19 pandemic. The project involved asynchronous and synchronous learning, with recorded videos providing the asynchronous didactics and remote simulation sessions providing the synchronous learning experience. The goal was to teach clinicians ventilator management in COVID-19 respiratory failure and basic principles of ARDS and cardiopulmonary interactions. The telesimulation sessions were about 40 minutes long and included discussions on various topics related to ventilator management. The project used a multidisciplinary team of simulation experts and invited interested non-critical care providers to participate. The tele-simulation sessions were conducted using video conferencing platforms like Zoom and involved the use of ventilators and test lungs to provide a realistic learning experience. The project also highlighted the benefits and challenges of using tele-simulation, including the need for adequate technology, pre-briefing sessions, and clear communication during the remote simulations. Overall, the project demonstrated the effectiveness of telesimulation in providing remote education and training in critical care settings.

Asset Subtitle

Professional Development and Education, 2022

Asset Caption

COVID-19 affected undergraduate and graduate medical education for all trainees in all disciplines, including clinical bedside experiences, knowledge assessments in high-stakes certification examination administration, and case volume decrement for procedural and operative disciplines. Traditional in-person simulations of small and large scale were affected by the paucity of personal protective equipment and the risk of clinicians congregating in groups. Variation in ability and resources to deliver simulation in person warranted rapid expansion of telesimulation and creative solutions to close the experience and knowledge gap, which continued for several months during the pandemic. Learning Objectives: -Review examples of successful telesimulation in critical care -Identify key structures and formulas for successful faculty development and technology support for telesimulation -List three areas of continued growth and expansion of critical care simulation education

Meta Tag

Content Type Presentation

Knowledge Area Professional Development and Education

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Innovation

Tag Simulation

Tag Telemedicine eICU

Year 2022

Keywords

tele-simulation

non-ICU physicians

ventilator management

COVID-19 pandemic

asynchronous learning

synchronous learning

ARDS

cardiopulmonary interactions

telesimulation sessions

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