SCCM Resource Library-What Was New Is Even More New Again

Video Transcription

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 institutions has widely varied.  The massive open online courses that have had global impact are the Maintenance of 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 context, which is the social presence.  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.  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 at the 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 in 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 tele-simulation. So what are the tips for domains specific to tele-simulation?  In a needs assessment, we need to consider technology available to the learners, their internet speed limitations, institutional firewalls, audio-visual 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 tele-simulation 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 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 through 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, et cetera. 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 hotspots 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 on Knee Tech, 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.

Video Summary

In this presentation at the Society of Critical Care Medicine Annual Congress, Dr. Pooja Nawate discusses the use of tele-simulation and technology in critical care education. She emphasizes the need for innovation and adaptability during the pandemic to meet the learner needs. Dr. Nawate explores the concept of virtual learning environments and the importance of educator presence, cognitive presence, and social presence in creating successful online learning spaces. She also provides strategies for effective tele-simulation debriefing, such as optimizing technology and encouraging learner engagement. Dr. Nawate then discusses the concept of hybrid simulation, where distance learning is combined with in-person simulation sessions. She shares examples of successful hybrid simulations conducted during the pandemic. Additionally, she highlights the potential of augmented and virtual reality in medical education and suggests partnering with video game developers and the military to leverage these technologies. Dr. Nawate concludes by encouraging the acceptance of innovative changes in critical care education for the benefit of students, patients, and the community.

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.

Meta Tag

Content Type Presentation

Knowledge Area Professional Development and Education

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Innovation

Tag Simulation

Year 2022

Keywords

tele-simulation

technology

critical care education

virtual learning environments

hybrid simulation

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