Simulation-Based Training in Measurement of Blood Pressure: A Randomized Study of Impact in Real-Life Settings Introduction Simulators are used for training competencies including blood pressure (BP) measurement. Whether such training translates to competency in real life is unclear. Methods We randomized 145 first-year undergraduate medical students to train on a BP simulator or arms of colleagues. After training, all students were assessed for accuracy (within 4 mm Hg above or below assessor's simultaneous recording) and methodology of BP recordings by an objectively structured clinical examination on real patients. Results Overall, 67 (46.2%) and 92 (63.4%) students accurately measured systolic and diastolic BP, respectively. Forty-three (58.1%) of 74 students in the conventional training recorded systolic BP accurately compared with 24 (33.8%) of 71 students in simulator training (P = 0.005). Diastolic BP was accurately recorded by 56 (75.7%) of 74 students in conventional group as against 36 (50.7%) of 71 students trained on simulator (P = 0.002). Median (interquartile range) objectively structured clinical examination score in conventional group was 8 (7–9) compared with 6 (5–7) in simulator group (P < 0.001). Conclusions Simulator-based training did not translate to clinical competence in terms of accuracy and methodology of BP recordings in real-life settings. Notwithstanding its advantages, simulator-based BP training needs integration with human element to make it meaningful and relevant to clinical practice. Reprints: Aneesh Basheer, MD, Pondicherry Institute of Medical Sciences, Ganapathichettikulam, Kalapet, Puducherry, India 605014 (e-mail: basheeraneesh@gmail.com). This study was done as part of an advance course in Medical Education by Dr. Aneesh Basheer at Sri Ramachandra Medical College and Research Institute, Chennai, a nodal center for faculty development programs under the Medical Council of India. © 2019 Society for Simulation in Healthcare

The Impact of Transport Modality on Efficiency of Simulated Neonatal Endotracheal Intubation Introduction Although the transport of neonates is generally safe, adverse events can occur where equipment is a contributing factor. The aims of the study were to explore how the types of neonatal intensive care unit bed in use could impact a simulated emergency endotracheal intubation and to identify future areas for training and education. Methods The efficiency of endotracheal intubation performed during simulated neonatal transport using 3 different transport modalities (closed incubator bed, open incubator bed, and open radiant warmer bed) was assessed. Twenty participants were enrolled. Outcomes included time to intubation, intubation success, and ease of mannequin access and were compared using Wilcoxon signed-rank tests and McNemar exact tests. Result Median times to intubation were 59, 44, and 37 seconds with the incubator top closed, with the top open, and with the open radiant warmer bed, respectively. Intubation was slowest and subjective ease of access was most difficult with the incubator top closed. Conclusions Experienced anesthesia providers had significantly greater difficulty with simulated emergency endotracheal intubation when performing neonatal transport with the incubator top closed compared with available alternative modes. Reprints: Alok Moharir, MD, Nationwide Children's Hospital, Department of Pediatrics, Division of Critical Care Medicine, 700 Children's Drive Columbus, Ohio 43205 (e-mail: alok.moharir@nationwidechildrens.org). The authors declare no conflict of interest. This study should be attributed to Nationwide Children's Hospital in Columbus, Ohio. © 2019 Society for Simulation in Healthcare

Evaluating Best Methods for Crisis Resource Management Education: Didactic Teaching or Noncontextual Active Learning Introduction Health care training traditionally focuses on medical knowledge; however, this is not the only component of successful patient management. Nontechnical skills, such as crisis resource management (CRM), have significant impact on patient care. This study examines whether there is a difference in CRM skills taught by traditional lecture in comparison with low-fidelity simulation consisting of noncontextual learning through team problem-solving activities. Methods Two groups of multidisciplinary preclinical students were taught CRM through lecture or noncontextual active learning. Both groups were given a cardiopulmonary resuscitation simulation and clinical performance assessed by basic life support (BLS) checklist and CRM skills by Ottawa Global Rating Scale. The groups were reassessed at 4 months. A third group, who received no CRM education, served as a control group. Results The mean BLS scores after CRM education were 18.9 and 24.9 with mean Ottawa Global Rating Scale (GRS) scores of 22.4 and 29.1 in the didactic teaching and noncontextual groups, respectively. The difference between intervention groups was significant for BLS (P = 0.02) and Ottawa GRS (P = 0.03) score. At 4-month follow-up, there was no statistically significant difference in BLS (P = 1.0) or Ottawa GRS score (P = 0.55) between intervention groups. In comparison with the control group, there was a marginally significant difference in Ottawa GRS score (P = 0.06) at 4-month follow-up. Conclusions Noncontextual active learning of CRM using low-fidelity simulation results in improved CRM performance in comparison with didactic teaching. The benefits of CRM education do not seem to be sustained after one education session, suggesting the need for continued education and practice of skills to improve retention. Reprints: Sandy Widder, MD FRCSC, Department of Surgery, University of Alberta Hospital, 8440-112 St NW, 2D4.27 Walter C MacKenzie Health Sciences Centre, Edmonton, AB T6G 2B7, Canada (e-mail: Sandy.Widder2@albertahealthservices.ca). The authors declare no conflict of interest. © 2019 Society for Simulation in Healthcare

Use of a Virtual Reality Device for Basic Life Support Training: Prototype Testing and an Exploration of Users' Views and Experience Introduction Immediate initiation of cardiopulmonary resuscitation significantly increases the chances of survival after a cardiac arrest. Virtual reality devices allow the integration of features of real patients into training to facilitate interaction and feedback, thus improving performance. However, its use as a training tool remains underexplored. The aims of this study were to undertake initial testing of a virtual reality basic life support prototype and to explore users' views and experiences. Methods We recruited 23 adult staff members working at a Central London University in England and exposed them to a 5-minute virtual reality experience. Each participant completed a prequestionnaire and postquestionnaire and took part in a focus group discussion. Quantitative data were descriptively analyzed, whereas qualitative data underwent thematic analysis. Results Regardless of prior experience of using virtual reality and/or performing basic life support, most participants scored more than 90% for chest compressions and reported an increase in confidence and competence after the experience. Focus group discussions identified the following 4 key themes: experience and expectations; performance and feedback; interaction and immersion; and potential. Conclusions Our study suggests that virtual reality is an enjoyable method by which to teach basic life support. Although concerns over the accuracy of the tracking system and the small sample size weaken our conclusions regarding its ability to assess performance, our exploratory data are of value to educators, researchers, and policy makers. Future work needs to address our study limitations, consider how virtual reality fits into the broader context of training, and attend to accreditation and resource issues. Reprints: Suzanne Bench, PhD, School of Health and Social Care, London, South Bank University, 103 Borough Rd, London, SE1 0AA, England (e-mail: benchs@lsbu.ac.uk). The authors declare no conflict of interest. This study was attributed to School of Health and Social Care, London South Bank University. © 2019 Society for Simulation in Healthcare

Certified Basic Life Support Instructors Identify Improper Cardiopulmonary Resuscitation Skills Poorly: Instructor Assessments Versus Resuscitation Manikin Data Introduction During basic life support (BLS) training, instructors assess learners' cardiopulmonary resuscitation (CPR) skills and correct errors to ensure high-quality performance. This study aimed to investigate certified BLS instructors' assessments of CPR skills. Methods Data were collected at BLS courses for medical students at Aarhus University, Aarhus, Denmark. Two certified BLS instructors evaluated each learner with a cardiac arrest test scenario, where learners demonstrated CPR on a resuscitation manikin for 3.5 minutes. Instructors' assessments were compared with manikin data as reference for correct performance. The first 3 CPR cycles were analyzed. Correct chest compressions were defined as 2 or more of 3 CPR cycles with 30 ± 2 chest compressions, 50 to 60 mm depth, and 100 to 120 min−1 rate. Correct rescue breaths were defined as 50% or more efficient breaths with visible, but not excessive manikin chest inflation (for instructors) or 500 to 600mL air (manikin data). Results Overall, 90 CPR assessments were performed by 16 instructor pairs. Instructors passed 81 (90%) learners, whereas manikin pass rate was 2%. Instructors identified correct chest compressions with a sensitivity of 0.96 [95% confidence interval (CI) = 0.79–1) and a specificity of 0.05 (95% CI = 0.01–0.14), as well as correct rescue breaths with a sensitivity of 1 (95% CI = 0.40–1) and a specificity of 0.07 (95% CI = 0.03–0.15). Instructors mistakenly failed 1 learner with adequate chest compression depth, while passing 53 (59%) learners with improper depth. Moreover, 80 (89%) improper rescue breath performances were not identified. Conclusions Certified BLS instructors assess CPR skills poorly. Particularly, improper chest compression depth and rescue breaths are not identified. Reprints: Bo Løfgren, MD, PhD, Department of Internal Medicine, Randers Regional Hospital, 8930 Randers NE, Denmark (e-mail: bl@clin.au.dk). The authors declare no conflicts of interest. Salary support for the lead author of the study was provided by Aarhus University, Denmark. Office supplies were provided by Research Center for Emergency Medicine, Aarhus University Hospital, Denmark. The funding bodies were not involved in designing the study, data analysis, interpretation, or writing the article. This study is attributed to Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark. © 2019 Society for Simulation in Healthcare

Comparing the Learning Effectiveness of Healthcare Simulation in the Observer Versus Active Role: Systematic Review and Meta-analysis Summary Statement The benefits of observation in simulation-based education in healthcare are increasingly recognized. However, how it compares with active participation remains unclear. We aimed to compare effectiveness of observation versus active participation through a systematic review and meta-analysis. Effectiveness was defined using Kirkpatrick's 4-level model, namely, participants' reactions, learning outcomes, behavior changes, and patient outcomes. The peer-reviewed search strategy included 8 major databases and gray literature. Only randomized controlled trials were included. A total of 13 trials were included (426 active participants and 374 observers). There was no significant difference in reactions (Kirkpatrick level 1) to training between groups, but active participants learned (Kirkpatrick level 2) significantly better than observers (standardized mean difference = −0.2, 95% confidence interval = −0.37 to −0.02, P = 0.03). Only one study reported behavior change (Kirkpatrick level 3) and found no significant difference. No studies reported effects on patient outcomes (Kirkpatrick level 4). Further research is needed to understand how to effectively integrate and leverage the benefits of observation in simulation-based education in healthcare. Reprints: Megan Delisle, MD, Department of Surgery, University of Manitoba, Room 344-825 Sherbrook St, Health Sciences Centre, Winnipeg, Manitoba, Canada R3A 1R9 (e-mail: megandelisle@gmail.com). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.simulationinhealthcare.com). © 2019 Society for Simulation in Healthcare

PEARLS for Systems Integration: A Modified PEARLS Framework for Debriefing Systems-Focused Simulations Summary Statement Modern healthcare organizations strive for continuous improvement in systems and processes to ensure safe, effective, and cost-conscious patient care. However, systems failures and inefficiencies lurk in every organization, often emerging only after patients have experienced harm or delays. Simulation and debriefing, focused on identifying systems gaps, can proactively lead to improvements in safety and quality. Systems-focused debriefing requires a different approach than traditional, learner-focused debriefing. We describe PEARLS for Systems Integration, a conceptual framework, debriefing structure and script that facilitators can use for systems-focused debriefing. The framework builds on Promoting Excellence And Reflective Learning in Simulation, using common debriefing strategies (plus/delta, focused facilitation, and directive feedback) in a modified format, with new debriefing scripts. Promoting Excellence And Reflective Learning in Simulation for System Integration offers a structured framework, adaptable for debriefing systems-focused simulations, to identify systems issues and maximize improvements in patient safety and quality. Reprints: Mirette Dubé, MSc, Alberta Health Services and University of Calgary, Foothills Medical Centre, 1403 29th Street NW, McCaig Tower, Room 04154 Calgary, AB, T2N 2T9 (e-mail: Mirette.Dube@albertahealthservices.ca). V.G., W.E., and A.C. receive remuneration as faculty for the Debriefing Academy, which teaches debriefing courses. © 2019 Society for Simulation in Healthcare

Educational Interventions to Enhance Situation Awareness: A Systematic Review and Meta-analysis Summary Statement We conducted a systematic review to evaluate the comparative effectiveness of educational interventions on health care professionals' situation awareness (SA). We searched MEDLINE, CINAHL, HW Wilson, ERIC, Scopus, EMBASE, PsycINFO, psycARTICLES, Psychology and Behavioural Science Collection and the Cochrane library. Articles that reported a targeted SA intervention or a broader intervention incorporating SA, and an objective outcome measure of SA were included. Thirty-nine articles were eligible for inclusion, of these 4 reported targeted SA interventions. Simulation-based education (SBE) was the most prevalent educational modality (31 articles). Meta-analysis of trial designs (19 articles) yielded a pooled moderate effect size of 0.61 (95% confidence interval = 0.17 to 1.06, P = 0.007, I2 = 42%) in favor of SBE as compared with other modalities and a nonsignificant moderate effect in favor of additional nontechnical skills training (effect size = 0.54, 95% confidence interval = 0.18 to 1.26, P = 0.14, I2 = 63%). Though constrained by the number of articles eligible for inclusion, our results suggest that in comparison with other modalities, SBE yields better SA outcomes. Reprints: Nuala Walshe, RN, MTLHE, School of Nursing and Midwifery, Brookfield Health Science Complex, University College Cork, Cork T12 K8AF, Ireland (e-mail: n.walshe@ucc.ie). The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.simulationinhealthcare.com). © 2019 Society for Simulation in Healthcare

A Porcine Model for Learning Ultrasound Anatomy of the Larynx and Ultrasound-Guided Cricothyrotomy Background Difficulty with tracheal intubation is the most common cause of serious adverse respiratory events during anesthesia. Cricothyrotomy is a life-saving procedure that is seldom performed by anesthesiologists. Anesthesiology residents are traditionally trained to perform cricothyrotomy with artificial mannequins and exposed larynx models from animals. These models lack the tissue feel of performing a cricothyrotomy on a patient with difficult neck anatomy. To improve the training experience, we developed a novel training model for cricothyrotomy using a porcine larynx, which incorporates ultrasonographic examination to identify the cricothyroid membrane, and permits varying degrees of difficulty. Methods Twenty-five residents were enrolled in a training curriculum consisting of (1) preprocedure training modules, (2) preprocedure hands-on demonstrations, and (3) three separate cricothyrotomy procedures using a porcine trachea. The first two procedures consisted of residents performing an open and a percutaneous cricothyrotomy on a model, which consisted of porcine trachea with chicken skin pinned over the larynx. The third procedure involved performing an open cricothyrotomy on a more challenging model, constructed by placing several layers of bacon fat between the larynx and chicken skin, making digital palpation of the laryngeal landmarks impossible. Before performing the procedure, residents located the cricothyroid interval with ultrasound. A postcurriculum survey was administered. Results Twenty-three of 25 residents were able to perform the open cricothyrotomy by digital palpation on the airway model on the first attempt. With the more challenging model, all 25 residents were able to locate the cricothyroid membrane by ultrasound and successfully perform open and percutaneous cricothyrotomy. Participants felt that they learned new information regarding ultrasound identification of laryngeal anatomy and gained valuable procedural experience in this training exercise. Conclusions Use of the porcine trachea with overlying animal skin and fat provides an effective partial-task trainer for open and percutaneous surgical airway education and lends itself to integration of ultrasound imaging for real-time identification of laryngeal and tracheal anatomy. Reprints: Steven L. Orebaugh, MD, UPMC-Southside/Mercy Outpatient Surgery Center, 2000 Mary St, Pittsburgh, PA 15203 (e-mail: orebaughsl@anes.upmc.edu). The authors declare no conflict of interest. Departmental funds were used for this project. © 2019 Society for Simulation in Healthcare