l’uso delle tecnologie nella didattica dell’emergenza

L’uso delle tecnologie nella didattica dell’Emergenza

R. Furlan, F. Dipaola

Congresso Nazionale AcEMC, Brescia, 21 novembre 2019

Disclosures: none

Outline

➢ Simulation methodologies in Emergency Medicineeducation

➢ The Humanitas M. Luzzatto Simulation Center

➢Humanitas Cognitive tutor

Simulation methodologies in Emergency Medicine education

Medical simulation: the use of a device or series of devices toemulate a real patient situation for the purposes of education,evaluation, or research.

➢ Mannequin-based simulation: high-fidelity human patientreplica capable of exhibiting a wide range of physiologic andpathologic responses, dynamic clinical states, and realisticresponses to monitoring, interventions, and therapies.

➢ Partial-task simulation: the use of a partial mannequin ormodel, designed to allow a learner to learn or practice aparticular technical skill.

➢ Microsimulation: the use of an interface, typically a personalcomputer, networked, or Internet-based software, to allow alearner to interact with a simulated patient.

Binstadt E.S. et al. Ann Emerg Med 2007 Apr;49(4):495-504


Because simulation permits learners to evaluate and treat high-risk conditions without risking injury to a patient, it is rapidlybecoming a key educational tool for many medical disciplines.

Main advantages:

➢ Never a risk to the patient

➢ Allows presentation of wide variety of scenarios, includinguncommon events

➢ Scenarios may be repeated as many times as necessary toreach proficiency

➢ Students are required to interact with actual equipment andpersonnel

➢ Permits targeted and flexible scheduling of training

Modified from: Hammond J. Curr Opin Crit Care. 2004 Oct;10(5):325-9.


With increased exposure to simulation and growingunderstanding of its applications, simulation is being used notonly to enhance teamwork and systems analysis but also to teachcore academic content in a hands-on manner similar totraditional bedside teaching, with the added ability to manipulatetime and human physiology to enhance learning.

…The “Harvard experience”



In February 2004, the Department of Emergency Medicine atBrigham and Women’s Hospital (Boston, MA) opened acomprehensive medical simulation center with a tripartitemission of education, research, and novel applications of new

technologies.

The Simulation Training, Research, and Technology UtilizationSystem (STRATUS) Center for Medical Simulation is a uniquesimulation center, in that it encompasses high-fidelity,mannequin-based simulation, computer-based microsimulation,and a comprehensive advanced skills laboratory that uses a seriesof “partial-task” simulators designed to teach specific procedures..




This staged learning modelemphasizes individual andteam performance andstresses that a team canfunction effectively andachieve specific outcomesor goals only when eachteam member is highlyindividually capable.


STRATUS Center Human Patient Simulation Laboratory: It consistsof 3 rooms. The first is a control center separated from thesimulation rooms by 1-way glass. There are 2 other rooms,designed to replicate ED treatment or resuscitation areas, eachwith a high-fidelity human patient simulator.

The ‘patient’'s clinical presentationand course over time can beprogrammed or can be adjusted inreal time by the instructor through anintuitive interface as the traineestreat the patient. Faculty facilitatorsprovide the “voice” of the patient,observe all scenarios, and provide anobjective-based debriefing sessionimmediately after the session.



Does Simulation-Based Medical Education With Deliberate Practice Yield Better Results Than Traditional Clinical Education?

McGaghie W.C. et al. Acad Med. 2011 Jun;86(6):706-11.


Technology-enhanced Simulation in Emergency Medicine:

A Systematic Review and Meta-Analysis

Ilgen J.S. et al. Acad Emerg Med 2013;20(2):117–27


ARIM program was designed as a non-clinical simulation training program aimingat providing the theoretical and practical skills to safely approach, as junioranesthesiologists, the operating rooms.

For each participant (n= 15), specific knowledge, procedural skills and non-technical performance were assessed with a pre and post-test approach, beforeand immediately after the participation in the study.


Barra F.L. et al. Minerva Anestesiol 2018 Dec;84(12):1377-1386.

Outline




The M. Luzzatto Simulation Center

➢ A Simulation Lab of 2,500 m2, one of the largest and mosttechnologically advanced in Europe, integrated with theHumanitas Campus.

• 3 high-fidelity and 2 medium-low-fidelity simulation rooms

• 1 anatomy lab – with 8 dissection tables

• 3 control booths equipped with the latest simulation softwareand monitoring system

• 3 conference rooms - with seating capacity for up to 250 people

• Surgical Suturing and Skill Lab

• Virtual Reality Arthroscopy and Laparoscopy CUBE

• More than 250 courses per year

• Participants from 30 different countries

• Ongoing research activities


ESERCITAZIONI AL SIMULATION CENTER

SSM in Medicina d’Emergenza-Urgenzaa.a. 2018-2019

27-31 maggio 2019

Outline




What is the Humanitas Cognitive Tutor for Medicine?

It is a suite of intelligent sofware through which studentslearn to formulate a diagnosis and plan a therapy whileexamining the data of a virtual patient.

➢ By using natural language processing, students are requiredto formulate their own anamnestic questions, performphysical examination, order medical tests, interpret theresults and provide a list of differential diagnosis, therebyemulating real life doctors.

➢ Feedback is constantly provided throughout the simulation inorder to help guide the students and enhance learning.

Test-1

Pre and post simulation test scores

pre s

imula

tion

post s

imula

tion

0

6

12

18

2422

sco

re

Test scores

pre simulation

post simulation

* p = 0.0001

*

pre s

imula

tion

post s

imula

tion

0

6

12

18

2422

sco

re

Test scores

** p = 0.0001

Pre and post simulation test (22 multiple choice questions) scores of 15 students.Topic: Pulmonary embolism. Overall, there was a significant improvement in theaverage test score from pre simulation test to post simulation test (14.6 ± 3.15 vs17.8 ± 1.48 (mean ± SD); p = 0.0001).

(Individual performance)

The Humanitas Cognitive Tutor

Test-2

25 students of the Patient Management course (5° year)executed a simulation with HCT (chief complaint: dyspnea).

Their actions were logged and subsequently analyzed with theobjective of understanding their performance.

Students performance was analyzed against seven main metrics: SC(scenario), AN (anamnesis), PE (physical exam), MT (medical tests), HY(diagnostic hypothesis), BA (binary analysis), RS (final diagnosis).

For each section we computed a sensitivity metric (i.e., how many of therelevant information contained in each section was the student able to find)and a precision metric (i.e., how many actions performed by the student wereconsidered correct). These two components were combined with a harmonic(F1) thereby obtaining a single score between 0 and 1 (1= perfect sensitivityand precision). Combining these latter 7 F1-metric scores provided a singlenumber which was used as the student’s overall score and was compared tothe class performance average.

The Humanitas Cognitive Tutor

➢ Overall mean performance score was 0.600 ±0.056 standarddeviation. 14 students had an overall F1 performance scorebetween 0.6-0.7. 11 students had a score below 0.6; nostudent had a score above 0.7.

➢ Analysis vs collection.

The Humanitas Cognitive TutorResults

User 202041

User 202025

Student 202025 and 202041 hadidentical overall scores (0.63) but fordifferent reasons: 202041 performedworse at data collection (collectionrank 12, analysis rank 5), while202025 performed poorly at dataanalysis (collection rank 3, analysisrank 11). This may highlight thedifferent educational needs of the twostudents.

➢ Comparing students.

The Humanitas Cognitive TutorResults-2

Top Performer Bottom Performer

For example, student 202002 had a very high analytical score (rank 1) due to his goodperformance in the diagnostic hypothesis section (rank 1) despite an averageperformance in the binary analysis section (rank 6). This may be of help inindividualizing educational paths to specific and personalized student’s needs.

Conclusions

➢ The Humanitas Cognitive Tutor may be a valid andinnovative tool to assess and represent students’ ability inapplying medical knowledge into clinical scenarios.

It may be used to detect specific areas of the diagnosticprocess which need to be strengthened in order tosolidify the skill necessary for diagnostic reasoning.

➢ Incorporating the Humanitas cognitive tutor as a didactictool into medical school curriculum may allow students totrain on simulated clinical cases targeted to theireducational needs.

Simulation corpusHow will we scale in the future

Semester 1Sep-Dec 2019

• FUO 1

• FUO 2

• Chest Pain 1

• Chest Pain 2

• Dyspnea 1

• Dyspnea 2

• Dyspnea 3

• Purpura

• Altered Mental Status

• Syncope 1

• Syncope 2

Semester 2Jan-Mar 2020

• Abdominal Pain 1*

• Abdominal Pain 2*

• Back Pain

• Diarrhea

• Jaundice 1*

• Jaundice 2

• Dysphagia*

• Weight Loss 1*

• Weight Loss 2

• Vomit

Next yearSep 2019 – June 2020

• 2018/2019 corpus

• Elective

• Exams

• Cloning

*in cooperation with the General Surgery team

Integration of simulation corpus in possible didactical planPatient Management and Emergencies classes

First semester 5th year

1 sim lesson

1 sim exam

5 sim offlin

e

authoring

elective

Emergencies

Patient management

Second semester 5th yearFirst semester 6th year

1 sim lesson

1 sim lesson

5 sim offlin

e

1 sim lesson

1 sim exam

1 sim lesson

1+1 sim exam

5 sim offlin

e1 sim

lesson

Sixth year requirestherapy and additionalsimulations

Humanitas Research HospitalRaffaello FurlanEnrico BrunettaFranca DipaolaRoberto MenèDana ShifferAnna Giulia BottaccioliAlessandro Giaj Levra

Humanitas IT departmentMarco Anastasio

IBMMauro GattiChiara Marchiori Vincenzo SaturninoValerio ChieppaMichele SavoldelliJacopo BaloccoLuca VinciottiRanda SalemMyriam Battelli

HumanitasCognitive Tutor

Thank you!


➢ Computer Simulation Laboratory: uses computer-based patientsimulation and debriefing software to enable individuals orsmall groups to work independently or with faculty facilitatorsto acquire knowledge and practice medical decisionmakingwhile treating computer-simulated patients in the out-of-hospital, inhospital, or military field environment.

Learners can trigger various activities through the simulatedproviders, such as interviewing the patient; performing physicalexaminations; obtaining and interpreting laboratory,radiograph, monitoring, or ECG data; performing procedures;and administration of medications.

After selecting actions and interventions from variousdropdown menus, students observe how their choices affectthe simulated patient.



➢ Advanced Skills Laboratory: consists of a variety of partial-tasktrainers that are used to teach the psychomotor skills necessaryto perform a variety of essential procedures.

It also provides residents with the opportunity to explore the useof new or infrequently used procedures or technologies (ie,fiberoptic intubating bronchoscopes, invasive and noninvasivecardiac pacing equipment...) under the close supervision ofskilled physician faculty in a controlled setting.



➢ Classroom: Classroom-based interactive seminar teaching is anintegral part of all STRATUS programs and plays a particular rolein the Harvard Affiliated Emergency Medicine Residencycurriculum.

➢ The Residency curriculum. An expert panel composed of the leadersof the Harvard Affiliated Emergency Medicine Residency and STRATUSSimulation Center used a consensus approach to identify the bestteaching methodology (eg, large group lecture, small group seminar,microsimulation, selfdirected learning or reading, partial-tasksimulation training, human patient simulation, clinical teaching in theED) for each learning objective. The intent was to transition from thetraditional lecture series to a curriculum that integrated simulationbased teaching methods, creating a consistently active learningenvironment.




Residents responded favorably to the replacement of traditional lectureteaching with more active teaching formats and were extremely positive intheir evaluations of the new curriculum.


CJEM 2018 Jan;20(1):132-141

SBE is frequently used by Canadian EM residency programs.However, there exists considerable variability in the structure,frequency, and timing of simulation-based activities.

Acad Emerg Med 2016 Sep;23(9):1054-60


Acad Emerg Med 2016 Sep;23(9):1054-60

Sauter TC et al. GMS J Med Educ. 2018 Nov 15;35(4):Doc44


The Center offers virtual and augmented reality, 3-D learning, livesurgery streaming, and simulation activities of different fidelitylevels:

• low fidelity: task trainers to build specific skills, e.g. cannula or tubeinsertion, basic CPR skills

• medium fidelity: laparoscopic simulator boxes, Basic and AdvancedLife Support courses, Suturing Skill Table, Airway and EmergencySimulator, etc.

• high fidelity: most realistic experience like the anatomy lab topractice on human specimens, and computer-based mannequins andrealistic environments to mimic operating rooms, emergency wardsor interventional departments.

l’uso delle tecnologie nella didattica dell’emergenza

Documents