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Tunis Med
Tunis Med
Tunis Med
La Tunisie Médicale
0041-4131
2724-7031
Tunisian Society of Medical Sciences

39129568
Article
Mise en place des formations par simulation dans les Unités de Soins Intensifs (USI) pendant la pandémie de COVID-19: Un examen de la portée
Implementation of simulation training in the Intensive Care Units (ICU) during the COVID-19 pandemic: A scoping reviewNouira Hajer 112
Jaoued Oussama 112
Ouanes Islem 223
Jrad Maissa 112
Chtioui Soumaya 112
Gharbi Rim 112
Fekih Hassen Mohamed 112
Ben Sik Ali Habiba 112
Elatrous Souheil 112
1. Department of Intensive Care, Taher Sfar Hospital, Mahdia, Tunisia
2. University of Monastir, Faculty of Medicine Monastir, Tunisia
3. Department of Intensive Care, El Yosr International Clinic, Sousse, Tunisia
8 2024
05 8 2024
102 8 433439
2022
https://creativecommons.org/licenses/by-nc-nd/4.0/ This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 Unported License. To view a copy of this license, visit https://creativecommons.org/licenses/by-nc-nd/4.0/
RESUME

Introduction: Face à l'important afflux de patients en réanimation ainsi qu'à la limitation des ressources, la simulation serait un outil pédagogique garantissant la continuité de la formation médicale. Objectif : Evaluer l'impact de la formation par simulation en réanimation sur l'éducation et les performances liées au développement de protocoles pendant la pandémie COVID-19. Méthodes: Cette revue de la portée a été rédigée conformément à la directive PRISMA. Les études ont été identifiées en effectuant des recherches dans "MEDLINE", "Cochrane library" et "Clinical trial.gov. Le modèle de Kirkpatrick est un outil permettant d'évaluer le niveau de l'impact des résultats de la formation selon quatre niveaux. Résultats: L'algorithme de recherche a fourni seize articles, dont huit ont satisfait les critères d'inclusion et finalement sept étaient disponibles. Le nombre de participants variait de 12 à 108, avec une médiane de 61 (IQR : 8-76). La durée de l'intervention variait de 12 minutes à trois heures, avec une médiane de 38 minutes (IQR : 12-135). Les études ont rapporté que la simulation avait un impact plus important que la formation théorique seule pour améliorer les connaissances et la confiance. Pour le développement de protocoles, les résultats ont montré qu'en pré-test, tous les participants échouaient à enfiler et à retirer l'équipement de protection individuelle (EPI), la charge cognitive moyenne était élevée (7,43±0,9 points) et la performance était faible (2,5±0,8), tandisqu'en post-test, 100% des participants réussissaient à enfiler l'EPI, la charge cognitive moyenne diminuait (4,1±1,4 points) et la performance augmentait (7,9±1,1). Cinq études ont montré des changements de comportement après la formation, ce qui a permis d'atteindre le niveau trois du modèle de Kirkpatrick. Conclusion: Les résultats ont soutenu l’impact de la simulation en réanimation en tant que méthode efficace pour améliorer les connaissances, la confiance, et le développement de protocoles lors de pandémies telles que la COVID-19.

ABSTRACT

Introduction: In response to the important influx of critically ill patients as well as resources limitation, simulation would be a tool ensuring the continuum of medical training. Aim: To assess the impact of simulation training on both education and performance related to protocol development during COVID-19 pandemic, in critical care. Methods: This scoping review was written in accordance with the PRISMA Guideline. Data sources and studies were identified by searching “MEDLINE”, “Cochrane library” databases and “Clinical trial.gov”. Study inclusion adhered to the PICO criteria: Population, Intervention, Comparison, and Outcomes. The Kirkpatrick Model, is a tool for evaluating the level of impact of training results according to four levels Results: The search algorithm yielded sixteen articles of which eight were meeting criteria for inclusion and finally seven were available. The number of participants ranged from 12 to 108 with a median of 61 (IQR: 8-76). The length of intervention ranged from 12 min to three hours with a median of 38 min (IQR: 12-135). Studies reported that incorporating simulation yields a more pronounced impact compared to theoretical and clinical training alone in enhancing knowledge and confidence. Regarding the role of simulation in protocol development, results have shown that in the pre-test, all the participants failed donning and doffing Personal Protective Equipment (PPE), the mean cognitive load was high (7.43±0.9 points) and the performance was low (2.5±0.8) while in the post-test, 100% of participants were successful in donning the PPE, the mean of the cognitive load decreased (4.1±1.4 points), and the performance substantially increased (7.9±1.1). In addition, five studies showed behavioral changes after training and thus the simulation reached Kirkpatrick level three. Conclusion: Results supported the impact of simulation, in critical care, as an effective method to enhance knowledge and confidence, and to improve protocol development during pandemics such as COVID-19.

Mots clés

Formation par simulation
Soins de réanimation
Education pour la santé
COVID
Adhésion aux directives
Keywords

Simulation Training
Critical Care
Health Education
COVID
Guideline Adherence
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pmc1. INTRODUCTION

Simulation has been defined as a material, device and/or environment that replicate some or nearly all of an aspect of clinical situation (1). In the past, the value of this approach has been also recognized to improve preparedness in an outbreak (2). It is a pedagogic tool that has been emerged to ensure the continuum of medical training whilst attempting to avoid the risk of contamination and could have an integral role especially during a pandemic. The French National Authority for Health (HAS) has published in 2012 a guide practices in health simulation (in French). This initiative would facilitate the application of this challenging pedagogical tool within well-defined rules (3). The Coronavirus pandemic has created the largest challenge to health systems joining a list of other pandemics that have tested the resilience and capacity of healthcare systems worldwide (4, 5). In response to ongoing concerns regarding the important influx of hospitalized and critically ill patients, healthcare workershave grappled with the need for rapid and efficient preparedness (6). They have adopted several strategies including expanding intensive care unit bed capacities, training redeployed practitioners, addressing knowledge gaps as well as establishing infection control and mitigation protocols. Along side the challenge faced on health care systems to cope with the burden COVID-19, the shut down of academic institutions have taken a profound impact on medical education (7). In this scoping review, we aimed to assess the impact of simulation training on both education and performance related to protocol development during COVID-19 pandemic, in critical care

2. METHODES

This is a scoping review of articles on the Simulation training amidst the COVID-19 pandemic, in Critical Care. This review was written in accordance with the PRISMA 2020 Guideline (8). Data sources and studies were identified by searching “MEDLINE”, “Cochrane library” data bases and “Clinical trial.gov”. The last search was run on 01 May 2021. It was conducted using the following search strategies: MEDLINE: ("Critical Care"[Mesh] OR "Intensive Care Units"[Mesh]) AND ("Simulation Training"[Mesh]) AND ("COVID-19"[Mesh] OR "SARS-CoV-2"[Mesh] OR "Coronavirus"[Mesh]); Cochrane: (simulation) AND (covid19 OR coronavirus OR SARS cov2) AND (critical care OR intensive care); Clinical trial.gov: (COVID-19 | simulation training).Study inclusion adhered to the PICO criteria: Population, Intervention, Comparison, and Outcomes. Population included health care providers (physicians, residents, nurses, paramedic’s and therapists), medical students and other paramedical specialties such as nursing and midwifery students. Intervention included any application of simulation during the COVID-19 era, in Critical Care. For the Comparison, we aimed to investigate studies comparing participant knowledge and/or performance between intervention and control groups. Comparisons between pre- and post-intervention outcomes were also accepted. Outcomes investigated the impact of such interventions on education and on performance related to protocol development during COVID-19 pandemic.The results of this literature search were selected and limited to articles published in English; we excluded also letters to the editor, commentaries and editorials. Two different authors independently selected and retrieved the outcomes. The Kirkpatrick Model (9), first developed by Donald Kirkpatrick in 1959, is a tool for evaluating the effectiveness of a training program. The model stratifies the level of impact of training results according to four levels: performance and patient outcomes (level 4), behavioral change after training (level 3), individual learning (level 2), and participants’ reactions to training (level 1). For each included article, the bibliometric characteristics were collected and methodological information were summarized in tabular form. Moreover, the main results and the Kirkpatrick level investigated were sorted and we performed structured synthesis of the available data in three thematic axes which were expanded in the discussion section (Impact of simulation oneducation, on performance related to protocol development and challenges encountered with implementing simulation for COVID-19).

3. RESULTATS ET DISCUSSION

The search algorithm yielded sixteen articles from “MEDLINE” and “Cochrane library”. No results for the search on “Clinical trial.gov”. Based on the language (English) and on the type of article, 13 articles were selected, of which eight were meeting criteria for inclusion and finally seven (10 -16) were available. Figure n°1 summarizes the study selection process and exclusion reasons.

Bibliometric characteristics of the articles included in this scoping review are detailed in Table 1. Among the seven articles, five were published during 2020. The included articles were three Randomized Controlled Trials and four Journal articles. Studies were carried out in USA (3 studies), Australia (2 studies), Austria (1study) and Jordan (1 study). The included number of participants ranged from 12 to 108 with a median of 61 (interquartile range: 38-76)

In addition to physicians, two studies included nurses, one study included midwifery students and one study included nursing students. Interventions used were diverse (Table 2). The length of intervention ranged from 12 min to three hours with a median of 38 min (interquartile range: 12-135). All the three studies investigating the impact of simulation on education reported a significant impact of simulation on enhancing knowledge and confidence (Table 3). Regarding the role of simulation in COVID-19 specific protocol development, Díaz-Guio DA et al. have shown that in the pre-test, all the participants failed donning and doffing Personal Protective Equipment (PPE), the mean cognitive load was high (7.43±0.9 points) and the performance was low (2.5±0.8) while in the post-test, 100% of participants were successful in donning the PPE, the mean of the cognitive load decreased (4.1±1.4 points), and the performance substantially increased (7.9±1.1). Two simulation studies focused on airways management in patients with COVID-19, founding that the use of the aerosol box increased time to intubation and presented subsequently a higher risk of hypoxia. Kienbacher CL et al. examined the effects of PPE on the quality of Cardio Pulmonary Resuscitation (CPR). This randomised controlled trial has revealed that PPE, including masks with and without valves, does not impair CPR quality (mean compression depth was 56 mm (SD=3.7) using no additional PPE (control), 56 mm (SD=3.6) using a FFP2 mask with a valve and 56 mm (SD=3.6) using a FFP2 mask (without a valve). In addition, five studies showed behavioral changes after training and thus the simulation reached Kirkpatrick level 3. Two studies assessed Kirkpatrick level 2. The impact of training on patient outcomes has not been assessed in any study.

4. DISCUSSION

This scoping review has been carried out to assess the impact of simulation on both education and performance related to protocol development during COVID-19 pandemic, in critical care. In fact, an array of simulation techniques can be leveraged for usually two purposes: education and assessment (17). The included studies showed that simulation training improved participants’ knowledge, confidence and comfort in the management of ICU patients. These results were also echoed in several randomized controlled trials which asserted that simulation was superior regarding its effect on knowledge compared with traditional training (18, 19). Moreover, Robyn P. et al published a systematic review (20) on simulation in nurse education, in which, all included studies reported a significant impact of simulation as a method to enhance knowledge, confidence and critical thinking ability. These results could be explained by the safe learning environment that offers the simulation for trainees, allowing a move away from simple to complex tasks and providing psychological support (21).The current context of the coronavirus pandemic has undeniably led to an important disruption of education systems in order to slow down the spread of the virus. These facts highlighted the importance of implementing new technologies as adaptive training including e-learning, tele-conferences and webinars ( 22). In this review, Prasad N et al (12) reported that online simulation delivered in an e-learning format may be beneficial and can be applicated. These findings expand on those of a recent scoping review carried out by Dedeilia A. et al (23) who underlined the importance of this technology as a useful tool for minimizing the educational gap during the COVID-19 pandemic. This tool could also be needed for redeployment of health professionals due to the increasing number of patients requiring hospitalization in ICUs. Yuriditsky E et al (11) has shown that simulation-based training improved knowledge in the management of ICU patients for participants who were going to be deployed to COVID-19 intensive care. In the literature, there has been considerable interest in the integral role of simulation in cross-skilling healthcare workers in the past, during the Influenza and Severe Acute Respiratory Syndrome (SARS) pandemics (24).The pandemic has led to dramatic consequences for human health and therefore, it has required an urgent need of innovating new protected protocols and reconciling existing guidelines such us protocols for intubation, donning and doffing of PPE, cardiac arrest protocol and proning protocol. The present study pointed at the significant impact of simulation on the improvement of participants’ performance and safety in donning and doffing PPE.

Indeed, the use of PPE is a lifesaving procedure. However, we should remember that there is an important threat related to viral exposure in doffing the PPE and thus, a high cognitive load would be generated. Moreover, the airway management of patients with COVID-19 present a high-risk situation not only for healthcare workers but also for the patient who is already susceptible to rapid desaturation (25). For these reasons, before the practice of a new protocol in real-life, we should ensure safety, assess efficacy, identify misconceptions and familiarize staff with this protocol. Two studies (14, 16) in this scoping review focused on the impact of using aerosol boxes for intubation. The authors demonstrated that aerosol boxes increase intubation times and may expose staff to an elevated risk by causing breaches of PPE. Thus, simulation serves for a safe tool with iterative and various drills allowing further revisions, assessing performance, mitigating error as well as decreasing cognitive loads (26). The question then is what are the difficulties and obstacles encountered in implementing simulations during the COVID-19 pandemic? Firstly, participants’ safety and social distancing present a major area of concern.Prasad N et al implemented in the included study (12) an e-learning platform to avoid close gatherings of participants.Yuriditsky E (11) et al devided the experimental group of students into three groups, 12-13 students per group. In the literature, the tele simulation and the limited number of groups were also implemented as strategies to bridge this barrier ( 23, 27). Secondly, shortage of PPE is one of the most important challenges. In fact donning and doffing PPE are frequently needed to be incorporated in simulation training. This concern has resulted in tension between the two necessities: conserving PPE as a limited resourceand using it for the scenario. In the authors’ experience reported in this systematic review, participants used standard clinical gloves in order to conserve precious PPE supplies (16)

Further considerations were implemented in other studies (26, 27) such as merging various scenarios and keeping their PPE on until the end of simulation. Finally, it is known that educators were composed foremost of healthcare workers in critical care, anesthesiology or emergency medicine. Nevertheless, because of the important influx of patients, they were not usually available to ensure the traditional schedule of simulation in the center, leading to an important shortage of simulation support staff. In response to this concern,many studies, such as the one of Begley JL et al (16), were carried out in-situ.This scoping review has a number of limitations: First the paucity of available literature is the main one. Further databases would be searched such as "Embase" for further studies but note that it wasn’t available in our country. Add to that, we did our research on two large databeses “MEDLINE” and “Cochrane Library” which include large indexed Journals that cover a big part of the English and French literature. We did the search on Clinical Trials.gov as well but no articles were found, it could be explained by the pandemic situation. Then, to broaden the number of included studies, the scarcity of sources constrained us to accept other study designs in addition to randomized controlled trials. However, the justification is that the review outlines a recent topic about simulation, during an ongoing pandemic and there is a need to rapidly cope with the many challenges faced such as the eductional gap. In addition, the use of self-reported outcome measures could restrict quantifying results and thus it could be associated with information bias. To conclude, in this scoping review, results supported the significant impact of simulation as an effective method to enhance knowledge and confidence, to improve protocol development and to adapt learning pedagogy, in critical care settings, with emerging and re-emerging diseases, particularly pandemics such as COVID-19, H1N1 and others. For that, it was suggested to create a contingency plan for the implementation of simulation programs, with a considerable ‘buy-in’ from clinicians to improve performing skills during this pandemic. Cooperative means in the faculty are also needed to pave the way for including simulation to be used as main education approach. Finally, it would be of great interest to carry out additional well-designed studies reporting findings on the highest Kirkpatrick levels and making possible to transfer learning to patient outcomes.
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