By Catherine Albin, MD, and Deepa Malaiyandi, MD
Simulation in critical care training has exploded over the last decade, but its application to neurocritical care has been met with some skepticism. High-fidelity simulation aims to create safe learning environments that mimic real-life scenarios. This involves accounting for the actions or elements to be learned, the interactions between them, and key environmental factors. Employing high-fidelity simulation to train physicians in the management of neurological illness is not a new concept. It dates back at least to the 1960s when Dr. Howard Barrows described the use of standardized patients to “effectively enact coma, seizures, sensory loss, reflex changes, and blindness.”
Proponents for the use of high fidelity simulation training in neurocritical care report multiple unique benefits, including:
1) Exposure to rare but fundamentally important diseases
Fellows are frequently the initial decision makers for in-house emergencies and need baseline competency in neurologic emergency management at the start of their training. However, this is often not the case as trainees enter fellowship from diverse backgrounds (e.g., neurology, neurosurgery, internal medicine, anesthesiology, emergency medicine). Even for neurology and neurosurgery residents, work hour restrictions and regionalization of care may limit exposure to core elements of practice. Creating a simulated orientation or incorporating it into an existing one can serve to quickly bring a group of learners to a unified starting point. This can also account for institution-specific environmental factors, which may differ from previous training.
2) Direct observation and timely feedback
In traditional didactic sessions, the ability to retain and apply content is difficult to assess. High-fidelity environments allow for direct observation of and timely feedback on trainee performance. During a simulated scenario, one can observe a trainee’s situational awareness, problem-solving skills, leadership ability, effectiveness of communication and command of available resources without risk of harm to patients. Performance can then be debriefed in real-time without concern that the trainee is not cognitively able to process the feedback, which can be the case following an actual acute patient event.
3) Learner evaluations are consistently higher for simulated curricula
Surveys given to trainees have repeatedly shown overwhelmingly positive feedback regarding the perceived utility of simulated exercises. The hands-on nature of simulation commands better attention and participants frequently note forgetting they are in a training environment. Not only do trainees report the experiences as enjoyable, but also that they feel a greater sense of confidence in their ability to perform in clinical practice.
4) Simulation can be made accessible via an online platform
Serious games are medical gaming programs that can be designed as single or multiplayer virtual environments. They afford many of the benefits of in-person simulation and have the added benefit of being accessible anytime and anywhere. They also have the potential to overcome many of the limitations specific to using high-fidelity simulation for neurological presentations. They present a relatively untapped opportunity for neurocritical care education.
While some have successfully incorporated simulation into their neurocritical care training curricula, others frequently site the following three limitations as reasons for avoiding doing so.
1) Inability to accurately simulate neurological findings for advanced trainees
Requiring the advanced learner to accept a standardize patients’ give-way weakness as real can subconsciously compromise the scenarios’ degree of fidelity. Furthermore, many focal findings are neither able to be enacted by standardized patients nor programmed into currently available simulators.
2) Neurological emergencies often co-manifest
A patient with a subarachnoid hemorrhage who seizes, re-bleeds and begins to herniate is one possible neurological equivalent to the “mega-code” scenarios of ACLS. Individually simulating each disease scenario does not adequately prepare the trainee to prioritize and multitask. However, simulating multiple neurological processes simultaneously increases the potential for variability in interpretation of key signs and symptoms. This creates uncertainty for educators designing curricula who need to be able to predictably cue learners through the intended learning objectives.
3) Insufficient data to demonstrate that high fidelity simulation in neurocritical care improves clinical performance or outcomes beyond traditional teaching methods
Increasing budget constraints limit the ability of many institutions to justify the investment needed to run simulation curricula. These costs include the facilities themselves, simulation specialists, educator time and diversion of trainee time away from clinical experience.
While there is validity to these arguments, they do not negate the potential benefits of high-fidelity simulation training in our field. The Kirkpatrick scale is widely accepted for evaluating the effectiveness of any curriculum and provides an example of the data gap for simulation training in neurocritical care versus other areas of critical care. The scale ranges from 1-5 as follows: trainee satisfaction/confidence; acquisition of knowledge/skills/behaviors; improved performance on the job; better outcomes; and institutional cost effectiveness.
To date, there are few studies in neurocritical care to support high-fidelity simulation. Although well done, these studies have been small, single-center experiences. For example, studies have reported using simulation to teach the management of status epilepticus, neurogenic respiratory failure, spinal shock and brain herniation. Others have used simulation to grade trainees’ competence in determining brain death or performing lumbar puncture. These studies used pre- and post-test assessments and surveys to demonstrate trainee enjoyment and improved confidence (Kirkpatrick Level 1) as well as improvement in knowledge (Kirkpatrick Level 2).
In contrast, better clinical outcomes (Kirkpatrick 4) have been demonstrated in other critical care fields. In this respect, pediatric and trauma critical care boast the most robust literature. For example, it has been demonstrated that in situ simulation of a pediatric medical emergency resulted in faster recognition of a deteriorating patient and more rapid escalation to intensive care. Similarly, training with a human patient simulator resulted in real-life improvement in teamwork scores, speed and completeness for 100 subsequent blunt trauma resuscitations.
Comparable simulation curricula in neurocritical care are taking shape at a few large academic institutions. However, for some centers, evidence that these efforts translate to improved outcomes will be necessary to justify the investment required to develop such programs. As a first step to developing a curriculum that assesses outcome measures of simulation training comparable to our critical care colleagues, we will be surveying program directors of UCNS-accredited fellowships. Our aim is to better understand attitudes toward simulation training and how it is being used and evaluated in neurocritical care.
The onus is on us as educators to follow the path of our colleagues in other areas of critical care to demonstrate the benefit of high-fidelity simulation for our patient population. This data will not only support the investment of resources to develop simulation curricula but will also drive the creation of next-generation technology, such as mannequins or virtual immersion realities that allow for accurate portrayal of neurological presentations. Regardless of where we stand now relative to the pack, and despite the challenges, the future of simulation training in neurocritical care remains bright and exciting.