Introduction

Historically, the model of trauma training was preceptors demonstrating techniques or lecturing before the development and implementation of Advanced Trauma Life Support (ATLS) as a basis for trauma education. [American College of Surgeons Committee on Trauma. Advanced Trauma Life Support student course manual, 10th ed. Chicago, IL: American College of Surgeons; 2018] In the nearly 40 years of ATLS, trauma education has transformed into training providers on evidence-based, standardized assessments and treatment protocols that incorporate practical skills alongside the lecture component.[1] Over time, ATLS has become the standard for skill introduction for the initial treatment of injured patients.[1] Whether intentional or not, ATLS sparked a paradigm shift in trauma education by introducing practical skills, which helped to expand simulation-based training in trauma. Simulation-based training is important because it assists novice clinicians in receiving more exposure to critical thinking skills, which increases the ability to prioritize patient safety.[2]

Function

Simulation provides an opportunity to educate medical providers on non-technical skills to reduce the risk of adverse events, therefore resulting in increased patient safety.[3] For example, researchers identified risk reduction associated with non-technical skills such as teamwork, situational awareness, and communication.[3][4] Researchers have found positive associations between high fidelity simulation programs and safety attitudes, changes in organizational performance, and teamwork improvement.[3] Furthermore, surgical educators believed that simulation is an excellent training tool, which has a range of application (e.g., basic surgical skills for novices, non-technical skill acquisition, and consultant-led simulations).[5] Researchers found that approximately 50% of errors in communication occurred during trauma team resuscitations, the earliest point of hospital-based care,[6] thus demonstrating the need for trauma simulations to address non-technical skill development.

Specific to trauma, there is the opportunity to benefit from simulation courses or workshops (including ATLS) periodically to increase the accessibility of the training modality.[4] Furthermore, research has demonstrated the value of simulation with evidence of learner’s ability to retain the skills gained in simulation within the trauma unit.[4] ATLS as a form of trauma simulation is a strong foundation for trauma education; it is comprised of established treatment approaches designed to systematically provide early care for trauma patients.[1] ATLS provides physicians with the skills to recognize and successfully treat injured patients during the “golden hour” to decrease the risk of mortality and morbidity.[7] The improved outcomes are accomplished by identifying trauma as a surgical disease and refining skills through ATLS to prioritize the life-threatening injuries first. There is research to demonstrate the positive impact ATLS has on mortality rates as it relates to trauma patients.[8][9] Researchers found only one independent variable with a significant decrease in patient mortality, which was the systematic use of the ATLS protocol.[8] Similarly, providers who used the ATLS protocol resulted in significantly higher survival rates for high risk injured patients.[9] Though ATLS continues to update the curriculum, others have developed curricula for trauma-based education.

Curriculum Development

Simulation curriculum development has, what seems like, infinite possibilities, but answering basic questions can assist in the creation of a successful curriculum. The first step is to identify the goal of the simulation, which will then dictate the simulation design. Two prevalent designs are skill-based (e.g., improvements in medical knowledge, communication, the time associated with skill completion, self-efficacy, etc.) and scenario-based (e.g., prioritizes reflection and the debriefing process as a learning approach).[10] After identifying the design of the simulation, a team (comprised of content experts, simulation curriculum developers, and other stakeholders) can be developed to create the simulation curriculum. The team should keep in mind the availability of resources (e.g., financial, technology, simulation patients/mannequins, etc.) and simulation as an educational paradigm (e.g., number of participants, time to set up the simulation, time allowed for training, etc.).[11] After identifying resources, educators may consider following a common simulation three-step model: briefing, scenario, and debriefing.[12]

As ATLS has expanded and cycled through nine different editions, the newest is the tenth edition, trauma simulation as a field has evolved. An exploratory PubMed search with the keywords ‘medical simulation AND trauma’ included publication dates in five-year increments beginning in 1990 and ending in 2019, resulted in 55, 102, 205, 422, 721, and 847 articles, respectively. Clearly, there were more medical simulation articles published as time proceeded. Simulations related to clinical care for trauma patients (i.e., trauma resuscitation,[13] pediatric traumas,[14] and mechanically ventilated patients have resulted in statistically significant improvements in knowledge, confidence, and performance from the pre-simulation training to post-simulation.[14][15] Simulation by telecommunication is increasingly prevalent; researchers have shown that focused assessment with sonography for trauma (FAST) examinations taught in-person versus via telepresence demonstrated no statistical differences in knowledge, confidence, or performance.[16] While some simulation-based training has been restricted to a laboratory or off-site setting to ensure a controlled environment, others have occurred within the natural environment.

In situ simulation, training taking place in the natural environment has served as an educational approach to practice in the working or clinical environment.[17] Evidence has supported improved outcomes in both clinical and non-technical skills using in situ simulation-based training.[17][18][19][20] The clinical outcomes that have been the object of study include improvements in the clinical team skills (CTS) scale and improved overall resuscitation time in the emergency department (ED) as well as task completion.[18][19] Furthermore, the CTS scale improvements were better for learners during the in situ simulation phase compared to the didactic training phase alone.[18] Non-technical skills, which improved using in situ simulation-based training, included communication,[17][18] teamwork,[18][19] and situational awareness as demonstrated by self-efficacy.[17] Organizational impact was an improved outcome as well[17][21]; aspects were clinical readiness, trauma readiness,[17] workspace satisfaction,[17][21] and location or materials and medications.[21]

Clinical Clerkships

Medical student involvement in simulation began as early as 1975 with the development of the Objective Structured Clinical Examination (OSCE),[22] with several simulation-based studies resulting in positive outcomes.[23][24] When engaged in simulation training, medical students reported significant improvements regarding knowledge scores, self-efficacy, and “confidence to correct another health care provider at the bedside in a collaborative manner.”[24] Additionally, medical students demonstrated the largest change increase in “confidence to always close the loop in patient care.”[24] Medical students reported over 4.9 out of a 5-point Likert scale that the activity was applicable and educationally beneficial.[24] When medical students were engaged in mass casualty incident (MCI) simulation training, three themes emerged as important: the impact of fidelity on student learning, reflexivity placed on the importance of non-technical skills, and the opportunities for collaborative teamwork.[23] Researchers discovered that there was a positive association between the fidelity of large class MCI simulations and the engagement in the learning process.[23] Simulation allows a focused educational foray into a specific aspect of a clinical situation. As more teams and processes become engaged, the simulation and assessment methodologies become increasingly complex.

Simulation-based training provides an opportunity for a variety of assessments to demonstrate outcomes based on the goals of the simulation. Researchers have focused on the clinical care component of simulation,[18][19][24][25][26] non-technical skills,[17][18][19][27][28] and organizational process.[17][20][21] Clinical care outcomes, not previously discussed within the in situ simulation, were the completion of clinical skills (i.e., trauma tasks and cervical spine immobilization),[25] related to triage (i.e., skills, knowledge, and accuracy),[26] and assessments (i.e., primary survey completion time).[25][26] Non-technical skills continued to include situational awareness in the forms of self-efficacy and perception of preparedness.[28][27] While these are examples of previously utilized measurements for the practice of simulation-based training, it is not to say assessments are limited to these outcome variables.

Medical Decision Making and Leadership Development

While simulation has been a teaching method in medical education for several years, the assessment methods to measure medical decision making is a more recent area of study.[29] Medical decision making is an invaluable skill of any medical provider,[30] recognized by the American College of Graduate Medical Education (ACGME) as a core competency[31]; however, a validated measure has been elusive. Performing tasks, the order of tasks, the time to complete tasks, the patient’s response to intervention, or the lack thereof, interpreting results, and resolving a clinical assessment are interdependent components of medical decision making that cannot be measured intuitively on a linear scale. Emphasis placed upon medical decision making can now be assessed using the Medical Judgement Metric (MJM) to measure medical decision making within simulation-based training.[29] Using the MJM during simulation-based training is an opportunity to further enhance the educational experience of learners by helping to understand better not only the clinical outcomes but the process of making those decisions. 

Clinical Significance

Simulation as a means of impacting healthcare education has been supported by a robust body of literature as a training modality to significantly improve not only clinical,[18][19][24][25][26] but also non-technical skills.[17][18][19][27][28] Improving clinical and non-technical skills through simulation is a way to increase patient safety by decreasing mistakes in care within a secure environment where all learning can serve as opportunities for improvement.[17][20] Low frequency, high-risk clinical scenarios can be practiced in a controlled environment. Medical simulation is a modality that has been demonstrated to assist adult learners at different stages of their professional career from pre-clinical through ongoing professional development.[18][19][23][24][25][26][27][32] As the field of healthcare continues to evolve, the need to provide appropriate evidence-based training will also change. Simulation has been incorporated into trauma education for nearly 40 years after ATLS utilized practical skills as part of its curriculum. Advancements in simulation-based education have subsequently increased the fidelity of the training for learners and assess for the effectiveness of the modality of education via different outcome measures. While simulation provides a basis for skill introduction or refinement, it is important to note that developing proficiency occurs through repetition and clinical care.

Enhancing Healthcare Team Outcomes

Inherently difficult to measure, since the ultimate endpoint is improved patient care which is an endpoint beyond the scope of most simulation-based medical education programs, much research focusses on technical skills, non-technical skills, and organizational outcomes. Accordingly, the surrogates to improved outcomes are measured precursors to the clinical care of a given patient. The evidence to support simulation-based training has been a discussion topic throughout, but there is additional research that supports outcomes for interprofessional training through the use of simulation.[2][21][24][33] Within interprofessional training, there are a variety of non-technical skills with improved outcomes after simulation-based training.

Whether identified as teamwork or better understanding others’ professional role, simulation has demonstrated improved outcomes.[2][12][21] Similarly, communication as a concept was demonstrated by improvements in collaboration and communication.[2][24] Additionally, situational awareness was captured by self-efficacy,[24] confidence,[33] and competency.[33] The field of healthcare owes some of its advancements in education to the use of simulation, and simulation-based training has clearly improved the care of the injured.

In a traumatic situation, all practitioners need to be able to perform at their highest level of competency under heavy duress, make rapids assessments, and formulate decisions as well as execute maneuvers that can save patient lives. Simulation teaches these skills plus the most important skill of communication among the professions involved. This paradigm applies to clinicians (MDs, DOs, NPs, PAs), nursing staff, and pharmacists alike. All must learn the same level of execution and performance under stress within their particular sphere of clinical practice, so they can function effectively as an interprofessional team when the need arises, and achieve optimal patient outcomes through communicating changes in the patient as the need arises. This simulation activity assists the learner in improving interprofessional team communication skills. [Level V]