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Simulation in emergency medicine

Simulation is an educational tool that artificially recreates a real-world scenario in a guided experience to facilitate learning. It has long been used in many disciplines; the military have used simulation training from the early strategy games of the 18th century to the complex major field exercises of today. Aviation, to whom medicine often looks as an example for training and safety, uses both high-fidelity flight simulators to train technical skills and the practice of crew resource management (CRM) to improve non-technical skills. Other high-risk industries like the nuclear power industry or disaster planning have utilised it to test systems and preparedness such as the UK government’s multi organisational simulation to assess pandemic preparedness, now eerily prescient in the wake of the COVID 19 pandemic. The importance of experiential learning has been emphasised in medicine since the time of Osler, and developments in educational theory of adult learners recognise the importance of active engagement with the learning materials rather than passively being taught. Simulation has featured in medical education as far back as the 1960s with the introduction of the Resusc-Anne mannequins used for the training of CPR. The method, and the mannequins, slowly developed in the background of medical education during that decade with more realistic mannequins but did not really establish a foothold in mainstream medical education until recently. Initially simulation was established within the domain of surgical skills, particularly in laparoscopic and procedural training. However, after the recognition of human error as a factor in many serious adverse events, there was an attempt to try to improve this, particularly in the domains of team working and interprofessional collaboration. The CRM developed by the aviation industry was adopted and adapted to a medical setting by the field of anaesthetics and became the basis of a number of advances in medical simulation to train non-technical skills. In more recent decades with modernising medical curriculums, there has been recognition that students need to be trained in clinical and communication skills. There has also been a shift in post-graduate medicine with the expectation of continuing medical education and revalidation. As such most medical schools and hospitals now offer clinical skills training using simulators, and there has been development of simulation-based courses like ALERT or CPR training. Using simulation for assessment in the OSCE is now well established in undergraduate education and is becoming widespread in speciality training examinations with ACEM use of OSCE in part 2 examinations. As such most of us have encountered simulation at some point in our medical careers and it is now a mainstay of medical training. Although simulation is widely accepted, the evidence to support its effectiveness has been challenging to obtain. It is difficult to measure how a clinician’s practice has changed solely because of simulation education and not been influenced by other factors. In general, research has focused on learning at Kirkpatrick levels 1 and 2, with a few studying level 3 acquisition, showing that in numerous disciplines from trauma to obstetric care simulation can teach skills and affect behaviours and attitudes. There are improvements in performance at cardiac arrest, central line insertion with fewer catheter-related bloodstream infections and laparoscopic surgical performance. However, it is hard to prove that any of these interventions have resulted in improved patient care, as studies that investigate these effects are difficult to both design and execute. A large meta-analysis in JAMA encompassing 609 studies agreed that simulation training was consistently associated with improved outcomes in regards to acquisition of knowledge, skills and behaviours, and while acknowledging that it was more difficult to assess, felt there was moderate improvement in patientrelated outcomes.