2019 HSC Section 2 - Practice Management

(second-year interns) were recruited to the study on two sepa- rate days. At the start of each session the doctors were random- ized to one of two approximately equal-sized groups via a sealed envelope technique. No candidate had previously completed an ENT post or routinely covered ENT out of hours. Consent was obtained from all candidates, and independent approval for the study was granted by the hospital training committee. Training Both groups separately received a total of 90 minutes of training delivered by an experienced otorhinolaryngology spe- cialist trainee. Slides were presented covering the basic system- atic assessment of a critically ill patient as per Advanced Life Support (ALS) 8 and Advanced Trauma Life Support (ATLS) 9 guidelines as well as the specific management of ENT emergen- cies. The management of four key topics was covered in detail; airway obstruction of infective origin, epistaxis, post- tonsillectomy bleeding, and neck trauma. Both groups received exactly the same initial slides. In addition, the traditional train- ing group had extra slides covering the presentation, assess- ment, and management in more detail. The simulation group was provided with mannequins (Laerdal Airway Management Trainer; Laerdal Medical, Sta- vanger, Norway; and Nasal cavity model BIX-LV17; Chinon Ind., Shanghai, China), apparatus typically found in a resusci- tation room, and additional specialist ENT equipment such as nasal packs. Patient scenarios were presented following the standard slides for each of the four taught emergencies. In pairs and in front of the teaching group, each candidate was given the opportunity to work through an emergency scenario as either a leader or assistant, with help from the group if required. Candidates were encouraged to act out the patient’s assessment and interventions in as realistic a manner as possi- ble. Each candidate participated during the session, but not in every scenario, and no time for repetition was available. Candidate Perception After candidates had completed the training period, they were asked to complete a questionnaire. The questions and marking system were taken from the Perception of Learning section of the validated Dundee Ready Education Environment Measure (DREEM) scoring system, 10 which has been widely used in the assessment of medical educational environments (see Supporting Information, ENT Emergencies Training Ses- sion Candidate Questionnaire, in the online version of this arti- cle). Candidates were asked to respond to each of 12 statements using a five-point Likert-type scale ranging from “strongly agree” to “strongly disagree.” Scores for this modified DREEM score were then interpreted based on the DREEM guidelines. Candidates were separately asked if they would recommend the course to other junior doctors, using a scale similar to the ques- tionnaire. Candidates did not know the content of the other groups teaching when they completed their questionnaires, therefore eliminating a potential source of bias. Formal Assessment All candidates were assessed with a one-to-one viva led by an experienced otorhinolaryngologist who was blinded to the candidate’s teaching group. All candidates were read the same two emergency scenarios; one based on an epiglottitis patient with airway compromise and another on a patient with uncon- trolled epistaxis. Candidates were scored using a marking sheet with a detailed breakdown of the elements required in the assessment and treatment of the patient, thus standardizing

the marking. Two points were awarded for describing the rele- vant step, or one point was awarded if prompting from the examiner was required. Fifteen key elements were included in each case, giving a maximum possible score of 30 for each sce- nario. An example marking sheet is provided (Fig. 1). Analysis and Statistics Data were analyzed in Microsoft Excel 2008 (Microsoft Corp, Redmond, WA). A Student t test was used for intergroup statistical analysis, with a P value of .05 deemed significant. RESULTS Thirty-eight junior doctors consented to be included in the study, with 20 allocated to the simulation group and 18 to the control group (Fig. 2). The candidates in the simulation group performed significantly better in both viva assessments ( P < .05). Using the standard interpretation categories for the modified DREEM score, candidates trained with the simulation technique rated the training as “highly thought of,” an improvement over the “more positive approach” category applied to the standard training. Candidates in the simulation group were also more likely to recommend the teaching to a colleague ( P 5 .003). The results are summarized in Table I and Figures 3 through 5. DISCUSSION Simulation for specific procedures is becoming increasingly established in ENT training schemes, though the specialty still lags behind general surgery in this respect. 6 Within ENT, both simple mannequin train- ers 11 and virtual reality systems 12 have been shown to provide improved trainee performance when performing procedures on patients. Boot camps that include a significant simulation component have been established in Canada and the United States to provide teaching for junior specialist ENT trainees (residents). 13,14 Chin et al. 13 included high fidelity simulation of emergency scenarios in their 1-day course and received excellent feedback from trainees, though no objective outcomes were measured. Locally, the greatest need is in teaching nonspecial- ist junior doctors, who would often be the first to encounter ENT emergencies in jobs in the emergency department or covering hospital wards. We therefore did not cover tracheostomy, bronchoscopy, or specialist skills, and instead focused on initial assessment, resuscitation, and more basic interventions such as nasal packing, C- spine immobilization, and cricothyroidectomy. Our simu- lations required the candidates to use a systematic approach to the care of a sick patient, ensuring that when faced with a real scenario the basics of manage- ment (such as monitoring observations or providing oxy- gen and appropriate fluids) are not eclipsed by more complex tasks. This type of simulation also involves developing communication and leadership skills, although this was not the primary aim of the teaching. Realizing that procedural skills are often taught separately from communication skills and not in the same context, Kneebone et al. published a study where

Laryngoscope 125: August 2015

Smith et al.: Simulation Training for ENT Emergencies

217