Off-site simulation-based training on management of postpartum hemorrhage amongst final-year medical students

Lakshmi Renganathan; Karuna Datta; Atul Seth; Navdeep Sethi; Madhuri Kanitkar

doi:10.1016/j.mjafi.2020.05.006

. 2020 Aug 1;78(Suppl 1):S152–S157. doi: 10.1016/j.mjafi.2020.05.006

Off-site simulation-based training on management of postpartum hemorrhage amongst final-year medical students

Lakshmi Renganathan ^a, Karuna Datta ^b,^∗, Atul Seth ^c, Navdeep Sethi ^d, Madhuri Kanitkar ^e

PMCID: PMC9485733 PMID: 36147387

Abstract

Background

Postpartum hemorrhage (PPH) is an obstetric emergency, and training of health-care providers for early diagnosis and intervention improves morbidity and mortality. Regular simulation-based training modules are conducted in our institute for health-care providers. The objective of this study was to assess the final-year medical students on their subjective improvement in the management of PPH after an off-site simulation-based training which was conducted after a conventional lecture.

Methods

A survey was administered on medical students and their subjective retrospective analysis of both pre and post off-site simulation was collected. The survey was analyzed, and results were formulated.

Results

Forty-six students completed the survey. Although students felt their confidence level in enumerating the steps in management of PPH less than 50% before the drill, it increased to 70% after the drill. The confidence of the students in carrying out the procedures of PPH also increased. The results showed a considerable subjective improvement in skill and cognitive enhancement after an off-site simulation-based training. There was a significant improvement in the pre and postsimulation training scores in the test. The faculty felt that there was an enhancement in learning after the simulation training.

Conclusion

Off-site simulation of an emergency condition improves both knowledge and skill in students.

Keywords: Faculty perspective, Off-site simulation, Postpartum hemorrhage, Students' Performance, Skill learning

Introduction

Postpartum hemorrhage (PPH) is an obstetric emergency, and training of health-care providers for early diagnosis and intervention improves morbidity and mortality.¹ In order to provide increased competency, maximum exposure, and efficient training, simulation-based training seems relevant.¹^,²^,³^,⁴^,⁵^,⁶^,⁷ Simulation is increasingly used in emergency situations as there is a need for timely management and compatible team with high-level communication to efficiently combat the crisis and save a life.⁸^,⁹ Therefore, there is a need for repeated protocol-based training practice for the team as a whole in management of such critical clinical scenarios without compromising on ethical and legal rights of the patient. Simulation-based training is advocated in our institute to increase the proficiency of the clinical skills of the medical students. Off-site simulation-based training promotes comprehensive and practical training of medical undergraduates in a simulated environment, whereas in situ–based simulation training provides training in the actual patient care setup.⁵^,¹⁰ The objective of this study was to assess the final-year medical students on their subjective improvement in the management of postpartum hemorrhage after an off-site simulation-based training which was conducted after a conventional lecture based training.

The aim of the study was to evaluate the impact of off-site simulation-based training on management of PPH and to determine the change in the confidence level, if any, amongst the final-year medical students to approach the case of PPH after the off-site simulation-based training

Materials and methods

A cross-sectional study was conducted on final-year medical students who attended the pilot off-site simulation-based training (n = 47) which was conducted the next day after a conventional lecture-based training on management of PPH at our institute. This training was conducted in the department of obstetrics and gynecology as small group sessions. The total strength of the conventional lecture-based training was 108 of the 137 final-year students. At the end of the conventional lecture of PPH, faculty members as a part of internal assessment, took a structured viva of the entire batch (n = 108). To remove bias, structured viva was taken by other faculty members of the department other than the instructor of the simulation training, and they were blinded to the intervention. Later the entire batch was divided into two batches. Only the first batch (n = 47, 07 were absent) which happened the next day of conventional lecture was given simulation training and taken for survey. This was performed to prevent passage of time between conventional lecture and simulation training as a confounding factor. The wide gap between the two methods would have created a recall bias. The training equipment layout is shown in Fig. 1, Fig. 2. The training session was taken by one faculty for 45 min duration in small groups (two groups of 24 and 23 students). This was taken by a trained faculty in simulation. The training included hands-on management of various case based scenarios of PPH. Quantification of blood loss was taught by assessing the blood in gauge piece, abdominal swab, kidney tray and a clot of a size of a fist. Details about uterotonics, IV expanders, and maneuvers such as bimanual and aortic compression were demonstrated using scenarios. After the demonstration a 60min session of hands-on assessment of the students was undertaken using various case-based scenarios by other faculty members where students worked in teams to handle the emergency scenario. A revision of the various signs and symptoms and management protocol was carried out after both conventional methods and simulation training. The students attending the training were asked to fill a survey form immediately on completion of the training. The objective of the survey was explained to every individual before they took up the survey on survey monkey (https://www.surveymonkey.com/r/PK2KXCN). The survey was voluntary, and the students had a will to withdraw at any time during the study. The survey was formed after a brain storming session with the faculty and was open only for duration of 4 h from 1800h to 2200 h. This was performed to avoid discussions among the students while filling the form. Evening time was preferred for collecting data because of easy accessibility of internet to students during their leisure time. The survey consisted of 10 items with each having both pre and post retrospective analysis of the off-site simulation-based training (which was conducted after a conventional lecture-based training) on management of PPH. The questions were framed to test their skill enhancement and reinforcement of cognitive domain of learning such as recall and identification of signs and symptoms, their ability to diagnose and treat the patient, and also to test their capability to work as a team. The students were made to self-assess their confidence level before and after the training (survey form Appendix A, available as online supplementary data). Later, the survey was closed, and results were compiled. Another time, the same viva was conducted at the end of the term. Being a must-know topic, the viva was taken for all the students, and the scores of students who attended both the sessions, as before (i.e. after the conventional lecture) and after the off-site simulation training session (which was performed after the conventional lecture session and simulation training session), were compared. The viva scores obtained were analyzed. The study was approved by the Institutional Ethics Committee. A written informed consent was taken from all patients/participants for inclusion in the study.

Fig. 1 — This figure depicts the arrangement of all equipment and drugs for the simulation training.

Fig. 2 — This figure shows the layout of the tray used for simulation training.

Results

Forty-six of the 47 students took up the survey through the web link that was sent to them individually. The results of the survey questions are shown in Fig. 3, Fig. 4, Fig. 5 for change in knowledge and skill level, respectively, as assessed by students. In the survey, before the simulation training, four students reported as ‘not confident’ and seven marked ‘not sure’ of their confidence in conducting the complete clinical examination for a live patient of PPH. This reduced to only three marked as ‘not sure’ after the simulation training as assessed by students themselves.

Fig. 3 — Self-assessment of knowledge (more than 50%), before and after simulation training.

Fig. 4 — Self-assessment of ‘skill level’ (more than 50%) before and after simulation training.

Fig. 5 — Self-assessment of ‘knowledge and skill level’ (more than 85%) before and after simulation training.

Test results and faculty perspective

The faculty felt that only 40–50% of the students were giving correct answers to the questions that were posed to them after a conventional lecture-based training, whereas the percentage was as high as 80–90% after the off-site simulation-based training. They also felt that the students were able to recollect and remember almost 30–40% of the total number of points in the management of PPH, whereas the number was nearly 70–80% after the drill which clearly depicts better reinforcement of knowledge. In addition, the faculty members observed the increase in confidence to conduct the clinical examination, carrying out the steps of PPH, ability to diagnose a case of PPH, and their coordination to work as a team after the off-site simulation-based training among students.

Of the batch of 108 students, of 137 who completed both sessions, the viva scores were analyzed. There was a significant improvement (p = 0.029) in the viva scores of students before and after the simulation training session.

Discussion

The study results correlate with those of Hogg et al.⁴ in terms of the gain in confidence level of students after a session of off-site based simulation training. Sakomoto et al. ³ reported that simulation-based training has taken over the traditional method of training for effective imparting of knowledge in the field of medicine. The study results also suggest a clear rise in the understanding of the subject after a session of off-site simulation-based training. This correlates with Takayesu et al.¹¹ where it was found that simulation-based training is stated to have helped the health-care provider in better teamwork and communication skills, procedural/hands-on skill with applied cognition, and critical thinking. Also according to Bearman et al.,¹² simulation provides a learner-centered environment for better understanding of the subject and skill development because the health-care provider is not under stress and is constantly supervised and corrected leading to enhancement of skills. We used a pre and post retrospective survey which is advocated in such studies.¹³

Some studies¹⁴ have found case-based learning to be superior to human patient simulators. In a randomized controlled trial conducted by Ten Eyck et al.,⁸ simulation was found to promote learning. Better learning was also observed in our study.

The study results also showed an enhancement in clinical skills which is evident from the increase in confidence to identify signs, symptoms, equipment, and drugs and to conduct the complete clinical examination. Many studies have reported¹¹^,¹⁵^,¹⁶^,¹⁷ increased skill enhancement after simulation-based training. Ramsingh et al.⁷ showed that simulation-based training helps in teaching the skills better, and hence, the students understand the concepts better which improves their performance.

An improvement in self-confidence of students post offsite simulation due to reinforcement of knowledge and skill enhancement was seen in our study which is also reported by others.¹⁶^,⁴ This may be due to the fact that off-site simulation-based training has reinforced the steps and procedures of the clinical examination along with skill enhancement. This made them confident to approach a patient of postpartum hemorrhage and also showed confidence to merge as a team member.¹¹^,¹⁸^,¹⁹ The study results confirm reinforcement of knowledge or cognitive domain of learning such as greater retention, memory, and understanding protocol, and similar results are declared in studies carried out by other authors.²⁰^,³^,⁷ The rise in the self-confidence is an indirect measure of satisfaction and is clearly evident in the study; this is also reported before by Ten Eyck et al,⁸ and Cheng et al.²¹ showed improvement in learning and satisfaction with simulation-based curriculum when compared with group discussion.

Nara et al.⁶ have reported that students and tutors both recognize the effectiveness of simulation-based learning in medical education and the same is evident in our study too. There was a significant increase in students' viva scores after an off-site simulation training and conventional lecture as compared to conventional lecture alone. Similar results were reported by Solymos et al..²² They also reported that simulation though is more enjoyable by students but is more resource intensive, as demonstrated by increased requirement of personnel. It does improve communication skills and comfort of the student in handling such a situation as compared with a didactic training.²³

The authors admit that though there are merits of simulation-based training in medical education, it does have its own demerits. Off-site simulation cannot create exact emergency environment and requires expert supervision to reap maximum benefit. The training becomes resource intensive and also because the simulators are artificial in appearance and feel, the health-care provider is often unable to believe and fully immerse in the scenario. Repeated practice on live patients also gives better insight into human anatomy and its variation as reported by Patel et al..²⁴ It is reported that in situ simulation-based training is superior to off-site simulation-based training,¹⁰ but it is important as teachers to understand that an initial off-site simulation for training may be necessary to plan an in situ training for these students and that in situ training should not be the only available method specially for undergraduate training. After the simulation-based training, the medical student qualifies to treat such situations under supervision till the teacher assesses and finds that the student is capable of the management alone.

Conclusion

As per the students and faculty members, off-site simulation-based training did make an impact on learning the management of PPH. It helped the final-year students subjectively understand the concept better and get an insight into clinically approaching the patient in an emergency situation. It subjectively also improved their confidence to work as a team member, and a significant improvement was seen in the viva scores in internal assessment.

Disclosure of competing interest

All authors have none to declare.

Acknowledgements

The authors thank the college authorities for promoting and providing an environment that is conducive for educational research.

Footnotes

^{Appendix A}

Supplementary data to this article can be found online at https://doi.org/10.1016/j.mjafi.2020.05.006.

Appendix A. Supplementary data

The following is/are the Supplementary data to this article:

Multimedia component 1

mmc1.docx^{(320.6KB, docx)}

References

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22.Solymos O., O'Kelly P., Walshe C.M. Pilot study comparing simulation-based and didactic lecture-based critical care teaching for final-year medical students. BMC Anesthesiol. 2015;15:153. doi: 10.1186/s12871-015-0109-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
23.Downar J., McNaughton N., Abdelhalim T., et al. Standardized patient simulation versus didactic teaching alone for improving residents' communication skills when discussing goals of care and resuscitation: a randomized controlled trial. Palliat Med. 2017;31:130–139. doi: 10.1177/0269216316652278. [DOI] [PubMed] [Google Scholar]
24.Patel N.R., Makai G.E., Sloan N.L., et al. Traditional versus simulation resident surgical laparoscopic salpingectomy training: a randomized controlled trial. J Minim Invasive Gynecol. 2016;23:372–377. doi: 10.1016/j.jmig.2015.11.005. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

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[bib1] 1.Lutgendorf M.A., Spalding C., Drake E., et al. Multidisciplinary in situ simulation-based training as a postpartum hemorrhage quality improvement Project. Mil Med. 2017;182:e1762–e1766. doi: 10.7205/MILMED-D-16-00030. [DOI] [PubMed] [Google Scholar]

[bib2] 2.Bodamer C., Feldman M., Kushinka J., et al. An internal medicine simulated practical examination for assessment of clinical competency in third-year medical students. Simulat Healthc J Soc Med Simulat. 2015;10:345–351. doi: 10.1097/SIH.0000000000000108. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib3] 3.Sakamoto Y., Okamoto S., Shimizu K., et al. Hands-on simulation versus traditional video-learning in teaching microsurgery technique. Neurol Med -Chir. 2017;57:238–245. doi: 10.2176/nmc.oa.2016-0317. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib4] 4.Hogg G., Miller D. The effects of an enhanced simulation programme on medical students' confidence responding to clinical deterioration. BMC Med Educ. 2016;16:161. doi: 10.1186/s12909-016-0685-2. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib5] 5.Sorensen J.L., Ostergaard D., LeBlanc V., et al. Design of simulation-based medical education and advantages and disadvantages of in situ simulation versus off-site simulation. BMC Med Educ. 2017;17:20. doi: 10.1186/s12909-016-0838-3. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib6] 6.Nara N., Beppu M., Tohda S., et al. The introduction and effectiveness of simulation-based learning in medical education. Intern Med. 2009;48:1515–1519. doi: 10.2169/internalmedicine.48.2373. [DOI] [PubMed] [Google Scholar]

[bib7] 7.Ramsingh D., Alexander B., Le K., et al. Comparison of the didactic lecture with the simulation/model approach for the teaching of a novel perioperative ultrasound curriculum to anesthesiology residents. J Clin Anesth. 2014;26:443–454. doi: 10.1016/j.jclinane.2014.01.018. [DOI] [PubMed] [Google Scholar]

[bib8] 8.Ten Eyck R.P., Tews M., Ballester J.M. Improved medical student satisfaction and test performance with a simulation-based emergency medicine curriculum: a randomized controlled trial. Ann Emerg Med. 2009;54:684–691. doi: 10.1016/j.annemergmed.2009.03.025. [DOI] [PubMed] [Google Scholar]

[bib9] 9.Thinggaard E., Kleif J., Bjerrum F., et al. Off-site training of laparoscopic skills, a scoping review using a thematic analysis. Surg Endosc. 2016;30:4733–4741. doi: 10.1007/s00464-016-4834-9. [DOI] [PubMed] [Google Scholar]

[bib10] 10.Sorensen J.L., Navne L.E., Martin H.M., et al. Clarifying the learning experiences of healthcare professionals with in situ and off-site simulation-based medical education: a qualitative study. BMJ Open. 2015;5 doi: 10.1136/bmjopen-2015-008345. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib11] 11.Takayesu J.K., Farrell S.E., Evans A.J., et al. How do clinical clerkship students experience simulator-based teaching? A qualitative analysis. Simulat Healthc J Soc Med Simulat. 2006;1:215–219. doi: 10.1097/01.SIH.0000245787.40980.89. [DOI] [PubMed] [Google Scholar]

[bib12] 12.Bearman M., Nestel D., Andreatta P. In: Oxford Textbook of Medical Education. Walsh K., editor. Oxford University Press; 2013. Simulation-based medical education; pp. 186–197. [Google Scholar]

[bib13] 13.Bhanji F., Gottesman R., de Grave W., et al. The retrospective pre-post: a practical method to evaluate learning from an educational program: retrospective pre-post. Acad Emerg Med. 2012;19:189–194. doi: 10.1111/j.1553-2712.2011.01270.x. [DOI] [PubMed] [Google Scholar]

[bib14] 14.Schwartz L.R., Fernandez R., Kouyoumjian S.R., et al. A randomized comparison trial of case-based learning versus human patient simulation in medical student education. Acad Emerg Med. 2007;14:130–137. doi: 10.1197/j.aem.2006.09.052. [DOI] [PubMed] [Google Scholar]

[bib15] 15.Scavone B.M., Toledo P., Higgins N., et al. A randomized controlled trial of the impact of simulation-based training on resident performance during a simulated obstetric anesthesia emergency. Simulat Healthc J Soc Med Simulat. 2010;5:320–324. doi: 10.1097/SIH.0b013e3181e602b3. [DOI] [PubMed] [Google Scholar]

[bib16] 16.Barsuk J.H., McGaghie W.C., Cohen E.R., et al. Use of simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit. J Hosp Med. 2009;4:397–403. doi: 10.1002/jhm.468. [DOI] [PubMed] [Google Scholar]

[bib17] 17.McCoy C.E., Menchine M., Anderson C., et al. Prospective randomized crossover study of simulation vs. didactics for teaching medical students the assessment and management of critically ill patients. J Emerg Med. 2011;40:448–455. doi: 10.1016/j.jemermed.2010.02.026. [DOI] [PubMed] [Google Scholar]

[bib18] 18.Walton A., Kestler E., Dettinger J.C., et al. Impact of a low-technology simulation-based obstetric and newborn care training scheme on non-emergency delivery practices in Guatemala. Int J Gynaecol Obstet. 2016;132:359–364. doi: 10.1016/j.ijgo.2015.08.009. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib19] 19.Rosen M.A., Salas E., Wu T.S., et al. Promoting teamwork: an event-based approach to simulation-based teamwork training for emergency medicine residents. Acad Emerg Med. 2008;15:1190–1198. doi: 10.1111/j.1553-2712.2008.00180.x. [DOI] [PubMed] [Google Scholar]

[bib20] 20.Maddry J.K., Varney S.M., Sessions D., et al. A comparison of simulation-based education versus lecture-based instruction for toxicology training in emergency medicine residents. J Med Toxicol. 2014;10:364–368. doi: 10.1007/s13181-014-0401-8. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib21] 21.Cheng A., Goldman R.D., Aish M.A., et al. A simulation-based acute care curriculum for pediatric emergency medicine fellowship training programs. Pediatr Emerg Care. 2010;26:475–480. doi: 10.1097/PEC.0b013e3181e5841b. [DOI] [PubMed] [Google Scholar]

[bib22] 22.Solymos O., O'Kelly P., Walshe C.M. Pilot study comparing simulation-based and didactic lecture-based critical care teaching for final-year medical students. BMC Anesthesiol. 2015;15:153. doi: 10.1186/s12871-015-0109-6. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib23] 23.Downar J., McNaughton N., Abdelhalim T., et al. Standardized patient simulation versus didactic teaching alone for improving residents' communication skills when discussing goals of care and resuscitation: a randomized controlled trial. Palliat Med. 2017;31:130–139. doi: 10.1177/0269216316652278. [DOI] [PubMed] [Google Scholar]

[bib24] 24.Patel N.R., Makai G.E., Sloan N.L., et al. Traditional versus simulation resident surgical laparoscopic salpingectomy training: a randomized controlled trial. J Minim Invasive Gynecol. 2016;23:372–377. doi: 10.1016/j.jmig.2015.11.005. [DOI] [PubMed] [Google Scholar]

PERMALINK

Off-site simulation-based training on management of postpartum hemorrhage amongst final-year medical students

Lakshmi Renganathan

Karuna Datta

Atul Seth

Navdeep Sethi

Madhuri Kanitkar