BACKGROUND
Traditionally, in postgraduate medical education, each specialty is taught in isolation. This results in minimal emphasis on interprofessional education (IPE), and this deficiency can act as a hidden curriculum that negatively affects health care team structures. We identified an opportunity to address IPE while teaching best practice sepsis management guidelines.
RATIONALE
There is increasing evidence that improved communication and collaboration by interprofessional teams lead to better care.Reference Brock, Abu-Rish and Chiu 1 Technology-enhanced simulation is beneficial in improving team dynamics during medical crises through practicing teamwork in a controlled, adaptable environment.Reference Mundell, Kennedy and Szostek 2 The merits of IPE using simulation have been shown to break down unhelpful social constructs of hierarchy and silo mentality in high-stakes interprofessional situations, such as in operating rooms and during cardiac resuscitation.Reference Doumouras, Keshet and Nathens 3 – Reference Hunziker, Johansson and Tschan 5
Sepsis management is intrinsically interprofessional, with various health care providers involved at many levels. It is also high-stakes; hospitalized patients with sepsis have a high mortality rate and account for significant health care expenses. Fortunately, sepsis outcomes are highly influenced by educational interventions that improve guideline compliance.Reference Levy, Dellinger and Townsend 6 This module that we designed fulfills the need of both practical sepsis education and IPE.
DESCRIPTION OF INNOVATION
We designed a pilot program for McMaster trainees that was delivered over two sessions in February and April 2012. Twenty-two participants enrolled: 15 residents from the Royal College of Physicians and Surgeons of Canada Emergency Medicine (RCPS-EM) and from the College of Family of Physicians of Canada (CFPC-EM), and internal medicine training programs, 4 emergency nurses (registered nurses [RNs]), and 2 respiratory therapists (RTs). Our aim was to create an educational resource that addressed 1) knowledge, through test-enhanced learning on the sepsis guidelines, and 2) behaviour, through using simulation to provide a practical experience of sepsis management and interprofessional teamwork.
Participants were recruited on a first-come basis through emails from the residents’ respective program offices, and clinical educators (in the case of RNs and RTs). Each session for participants started with a pretest and ended with a posttest to characterize baseline knowledge and learning. A 1-hour case-based interactive presentation on sepsis management was given prior to simulation practice. Both the test and presentation were peer-reviewed by content experts from the RCPSC for content validity and relevance regarding pathophysiology, and for the diagnosis and management of sepsis. After the presentation, the group was divided in half in a manner intended to optimize the distribution of the interprofessional members. Each group went through 2 hours of simulation, 1 hour of which involved a high-fidelity simulator, and the other hour of which involved a virtual patient simulator (Figure 1).
Figure 1 Description of group arrangement and scheduling.
The high-fidelity mannequin (Laerdal SimMan 3G) was used to address interprofessional team behavior while attending to a patient with progressive septic shock. The scenarios included acute peritonitis, meningitis, and pneumonia. “Distractors,” such as serious arrhythmias, were used to necessitate the need for efficient crew resource management of all interprofessional members. Each team was composed of an RN, an RT, a physician team leader, and 1–2 other physician helpers. When not actively in the simulation, other participants learned through observation and participating in the provision of feedback. Each scenario ended with video-enhanced, semi-structured feedback. The feedback focused on the proper medical management of sepsis resuscitation and process of interprofessional teamwork, communication, and collaboration.
The second simulation used a virtual patient simulator (RCSim, RCPSC) with a scenario of urosepsis and shock. Participants learned in a constructivist fashion, through facilitated discussion as the scenario progressed. The simulation ended with a semi-structured feedback, focusing on management prioritization, decision-making processes of the various interprofessional peers, and reflections on experiences.
The program ended with a quantitative evaluation of the program that also included the option to provide general free-text feedback.
An online follow-up was completed 8 months later, involving a repeat of the knowledge quiz and a survey asking the participants to reflect on the module’s effect on their sepsis management and interprofessional teamwork skills.
DISCUSSION
We chose the mixed simulation modalities for two reasons. First, high-fidelity mannequin costs can be prohibitive, and containing cost is important for decreasing barriers to repetitive and deliberate practice, which are the hallmarks of simulation training.Reference Zendejas, Wang and Brydges 7 – Reference McGaghie, Issenberg and Petrusa 8 Second, high-fidelity simulation, although effective for team behaviours, is not necessarily needed for developing decision-making skills or clinical judgment.Reference Nyssen, Larbuisson and Janssens 9 It can also negatively affect learning through overly heightened emotions or cognitive load.Reference Fraser, Ma and Teteris 10 We felt the slower pace and constructivist approach of the RCSim, which may provide a different avenue for deeper learning and consolidation of knowledge.
The learner acceptability of the studied tool was high. Participants found the structure of the module helpful in knowledge and consolidation. This was supported by our finding of a significant improvement in pre- and post-knowledge test scores from 75% to 85%, respectively (p<0.0001). This improvement magnitude was relatively consistent between subspecialties and across years of training. The 8-month follow-up knowledge retention test found no evidence of knowledge decay.
Predominant themes generated from the evaluation and feedback of the program indicated high value for knowledge gain, and improvements in collaborative behaviours. The 8-month follow-up survey found similar lasting value in self-reported collaborative skills and team communication.
As a pilot study, we focused on formative assessment as the major tool to provide deeper learning. We did not use objective measurement scales because behaviour scales are intrinsically task-specific, and we felt that they would be challenging to implement due to the interprofessional nature of the teaching module. We believe that the approach that we used is more flexible in that it would allow various types of health care professionals to use this tool. Technology-enhanced simulation is becoming much more accessible, and, with evidence of improvement in team processes and with focus on patient safety, there is increasingly compelling evidence to use this in the training of our health care trainees and team members.
SUMMARY
We developed and assessed a module that we feel meets the increasing demand for IPE by using a broadly relevant and high impact medical content of sepsis management. The module that we developed provides collaborative learning of an interprofessional nature and incorporates reflective practice. It resulted in a high level of acceptability and knowledge retention as well as relative cost-effectiveness. We believe that our sepsis module is an effective way to introduce interprofessional learning that can be easily integrated into any existing postgraduate or continuing medical education curriculum.
Acknowledgements
We thank Angele Landriault and Dr. Joshua Peachey for their invaluable support in running the simulation sessions.
Competing interests: The pilot study was funded, in part, through Pfizer Canada. The funding was granted through the Practice, Performance and Innovation (PPI) branch of the Royal College of Physicians and Surgeons of Canada (RCPSC) with no restrictions. The PPI branch of RCPSC also provided in-kind support for costs of intellectual property through the right to use RCSim.
