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Comparison of the Bleeding Cricothyrotomy Model to SimMan for Training Students and Residents Emergency Cricothyrotomy

Comparison of the Bleeding Cricothyrotomy Model to SimMan for Training Students and Residents... Comparison of the bleeding CRIC to SIM man for training cricothyrotomy Wray A et al. Short Communication Journal of Advances in Medical Education & Professionalism Comparison of the bleeding cricothyrotomy model to SimMan for training students and residents emergency cricothyrotomy 1 2 1 1 A L I S A W R AY *, FA R A Z K HA N , J O H N R AY , RO B E R T RO W E , M E GA N B OY S E N- 1 1 1 O SBO R N , WA R R E N WI E C HM A N N , S H A N N O N T O O H E Y 1 2 University of California, Irvine, Department of Emergency Medicine, Orange, CA, USA; University of California, Irvine, School of Medicine, Irvine, CA, USA *Corresponding author: Introduction: A cricothyroidotomy is an emergency procedure Alisa Wray that few emergency medicine residents see or perform during UC Irvine School of their training. Therefore, there is a need for low cost, high d fi elity Medicine, City Tower, models for training. In this study, we explore a new training model Ste 640. 333 City Blvd W, for cricothyroidotomies (the bleeding CRIC [cost-effective realistic Orange, CA 92868 interactive cricothyroidotomy]) to determine if this new task- Tel: +1-714-456-7916 trainer is non-inferior compared to the current standard of training. Fax: +1-714-456-3714 Methods: Authors conducted a randomized control non- Email: awray@hs.uci.edu inferiority study. There were seventeen residents and medical Please cite this paper as: students enrolled by convenience sample to partake in the study. Wray A, Khan F, Ray J, The participants were randomized by block randomization to be Rowe R, Boysen-Osborn M, Wiechmann W, Toohey S. taught how to perform a cricothyroidotomy on either the new Comparison of the bleeding task trainer or the current standard task trainer and then were cricothyrotomy model asked to perform the procedure on a pig trachea model. Primary to SimMan for training outcome measures were scores on a previously validated objective students and residents assessment tool and secondary outcomes were comfort levels and emergency cricothyrotomy. realism scores based on pre and post survey results which were J Adv Med Educ Prof. analyzed with ANOVA. 2019;7(3):144-148. DOI: Results: There was found to be no statistically signica fi nt difference 10.30476/JAMP.2019.74895. between the groups in assessment scores, time to completion, or Received: 27 October 2018 comfort levels pre- and post-intervention. There was a statistically Accepted: 3 June 2019 signica fi nt difference in that the participants gave higher realism scores in post-test analysis to the Bleeding CRIC compared to the SimMan. Both groups demonstrated that they had signica fi ntly improved comfort levels from baseline post-intervention. Conclusion: Overall, the new task trainer was rated by learners to feel more realistic than the current standard. This study demonstrates non-inferiority of the new task trainer and further studies with larger sample sizes should be conducted to determine its true efca fi cy. Keywords: Graduate, Medical education, Simulation training, High fidelity simulation training Residents are often unable to receive training on Introduction live patients as the procedure is rare and often the cricothyroidotomy is an emergent procedure more senior physicians perform the procedure A done to establish an airway in a patient who (2-4). It is estimated that 0.5 to 2.5 per 10,000 cannot be intubated or ventilated (1). It is a cases will require a surgical airway (1). Nearly procedure that requires appropriate training and half of all emergency medicine residents will practice as it is only done in emergency situations. 144  J Adv Med Educ Prof. July 2019; Vol 7 No 3 Abstract Wray A et al. Comparison of the bleeding CRIC to SIM man for training cricothyrotomy never see a cricothyroidotomy during training, All residents and students participated in the and less than one quarter will perform one (1, 5). teaching and training as a part of their normal Task trainers are essential for residents to receive education activities however participation in the appropriate training, however, these task trainers study was optional. Three students and residents are often unrealistic or expensive (6). One of the present at the simulation education day opted not most commonly used task trainers is part of the to participate. We provided study information Laederal SimMan, a mechanical manikin used sheets and explained the study prior to the start for simulation training. An artificial skin can of the session. A total of seventeen students be placed over his neck and a cricothyrotomy and residents participated in the study. Authors can be practiced on the site. One of the primary randomized them using block randomization limitations of this task trainer is the cost of the (with block sizes of 4) and all participants artificial skin and that it is not intended to be completed all aspects of the study as shown in used multiple times (7-10). Figure 1. As such, it is important to evaluate new task trainers that can provide a realistic simulation experience and decrease the cost of medical education. Dr. Alisa Wray and John Ray developed a task trainer, the bleeding CRIC (cost- effective realistic interactive cricothyroidotomy) using materials easily purchased on the Internet. The task trainer is relatively inexpensive and simple to produce. This study explores this new cricothyroidotomy task trainer to determine if it improves the user’s comfort and success in performing cricothyroidotomies while being non-inferior to the existing standard task trainer. Figure 1: Participant Inclusion Methods This study is a randomized controlled non- inferiority study evaluating the efca fi cy for The primary outcome was participant learning cricothyroidotomy on either bleeding completion of a cricothyroidotomy on the pig CRIC or SimMan. Twenty volunteer participants model evaluated by a previously validated were recruited and randomized using block Objective Structured Assessment of Technical randomization. We created participant numbers in Skills (OSATS) (11). Secondary outcomes advance, used block randomization to randomize were the participants’ comfort levels measured those participant numbers into blocks of four and by the visual analog scale before and after then assigned participant numbers at random training and evaluation (12). Pre-surveys also once participants were consented. included questions regarding the number of The authors created the bleeding CRIC task cricothyroidotomy simulations previously trainer from materials readily available on the performed, as well as the number of real Internet or in the hospital, including ventilator cricothyroidotomies previously performed. Post- tubing, a hot glue gun, tape, a life-size styrofoam surveys asked the participants to rate the realism wig head, Dragon Skin 10 Medium (TM) by of the pig trachea, Bleeding CRIC, and SimMan Smooth-On, stage blood, polyester b fi erfill via a previously validated visual analog scale and silicone glue. Instructions are available on which was a 100mm line with two end-points http://www.cricproject.com/cricbuild.html. The ranging from ‘not at all’ to ‘extremely.’ SimMan used for the study was a Laderal (TM) 1) All students and residents at the simulation SimMan (R). The authors ordered fresh frozen training day received a brief verbal explanation pig larynges from an online scientic fi supply of the study and a study information sheet. company and defrosted them prior to the study. 2) The participants were assigned a number to Human cadavers were not financially feasible for ensure data collection was anonymous. the study. We conducted the study at the UC Irvine 3) The participants completed a pre-instruction School of Medicine Simulation Center during a survey. scheduled monthly resident simulation day. 4) The authors randomized the participants, by 15 UC Irvine emergency medicine residents block randomization, to receive cricothy roidotomy and 5 UC Irvine fourth year medical students instruction on either the bleeding CRIC or were present at the simulation education day. SimMan task trainer. J Adv Med Educ Prof. July 2019; Vol 7 No 3  145 Comparison of the bleeding CRIC to SIM man for training cricothyrotomy Wray A et al. 5) A single instructor taught the participants p=0.84). A summary of the number of medical how to perform a cricothyroidotomy on their students and residents in each group can be found assigned task trainer. in Table 1. There was also no difference between 6) A single evaluator, who was blinded to the pre-intervention comfort levels between the two method of instruction, tested the participants on a groups; the SimMan group mean was 41.1 (95% pig trachea and evaluated them using a validated CI 25.6-56.7), and the CRIC group mean was 32.3 OSATS (11). (95% CI 13.1-51.6) (t=0.81, p=0.43). 7) The participants crossed over and practiced The summary of outcomes can be found performing a cricothyroidotomy on the task in Table 2. The mean time to complete the trainer they were not randomized to. This allowed cricothyroidotomy on the pig trachea was 1:41.00 all participants to experience performing a (95% CI 0:50.93-2:30.98) for the bleeding CRIC cricothyroidotomy on the SimMan, the bleeding group and 2:25.20 (95% CI 00:47.36-4:03.09) for CRIC and the pig trachea model. the SimMan group (t=0.98, p=0.34). The average 8) The participants completed post-instruction OSATS score was 10/12 for the bleeding CRIC survey. group (95% CI 7.9-12) and 9.25/12 (95% CI 7.7- A power calculation was performed based on 10.8) for the SimMan group (t=-0.66, p=0.52). The a previously shown novice mean of 3.2 points mean post-intervention comfort levels were 60.67 per minute with a standard deviation of at least (95% CI 43.8-77.5) for the bleeding CRIC group 1 point per minute (11). Using a two-sided t-test and 64.25 (95% CI 52.4-76.1) for the SimMan with an alpha of 0.05 and a power of 90%, we group with no statistically signica fi nt difference needed a total sample size of 43. Unfortunately, between the two groups (t=0.39, p=0.70). we were unable to have this number with our Both groups showed a statistically signica fi nt available study population. increase in comfort levels from baseline post- The data was collected, tabulated, and coded intervention (bleeding CRIC: 32.33 to 60.66; t=- by a research assistant not involved in any 2.55, p=0.021; SimMan: 41.13 to 64.25; t=-2.80, teaching aspects of the study. The means and p=0.014). There was also a statistically signica fi nt standard deviations were calculated for OSATS difference between the realism that participants scores and visual analog scores. The means for attributed to each task trainer (F=5.14, p<0.01). OSATS and visual analog scores were compared The participants believed that the bleeding CRIC between the groups using a t-test (Microsoft task trainer felt more realistic (mean=70.24) than Excel version 16.16.9). ANOVA was performed the SimMan (mean=51.88) (t=3.09, p=0.004). to analyze the realism scores among the three task trainers. Discussion Ethical approval: The institutional review The authors conducted the study to determine board at the University of California, Irvine if the bleeding CRIC task trainer demonstrated approved this study. non-inferiority to the current standard of teaching. Although we did not reach our goal Results subject number, the results from the study There were 8 participants randomized into the suggest there be no difference in outcomes for SimMan group and 9 participants randomized the participants taught on the bleeding CRIC into the bleeding CRIC group. There were no task trainer versus those taught on the SimMan. statistically signica fi nt differences between the In the evaluation phase, the participants taught groups in the level of training (Chi-square=0.81, on the bleeding CRIC task trainer completed Table 1: Numbers of participants in each group based on level of training Group Total MS R1 R2 R3 SIM man 8 1 2 3 2 Bleeding Cric 9 1 4 2 2 Table 2: OSATS and survey results between groups Group Pre-comfort levels OSATS Completion time Post-comfort levels SIM man 41.13±25.06 9.25±2.69 02:25.2±01:05.1 64.25±21.93 (95% CI 25.6-56.7) (95% CI 7.7-10.8) (95% CI 00:47.36-4:03.09) (95% CI 52.4-76.1) Bleeding Cric 32.33±18.59 10±1.83 01:41.0±01:57.1 60.66±12.15 (95% CI 13.1-51.6) (95% CI 7.9-12) (95% CI 0:50.93-2:30.98) (95% CI 43.8-77.5) P value for difference 0.43 0.52 0.34 0.7 Mean (Standard Deviation) 146  J Adv Med Educ Prof. July 2019; Vol 7 No 3 Wray A et al. Comparison of the bleeding CRIC to SIM man for training cricothyrotomy the cricothyroidotomy in less time and with can provide signica fi nt cost savings for users. a better OSATS score on average than those taught on SimMan; however, the difference Conclusion was not statistically signica fi nt. Both groups The study data shows promising results for the did demonstrate a signica fi nt improvement bleeding CRIC task trainer as it can be seen as in comfort levels from baseline. Lastly, the non-inferior to the SimMan and trended towards participants reported that the bleeding CRIC felt superiority in realism. Given that the bleeding more realistic compared to the SimMan. CRIC is substantially less expensive to produce Similar studies have been conducted to and use than the SimMan, it may be useful to evaluate new teaching models on resident and continue to investigate this new task trainer. If medical student education. One study evaluated the data continues to show at least non-inferiority, the efca fi cy of new cricothyroidotomy teaching this tool can be used for cricothyroidotomy model by having one hundred twenty final training and not only reduce expenses, but also year medical students complete pre- and post- signica fi ntly enhance the training experience. teaching session surveys on cond fi ence levels as well as having 30 of the students complete an Funding Disclosure: No funding received for objective skills assessment similar to our current the current study. study (13). They found that there was a signica fi nt improvement in post-session cond fi ence levels Conflict of Interest Disclosure and all 30 students were deemed competent The Bleeding CRIC task trainer was produced in performing cricothyroidotomy despite no by the current study’s lead author, Dr. Alisa Wray. comparison group. Likewise, another study Dr. Wray has a free open access website www. evaluated a high-de fi lity epistaxis task trainer cricproject.com that explains how to build this on training junior surgical residents for epistaxis model; she has received no revenue from this task management (13). They enrolled 13 residents trainer. There is no financial gain or conflicts of in a cohort study and found that there was a interest to report. statistically signica fi nt improvement in global rating scores across all measured items after the References 1. Makowski AL. The ethics of using the recently intervention compared to pre-intervention scores. deceased to instruct residents in cricothyrotomy. Ann Both studies concluded that their teaching models Emerg Med. 2015;66(4):403-8. led to an improvement in educational outcomes 2. Reiter DA, Lakoff DJ, Trueger NS, Shah KH. Individual for their participants. Our study was designed interactive instruction: an innovative enhancement to resident dducation. YMEM. 2013;61(1):110-3. to include a comparison group and used pre and 3. Burnette K, Ramundo M, Stevenson M, Beeson MS. post surveys as well as a previously validated Evaluation of a web-based asynchronous pediatric objective assessment tool similar to these two emergency medicine learning tool for residents and studies to strengthen our conclusions. medical students. Acad Emerg Med. 2016;16:S46-S50. 4. Toohey SL, Wray A, Wiechmann W, Lin M, Boysen- Our study however was limited largely due Osborn M. Ten tips for engaging the millennial to the small sample size of residents. As this is a learner and moving an emergency medicine preliminary study, we determined the sample size residency curriculum into the 21st century. WestJEM. to be satisfactory to report given it showed some 2016;17(3):1-9. signica fi nt results. The results trended toward 5. Makowski A. A survey of graduating emergency medicine residents’ experience with cricothyrotomy. better outcomes for the bleeding CRIC group with WestJEM. 2013;14(6):654-61. a few outliers. Had there been a larger sample, we 6. ACGME program. ACGME program requirements may have seen more signica fi nt results. Further for graduate medical education in emergency research should be conducted with larger sample medicine [internet].[Cited: May 26, 2016. Accessed May 26, 2016]. Available from: https://www.acgme. sizes to determine the true differences between org/Portals/0/PFAssets/ProgramRequirements/110_ the two task trainers. More studies should be emergency _medicine_07012015.pdf. performed to determine whether the bleeding 7. Greif R, Egger L, Basciani RM, Lockey A, Vogt A. CRIC task trainer can be a viable model to Emergency skill training – a randomized controlled study on the effectiveness of the 4-stage approach implement in cricothyroidotomy training. compared to traditional clinical teaching. Resuscitation. Importantly, the creation of a bleeding CRIC 2010;81(12):1692-7. task trainer costs approximately $88 for the 8. Cho J, Kang GH, Kim EC, Oh YM, Choi HJ, Im TH, initial purchases that create 40+ attempts at a et al. Comparison of manikin versus porcine models in cricothyrotomy procedure training. Emerg Med J. cricothyroidotomy. In comparison a traditional 2008;25(11):732-4. SIM manikin or task trainer can cost more than Malekzadeh S, Malloy KM, Chu EE, Tompkins J, $2,000 (13). Our results suggest that outcomes Battista A, Deutsch ES. ORL emergencies boot camp: between the two are not different, but the former using simulation to onboard residents. Laryngoscope. J Adv Med Educ Prof. July 2019; Vol 7 No 3  147 Comparison of the bleeding CRIC to SIM man for training cricothyrotomy Wray A et al. 2011;121(10):2114-21. cricothyroidotomy skills. Otolaryngol Head Neck 10. Murphy C, Rooney SJ, Maharaj CH, Laffey JG, Surg. 2015;152(2):260-5. Harte BH. Comparison of three cuffed emergency 12. Berry M, Lystig T, Reznick R, Lönn L. Assessment of percutaneous cricothyroidotomy devices to a virtual interventional simulator trainer. J Endovasc conventional surgical cricothyroidotomy in a porcine Ther. 2006;13(2):237-43. model. Br J Anaesth. 2011;106(1):57-64. 13. Laerdal. Deluxe Difc fi ult Airway Trainer [internet]. 11. Melchiors J, Todsen T, Nilsson P, Wennervaldt K, [Accessed October 21, 2018]. Available from: https:// Charabi B, Bøttger M, et al. Preparing for emergency: www.laerdal.com/us/item/261-10001. a valid, reliable assessment tool for emergency 148  J Adv Med Educ Prof. July 2019; Vol 7 No 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Advances in Medical Education & Professionalism Pubmed Central

Comparison of the Bleeding Cricothyrotomy Model to SimMan for Training Students and Residents Emergency Cricothyrotomy

Journal of Advances in Medical Education & Professionalism , Volume 7 (3) – Jul 1, 2019

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Copyright: © Journal of Advances in Medical Education & Professionalism
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2322-2220
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2322-3561
DOI
10.30476/JAMP.2019.74895
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Abstract

Comparison of the bleeding CRIC to SIM man for training cricothyrotomy Wray A et al. Short Communication Journal of Advances in Medical Education & Professionalism Comparison of the bleeding cricothyrotomy model to SimMan for training students and residents emergency cricothyrotomy 1 2 1 1 A L I S A W R AY *, FA R A Z K HA N , J O H N R AY , RO B E R T RO W E , M E GA N B OY S E N- 1 1 1 O SBO R N , WA R R E N WI E C HM A N N , S H A N N O N T O O H E Y 1 2 University of California, Irvine, Department of Emergency Medicine, Orange, CA, USA; University of California, Irvine, School of Medicine, Irvine, CA, USA *Corresponding author: Introduction: A cricothyroidotomy is an emergency procedure Alisa Wray that few emergency medicine residents see or perform during UC Irvine School of their training. Therefore, there is a need for low cost, high d fi elity Medicine, City Tower, models for training. In this study, we explore a new training model Ste 640. 333 City Blvd W, for cricothyroidotomies (the bleeding CRIC [cost-effective realistic Orange, CA 92868 interactive cricothyroidotomy]) to determine if this new task- Tel: +1-714-456-7916 trainer is non-inferior compared to the current standard of training. Fax: +1-714-456-3714 Methods: Authors conducted a randomized control non- Email: awray@hs.uci.edu inferiority study. There were seventeen residents and medical Please cite this paper as: students enrolled by convenience sample to partake in the study. Wray A, Khan F, Ray J, The participants were randomized by block randomization to be Rowe R, Boysen-Osborn M, Wiechmann W, Toohey S. taught how to perform a cricothyroidotomy on either the new Comparison of the bleeding task trainer or the current standard task trainer and then were cricothyrotomy model asked to perform the procedure on a pig trachea model. Primary to SimMan for training outcome measures were scores on a previously validated objective students and residents assessment tool and secondary outcomes were comfort levels and emergency cricothyrotomy. realism scores based on pre and post survey results which were J Adv Med Educ Prof. analyzed with ANOVA. 2019;7(3):144-148. DOI: Results: There was found to be no statistically signica fi nt difference 10.30476/JAMP.2019.74895. between the groups in assessment scores, time to completion, or Received: 27 October 2018 comfort levels pre- and post-intervention. There was a statistically Accepted: 3 June 2019 signica fi nt difference in that the participants gave higher realism scores in post-test analysis to the Bleeding CRIC compared to the SimMan. Both groups demonstrated that they had signica fi ntly improved comfort levels from baseline post-intervention. Conclusion: Overall, the new task trainer was rated by learners to feel more realistic than the current standard. This study demonstrates non-inferiority of the new task trainer and further studies with larger sample sizes should be conducted to determine its true efca fi cy. Keywords: Graduate, Medical education, Simulation training, High fidelity simulation training Residents are often unable to receive training on Introduction live patients as the procedure is rare and often the cricothyroidotomy is an emergent procedure more senior physicians perform the procedure A done to establish an airway in a patient who (2-4). It is estimated that 0.5 to 2.5 per 10,000 cannot be intubated or ventilated (1). It is a cases will require a surgical airway (1). Nearly procedure that requires appropriate training and half of all emergency medicine residents will practice as it is only done in emergency situations. 144  J Adv Med Educ Prof. July 2019; Vol 7 No 3 Abstract Wray A et al. Comparison of the bleeding CRIC to SIM man for training cricothyrotomy never see a cricothyroidotomy during training, All residents and students participated in the and less than one quarter will perform one (1, 5). teaching and training as a part of their normal Task trainers are essential for residents to receive education activities however participation in the appropriate training, however, these task trainers study was optional. Three students and residents are often unrealistic or expensive (6). One of the present at the simulation education day opted not most commonly used task trainers is part of the to participate. We provided study information Laederal SimMan, a mechanical manikin used sheets and explained the study prior to the start for simulation training. An artificial skin can of the session. A total of seventeen students be placed over his neck and a cricothyrotomy and residents participated in the study. Authors can be practiced on the site. One of the primary randomized them using block randomization limitations of this task trainer is the cost of the (with block sizes of 4) and all participants artificial skin and that it is not intended to be completed all aspects of the study as shown in used multiple times (7-10). Figure 1. As such, it is important to evaluate new task trainers that can provide a realistic simulation experience and decrease the cost of medical education. Dr. Alisa Wray and John Ray developed a task trainer, the bleeding CRIC (cost- effective realistic interactive cricothyroidotomy) using materials easily purchased on the Internet. The task trainer is relatively inexpensive and simple to produce. This study explores this new cricothyroidotomy task trainer to determine if it improves the user’s comfort and success in performing cricothyroidotomies while being non-inferior to the existing standard task trainer. Figure 1: Participant Inclusion Methods This study is a randomized controlled non- inferiority study evaluating the efca fi cy for The primary outcome was participant learning cricothyroidotomy on either bleeding completion of a cricothyroidotomy on the pig CRIC or SimMan. Twenty volunteer participants model evaluated by a previously validated were recruited and randomized using block Objective Structured Assessment of Technical randomization. We created participant numbers in Skills (OSATS) (11). Secondary outcomes advance, used block randomization to randomize were the participants’ comfort levels measured those participant numbers into blocks of four and by the visual analog scale before and after then assigned participant numbers at random training and evaluation (12). Pre-surveys also once participants were consented. included questions regarding the number of The authors created the bleeding CRIC task cricothyroidotomy simulations previously trainer from materials readily available on the performed, as well as the number of real Internet or in the hospital, including ventilator cricothyroidotomies previously performed. Post- tubing, a hot glue gun, tape, a life-size styrofoam surveys asked the participants to rate the realism wig head, Dragon Skin 10 Medium (TM) by of the pig trachea, Bleeding CRIC, and SimMan Smooth-On, stage blood, polyester b fi erfill via a previously validated visual analog scale and silicone glue. Instructions are available on which was a 100mm line with two end-points http://www.cricproject.com/cricbuild.html. The ranging from ‘not at all’ to ‘extremely.’ SimMan used for the study was a Laderal (TM) 1) All students and residents at the simulation SimMan (R). The authors ordered fresh frozen training day received a brief verbal explanation pig larynges from an online scientic fi supply of the study and a study information sheet. company and defrosted them prior to the study. 2) The participants were assigned a number to Human cadavers were not financially feasible for ensure data collection was anonymous. the study. We conducted the study at the UC Irvine 3) The participants completed a pre-instruction School of Medicine Simulation Center during a survey. scheduled monthly resident simulation day. 4) The authors randomized the participants, by 15 UC Irvine emergency medicine residents block randomization, to receive cricothy roidotomy and 5 UC Irvine fourth year medical students instruction on either the bleeding CRIC or were present at the simulation education day. SimMan task trainer. J Adv Med Educ Prof. July 2019; Vol 7 No 3  145 Comparison of the bleeding CRIC to SIM man for training cricothyrotomy Wray A et al. 5) A single instructor taught the participants p=0.84). A summary of the number of medical how to perform a cricothyroidotomy on their students and residents in each group can be found assigned task trainer. in Table 1. There was also no difference between 6) A single evaluator, who was blinded to the pre-intervention comfort levels between the two method of instruction, tested the participants on a groups; the SimMan group mean was 41.1 (95% pig trachea and evaluated them using a validated CI 25.6-56.7), and the CRIC group mean was 32.3 OSATS (11). (95% CI 13.1-51.6) (t=0.81, p=0.43). 7) The participants crossed over and practiced The summary of outcomes can be found performing a cricothyroidotomy on the task in Table 2. The mean time to complete the trainer they were not randomized to. This allowed cricothyroidotomy on the pig trachea was 1:41.00 all participants to experience performing a (95% CI 0:50.93-2:30.98) for the bleeding CRIC cricothyroidotomy on the SimMan, the bleeding group and 2:25.20 (95% CI 00:47.36-4:03.09) for CRIC and the pig trachea model. the SimMan group (t=0.98, p=0.34). The average 8) The participants completed post-instruction OSATS score was 10/12 for the bleeding CRIC survey. group (95% CI 7.9-12) and 9.25/12 (95% CI 7.7- A power calculation was performed based on 10.8) for the SimMan group (t=-0.66, p=0.52). The a previously shown novice mean of 3.2 points mean post-intervention comfort levels were 60.67 per minute with a standard deviation of at least (95% CI 43.8-77.5) for the bleeding CRIC group 1 point per minute (11). Using a two-sided t-test and 64.25 (95% CI 52.4-76.1) for the SimMan with an alpha of 0.05 and a power of 90%, we group with no statistically signica fi nt difference needed a total sample size of 43. Unfortunately, between the two groups (t=0.39, p=0.70). we were unable to have this number with our Both groups showed a statistically signica fi nt available study population. increase in comfort levels from baseline post- The data was collected, tabulated, and coded intervention (bleeding CRIC: 32.33 to 60.66; t=- by a research assistant not involved in any 2.55, p=0.021; SimMan: 41.13 to 64.25; t=-2.80, teaching aspects of the study. The means and p=0.014). There was also a statistically signica fi nt standard deviations were calculated for OSATS difference between the realism that participants scores and visual analog scores. The means for attributed to each task trainer (F=5.14, p<0.01). OSATS and visual analog scores were compared The participants believed that the bleeding CRIC between the groups using a t-test (Microsoft task trainer felt more realistic (mean=70.24) than Excel version 16.16.9). ANOVA was performed the SimMan (mean=51.88) (t=3.09, p=0.004). to analyze the realism scores among the three task trainers. Discussion Ethical approval: The institutional review The authors conducted the study to determine board at the University of California, Irvine if the bleeding CRIC task trainer demonstrated approved this study. non-inferiority to the current standard of teaching. Although we did not reach our goal Results subject number, the results from the study There were 8 participants randomized into the suggest there be no difference in outcomes for SimMan group and 9 participants randomized the participants taught on the bleeding CRIC into the bleeding CRIC group. There were no task trainer versus those taught on the SimMan. statistically signica fi nt differences between the In the evaluation phase, the participants taught groups in the level of training (Chi-square=0.81, on the bleeding CRIC task trainer completed Table 1: Numbers of participants in each group based on level of training Group Total MS R1 R2 R3 SIM man 8 1 2 3 2 Bleeding Cric 9 1 4 2 2 Table 2: OSATS and survey results between groups Group Pre-comfort levels OSATS Completion time Post-comfort levels SIM man 41.13±25.06 9.25±2.69 02:25.2±01:05.1 64.25±21.93 (95% CI 25.6-56.7) (95% CI 7.7-10.8) (95% CI 00:47.36-4:03.09) (95% CI 52.4-76.1) Bleeding Cric 32.33±18.59 10±1.83 01:41.0±01:57.1 60.66±12.15 (95% CI 13.1-51.6) (95% CI 7.9-12) (95% CI 0:50.93-2:30.98) (95% CI 43.8-77.5) P value for difference 0.43 0.52 0.34 0.7 Mean (Standard Deviation) 146  J Adv Med Educ Prof. July 2019; Vol 7 No 3 Wray A et al. Comparison of the bleeding CRIC to SIM man for training cricothyrotomy the cricothyroidotomy in less time and with can provide signica fi nt cost savings for users. a better OSATS score on average than those taught on SimMan; however, the difference Conclusion was not statistically signica fi nt. Both groups The study data shows promising results for the did demonstrate a signica fi nt improvement bleeding CRIC task trainer as it can be seen as in comfort levels from baseline. Lastly, the non-inferior to the SimMan and trended towards participants reported that the bleeding CRIC felt superiority in realism. Given that the bleeding more realistic compared to the SimMan. CRIC is substantially less expensive to produce Similar studies have been conducted to and use than the SimMan, it may be useful to evaluate new teaching models on resident and continue to investigate this new task trainer. If medical student education. One study evaluated the data continues to show at least non-inferiority, the efca fi cy of new cricothyroidotomy teaching this tool can be used for cricothyroidotomy model by having one hundred twenty final training and not only reduce expenses, but also year medical students complete pre- and post- signica fi ntly enhance the training experience. teaching session surveys on cond fi ence levels as well as having 30 of the students complete an Funding Disclosure: No funding received for objective skills assessment similar to our current the current study. study (13). They found that there was a signica fi nt improvement in post-session cond fi ence levels Conflict of Interest Disclosure and all 30 students were deemed competent The Bleeding CRIC task trainer was produced in performing cricothyroidotomy despite no by the current study’s lead author, Dr. Alisa Wray. comparison group. Likewise, another study Dr. Wray has a free open access website www. evaluated a high-de fi lity epistaxis task trainer cricproject.com that explains how to build this on training junior surgical residents for epistaxis model; she has received no revenue from this task management (13). They enrolled 13 residents trainer. There is no financial gain or conflicts of in a cohort study and found that there was a interest to report. statistically signica fi nt improvement in global rating scores across all measured items after the References 1. Makowski AL. The ethics of using the recently intervention compared to pre-intervention scores. deceased to instruct residents in cricothyrotomy. Ann Both studies concluded that their teaching models Emerg Med. 2015;66(4):403-8. led to an improvement in educational outcomes 2. Reiter DA, Lakoff DJ, Trueger NS, Shah KH. Individual for their participants. Our study was designed interactive instruction: an innovative enhancement to resident dducation. YMEM. 2013;61(1):110-3. to include a comparison group and used pre and 3. Burnette K, Ramundo M, Stevenson M, Beeson MS. post surveys as well as a previously validated Evaluation of a web-based asynchronous pediatric objective assessment tool similar to these two emergency medicine learning tool for residents and studies to strengthen our conclusions. medical students. Acad Emerg Med. 2016;16:S46-S50. 4. Toohey SL, Wray A, Wiechmann W, Lin M, Boysen- Our study however was limited largely due Osborn M. Ten tips for engaging the millennial to the small sample size of residents. As this is a learner and moving an emergency medicine preliminary study, we determined the sample size residency curriculum into the 21st century. WestJEM. to be satisfactory to report given it showed some 2016;17(3):1-9. signica fi nt results. The results trended toward 5. Makowski A. A survey of graduating emergency medicine residents’ experience with cricothyrotomy. better outcomes for the bleeding CRIC group with WestJEM. 2013;14(6):654-61. a few outliers. Had there been a larger sample, we 6. ACGME program. ACGME program requirements may have seen more signica fi nt results. Further for graduate medical education in emergency research should be conducted with larger sample medicine [internet].[Cited: May 26, 2016. Accessed May 26, 2016]. Available from: https://www.acgme. sizes to determine the true differences between org/Portals/0/PFAssets/ProgramRequirements/110_ the two task trainers. More studies should be emergency _medicine_07012015.pdf. performed to determine whether the bleeding 7. Greif R, Egger L, Basciani RM, Lockey A, Vogt A. CRIC task trainer can be a viable model to Emergency skill training – a randomized controlled study on the effectiveness of the 4-stage approach implement in cricothyroidotomy training. compared to traditional clinical teaching. Resuscitation. Importantly, the creation of a bleeding CRIC 2010;81(12):1692-7. task trainer costs approximately $88 for the 8. Cho J, Kang GH, Kim EC, Oh YM, Choi HJ, Im TH, initial purchases that create 40+ attempts at a et al. Comparison of manikin versus porcine models in cricothyrotomy procedure training. Emerg Med J. cricothyroidotomy. In comparison a traditional 2008;25(11):732-4. SIM manikin or task trainer can cost more than Malekzadeh S, Malloy KM, Chu EE, Tompkins J, $2,000 (13). Our results suggest that outcomes Battista A, Deutsch ES. ORL emergencies boot camp: between the two are not different, but the former using simulation to onboard residents. Laryngoscope. J Adv Med Educ Prof. July 2019; Vol 7 No 3  147 Comparison of the bleeding CRIC to SIM man for training cricothyrotomy Wray A et al. 2011;121(10):2114-21. cricothyroidotomy skills. Otolaryngol Head Neck 10. Murphy C, Rooney SJ, Maharaj CH, Laffey JG, Surg. 2015;152(2):260-5. Harte BH. Comparison of three cuffed emergency 12. Berry M, Lystig T, Reznick R, Lönn L. Assessment of percutaneous cricothyroidotomy devices to a virtual interventional simulator trainer. J Endovasc conventional surgical cricothyroidotomy in a porcine Ther. 2006;13(2):237-43. model. Br J Anaesth. 2011;106(1):57-64. 13. Laerdal. Deluxe Difc fi ult Airway Trainer [internet]. 11. Melchiors J, Todsen T, Nilsson P, Wennervaldt K, [Accessed October 21, 2018]. Available from: https:// Charabi B, Bøttger M, et al. Preparing for emergency: www.laerdal.com/us/item/261-10001. a valid, reliable assessment tool for emergency 148  J Adv Med Educ Prof. July 2019; Vol 7 No 3

Journal

Journal of Advances in Medical Education & ProfessionalismPubmed Central

Published: Jul 1, 2019

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