Simulation Sessions: Simulation at a Distance for Remote and Resource-Limited Settings

December 2, 2022

The power of simulation is in the hands-on nature so often it is assumed that simulation must happen in person. Simulation at a distance has been around for several decades as a method that connects educators and learners across space and time. The pandemic rapidly accelerated the use and development of this modality and led to many innovative simulations in the last few years. Join us as Dr. Elizabeth Sanseau, a pediatric emergency physician from Children’s Hospital of Philadelphia (CHOP), shares some of the ways she has used this modality and how others can take advantage of its flexibility in their own settings.

Transcript

Dr. Angela Kade Goepferd:  This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to The Kid Experts, where the complex is our every day. Each week, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge and perhaps change how you care for kids.

Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. The pandemic has made us see new virtual frontiers when it comes to both how we provide care to our patients and how we learn to provide that care. In this episode, join guest host Dr. Samreen Vora to learn how we can optimize the impact of virtual or hybrid simulation, to better reach our remote healthcare communities and the pediatric patients they serve.

Dr. Samreen Vora: Hello and welcome to Talking Pediatrics simulation sessions with Dr. Samreen Vora. I’m so excited to have you today. And today we are going to be talking about distance simulation. We have a really special guest I’m really excited to welcome Dr. Elizabeth Sanseau, who is a physician who specializes in pediatrics, emergency medicine and global health. She currently practices clinically as a pediatric emergency medicine provider at the Children’s Hospital Philadelphia, CHOP, while partnering with several national and international healthcare organizations to co-create, implement, and evaluate simulation based medical education, adapted for both in-person and remote facilitation. She co-leads the Indian Health System Emergency Medical Services for Children hybrid simulation program with the mission to optimize pediatric emergency preparedness for American Indian and Alaska Native patients. And welcome Dr. Sanseau.

Dr. Elizabeth Sanseau: Thank you so much for having me, Samreen. It’s an honor to be here today.

Dr. Samreen Vora: I remember the first time I met you and I was just so intrigued by the experiences you were sharing, from even before coming into pediatric emergency medicine. I thought, “Well, this is someone I want to keep talking to and someone I want to be friends with.” And so I wonder if you could share with our listeners a little bit about your background and experiences that led to the work you’re doing today?

Dr. Elizabeth Sanseau: Certainly. So prior to specializing in pediatric emergency medicine where I currently practice in an urban setting, I worked for several years actually as a general pediatrician in the Alaska Bush. So I worked in the tundra in a system without a road system connecting the region. So this means that patients literally accessed health care by foot, boat, plane, snow machine, and get this, even dog sled.

I know. And the community health practitioners are actually the role that provides the bulk of the care as a key component in the robust Alaska Native medical system. And really it was 10 years ago, pre-COVID-19 pandemic, working with these health practitioners, who they themselves actually identified that simulation based medical education, both in-person and provided at a distance, would be the most useful for them to practice their preparedness to respond to ill and injured pediatric patients in their community. And that’s what led me here to this point today. That’s why I’m interested in this.

Dr. Samreen Vora: My conversations on this topic have really become more robust once COIVD hit. But you have been really thinking about this and others out there and working on this in various ways for a long time. And I’m curious… When you describe that community, healthcare can be really hard to access. And I think there are places that applies to very much the same in the U.S. and I know you’ve talked a little bit about some of that data too around pediatric care. Can you share some of that?

Dr. Elizabeth Sanseau: So I mean, as you know, there are really unacceptable deficiencies in the accessibility of basic pediatric emergency care around the world. And focusing just on the United States for now, more than 85% of children who need emergency care go to the general emergency department, which concurrently cares for children and adults without access to pediatric specialists. And research actually shows that many of these EDs are not pediatric ready or well prepared to care for children. Studies have also shown that longer travel times to healthcare facilities are associated with a lower likelihood of seeking care and higher mortality.

So I’m really interested in optimizing the pediatric emergency preparedness of these EDs, specifically in remote settings, such as the context that I described initially in Alaska. And one important piece of enhancing the capacity of these frontline providers and teams is via education and system preparation. And if you ask adult learners working in some of these most remote settings in the United States, they will unsurprisingly tell you that they want hands-on, active learning to enhance their skills. And so really simulation conducted at a distance is one way to meet this request for active learning and remote or hard to reach settings. And I really think it’s a tool that can overcome barriers to access traditional in-person simulation like geography, weather, resources of time, personnel and cost, just to name a few.

Dr. Samreen Vora: The cool part that I’m excited to talk about today is you use the words “hands-on training.” They want something where they actually get to practice and then you said, “Well, we do it in a distance.” And I think I’m really excited to keep talking and have you describe what does that look like? Because I think this hits really close to home for us in Minnesota, and I’ve been here over the last six years. I’ve realized what a vast community Children’s Minnesota serves. It stretches all the way to our northern most remote towns in our state into the Dakotas. And really we offer that specialized pediatric care.

You talked about the kids that are going into these EDs that… Not that those EDs are not serving them, but then there’s this next level of care and even helping those EDs be prepared to offer that next level of care. And so I’m really excited to learn from you how we can better serve these communities within our own bounds here, even if we can’t sometimes physically get to them, how do we get our kid expertise to them? So can you tell me a little bit more about what you mean by simulation conducted at a distance or the terms you’re using? How do we do that hands-on but from far away?

Dr. Elizabeth Sanseau: When we think about traditional simulation, we envision a hands-on, didactic experience that enables practice and facilitates learning. And that word “simulate” really has its origins in Latin roots. The past participle of simulare, which means to make like or imitate, copy or represent.

So I think of simulation conducted at a distance as a simulation experience where the basics are connected across a physical distance. And so consider the physical setup of the last simulation that you participated in. So envision what that was in-person. So basic components of a classic in-person simulation include that manikin or that task trainer, the manikin operator, the facilitator educator, the other learner participants around you. And in that traditional, in-person simulation where you’re doing CPR and the manikin, these components are physically together in one room.

Now consider that the facilitator is physically elsewhere and they’re tele-connecting into a room via the internet streaming device where the learners and the manikin and an operator are all located. Or consider even mixing up the bag even more that the facilitators and learners are each in a separate location and they are tele-connecting into a room where there is the manikin and the manikin operator in the room together, all engaged in the simulation drill. Or remove the manikin and operator all together and consider using video or still images as the focal point of the simulation based learning activity or even imagine connecting into a virtual reality platform or a simulation game.

So as you can see, there are many different options. And as you can imagine, having so many different options can make it difficult to describe specifically the who, what, where, when, why of what you’re doing. That can become very challenging, fast. And we’re on a podcast, so we’re not looking, not reading words and we’re not looking at pictures right now, but often recognizing an image is easier than reading a text. So I love how some folks in the simulation research community have really decided to describe simulation at a distance using pictograms or stylized figurative drawing used to convey the information instead of words.

But we really need to standardize the words that we are using to describe these various ways to conduct simulation at distance. And lucky for us, there are many people thinking about this and who have written the Healthcare Simulation Dictionary, which is free to download. I actually just downloaded it last night and it’s from the Society for Simulation and Healthcare, the SSH website. And pull this up after this podcast. It’s pretty fun, which is pretty geeky, but it’s pretty fun to look through it and it really defines every possible scenario where facilitators, learners, task trainers, manikin, technicians, games, computers, anything can remotely connect. And I really do encourage you to take a look at that. They’ll start to clarify different ways that simulation can be conducted at a distance.

Dr. Samreen Vora: I know Dr. Maybelle Kou is just this incredible visual artist in just being able to put those pieces together. So that’ll be really cool once we have some of those images. And I know there’s a huge collaborative too, and I’m hoping to do future chats with some of the folks that are really involved in the healthcare distance sim collaborative. And I know that’s another website folks could go to and learn more, healthcaredistancesim.com. And so I’m really excited to think about how do we use those permutations to serve different communities. I mentioned that health care distance some. And a lot of the things that grew and rapidly grew I think due to COVID, but were already happening as you mentioned prior. So can you tell me a little bit more about that history of distance simulation or simulation at a distance, as you’ve said?

Dr. Elizabeth Sanseau: The technique is actually not new, believe it or not. It’s been around for several decades as a method described to connect educators and learners across space and time. Initially it was mostly used to overcome long distances such as global outreach simulations. Of course limitations to in-person trainings as a result of the COVID-19 pandemic rapidly pushed the modality into the mainstream. And so early 2020 educators and learners rapidly had to shift to innovative simulation at a distance methods. There has been so much that’s been done since 2020, it’s remarkable.

Dr. Samreen Vora: I remember one of our SIM education specialists was learning, she was doing a fellowship and she was able to remote into a SIM in Lavia. And then fast forward through COVID we’re like remoting into SIMS in Duluth or Sandstone, which are just towns in Minnesota. We are not even thinking so far away across the ocean. So I’m wondering if you could give us a little bit of a sense of just how these tools are being used and how they’re being researched now?

Dr. Elizabeth Sanseau: There are really so many incredible SIM educators and researchers working on this, focusing on developing collaborations across the world designed to innovate, evaluate, and really optimize simulation as a distance, as a pedagogical tool that really is here to stay. So one survey done with 32 countries with 618 respondents conducted during really the heights of the COVID-19 pandemic showed that before the pandemic only 28% of SIM centers conducted distance simulation. This number increased to 70% during the pandemic, and 82% indicated plans to maintain distance simulation beyond the pandemic, which is huge. So it’s here to stay. Folks who are super excited about this, the systematic review that I was just reading assessed about 7000 abstracts for relevance. And they identified 104 articles that strictly fit the criteria being distance and hybrid SIM. And this number is growing every month as this work that was done at the height of the pandemic continues to be published now.

And these publications really are united by the common theme that simulation at a distance is valuable to train healthcare professionals. And it really spans the gamut of competencies from teamwork, communication, psychomotor, surgical skills, medical knowledge, healthcare systems and process of care learning objectives. And really all seem to acknowledge that the COVID-19 pandemic and the need for social distancing really shifted traditional simulation based medical education towards these adaptive platforms. And there are myriad recommendations on how to adapt your curricula to the distance setting. And authors use various terms to describe the process of adapting a simulation to connect teachers and learners geographically separate from each other, yet still engaged in a hands-on learning activity. This area really is exciting. It’s rapidly growing.

Researchers are comparing what learning objectives are best adapted from in-site to distance simulation, how to tell a mentor, how to tell a [inaudible 00:13:56]. But really the top three research priorities identified in distance simulation really seem to be one, how to set and maintain that psychological safety that’s so crucial to running a simulation based learning activity on the remote setting, the cost effectiveness of it and faculty development. This is becoming mainstream and leaders have really called together the simulation across the world, like I said, to agree on high quality, methodologically rigorous studies and outcomes that are necessary at this point. And they are challenging authors to look beyond just, “Is this feasible?” Or “What are basic participant or facilitator attitudes on this?” And I want to point out that Dr. Isabel Gross of Yale and other simulation thought leaders have really united to a group of experts to develop consensus on the terminology and collectively identify future research priorities in this field.

Dr. Samreen Vora: Dr. Gross, and I think her other colleague, Janice Palaganas, I think has just really taken this and brought together this international community to work on this. Even hearing you say like, “Hey, this SIM is used not just for teamwork and communication,” which we can do over a virtual platform, “but also psychomotor and surgical skills,” and all the ways we’ve been able to harness those various permutations you talked about is really cool to better understand that so we could serve these communities is important. And I think the cost effectiveness… Often this was a tool, these ways of simulation were tool to get to communities that might not have all those giant resources that bigger centers would have. And so I think all of these things are really important to really better understand as we build this work and help our communities in pediatric emergency medicine or pediatrics in general. I know we mentioned a little bit ago how we met was some work on Simbox, but I don’t know if you could talk a little bit more about how you’ve been using simulation at a distance and maybe some examples?

Dr. Elizabeth Sanseau: I am interested in this didactic tool specifically to prepare frontline providers working in rural and resource limited settings. I really believe it can be an effective educational tool to bridge resource gaps around the world. So I help adapt the free and openly accessible web based simulation platform called the Simbox, which is what you mentioned, that can be used for simulation in-person while also simulation at a distance. It’s probably most correctly as a remote simulation tool according to that SSH dictionary that I mentioned prior. So Samreen, this is exactly how I met you. You were one of the initial founders of the Simbox along with Dr. Marc Auerbach, Dr. Maybelle Kou, who we already mentioned, amongst several others across the nation. And you really helped design the Simbox to target those novice SIM facilitators wanting to run their own hands-on drills with interdisciplinary emergency medical teams in the locations that they work without the need or even access to pediatric specialists or any fancy simulation labs or resources.

And we really adapted that same tool that you founded into simple ways to run this remotely. So to describe the Simbox for folks, the platform has videos that are posted to the internet that the facilitator simply plays for the learners to facilitate the drill. So it really can be done with all the participants and facilitators together in the same room using a computer to stream the video. Or that same computer can be a vehicle to telecommute in a live, remotely located teacher to facilitate the activity, say via Zoom. All you need is a room with your participants, a SIM doll if you have it, and all of the equipment you usually use and that computer.

So COVID really gave us the opportunity to trial using Simbox with different learners with who had gaps in their schedule to fill and their typical training schedules. And this included several learners, medical students, residents, medics, we ran them with nurses, humanitarian healthcare workers as well. We did one study with medical students and educators. They were all isolated at home during those initial months and they were all remotely tele-connecting into a session. So no two people were in the same room at the same time because we just weren’t allowed to be for obvious reasons.

Then we did a trial with medical residents all together in a room. So they were all in a room together for a day of bootcamp across town, across Philadelphia, tele-connecting in with a remotely located pediatric specialist who couldn’t make it in person because they’re about to do a shift 30 minutes later, but they could do that without having to drive across town. So remotely located facilitator with the learners altogether and the manikin in one room. And both wanted to be able to make it and they weren’t able to do it in-person, and this was a way to overcome that barrier.

And then finally we did a trial with the Simbox with frontline humanitarian healthcare providers working for Doctors Without Borders and Magar and Niger. And they were a brand-new group that had landed there, and their facilitators were not able to fly down from Geneva to train them up due to the COVID-19 restrictions to travel. So with that group, we were able to conduct a series of trainings, tele-connecting in the pediatric trainers, located actually in several different countries, not just Geneva, to these workers in Magar and Niger and show that it was feasible. So we’ve adapted it to various settings, all just using the free and accessible Simbox.

Dr. Samreen Vora: I imagine when you’re doing that, there’s also a lot of challenges that you face. Can you talk a little bit about what are the challenges that you’ve seen as you’ve been doing this work?

Dr. Elizabeth Sanseau: It’s amazing to see how the field has exploded, and there’s so many folks doing this in so many different ways. And so actually one of the major challenges that I see is this is now feasible. Folks are wanting it, and folks are willing to meet with you across the world in shorter amounts of time for bite-size remote simulations, the way that you’re willing and able to provide them. But I recognize the importance now of really unifying as a simulation based medical education and research international community to define what we’re doing, define the methods that we’re using, to evaluate what we’re doing, decide on outcomes, research goals, and approaches collectively to see now we’re doing this, this is feasible, folks like it. Now, is it actually moving the needle on real important outcomes?

We’ve talked about psychological safety and faculty development and cost effectiveness, really thinking about what are effective ways to teach different learning objectives and simulation? And are all of them translatable to remote settings? Yes, no, and why? How does remote simulation or distance simulation compare to traditional insights to simulation? Does teaching simulation, including business simulation, really improve real patient outcomes? Having access to remote facilitators and this type of training, does it decrease provider stress and burnout in remote, resource limited environments? So the list is really endless, and I see this as a perfect time to unite and engage in this and open dialogue and robust scholarship to tackle some of these questions.

Dr. Samreen Vora: Like you said, it’s endless and we can learn more and keep doing this better and growing. So I’m curious, what are your next steps?

Dr. Elizabeth Sanseau: So my next steps are to continue to do as much distance simulation as possible. One example that actually came to mind as we were talking about real patient outcomes that I want to call out is an example led by a collaboration between the University of Pennsylvania Annenburg School for Communication, led by Kyle Cassidy there. And a team at Christian Medical College in Vellore, India, led by Dr. Ebor Jacob James and Geetha Ramachandra. And together these groups developed an inexpensive and easy way to create online teaching modules using hot keys on your computer. So really, they took videos of patients and procedures linked to via hot key function on the computer, and the facilitator’s literally able to respond directly to a specific learner requested action via pressing that hot key on their computer that’s linked that image or that procedure being shown how to do, what have you.

So what was interesting about this example was Dr. James and his team were able to demonstrate that this hot key tele-simulation training in their setting was not only feasible, but it actually improved the process of care in their setting, time critical interventions, leadership according to comm-leadership scores in both the simulated and real patients, and resolution of shock in real patients. So to the best of my knowledge, this is one of the first studies that shows that remote simulation has shown improvement in real patient outcomes. And I know that took a lot of work for Dr. James and Ramachandra to do in India, collaborating with Kyle Cassidy, and I think that’s really exciting. I think it’s out there. I think we’re there to start looking at, “Is this translatable for real patient outcomes?”

Dr. Samreen Vora: That is incredible. I hadn’t heard of that work. And it’s incredible to see that translational piece of SIM… #simsaveslives. So I just thank you for sharing that example. I want to open it up. And is there anything else you’d like to share about next steps or your thoughts around this work?

Dr. Elizabeth Sanseau: I think part of what really drew me to want to pursue a career using simulation as an education and research tool was the collaborative spirit of the simulation community. And you and I met at a simulation conference. I was connected to the ImPACTS community model of simulation 10 years ago. And I really now am taking my experience and interest of working within the Indian Health Service and connecting academic medical centers to pediatric champions in Indian Health Service sites via a partnership that uses a hybrid simulation program to really build up partnerships and simulations designed to optimize pediatric emergency care in these settings.

We actually call the program that we started the Indian Health Service, EMSC Hybrid Simulation Program. And I have to say, if you are going to geek out with the SSH dictionary, hybrid simulation actually maybe is not the right term that we should have used when we thought about this program. Technically, it describes a little differently, but the point is we’re doing in-person simulations, remote simulations, and we’re connecting folks. And so using different ways that we’re all now starting to recognize as at least feasible, acceptable, and we’re starting to study in different settings, what works.

So I hope, speaking on this podcast, I really am reaching out to that simulation community that drew me into this 15 years ago. You’re out there, you know who you are. Please reach out to Samreen, myself if you would like to know more or if you are doing distance simulation. And we’d love to know what you’re doing and how you’re innovating this world, specifically of the free or low cost tele-simulation designed to reach those learners practicing in those remote and resource limited parts of the world.

Dr. Samreen Vora: Serving those communities that don’t always get the love and support they need. So I love that. Yes, please reach out, share with us what you’re doing, or reach out and say, “Hey, I want to get involved.” I love that. So that is awesome. Thank you for joining us today and sharing your depth of experience and knowledge on this topic, and I hope we can continue these conversations going forward. And thank you to our listeners for joining us today on our SIM sessions with Dr. Samreen.

Dr. Elizabeth Sanseau: Thank you, Dr. Samreen. So good to hear your voice, and thanks again for having me.

Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amy Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.