
3) Insufficient data to demonstrate that high fidelity simulation in
neurocritical care improves clinical performance or outcomes beyond
traditional teaching methods
Increasing budget constraints limit the ability of many
institutions to justify the investment needed to run simulation
curricula. These costs include the facilities themselves,
simulation specialists, educator time and diversion of trainee
time away from clinical experience.
While there is validity to these arguments, they do not negate
the potential benefits of high-fidelity simulation training in
our field. The Kirkpatrick scale is widely accepted for evaluating
the effectiveness of any curriculum and provides an example of
the data gap for simulation training in neurocritical care versus
other areas of critical care. The scale ranges from 1-5 as follows:
trainee satisfaction/confidence; acquisition of knowledge/skills/
behaviors; improved performance on the job; better outcomes;
and institutional cost effectiveness.
To date, there are few studies in neurocritical care to support
high-fidelity simulation. Although well done, these studies have
been small, single-center experiences. For example, studies have
reported using simulation to teach the management of status
epilepticus, neurogenic respiratory failure, spinal shock and
brain herniation. Others have used simulation to grade trainees’
competence in determining brain death or performing lumbar
puncture. These studies used pre- and post-test assessments
and surveys to demonstrate trainee enjoyment and improved
confidence (Kirkpatrick Level 1) as well as improvement in
knowledge (Kirkpatrick Level 2).
In contrast, better clinical outcomes (Kirkpatrick 4) have been
demonstrated in other critical care fields. In this respect, pediatric
and trauma critical care boast the most robust literature. For
example, it has been demonstrated that in situ simulation of a
pediatric medical emergency resulted in faster recognition of a
deteriorating patient and more rapid escalation to intensive care.
Similarly, training with a human patient simulator resulted in reallife
improvement in teamwork scores, speed and completeness for
100 subsequent blunt trauma resuscitations.
Comparable simulation curricula in neurocritical care are taking
shape at a few large academic institutions. However, for some
centers, evidence that these efforts translate to improved outcomes
will be necessary to justify the investment required to develop
such programs. As a first step to developing a curriculum that
assesses outcome measures of simulation training comparable to
our critical care colleagues, we will be surveying program directors
of UCNS-accredited fellowships. Our aim is to better understand
attitudes toward simulation training and how it is being used and
evaluated in neurocritical care.
The onus is on us as educators to follow the path of our colleagues
in other areas of critical care to demonstrate the benefit of highfidelity
simulation for our patient population. This data will not
only support the investment of resources to develop simulation
curricula but will also drive the creation of next-generation
technology, such as mannequins or virtual immersion realities
that allow for accurate portrayal of neurological presentations.
Regardless of where we stand now relative to the pack, and despite
the challenges, the future of simulation training in neurocritical
care remains bright and exciting.
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