Australian Dental Journal

Australian Dental Journal The official journal of the Australian Dental Association SCIENTIFIC ARTICLE Australian Dental Journal 2010; 55: 399 404 doi: 10.1111/j.1834-7819.2010.01260.x Simulation of medical emergencies in dental practice: development and evaluation of an undergraduate training programme JP Newby,* J Keast,* WR Adam* *Rural Health Academic Centre, The University of Melbourne, Victoria. Goulburn Valley Health, Shepparton, Victoria. ABSTRACT Background: The evidence available suggests that many dentists on graduation do not feel competent managing medical emergencies; a problem requiring improved undergraduate training. This study developed a comprehensive simulation based training programme for final year undergraduate dental students and assessed student attitudes towards training. Methods: Final year dental students (n = 52) from The University of Melbourne were required to complete simulation training incorporating an interactive tutorial and realistic, simulated emergency scenarios conducted in the students real clinical environment. A post-participation questionnaire utilizing a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree) assessed student attitudes. Results: Student responses supported simulation training, evidenced by the following selected questionnaire responses: achieved greater confidence in managing emergencies 4.65 ± 0.48 (n = 52); prefer lecture to simulation 1.46 ± 0.74 (n = 52); simulation training is important in undergraduate teaching 4.86 ± 0.35 (n = 43). Conclusions: Realistic simulation training in management of medical emergencies for dental students is an effective adjunct to traditional lecture style teaching. Given the importance of this subject, this mode of training would benefit students if incorporated into undergraduate dental courses. Keywords: Medical emergencies, dental education, simulation. Abbreviations and acronyms: BLS = Basic Life Support; CPR = cardiopulmonary resuscitation; DPBV = Dental Practice Board of Victoria. (Accepted for publication 16 March 2010.) INTRODUCTION There is a community expectation that dentists are capable of managing common medical emergencies which may occur in dental practice, particularly those related to dental procedures. Since 2005, the Dental Practice Board of Victoria (DPBV) has required dentists to complete mandatory basic life support training on an ongoing basis as a condition of continued registration. 1 There are currently no strict policies in Victoria regarding minimum requirements for medical equipment to be available in dental practice unless performing treatment under sedation. 2 Several studies have investigated both the frequency with which medical emergencies occur in the dental setting and the preparedness of the operator to manage them. 3 8 These studies concluded that medical emergencies of varying degrees occur commonly in the dental setting but severe life-threatening incidents are relatively rare. One of the studies estimated that in a practising lifetime of 40 years, an Australian dentist will be subjected to at least one medical emergency, and one in seven will be required to perform resuscitation (respiratory or cardiac). 3 The medical emergencies recorded in these studies include vasovagal syncope, reaction to local anaesthetic, angina, epileptic fit, hypoglycaemia, asthma, choking, anaphylaxis, hypertensive crisis, myocardial infarction and cardiac arrest. The available information suggests that dental graduates across the world may not be adequately prepared in the management of medical emergencies. 3 14 ª 2010 Australian Dental Association 399

JP Newby et al. Chapman 3 found that only 55% of Australian dental graduates felt competent in cardiopulmonary resuscitation (CPR) upon graduation. Studies in the United Kingdom have indicated similar concerns, with one showing only 30% of dental graduates felt well or fairly well prepared. 4 In another UK study, 39.5% of dentists surveyed felt they would be unable to provide initial management for a cardiac arrest. 5 A New Zealand study showed more than 50% of dentists were dissatisfied with undergraduate teaching for medical emergencies 9 and Brazilian dental undergraduates were also found to be similarly dissatisfied. 10 This study aimed to develop a simulation training programme in the management of medical emergencies for final year undergraduate dental students, and then assess their attitudes toward the programme. Its purpose was to provide additional training to that currently undertaken by undergraduate dental students from The University of Melbourne. Existing training provided in the third and fifth years of the Bachelor of Dental Science degree has primarily been information driven with a focus on lectures and self-directed learning. Practical training consists of basic CPR in a non-dental environment. The decision to use simulation based training as a key component of the teaching programme on medical emergencies was based on abundant pedagogical theory (see discussion). This paper evaluates whether students found a novel simulation training programme beneficial in building skills and confidence in the management of medical emergencies. METHODS Development of a training programme Training needs were identified by assessing studies of incidence of medical events in dental practice. 3 7 Recommendations from studies assessing dental practitioners knowledge and suggestions for suitable medical equipment for dental surgeries was also taken into account. 3,6,15 18 The programme consisted of three components: prereading, a hands-on basic life support workshop and simulation training. Students were given reading material covering the theory of management of medical emergencies in dental practice as recommended by the Australian Resuscitation Council and the Australian Dental Therapeutic Guidelines 2007. 18,19 Students were required to read this information prior to simulation training. A workshop introduced participants to simulation based training via video demonstration, discussion of practical management of a collapsed patient and handson practice. The workshop covered the current theory of Basic Life Support (BLS) as determined by the Australian Resuscitation Council. This is in line with requirements outlined by the DPBV regarding mandatory CPR training and current undergraduate teaching. In contrast to previous programmes, specific diagnoses were not the focal point. Instead a generic template on management of airway, breathing and circulation was utilized. The objective here was to simplify management by focusing on diagnosis of the presenting symptoms, i.e., is there a problem with the airway the breathing the circulation? Basic medical equipment (Fig 1), including oxygen and facemasks (Hudson and disposable face shield with one-way valve), bag-valve-mask device, Salbutamol with spacer, glucose and glucagon, Epi-pen Trainer (1:1000 adrenaline) and an automatic external defibrillator (LaerdalÒ AED Trainer 2) were demonstrated with opportunities for hands-on practice. Efficacy of ventilation and cardiac compression technique was measured using the Laerdal Resusci AnneÒ Skill Reporting software. This gave students immediate feedback on their efforts via a visual representation of their performed depth and rate of compression, correct hand position on the chest and volume of ventilation. Concurrent discussion included students perceptions on what constitutes minimum standards for medical equipment in dental practice and future planning for their own practice. The third component of the programme consisted of simulation based training in a hospital dental clinic. To enhance the realistic nature of the programme and create an appropriate context for medical emergency simulation, scenarios were developed to incorporate a dental component including any facial swelling, extractions, sinusitis, ill-fitting dentures, routine scale and clean, restorative work and endodontic treatment. A medical emergency was then introduced at an appropriate stage of treatment. The emergency scenarios developed were vasovagal syncope, hyperventilation, asthma, upper Fig 1. Basic medical training equipment. 400 ª 2010 Australian Dental Association

Simulation of medical emergencies airway obstruction, hypoglycaemia, anaphylaxis, chest pain and cardiac arrest. Initially, a Laerdal SimManÒ patient simulator mannequin was used as the patient. This was later replaced with a Laerdal Resusci AnneÒ Simulator which was capable of achieving the required level of simulation sophistication. This mannequin was more simple to control and set up, and is a much more costeffective alternative. The facilitator, in an adjacent room with viewing window, would act as the patient s voice via a microphone and speaker set-up, and also controlled the mannequin s heart rate and rhythm, respiratory rate and breathing sounds remotely. A second microphone and speaker system was used to allow observers in the adjacent room to hear the simulation. Figure 2 illustrates the set-up used for simulation training while Fig 3 shows simulation training in progress as seen by observers in the adjacent viewing room. During scenarios, students worked in pairs, one acting as the practitioner and the other as a dental assistant. Participants were required to complete one scenario each and observe the remaining scenarios with a maximum of five scenarios per session. Participants were required to take a medical history, elicit a history of the presenting dental complaint, make a diagnosis and simulate dental treatment using appropriate anaesthetics and instruments. A facilitator would give appropriate clinical information and prompt Operator Laerdal resusci anne simulator (controlled remotely by facilitator) Microphone (1) + lead Facilitators Assistant Observers Cordless microphone (2) Speaker (1) Cordless speaker (2) Fig 3. Simulation training (view from adjacent room). participants where required. Whilst treatment was in progress, the patient would become medically unwell, requiring supportive medical management. A pause and discuss style format was utilized which allowed participants or the facilitator to pause the simulation at salient points to assist with clinical management and allow for reflection in action. Each scenario was followed by a structured debriefing led by participants and observers. The debriefing allowed for immediate reflection on action in a safe and supported environment. Both dental and medical aspects were covered with a focus on appropriate management and communication with the patient and colleagues, leadership and teamwork. At the completion of training, students completed a written and practical assessment of BLS skills and knowledge. Successful completion of this assessment qualified students for certification in BLS (as endorsed by the Australian Resuscitation Council) for a period of 12 months. It was important to separate this formal assessment component from the simulated scenarios to reinforce the point that the scenarios were not an assessment but a learning opportunity. A post-participation questionnaire was designed to evaluate students perceptions of the effectiveness of the new simulation based training and compare it to existing training methods. Numerical results from the questionnaire (Table 1) are expressed as mean ± SD. Ethics approval for the study was obtained from The University of Melbourne Human Research Ethics Committee (HREC No. 071 8337). Equipment trolley Fig 2. Set-up for simulation training. RESULTS The results of the questionnaire (Table 1) strongly supported the appeal and effectiveness (questions 1 8, 10) of simulation training, particularly when compared to the previous training methods (question 9). ª 2010 Australian Dental Association 401

JP Newby et al. Table 1. Student perceptions of simulation training utilizing a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree) Question Result 1 I felt the simulation was realistic 4.62 ± 0.50 (n = 52) 2 The simulation provided a useful 4.85 ± 0.36 (n = 52) introduction to management of medical emergencies 3 The simulation clarified some issues 4.79 ± 0.41 (n = 52) for me regarding emergency management 4 There was adequate input from the 4.79 ± 0.46 (n = 52) facilitator during the simulation 5 The simulation went for an 4.56 ± 0.54 (n = 52) appropriate length of time 6 My prior knowledge of managing 3.19 ± 1.03 (n = 43) emergency situations was adequate 7 I will be more confident in managing 4.65 ± 0.48 (n = 52) these situations in real life as a result of simulation training 8 I felt overwhelmed in the simulation 2.96 ± 0.97 (n = 52) 9 I prefer a more traditional 1.46 ± 0.70 (n = 52) approach to learning, i.e., lecture 10 This training should remain a part of the undergraduate teaching programme 4.86 ± 0.35 (n = 43) DISCUSSION The DPBV has recognized the importance of maintaining knowledge and skills in the management of medical emergencies. Since 2005, Victorian dentists have been required to complete a minimum of two hours of BLS training over a two-year cycle to maintain their registration. 1 A survey conducted immediately prior to the introduction of this mandatory training found that the majority of dentists (69.2%) believed that this amount of training was adequate, while 26.6% felt it was too much, and only 4.2% believed it was not enough. 20 Whatever levels of skills in managing medical emergencies dental boards may require, public expectations are likely to be higher. Due to the lifethreatening nature of many medical emergencies, this aspect of training a dental student should be considered a high priority. 11 Within this framework, it is concerning that many dentists upon graduation feel unprepared to manage medical emergencies. This study on a novel, simulation based programme on medical emergencies in dental practice clearly shows that students felt they benefited from the programme and gained confidence to deal with medical emergencies (4.65 ± 0.48). The students favoured simulation training as illustrated by the results for those preferring a traditional approach to learning (1.46 ± 0.74). Students also felt strongly that this training should be incorporated into undergraduate teaching (4.86 ± 0.35). These results reiterate the findings of Balmer et al. 21 which found simulation training, tailored for dentists needs, to be highly effective. The likely benefits of using simulation in training programmes are consistent with a number of widely accepted learning theories as outlined below: Experiential Learning Theory provides a useful model for simulation training. Experience provides the main motivation for learning and new knowledge is established from reflection. 22 Constructivist Learning Theory supports building new knowledge on existing knowledge by providing building blocks for life-long learning. 23 Social Cognitive Theory where learners are in constant ongoing interaction with their environment, with their actions and the consequences of them. 24 Reflective Learning Theory which involves the reconfiguration of ideas, knowledge and meaning stimulated by a process of reflection either during or after an event. 22 Simulating what happens in the real world has relevance, links theory to practice, provides for interaction with colleagues and patients and builds on existing knowledge and skills. This type of learning with understanding leads to long-term retention. 25 Retention of resuscitation skills and knowledge is a known problem. Frequent refresher courses are essential to maintain acquired skills with studies showing a significant decrease in skills after 12 months and inadequacy of skills after 18 months. 26 28 Without long-term follow-up, it is difficult to determine the duration of retention of skills learnt in this programme or whether the knowledge gained translates into effective skills in practice. As this was a pilot study, a follow-up study in two years to measure knowledge, retention of skills learned and whether these skills were applied in real clinical situations would assist in measuring the true effectiveness and value of this type of training. The expectation is that some retraining would be required by dental practitioners at regular intervals if skills are to be maintained in the absence of frequent clinical experience in medical emergencies such is the case for the majority of dental practitioners. 3 7 The DPBV has determined two hours per two-year cycle as appropriate which seems to be acceptable to the majority of dental practitioners. 20 Cost and impact on the core student curriculum are important considerations when introducing an additional training programme. The cost of the Resusci AnneÒ Simulator is $13 189, the audio equipment $250, and medical training equipment listed previously (including computer software) under $1500. As this was shared equipment from an existing facility and only used for up to 60 hours per year, no new purchases were necessary and the resulting costs were kept to a minimum. 402 ª 2010 Australian Dental Association

Simulation of medical emergencies Other costs to be considered are employment of facilitators (a dentist and qualified medical simulation educator), and use of facilities including the use of a dental chair for the day of simulation training. Although the tutorial took place in an existing medical simulation laboratory, this could be conducted in any dental school facility as the equipment used is portable. Clinical downtime for students was kept to a minimum by offering two training sessions. The student group was divided into two, with half completing simulation training while the other half undertook normal clinical duties. Groups then swapped over for the second session. This structure allows for a potential of up to 30 students to complete training in one day including a one-hour tutorial for all and three sessions of simulation training (10 students per group), comprising two hours of simulation experience per group (five scenarios of 20 25 minutes duration). Should the programme be modified? This question can only be answered by comparative studies which are currently lacking. As noted above, the use of simulation based training is strongly supported by pedagogical theory and has been used extensively in training clinicians and others in the management of emergencies. A key factor in the success of simulation based training is engagement of the participants in the project. To this end, a reasonable blend between realism of the scenario and the ability to interrupt the scenario to support the participant in dealing with difficult issues, including the option to reconsider their actions, is important. There is also a considerable theoretical, but unproven, benefit of carrying out simulated scenarios in the dental chair whilst performing a dental procedure, in terms of student engagement. CONCLUSIONS Realistic simulation training in the management of medical emergencies for dental practitioners is an effective adjunct to traditional lecture style teaching and a favoured method of learning for undergraduate dental students. Given the importance of this subject, this mode of training would benefit students if incorporated into undergraduate dental courses. Having well-trained dental professionals in all aspects of patient management further improves the quality of care and safety of patients. ACKNOWLEDGEMENTS The authors wish to acknowledge the Rural Health Academic Centre, The University of Melbourne, Shepparton Campus and Goulburn Valley Health Shepparton, Dental Department, for use of facilities during this project and the Melbourne Dental School, The University of Melbourne. REFERENCES 1. Dental Practice Board of Victoria: Continuing Professional Development. Code of Practice Number C005[2008]. 2. Dental Practice Board of Victoria: General Anaesthesia and Conscious Sedation. Code of Practice Number C007[2007]. 3. Chapman PJ. Medical emergencies in dental practice and choice of emergency drugs and equipment: a survey of Australian dentists. Aust Dent J 1997;42:103 108. 4. Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great Britain. Part 1: Their prevalence over a 10-year period. Br Dent J 1999;186:72 79. 5. Girdler NM, Smith DG. Prevalence of emergency events in British dental practice and emergency management skills of British dentists. Resuscitation 1999;41:159 167. 6. Chapman PJ. A questionnaire survey of dentists regarding knowledge and perceived competence in resuscitation and occurrence of resuscitation emergencies. Aust Dent J 1995;40:98 103. 7. Müller MP, Hänsel M, Stehr SN, et al. A state-wide survey of medical emergency management in dental practices: incidence of emergencies and training experience. Emerg Med J 2008;25:296 300. 8. Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great Britain. Part 3: Perceptions of training and competence of GDPs in their management. Br Dent J 1999;186:234 237. 9. Broadbent JM, Thomson WM. The readiness of New Zealand general dental practitioners for medical emergencies. N Z Dent J 2000;96:138 139. 10. Carvalho RM, Costa LR, Marcelo VC. Brazilian dental students perceptions about medical emergencies: a qualitative exploratory study. J Dent Educ 2008;72:1343 1349. 11. Clark MS, Wall BE, Thölstrom TC, et al. A twenty-year followup survey of medical emergency education in US dental schools. J Dent Educ 2006;70:1316 1319. 12. Graham CA, Scollon D. Cardiopulmonary resuscitation training for UK undergraduate dental students. Resuscitation 1996;32: 105 108. 13. Atherton GJ, Pemberton MN, Thornhill MH. Medical emergencies: the experience of staff of a UK dental teaching hospital. Br Dent J 2000;188:320 324. 14. Fast TB, Martin MD, Ellis TM. Emergency preparedness: a survey of dental practitioners. J Am Dent Assoc 1986;112:499 501. 15. Chapman PJ. An overview of drugs and ancillary equipment for the dentist s emergency kit. Aust Dent J 2003;48:130 133. 16. Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great Britain. Part 2: Drugs and equipment possessed by GDPs and used in the management of emergencies. Br Dent J 1999;186:125 130. 17. Australian Dental Association Inc. Guidelines for Good Practice on Emergencies in Dental Practice [GGP3]. June 2005. Available from: http://www.ada.org.au/app_cmslib/media/lib/0703/m52398_ v1_ggp3emergencies.pdf. 18. Australian Resuscitation Council Guidelines Online. Available from: http://www.resus.org.au/public/guidelines/. 19. Dowden J, Abbott P, Goss AN, et al. Therapeutic Guidelines: Oral and Dental. 2007 Version 1. North Melbourne: Therapeutic Guidelines Limited, 2007. 20. Hopcraft MS, Marks G, Manton DJ. Participation in continuing professional development by Victorian dental practitioners in 2004. Aust Dent J 2008;53:133 139. 21. Balmer MC, Longman LP. A practical one day medical emergencies course for dentists and DCPs. Br Dent J 2008;204:453 456. ª 2010 Australian Dental Association 403

JP Newby et al. 22. Ker J, Bradley P. Simulation in medical education. Edinburgh: Association for the Study of Medical Education, 2007. 23. Dent JA, Harden RM. A practical guide for medical teachers. Churchill Livingstone, 2001:43. 24. Kaufman D, Mann K, Jennet P. Teaching and learning in medical education: how theory can inform practice. Edinburgh: Association for the Study of Medical Education, 2000:9. 25. Hertel J, Mills B. Using simulations to promote learning in higher education: an introduction. Sterling, VA: Stylus Publishing Inc., 2002:1 14. 26. Jabbour M, Osmond MH, Klassen TP. Life support courses: are they effective? Ann Emerg Med 1996;28:690 698. 27. O Steen DS, Kee CC, Minick MP. The retention of advanced cardiac life support knowledge among registered nurses. J Nurs Staff Dev 1996;12:66 72. 28. Chate RA. Evaluation of a dental practice cardiopulmonary resuscitation training scheme. Br Dent J 1996;181:416 420. Address for correspondence: Dr James Newby Rural Health Academic Centre The University of Melbourne 49 Graham Street Shepparton VIC 3630 Email: jnewby@unimelb.edu.au 404 ª 2010 Australian Dental Association