Virtual Simulation Training for Clinical Competence In FEES Dale R. Gregore, MS CCC SLP Janet H. Sechrist, MA CCC SLP Department of Speech Language Pathology
AUTHORS Dale Gregore, MS CCC SLP Program Manager, Speech Pathology, Christiana Care Health System, Delaware Clinical Instructor, West Chester University Pennsylvania Janet Sechrist, MA CCC SLP Senior Speech Pathologist, Christiana Care Health System
Notice of Disclosure Financial No relevant financial relationship. Nonfinancial No relevant nonfinancial relationship.
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
FEES COMPETENCY CRITERIA: Observe minimum of 20 FEES Assist with food preparation/ feeding during 20 FEES Identify patients who are appropriate or contraindicated for FEES Familiar with normal and pathological laryngeal anatomy and physiology, medical terminology, and principles and techniques of dysphagia management in general, FEES in particular. State/ describe the elements of a comprehensive endoscopic swallowing examination Identify, assemble, operate, disinfect and maintain FEES equipment Organize, store, and retrieve FEES data for quality assurance and treatment efficacy purposes. Insert and manipulate the endoscope in a manner that causes minimal discomfort and prevents unpleasant complications
Manipulate the endoscope within the nasal passages, nasopharynx, oropharynx, hypopharynx and endolarynx to obtain the desired view. Apply appropriate treatment interventions, implement postural changes, and alter the bolus or method of delivery to determine the effect on the swallow. Detect and interpret abnormal findings in terms of the underlying anatomy and pathophysiology Make appropriate recommendations or referrals for other examinations as needed Interpret and document findings/ recommendations Know when to re-evaluate swallowing function via FEES or videofluoroscopy Complete minimum of 20 examinations on normal adult with supervision Complete a minimum of 50 examinations on patients with supervision.
Virtual Education and Simulation Training (VEST) Center
Simulation Training Has increased in the medical setting due to Changes in health care delivery Limited patient availability as educational opportunities Outcome based education Need for measurable outcomes to demonstrate value Requirements to assess and demonstrate competency Advanced technology
Background At present, there are no published protocols regarding use of human patient simulators (HPS) for FEES training nor is there a published survey tool to determine Clinician in Training (CIT) confidence and skill proficiency pre and post instruction.
Proposed Study Incorporate SIM technology into the first phase of FEES training Determine +/- impact of this kinesthetic simulation on FEES proficiency Measure Clinician In Training (CIT) confidence and skill proficiency PRE and POST SIM training Develop/ implement survey; compare survey results to scope proficiency skills Measure endoscope insertion times across the SIM sessions Anticipated inverse correlation between scope passing times and FSCI score
Looking For Mr. Right
pictures VEST Center
FEES Skill and Confidence Index (FSCI) To measure the effectiveness of virtual simulation in FEES training, the FEES Skill and Confidence Index (FSCI) was developed and administered pre and post simulation training sessions. Using a five point scale, the clinicians ranked 10 phrases that began with I feel confident that I can 0 = Strongly disagree 1 = Disagree 2 = Neither agree or disagree 3 = Agree 4 = Strongly Agree
I feel confident that I can Clearly explain reason, purpose and FEES procedure Assemble, operate, disinfect and maintain equipment necessary to perform/ record endoscopic assessment Insert and manipulate the endoscope trans nasally in a timely manner (less than 60 *** seconds) Insert and manipulate the endoscope in a manner that causes minimal discomfort and prevents unpleasant complications Manipulate the endoscope within the nasal passages, nasopharynx, oropharynx, hypopharynx and endolarynx to obtain the desired view Apply appropriate treatment interventions/ implement postural changes to determine the effect on the swallow Detect and interpret abnormal findings in terms of the underlying anatomy and pathophysiology Use appropriate ergonomic posture and scope handling techniques Apply sound reasoning and problem solving during FEES procedure Complete the FEES procedure in a safe and competent manner
FEES SIM Process Two therapists identified ready for FEES training Initial training completed per protocol Baseline FSCI obtained Advanced to SIM training
CIT Evaluated on 6 Criteria Each SIM Session Assemble, operate and maintain equipment Timely trans-nasal insertion and manipulation of the endoscope Obtain optimal view of pertinent swallow anatomy Identification of normal vs abnormal laryngeal anatomy and physiology Detect and interpret abnormal findings Application of appropriate treatment interventions
Criteria for Advancement in Training: Clinician attains < than 6 goals return for further SIM training Clinician attains all 6 advance to normal subjects
Expected Actions-CIT What we expected the learner to do in response to the new findings, signs, or symptoms? Pause Problem solve Adjust scope Continue or terminate exam based on patient symptoms
Expected Action-Simulator What we designed the simulator to do in response to learner actions 1 normal and 5 problem scenarios were programmed into the HPS CIT to experience 1-2 normal exams; 1-3 problem scenarios; randomly assigned Simulator will stabilize patient vitals in 3/5 trials; two SIM trials will end in termination
FEES SIM Training Scenarios Normal Exam Following FEES equipment set up, CIT passes scope to velum; over and into oropharynx while being timed Anatomy identification completed What if scenarios completed
Trouble Shooting: What if. Questions Posed during NL Exam What would you do if unable to pass the scope? What would you do if you are unable to view the vocal folds?
Scoping Ergonomics: Posture, ergonomics and efficiency of scope holding; shoulder stabilization and arm positioning were monitored during SIM sessions This was completed in collaboration with our PEEPS Team
CIT Expectations During SIM Training CIT observation HR; pulse; RR; O2 SATs Problem Solving GOAL: The CIT will provide solutions to the following challenge scenarios
VEST FEES Training Challenge Scenarios RESPIRATORY DISTRESS NOSE BLEED ALLERGIC REACTION COUGHING / LARYNGOSPASM VASOVAGEL RESPONSE
Respiratory Distress Scenario Resting RR/ HR: WNL Clinician initiates FEES exam: proceeds to pass scope over velum then change of status / respiratory distress quickly occurs HR increases to >110 RR increases > 40 then gradually patient recovers normal HR / RR Outcome: continue FEES exam
Results Both CITs were able to achieve 6/6 criteria in 3 SIM sessions Able to demonstrate/maintain good ergonomics during duration of typical exam Demonstrated appropriate responses to What If and problem scenarios Proceeded to Normal Subjects Successfully
CIT FSCI versus Scope Passing Times PRE FSCI Confidence Index (%) PASS time Sess #1 POST FSCI % Improve ment PASS Time Sess #3 CIT N/40 seconds seconds Overall % change % Scoping Improve ment 1 23 57% 61 39 98% 32.9 41% 54% 2 16 40% 82.5 31 78% 34.4 38% 42% AVG 48% 71.75 AVG 88% 33.65 40% 47%
Correlation Between Increased Confidence and Scope Passage Time Clinician confidence increased by 40% Scope passage time decreased by 47%
60 50 40 30 20 10 0 Average Scope Passing Time over 4 SIM sessions seconds 70 CIT 1 61 40.59 35.64 17.33 0 1 2 3 4 5
Use of SIM Lab for Training with New Equipment 4 seasoned clinicians in need of training on new portable FEES equipment VEST lab training scenarios developed 3 endoscope passes timed, 2 dominant & 1 non dominant
Training With New Equipment
Pre SIM Training FSCI 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1 1 1 2 3 3 3 4 2 4 3 6 4 3 4 3 3 3 2 2 2 1 1 1 0 0 0 0 0 Q10 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 A4 A3 A2 A1 A0
Post SIM Training FSCI 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1 3 3 4 4 5 5 5 5 6 5 1 3 2 2 1 1 1 1 0 Q10 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 A4 A3 A2 A1 A0
Improved scoping dexterity, manipulation for optimal view Incorporating SIM into FEES Training Increased CIT scoping proficiency Improved seasoned clinician proficiency using unfamiliar equipment Improved CIT confidence for transition to normal subjects
Outcome FEES Skill and Confidence Index effectively measured clinician confidence pre and post SIM lab training.
Summary Study results confirmed the benefit of using virtual simulation education as a preliminary phase in training SLPs to perform endoscopic assessments. As a result of this study, VEST technology has been incorporated into FEES training protocol at Christiana Care Health System.
Study Limitations: Small sample size SIM dysphagia requires imagination Suggestions for future investigation: Comparing SIM versus non SIM FCSI scores from FEES training protocols Comparing scope insertion times between FEES trained SLP versus SIM CIT Determine whether addition of SIM training decreases duration of FEES training
Discussion
References 1 Scalese, Ross J, et al (2008) Simulation Technology for Skills Training and Competency Assessment in Medical Education. J Gen Intern Med. January; 23(Suppl 1): 46 49. Benadom, Elise M. and Nancy L. Potter. (2011) The Use of Simulation in Training Graduate Students to Perform Transnasal Endoscopy. Dysphagia. 26:352-360. Okuda, Yasuharu, MD, et al (2009) The Utility of Simulation in Medical Education: What is the Evidence?, Mount Sinai Journal of Medicine, 16, 330-343. Potter, NL, Allen, A (2013) Clinical Simulation in Nursing :Clinical Swallow Exam for Dysphagia: A Speech Pathology and Nursing Simulation Experience, 9:461-464 Web resources: http://ssih.org http://www.inacsl.org/