The Application of Low-fidelity Chest Tube Insertion Using Remote Telesimulation in Training Healthcare Professionals

Healthcare professionals practicing in rural, remote, or resource-restricted areas have little opportunity to practice “high stakes low-frequency” clinical procedures, despite having higher rates of injury-related death than city inhabitants. Availability of clinical skills instructors, the expense of practicing skills, lack of educational sessions, and distance to simulation centres can be a barrier to teaching and skill maintenance, particularly in rural settings. Telesimulation has the potential to overcome these challenges using audio-visual technology to connect rural learners with instructors in simulation centres. Using low-fidelity simulation models allows learners to acquire clinical skills through hands-on practice without risk or fear of harming real patients. Although not as realistic as high-fidelity models, the low-fidelity three-dimensional (3D) printed model for chest tube insertion is cost-effective and easy to set up and use and is a valid tool for teaching the clinical procedure. The purpose of this technical report was to describe the application of low-cost telesimulation to facilitate teaching chest tube insertion to medical students, emergency medicine residents, and doctors working in remote and rural environments.


Introduction
Chest tube insertion is a vital, if infrequent, procedure for emergency medicine physicians. It is typically performed under high-stress trauma situations but can be utilized in other resuscitation situations such as drainage of pleural effusion or empyema. It is important for physicians, particularly those who work in rural and remote areas where there may not be much backup, to be proficient in the procedure. Simulation-based learners have the opportunity to acquire technical skills in a hands-on environment without fear of harming patients, allowing them to increase their technical proficiency in clinical skills, and react to real-life situations with lower stress levels [1]. Simulation training is becoming a staple for medical education; however, its large expense acts as a major barrier to accessibility. A single high-fidelity simulator and its monitoring system can cost upwards of $200 000, excluding replacement parts such as synthetic skin and bodily fluids [1]. Lower-fidelity models are more cost-effective and only require basic technology if any at all, but they are static and lack realism or situational context [1]. That being said, low-fidelity models such as task trainers can be sufficient for technical skill training [2]. instructors, which can be prohibitive to skill maintenance [3]. There is a lack of opportunity to practice "high stakes low-frequency" procedures, such as chest tube insertion, despite an increased rate of injury-related death in rural areas [4]. These healthcare professionals often lack access to advanced skills training or opportunities to attend educational sessions [3]. Herein, we have created a telesimulation delivery model that will bridge the gap between rural and urban access to simulation-based learning. Telesimulation aims to educate, train, and/or assess participants at an off-site location [5]. It is demonstrated to be a cost-effective method of simulation training for participants at less-accessible off-site locations, who are unable to take advantage of similar educational tools in person [5]. By eliminating time and distance barriers in educational content delivery, the opportunity for the rapid circulation of new medical education brings the benefits of simulation training beyond the walls of the centre, while simultaneously creating an inter-institutional network and collaboration opportunity [5]. Without continued practice, technical skills may regress. Simulation of essential skills allows doctors understand current practices on proper insertion of chest tubes. Literature on costeffective telesimulation models for high stakes, low-frequency clinical procedures is limited. This technical report describes a novel chest tube insertion telesimulation model to add to the growing body of research in the area.
The overall goal of this technical report was to increase the technical performance of learners, including medical students, residents, and doctors located in resource-restricted areas in placing chest tubes. The learning objectives for the case are to clinically diagnose tension pneumothorax, become proficient in the chest tube insertion procedure, develop effective interpersonal and communication skills by calling for appropriate back up/help when needed, and effectively communicate with colleagues.

The case
A 35-year-old male presents to your rural hospital after striking a moose on the main highway near your town. Paramedics say the truck was found upside down in a ditch and the patient had been ejected from the vehicle. He has multiple injuries including significant bruising of the left chest wall, is pale, and experiencing shortness of breath. He is awake and in pain and is only able to speak about two words per breath. He has neither allergies nor is he on any current medications. His vitals are as follows: heart rate (HR) 120 bpm, O 2 saturation 93%, and blood pressure (BP) 100/70. Upon examination, the chest sounds are absent on the left side, and the patient's trachea is deviated to the right. Despite attempted decompression with the appropriate needle thoracostomy, the patient has ongoing respiratory distress and whether the patient requires urgent placement of a chest tube will be determined.
The organization and implementation of all elements of this simulation-based technical report follow a modified Context, Input, Process, and Product (CIPP) program development and evaluation model [6][7]. Its management is closely based on the technical report outlined by Gomersall et al. [8]. Please access the original sources for further details and pictorial representations [6][7][8].

Context
This simulation can be used in remote, rural, or resource-restricted acute care centers across Newfoundland and Labrador for the distribution of clinical skill training/ refreshers to medical students, residents, doctors, and nurses. These individuals will be connected to an expert skills instructor from the Memorial University's Clinical Learning and Simulation Centre. The case can be adjusted to accommodate location, learners, modality, and difficulty level to meet the needs of a variety of learners as outlined in Table 1. While there are a number of low-cost chest tube insertion simulations in the literature, there is still minimal research on using telesimulation for instructing chest tube insertion [9][10]. Table 1 provides inputs for managing a chest tube insertion procedure for a variety of indications.

Case Setting
A community hospital where the learner (clerk/resident/doctor) is responsible for leading the case and must call for help if necessary. The learner can obtain backup from a qualified surgeon/physician in their community hospital or seek contact with the simulation instructor through telecommunication. The room setup contains a triage report outlining the case as above and chest tube task trainer consisting of three-dimensional (3D)-printed ribs and skin on a stand affixed to a table.
Personnel Learners: Medical clerks/Emergency medicine residents/Doctors/Nurses Facilitators: One to two simulation center staff members, one to provide chest tube insertion skills instruction at the Memorial University site, and the other to observe and record information for debriefing technical support: readily available to assist with telecommunication equipment at   [4,[9][10][11] 2019 Garland et al. Cureus 11(12): e6273. DOI 10.7759/cureus. 6273 3 of 12

Process
The following scenario resembles the case produced by Renouf et al. adapted to fit this chest tube insertion simulation [4]. In this scenario, a nurse acted as a confederate and facilitator of the simulation at the rural site. They initiated contact with the Memorial University instructor prior to the start of the simulation for the purposes of pre-briefing and presenting the case, setting up the simulation equipment, and assisting the physician, who is the learner, during the procedure. If concerned about technical glitches, such as poor connection or difficulty with arranging equipment, the confederate and Memorial University instructor can arrange for extra time before the start of the simulation or at an earlier date to sort these out. Once ready, the physician learner entered the room and the instructor initiated a formal pre-briefing session and presented the case. The role of the instructor is to run the simulation, instruct the learner on the chest tube insertion technique when prompted by the learner, and ensure adherence to the scenario. A second staff member was present at the simulation center to observe and record information for debriefing, as well as assist the instructor during demonstration of the simulated procedure when necessary.

Pre-briefing
During the pre-briefing, the instructor outlined the schedule of events from the start of the simulation to de-briefing. They also emphasized the importance of maintaining a safe learning environment and introduced a quasi-contract. Foreseen technical limitations to telecommunication and simulation can be addressed during pre-briefing to minimize interruptions during the simulation. Learners are briefed on how the formative evaluation is conducted and provided with the initial information about the case.

Scenario
Following the pre-briefing, learners were provided with the pre-scenario information as outlined in Table 2.

Pre-scenario
You are working in the ER when a 35-year-old male presents to your hospital after striking a moose on the main highway. Paramedics say the truck was found upside down in the ditch, and the patient had been ejected from the vehicle. He has multiple injuries and is experiencing shortness of breath despite needle thoracostomy conducted by paramedics.

Products/Outcomes
The scenario ended when the patient had a functional chest tube inserted and is stable. A feedback and debriefing session occurred next, where all members of the simulation reflected on the learner's performance, interaction with other members of the trauma team (i.e. nurse and/or backup physician) and the efficacy of the telesimulation model, during which time the learning objectives were reviewed.

Feedback and debriefing
As mentioned previously, all people involved in the simulation participated in a verbal debriefing session following its completion. During this time the instructor and second simulation center staff member discussed the learner's performance with them for formative purposes on the basis of the learning objectives, emotions, actions, reflection, and next steps (LEARN) framework produced by Memorial University [12]. The teamwork between the learner and assisting nurse was also to be addressed as per the learning objectives. De-briefing provides an opportunity for continued education and sense of completion after a simulation session [13][14]. Time was also taken to discuss the execution of the telesimulation, including any technical issues or instructional difficulties the team might have had, so it can be used in the future to improve on the simulation experience.
An objective structured assessment of technical skills (OSATS) for chest tube insertion was completed by the instructor on learner performance, which will be used as feedback for the learner for continued education and for the simulation center staff to ensure the effectiveness of the telesimulation model. OSATS has been validated as a successful tool in teaching many surgical procedures. The modified OSATS tool that can be found in Table 3 has been adapted from a similar tool created and validated by Friedrich et al. [15][16].

1: Poor 2 3: Sufficient 4 5: Excellent
Correct identification of   [16] Each trainee will complete a feedback form to evaluate the learning experience and realism of the model as seen in Figure 1.

FIGURE 1: Feedback form for learners to assess learning experience and realism of model
Participants were asked to rate their opinion of the model on a Likert scale for questions such as the usefulness of the model in learning the procedure, fidelity of the corresponding anatomic landmarks in comparison with clinical reality, degree of self-confidence to perform the procedure on a patient, degree of realism, and satisfaction with the model [17].

Discussion
The use of simulation-based models in the continued education of learners (doctors, residents, and medical students) provides a promising method for ensuring competency in high stakes, low-frequency procedures such as chest tube insertion. Current literature on the use of simulation suggests a relationship between increased standardized learning outcomes and hours of simulation-based medical education [18]. Learners report a greater level of confidence, satisfaction, and enhanced learning regardless of the level of fidelity of the simulation [19]. Waiting for hands-on exposure to low-frequency procedures in a clinical setting is of low yield; therefore, routine simulation-based scenarios are essential for continued competency in these procedures [20].
This simulation scenario offers learners the opportunity to recognize tension pneumothorax and practice the chest tube insertion procedure in a safe, hands-on learning environment. Learner performance and teaching are based on an objective-structured assessment of technical skill tools. Having the learners assemble the supplies needed is a good way to test their knowledge on the location of the required tools and increase efficiency for future emergency situations. It incorporates the use of a nurse confederate to assess interpersonal skills and enhance teamwork, therefore touching on multiple CanMeds competencies. Learners have the option to contact appropriate back-up or help if needed and thus test their knowledge of who and how to contact other professionals in a high-stake setting. Variants in the level of difficulty are provided allowing for adaptability for the level of education of the learner and test their ability to prioritize tasks.
The scenario described in the technical report is of low fidelity because of the added challenge of conducting the scenario over teleconference. It is rather basic because it looks to teach a wide variety of learners. Variants to this scenario may be added, such as tension pneumothorax, femur fraction, or compromised airway, for more advanced learners. In addition, a standardized patient + task trainer variant, as described by Jamie Wilson, may add a dimension of realism, urgency, and patient-centred approach to a chest tube insertion simulation. Future directions for this project would be to test the smoothness of the scenario as it is and determine the feasibility of expanding the telesimulation to a more realistic, higher-fidelity simulation such as the standardized patient + task trainer so that soft skills can be tested and practiced.

Conclusions
This technical report describes the design and implementation of a low-cost, low-fidelity chest tube insertion simulation using a 3D-printed model for the teaching/practice of physicians, residents, and medical students through telecommunication. The model attempts to bridge the gap in continued education for learners residing in rural and remote areas who cannot access educational sessions and high-fidelity simulators located in urban areas. Low-fidelity simulation provides a safe, controlled learning environment where medical learners can practice their knowledge, procedures, and interpersonal communication without harm to patients. Staying up to date on high-stakes, low-frequency procedures, such as chest tube insertion, is vital to professional practice.

Additional Information Disclosures
Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.