International Pediatric Emergency Medicine and Critical Care Fellow Education: Utilizing Virtual Resuscitation Simulation in Settings With Differing Resources

Pediatric Emergency and Critical Care-Kenya (PECC-Kenya) is an international collaboration between the University of Nairobi and the University of Washington (UW) supporting a combined fellowship program in pediatric emergency medicine (PEM) and pediatric critical care medicine (PCCM) in Kenya. Typically, PEM/PCCM faculty from UW travel to Kenya to support in-person simulation, which was cancelled due to COVID-19 travel restrictions. This presented a need for alternative modalities to continue simulation-based education. This technical report describes the use of virtual simulation for pediatric emergency and critical care fellow education on the management of hypovolemic and septic shock, utilizing international guidelines and being based on resource availability.


Introduction
Simulation-based education has become an integral part of medical education in high-income countries, particularly in the field of emergency medicine, where providers are required to be proficient in the management of a wide variety of disease pathologies and procedural skills [1]. However, traditional simulation training often relies on dedicated simulation centers and advanced technology and can be resource-intensive. Virtual simulation training, also known as telesimulation, remote or distance simulation, uses the internet to connect educators and learners in remote locations [2]. This offers advantages including low-cost, ease of customization, and wide accessibility. Virtual simulation training has been shown to yield similar educational outcomes when compared with in-person training [3][4]. Given these advantages, virtual simulation is an optimal tool for use in rural or remote settings or settings without ready access to a simulation center.
Utilization of virtual simulation presented an opportunity to continue international medical simulation education amidst the COVID-19 pandemic with travel restrictions and limits to in-person educational activities. To continue supporting the education of pediatric emergency medicine (PEM) and pediatric critical care medicine (PCCM) fellows in Kenya, the existing international collaboration between faculty from the University of Washington and the University of Nairobi developed three virtual simulation scenarios. The virtual simulation scenarios were developed with a focus on international management of pediatric shock, using an existing virtual simulation platform called Virtual Resus Room, developed by Dr. Sarah Foohey [5].
Globally, diarrheal illness and pneumonia, with progression to circulatory instability, are leading causes of pediatric mortality [6]. Patients presenting with shock and circulatory impairment traditionally receive fluid resuscitation as part of their initial management. However, over the last 10 years, studies have raised caution about fluid resuscitation for patients presenting with shock depending on the available resources [7][8]. It is critical for providers around the world to understand the differing international guidelines.
The World Health Organization (WHO) requires three clinical criteria to be met to determine that a patient is in shock, including "cold extremities with capillary refill time greater than 3 seconds and a weak and fast pulse" [8]. Notably, this definition allows for providers to quickly identify a patient in shock in settings where a blood pressure cuff may not be readily available.
Fluid resuscitation recommendations for patients in shock differ depending on the guideline. This is largely due to evidence from a large randomized trial of children with fever and impaired perfusion in East Africa, 1 2 2 3 4 5 5 2 where mortality was increased in those who received crystalloid volume expansion [7]. The WHO Emergency Triage Assessment and Treatment (ETAT) guidelines recommend that patients presenting with shock, using the clinical definition described above, without severe anemia or malnutrition, receive a volume of 10-20 cc/kg of crystalloid fluid run over 30-60 minutes followed by a second bolus, if the patient did not have clinical improvement, of 10 cc/kg run over 30 minutes [8]. If a patient does not meet all three clinical criteria for shock per the WHO definition, it is recommended that fluid boluses be avoided and that children instead receive maintenance fluids. In contrast, the Surviving Sepsis International Guidelines, from the Society of Critical Care Medicine, for settings where there is ready access to an intensive care unit, recommend 40-60 cc/kg of crystalloid fluid rapidly within the first hour of care [9]. If there is no access to an intensive care unit, the Surviving Sepsis Guidelines recommend using blood pressure as a decision point. If the patient is hypotensive, it is recommended to give up to 40 cc/kg of fluid within the first hour. If the patient is not hypotensive, maintenance fluids are recommended and fluid boluses should be avoided.
Prompt recognition of a patient in shock, as well as a strong foundational knowledge of the global resuscitation guidelines, is crucial to reduce the morbidity and mortality from these common childhood illnesses in any setting. The goal of these case materials was to provide simulation education resources for providers practicing in low-to middle-income countries utilizing a virtual platform to increase international accessibility.

Technical Report Introduction
This set of simulations was designed to highlight the differences in shock management using international guidelines and prompt discussion and awareness about how availability of hospital resources can change recommended management. The scenarios were developed in collaboration between the University of Washington and University of Nairobi faculty. These simulations address the most common etiologies of shock globally including hypovolemic shock (Cases 1 and 2) and septic shock (Case 3), as well as common complications including hypoglycemia, electrolyte derangement, and volume overload. These simulations were designed using an existing, open-access, Google Slides (Mountain View, CA) based virtual simulation platform, VRR, with a video conferencing platform [5].

Participants
There were two target audiences for these simulations. The primary target audience was pediatric critical care and emergency medicine fellows practicing in low-to middle-income countries. The secondary audience was pediatric critical care or emergency medicine residents, fellows, or faculty traveling from highincome countries to low-to middle-income countries. For the secondary audience, simulations could be used prior to travel to prepare physicians to manage shock in settings with variable resources using international guidelines.

Setting and equipment
The simulations were designed to be entirely virtual to promote accessibility and international collaboration. Participants were required to have a computer and internet connection. For each case scenario, a Google Slides deck was developed using the free template materials available online at VRR [5]. The slide decks were shared with participants and facilitators at the time of the simulation, and participants interacted and edited the slides simultaneously throughout the case scenarios. The slides were designed to be customizable to allow for modification of the equipment and medications depending on resource availability.

Scenario template
Facilitator guides were developed for each of the three case scenarios (Tables 1-3) following a deteriorating patient scenario framework [10]. Each guide outlines the primary learning objectives, critical actions, case branch points, anticipated flow, and anticipated mistakes for each of the three scenarios. The cases were designed to increase difficulty and medical decision-making to allow learners time to adapt to the simulation platform.   If the learner requests rapid sequence intubation without addressing the patient's hypotension, the facilitator is to prompt with "a nurse is asking if it is safe to intubate with his blood pressure." If the learner suggests additional fluids for blood pressure support the facilitator can state "she has already received 2 boluses, are there any concerns with additional fluids?" For prebriefing, the facilitator guides were distributed to each of the case facilitators via email. Facilitators reviewed the scenarios and divided facilitator roles including management of the slides (i.e., updating vital signs), responding to learners' prompts (utilizing the case notes with branching points provided in the guide), and playing the role of the patient's parent for additional history. Learner participants were provided with a link for the VRR participant guidelines (https://virtualresusroom.com/761-2/) to familiarize them with the platform prior to the simulation [5].

Patient
In case 1, the patient is presenting to a rural clinic setting with history of diarrhea and lethargy. The ideal flow scenario is as follows: The learners enter the room to find the patient appearing lethargic and severely dehydrated. On initial assessment, they note that he has impaired circulation and meets the clinical definition of shock with delayed capillary refill greater than 3 seconds, cold extremities, and a weak and fast pulse. From the clinical history and physical examination, it is suspected that the patient has hypovolemic shock. Intravenous access is promptly obtained and the patient is given a bolus of normal saline or lactated ringers. If point-of-care electrolytes or glucose are requested, they are informed that this testing is not available at this facility. Glucose should thus be administered empirically. After glucose and the initial bolus of fluids, the patient is reassessed with minimal improvement. The patient is given an additional bolus of crystalloid fluid. The patient has minimal improvement in his vitals and examination. Given the lack of intensive care resources and laboratory evaluation, it is recommended that the patient be transferred to a referral or district-level hospital for additional management.
In case 2, the patient is again presenting with diarrhea and lethargy, though this time to a district-level hospital. The ideal flow scenario is as follows: The learners enter the room to find the patient lethargic and severely dehydrated. On initial assessment, they note that he has impaired circulation and meets the clinical definition of shock with delayed capillary refill greater than 3 seconds, cold extremities, and a weak and fast pulse. From the clinical history and physical examination, it is suspected that the patient has hypovolemic shock. Intravenous access is promptly obtained, and the patient is given a bolus of normal saline or lactated ringers. Emergency labs are obtained including electrolytes and glucose. The labs are remarkable for hypernatremia and marked hypokalemia. An EKG is obtained revealing T-wave flattening and visible U wave ( Figure 1). If potassium supplementation is not initiated, the patient becomes unresponsive with pulseless ventricular tachycardia. The participants should initiate CPR and deliver a shock via the defibrillator. The patient's vital signs stabilize, and a second fluid bolus is administered. Decision is made to admit for further management and monitoring of electrolyte derangements. In case 3, the patient is presenting with lethargy and fever to a district-level hospital. The ideal flow scenario is as follows: The learners enter the room to find the patient lethargic. On initial assessment, they note that she has impaired circulation and meets the clinical definition of shock per WHO with delayed capillary refill greater than 3 seconds, cold extremities, and a weak and fast pulse. They additionally note she is febrile with signs of increased work of breathing. From the clinical history and physical examination, it is suspected that the patient has septic shock in the setting of a lower respiratory tract infection. Intravenous access is promptly obtained, and the patient is given a bolus of normal saline or lactated ringers. She is started on supplemental oxygen, and emergency labs are obtained including electrolytes and glucose. She is additionally given empiric antibiotics. On repeat evaluation, she has had minimal improvement and is given a second fluid bolus. While the second bolus is being administered, she develops worsening tachypnea concerning for pulmonary edema. The patient does not have improvement with higher flow through the nasal cannula or with the non-rebreather mask. Additionally, the patient becomes hypotensive and requires blood pressure support with vasopressors prior to intubation. The learner intubates the patient and her vitals improve.

Supplementary materials
VRR Google Slides decks were developed for each of the three case scenarios using the open-access template materials available on the VRR website [5]. The figures are screen-captures from the slide decks showing the virtual resuscitation room (Figure 2), the medication tray (Figure 3), and the pediatric airway tray (Figure 4). These slides were accessed and edited simultaneously by the learners and facilitators to reflect real-time changes in the case. Medications and airway supplies were copied and pasted into the primary resuscitation room when required or administered.

Confident or Very Confident (After Simulation) (n = 8)
Demonstrate ability to assess and emergency manage a patient presenting in shock 87% 100% Understand how fluid resuscitation differs in areas with variable resources and access to care 25% 87%

Statement
Agree or Strongly Agree (n =

8)
Prior to this, I have participated in telesimulation in the past 50% The cases utilized during this simulation are relevant to work in resource-limited global health settings 100% The simulation cases were effective in teaching basic fluid resuscitation skills in settings with variable resources 100% The scenarios allowed practice of effective teamwork and communication skills 83% Telesimulation is an effective medium for learning 100%

TABLE 4: Post-simulation Feedback Survey Responses
Participants overall felt that virtual simulation was an effective medium for learning. VRR was new for 50% of the fellows and they expressed desire for continued practice with the format. Verbal feedback revealed that VRR worked best for participants with video capability and a computer-based reliable internet connection.

Discussion
The use of virtual simulation provided an effective modality for education on recognition and management of hypovolemic and septic shock, utilizing international guidelines. The VRR platform was well received by the PEM and PCCM fellows in Kenya. The cases were designed to increase in medical complexity, which allowed time for fellows to adapt to the modality. Utilizing the orientation video available on the VRR website assisted in preparing learners for the simulation format. Allowing the slides to be easily customizable provided a more realistic scenario for settings with variable resources. To make future simulation scenarios more realistic for providers practicing in low-to middle-income countries, simulations can be designed to involve fewer active participants, as these physicians expressed that they typically are functioning in multiple roles in a resuscitation. Expanding the number of participants observing the simulation, including observing communication and utilizing a critical actions checklist, would continue to allow for multiple learners to participate in the simulation. While survey results demonstrated improved self-confidence in the management of shock, further research, utilizing direct comparison of virtual simulation education to traditional in-person simulation, could further validate the efficacy of this modality, as has been demonstrated in prior virtual simulation studies [3][4].

Conclusions
VRR facilitated international collaboration and allowed for effective remote simulation education. Designing virtual simulation scenarios with content specifically highlighting management differences in settings with different resources allows for an adaptable and more realistic learning environment for providers practicing in or traveling to low-to middle-income countries. Further implementation is planned to assess VRR effectiveness and usability in multiple global settings.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. 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.