Cardiopulmonary Resuscitation Training in High School Using Avatars in Virtual Worlds: An International Feasibility Study
JOURNAL OF MEDICAL INTERNET RESEARCH
2013; 15 (1)
CliniSpace: a multiperson 3D online immersive training environment accessible through a browser.
Studies in health technology and informatics
2011; 163: 173-179
Approximately 300,000 people suffer sudden cardiac arrest (SCA) annually in the United States. Less than 30% of out-of-hospital victims receive cardiopulmonary resuscitation (CPR) despite the American Heart Association training over 12 million laypersons annually to conduct CPR. New engaging learning methods are needed for CPR education, especially in schools. Massively multiplayer virtual worlds (MMVW) offer platforms for serious games that are promising learning methods that take advantage of the computer capabilities of today's youth (ie, the digital native generation).Our main aim was to assess the feasibility of cardiopulmonary resuscitation training in high school students by using avatars in MMVM. We also analyzed experiences, self-efficacy, and concentration in response to training.In this prospective international collaborative study, an e-learning method was used with high school students in Sweden and the United States. A software game platform was modified for use as a serious game to train in emergency medical situations. Using MMVW technology, participants in teams of 3 were engaged in virtual-world scenarios to learn how to treat victims suffering cardiac arrest. Short debriefings were carried out after each scenario. A total of 36 high school students (Sweden, n=12; United States, n=24) participated. Their self-efficacy and concentration (task motivation) were assessed. An exit questionnaire was used to solicit experiences and attitudes toward this type of training. Among the Swedish students, a follow-up was carried out after 6 months. Depending on the distributions, t tests or Mann-Whitney tests were used. Correlation between variables was assessed by using Spearman rank correlation. Regression analyses were used for time-dependent variables.The participants enjoyed the training and reported a self-perceived benefit as a consequence of training. The mean rating for self-efficacy increased from 5.8/7 (SD 0.72) to 6.5/7 (SD 0.57, P<.001). In the Swedish follow-up, it subsequently increased from 5.7/7 (SD 0.56) to 6.3/7 (SD 0.38, P=.006). In the Swedish group, the mean concentration value increased from 52.4/100 (SD 9.8) to 62.7/100 (SD 8.9, P=.05); in the US group, the concentration value increased from 70.8/100 (SD 7.9) to 82.5/100 (SD 4.7, P<.001). We found a significant positive correlation (P<.001) between self-efficacy and concentration scores. Overall, the participants were moderately or highly immersed and the software was easy to use.By using online MMVWs, team training in CPR is feasible and reliable for this international group of high school students (Sweden and United States). A high level of appreciation was reported among these adolescents and their self-efficacy increased significantly. The described training is a novel and interesting way to learn CPR teamwork, and in the future could be combined with psychomotor skills training.
View details for DOI 10.2196/jmir.1715
View details for Web of Science ID 000315113200016
View details for PubMedID 23318253
Training healthcare personnel for mass-casualty incidents in a virtual emergency department: VED II.
Prehospital and disaster medicine
2010; 25 (5): 424-432
Immersive online medical environments, with dynamic virtual patients, have been shown to be effective for scenario-based learning (1). However, ease of use and ease of access have been barriers to their use. We used feedback from prior evaluation of these projects to design and develop CliniSpace. To improve usability, we retained the richness of prior virtual environments but modified the user interface. To improve access, we used a Software-as-a-Service (SaaS) approach to present a richly immersive 3D environment within a web browser.
View details for PubMedID 21335784
The use of virtual patients to assess the clinical skills and reasoning of medical students: initial insights on student acceptance
2009; 31 (8): 739-742
Training emergency personnel on the clinical management of a mass-casualty incident (MCI) with prior chemical, biological, radioactive, nuclear, or explosives (CBRNE) -exposed patients is a component of hospital preparedness procedures.The objective of this research was to determine whether a Virtual Emergency Department (VED), designed after the Stanford University Medical Center's Emergency Department (ED) and populated with 10 virtual patient victims who suffered from a dirty bomb blast (radiological) and 10 who suffered from exposure to a nerve toxin (chemical), is an effective clinical environment for training ED physicians and nurses for such MCIs.Ten physicians with an average of four years of post-training experience, and 12 nurses with an average of 9.5 years of post-graduate experience at Stanford University Medical Center and San Mateo County Medical Center participated in this IRB-approved study. All individuals were provided electronic information about the clinical features of patients exposed to a nerve toxin or radioactive blast before the study date and an orientation to the "game" interface, including an opportunity to practice using it immediately prior to the study. An exit questionnaire was conducted using a Likert Scale test instrument.Among these 22 trainees, two-thirds of whom had prior Code Triage (multiple casualty incident) training, and one-half had prior CBRNE training, about two-thirds felt immersed in the virtual world much or all of the time. Prior to the training, only four trainees (18%) were confident about managing CBRNE MCIs. After the training, 19 (86%) felt either "confident" or "very confident", with 13 (59%) attributing this change to practicing in the virtual ED. Twenty-one (95%) of the trainees reported that the scenarios were useful for improving healthcare team skills training, the primary objective for creating them. Eighteen trainees (82%) believed that the cases also were instructive in learning about clinical skills management of such incidents.These data suggest that training healthcare teams in online, virtual environments with dynamic virtual patients is an effective method of training for management of MCIs, particularly for uncommonly occurring incidents.
View details for PubMedID 21053190
Improvement in coronary anastomosis with cardiac surgery simulation
JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
2008; 136 (6): 1486-1491
Web-based clinical cases ("virtual patients", VPs) provide the potential for valid, cost-effective teaching and assessment of clinical skills, especially clinical reasoning skills, of medical students. However, medical students must embrace this teaching and assessment modality for it to be adopted widely.We examined student acceptance of a web-based VP system, Web-SP, developed for teaching and assessment purposes, in a group of 15 second-year and 12 fourth-year medical students.Student acceptance of this web-based method was high, with greater acceptance in pre-clinical (second-year) compared with clinical (fourth-year) medical students. Students rated VPs as realistic and appropriately challenging; they particularly liked the ability of VPs to show physical abnormalities (such as abnormal heart and lung sounds, skin lesions, and neurological findings), a feature that is absent in standardized patients.These results document high acceptance of web-based instruction and assessment by medical students. VPs of the complexity used in this study appear to be particularly well suited for learning and assessment purposes in early medical students who have not yet had significant clinical contact.
View details for DOI 10.1080/01421590903126489
View details for Web of Science ID 000269784700010
View details for PubMedID 19811211
Design, Development, and Evaluation of an Online Virtual Emergency Department for Training Trauma Teams
SIMULATION IN HEALTHCARE
2008; 3 (3): 146-153
Cardiac surgery trainees might benefit from simulation training in coronary anastomosis and more advanced procedures. We evaluated distributed practice using a portable task station and experience on a beating-heart model in training coronary anastomosis.Eight cardiothoracic surgery residents performed 2 end-to-side anastomoses with the task station, followed by 2 end-to-side anastomoses to the left anterior descending artery by using the beating-heart model at 70 beats/min. Residents took home the task station, recording practice times. At 1 week, residents performed 2 anastomoses on the task station and 2 anastomoses on the beating-heart model. Performances of the anastomosis were timed and reviewed.Times to completion for anastomosis on the task station decreased 20% after 1 week of practice (351 +/- 111 to 281 +/- 53 seconds, P = .07), with 2 residents showing no improvement. Times to completion for beating-heart anastomosis decreased 15% at 1 week (426 +/- 115 to 362 +/- 94 seconds, P = .03), with 2 residents demonstrating no improvement. Home practice time (90-540 minutes) did not correlate with the degree of improvement. Performance rating scores showed an improvement in all components. Eighty-eight percent of residents agreed that the task station is a good method of training, and 100% agreed that the beating-heart model is a good method of training.In general, distributed practice with the task station resulted in improvement in the ability to perform an anastomosis, as assessed by times to completion and performance ratings, not only with the task station but also with the beating-heart model. Not all residents improved, which is consistent with a "ceiling effect" with the simulator and a "plateau effect" with the trainee. Simulation can be useful in preparing residents for coronary anastomosis and can provide an opportunity to identify the need and methods for remediation.
View details for DOI 10.1016/j.jtcvs.2008.08.016
View details for Web of Science ID 000261970100016
View details for PubMedID 19114195
Simulation for team training and assessment: Case studies of online training with virtual worlds
WORLD JOURNAL OF SURGERY
2008; 32 (2): 161-170
Training interdisciplinary trauma teams to work effectively together using simulation technology has led to a reduction in medical errors in emergency department, operating room, and delivery room contexts. High-fidelity patient simulators (PSs)-the predominant method for training healthcare teams-are expensive to develop and implement and require that trainees be present in the same place at the same time. In contrast, online computer-based simulators are more cost effective and allow simultaneous participation by students in different locations and time zones. In this pilot study, the researchers created an online virtual emergency department (Virtual ED) for team training in crisis management, and compared the effectiveness of the Virtual ED with the PS. We hypothesized that there would be no difference in learning outcomes for graduating medical students trained with each method.In this pilot study, we used a pretest-posttest control group, experimental design in which 30 subjects were randomly assigned to either the Virtual ED or the PS system. In the Virtual ED each subject logged into the online environment and took the role of a team member. Four-person teams worked together in the Virtual ED, communicating in real time with live voice over Internet protocol, to manage computer-controlled patients who exhibited signs and symptoms of physical trauma. Each subject had the opportunity to be the team leader. The subjects' leadership behavior as demonstrated in both a pretest case and a posttest case was assessed by 3 raters, using a behaviorally anchored scale. In the PS environment, 4-person teams followed the same research protocol, using the same clinical scenarios in a Simulation Center. Guided by the Emergency Medicine Crisis Resource Management curriculum, both the Virtual ED and the PS groups applied the basic principles of team leadership and trauma management (Advanced Trauma Life Support) to manage 6 trauma cases-a pretest case, 4 training cases, and a posttest case. The subjects in each group were assessed individually with the same simulation method that they used for the training cases.Subjects who used either the Virtual ED or the PS showed significant improvement in performance between pretest and posttest cases (P < 0.05). In addition, there was no significant difference in subjects' performance between the 2 types of simulation, suggesting that the online Virtual ED may be as effective for learning team skills as the PS, the method widely used in Simulation Centers. Data on usability and attitudes toward both simulation methods as learning tools were equally positive.This study shows the potential value of using virtual learning environments for developing medical students' and resident physicians' team leadership and crisis management skills.
View details for DOI 10.1097/SIH.0b013e31817bedf7
View details for Web of Science ID 000207536200004
View details for PubMedID 19088658
Criterion-based training with surgical simulators: proficiency of experienced surgeons.
JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons
2007; 11 (3): 273-302
Individuals in clinical training programs concerned with critical medical care must learn to manage clinical cases effectively as a member of a team. However, practice on live patients is often unpredictable and frequently repetitive. The widely substituted alternative for real patients-high-fidelity, manikin-based simulators (human patient simulator)-are expensive and require trainees to be in the same place at the same time, whereas online computer-based simulations, or virtual worlds, allow simultaneous participation from different locations. Here we present three virtual world studies for team training and assessment in acute-care medicine: (1) training emergency department (ED) teams to manage individual trauma cases; (2) prehospital and in-hospital disaster preparedness training; (3) training ED and hospital staff to manage mass casualties after chemical, biological, radiological, nuclear, or explosive incidents. The research team created realistic virtual victims of trauma (6 cases), nerve toxin exposure (10 cases), and blast trauma (10 cases); the latter two groups were supported by rules-based, pathophysiologic models of asphyxia and hypovolemia. Evaluation of these virtual world simulation exercises shows that trainees find them to be adequately realistic to "suspend disbelief," and they quickly learn to use Internet voice communication and user interface to navigate their online character/avatar to work effectively in a critical care team. Our findings demonstrate that these virtual ED environments fulfill their promise of providing repeated practice opportunities in dispersed locations with uncommon, life-threatening trauma cases in a safe, reproducible, flexible setting.
View details for DOI 10.1007/s00268-007-9354-2
View details for Web of Science ID 000252477100005
View details for PubMedID 18188640
Virtual worlds and team training.
2007; 25 (2): 321-336
In our effort to establish criterion-based skills training for surgeons, we assessed the performance of 17 experienced laparoscopic surgeons on basic technical surgical skills recorded electronically in 26 modules selected in 5 commercially available, computer-based simulators.Performance data were derived from selected surgeons randomly assigned to simulator stations, and practicing repetitively during one and one-half day sessions on 5 different simulators. We measured surgeon proficiency defined as efficient, error-free performance and developed proficiency score formulas for each module. Demographic and opinion data were also collected.Surgeons' performance demonstrated a sharp learning curve with the most performance improvement seen in early practice attempts. Median scores and performance levels at the 10th, 25th, 75th, and 90th percentiles are provided for each module. Construct validity was examined for 2 modules by comparing experienced surgeons' performance with that of a convenience sample of less-experienced surgeons.A simple mathematical method for scoring performance is applicable to these simulators. Proficiency levels for training courses can now be specified objectively by residency directors and by professional organizations for different levels of training or post-training assessment of technical performance. But data users should be cautious due to the small sample size in this study and the need for further study into the reliability and validity of the use of surgical simulators as assessment tools.
View details for PubMedID 17931510
Stanford university medical media and information technologies hosts open source surgical simulation workshop.
Simulation in healthcare
2007; 2 (1): 43-44
An important component of all emergency medicine residency programs is managing trauma effectively as a member of an emergency medicine team, but practice on live patients is often impractical and mannequin-based simulators are expensive and require all trainees to be physically present at the same location. This article describes a project to develop and evaluate a computer-based simulator (the Virtual Emergency Department) for distance training in teamwork and leadership in trauma management. The virtual environment provides repeated practice opportunities with life-threatening trauma cases in a safe and reproducible setting.
View details for PubMedID 17574193
Avatars Alive! The Integration of Physiology Models and Computer Generated Avatars in a Multiplayer Online Simulation
MEDICINE MEETS VIRTUAL REALITY 15
2007; 125: 256-258
Stanford University Medical Media and Information Technologies's technical workshop "Prototyping of Surgical Simulators using Open Source Simulation Software" was held in August 2006 at Stanford University. The objectives, program, and topics covered are presented in this short report.
View details for DOI 10.1097/SMJ.0b013e31802ea34c
View details for PubMedID 19088609
Designing case-based learning for virtual worlds.
Simulation in healthcare
2007; 2 (4): 246-247
Virtual patient model for multi-person virtual medical environments.
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium
In a mass casualty incident, injured and at-risk patients will pass through a continuum of care from many different providers acting as a team in a clinical environment. As presented at MMVR 14 [Kaufman, et al 2006], formative evaluations have shown that simulation practice is nearly as good as, and in some cases better than, live exercises for stimulating learners to integrate their procedural knowledge in new circumstances through experiential practice. However, to date, multiplayer game technologies have given limited physiological fidelity to their characters, thus limiting the realism and complexity of the scenarios that can be practiced by medical professionals. This paper describes the status of a follow-on program to merge medical and gaming technologies so that computer generated, but human-controlled, avatars used in a simulated, mass casualty training environment will exhibit realistic life signs. This advance introduces a new level of medical fidelity to simulated mass casualty scenarios that can represent thousands of injuries. The program is identifying the critical instructional challenges and related system engineering issues associated with the incorporation of multiple state-of-the-art physiological models into the computer generated synthetic representation of patients. The work is a collaboration between Forterra Systems and the SUMMIT group of Stanford University Medical School, and is sponsored by the US Army Medical Command's Telemedicine and Advanced Technologies Research Center (TATRC).
View details for Web of Science ID 000270613800058
View details for PubMedID 17377279
Virtual Worlds for Teaching the New CPR to High School Students
MEDICINE MEETS VIRTUAL REALITY 15
2007; 125: 515-519
We describe the architecture of a virtual patient model, the Virtual ED Patient, for scenarios in emergency medicine. The model is rule-based, and uses four vital signs as a representation of its state. The model is used in a multi-person learning environment based on online gaming technology. The efficacy of the model and the Virtual ED learning environment is evaluated in a study where advanced medical students and first year residents manage six trauma cases. Pre and post-test performance results show significant learning, with results comparable to those obtained in human manikin simulators. Some future directions for development of the model are also presented.
View details for PubMedID 18693822
Comparison of training on two laparoscopic simulators and assessment of skills transfer to surgical performance
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2005; 200 (4): 546-551
In this study we created a virtual 3D world for learning to manage medical emergencies and evaluated it with 24 high school students in the USA and Sweden. We found that students in both groups felt immersed and found the online simulation easy to use. Scores for flow and self-assessed flow were significantly higher for the RHS group as compared to the HG group (p=.001 and .023 respectively; Mann Whitney U test). Self-efficacy scores for the HG group were significantly higher after training (p=.016 Mann Whitney U test). Males in the RHS group scored significantly higher on flow and self assessed flow than females (p=.006 and p=.023 respectively; Mann Whitney U test). This study demonstrates the potential value of using MMOS for learning to respond to medical emergencies.
View details for Web of Science ID 000270613800119
View details for PubMedID 17377340
A framework for evaluating new learning technologies in medicine.
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium
Several studies have investigated the transfer of surgical trainees' skills acquired on surgical simulators to the operating room setting. The purpose of this study was to compare the effectiveness of two laparoscopic surgery simulators by assessing the transfer of skills learned on simulators to closely matched surgical tasks in the animal laboratory.In this post-test-only Control group study design, 46 surgically naive medical student volunteers were randomly assigned to one of three groups: Tower Trainer group (n = 16), LapSim group (n = 17), and Control group (n = 13). Outcomes measures included both time and accuracy scores on three laparoscopic tasks (Task 1: Grasp and Place; Task 2: Run the Bowel; Task 3: Clip and Cut) performed on live anesthetized pigs, and a global rating of overall performance as judged by four experienced surgeons.The Tower Trainer group performed significantly better than the Control group on 1 of 7 outcomes measures-Task 3: Time (p < 0.032), although the LapSim group performed significantly better than the Control group on 2 of 7 measures-Task 3: Time (p < 0.008) and Global score (p < 0.005). In comparing the two simulators, the LapSim group performed significantly better than the Tower Trainer group on 3 of 7 outcomes measures-Task 2: Time (p < 0.032), Task 2: Accuracy (p < 0.030) and Global score (p < 0.005), although the Tower Trainer group did not perform significantly better than the LapSim group on any measure.This study demonstrated that naive subjects trained on a virtual-reality part-task trainer performed better on live surgical tasks in a porcine model as compared with those trained with a traditional box trainer. These findings could aid in selection of appropriate training methodologies.
View details for DOI 10.1016/j.jamcollsurg.2004.11.011
View details for Web of Science ID 000228085200007
View details for PubMedID 15804468
Evaluation of a surgical simulator for learning clinical anatomy
2004; 38 (8): 896-902
The SUMMIT Evaluation Framework provides a comprehensive model to guide researchers, developers and curriculum decision-makers in conducting the most relevant type of evaluation for a range of learning technologies. In this poster we present the framework and give examples of how we have used it to guide our evaluation efforts.
View details for PubMedID 16779449
Initial evaluation of a shoulder arthroscopy simulator: Establishing construct validity
JOURNAL OF SHOULDER AND ELBOW SURGERY
2004; 13 (2): 196-205
New techniques in imaging and surgery have made 3-dimensional anatomical knowledge an increasingly important goal of medical education. This study compared the efficacy of 2 supplemental, self-study methods for learning shoulder joint anatomy to determine which method provides for greater transfer of learning to the clinical setting.Two groups of medical students studied shoulder joint anatomy using either a second-generation virtual reality surgical simulator or images from a textbook. They were then asked to identify anatomical structures of the shoulder joint as they appeared in a videotape of a live arthroscopic procedure.The mean identification scores, out of a possible score of 7, were 3.1 +/- 1.3 for the simulator group and 2.9 +/- 1.5 for the textbook group (P = 0.70). Student ratings of the 2 methods on a 5-point Likert scale were significantly different. The simulator group rated the simulator more highly as an effective learning tool than the textbook group rated the textbook (means of 3.2 +/- 0.7 and 2.6 +/- 0.5, respectively, P = 0.02). Furthermore, the simulator group indicated that they were more likely to use the simulator as a learning tool if it were available to them than the textbook group was willing to use the textbook (means of 4.0 +/- 1.2 and 3.0 +/- 0.9, respectively, P = 0.02).Our results show that this surgical simulator is at least as effective as textbook images for learning anatomy and could enhance student learning through increased motivation. These findings provide insight into simulator development and strategies for learning anatomy. Possible explanations and future research directions are discussed.
View details for DOI 10.1111/j.1365-2929.2004.01897.x
View details for Web of Science ID 000223249000017
View details for PubMedID 15271051
Development and validation of assessment measures for a newly developed physical examination simulator
JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION
2002; 9 (5): 448-460
Formal evaluation of surgical simulators is essential before their introduction into training programs. We report our assessment of the Mentice Corp Procedicus shoulder arthroscopy simulator. This study tests the hypothesis of construct validity that experienced surgeons will score better on the simulator than individuals with minimal to no experience with the technique. Thirty-five subjects were stratified into three groups (novice, intermediate, and expert) based on their past 5 years' experience with shoulder arthroscopies. Each subject had an identical session on the simulator and completed anatomic identification, hook manipulations, and scope navigation exercises. We found statistically significant differences among the three groups in hook manipulation and scope navigation exercises, with the expert group performing the exercises more quickly (P =.013) and more accurately (P =.002) than the other two groups. No statistically significant differences were found among the groups in the identification of anatomic landmarks. Experts rated the simulator as an effective teaching tool, giving it a mean score of 4.22 and 4.44 (maximum, 5) for teaching instrument control and triangulation, respectively.
View details for DOI 10.1016/j.jse.2003.12.009
View details for Web of Science ID 000220272700014
View details for PubMedID 14997099
COMPUTER DATABASES AS AN EDUCATIONAL-TOOL IN THE BASIC SCIENCES
1990; 65 (1): 15-16
Define, extract and evaluate potential performance indicators from computer-generated data collected during simulated clinical female pelvic examinations.Qualitative and quantitative study analyzing computer generated simulator data and written clinical assessments collected from medical students who performed physical examinations on three clinically different pelvic simulators.Introduction to patient care course at a major United States medical school.Seventy-three pre-clinical medical students performed 219 simulated pelvic examinations and generated 219 written clinical assessments.Cronbach's alpha for the newly defined performance indicators, Pearson's correlation of performance indicators with scored written clinical assessments of simulator findings.Four novel performance indicators were defined: time to perform a complete examination, number of critical areas touched during the exam, the maximum pressure used, and the frequency at which these areas were touched. The reliability coefficients (alpha) were time = 0.7240, critical areas = 0.6329, maximum pressure = 0.7701, and frequency = 0.5011. Of the four indicators, three correlated positively and significantly with the written clinical assessment scores: critical areas, p < 0.01; frequency, p < 0.05; and maximum pressure, p < 0.05.This study demonstrates a novel method of analyzing raw numerical data generated from a newly developed patient simulator; deriving performance indicators from computer generated simulator data; and assessing validity of those indicators by comparing them with written assessment scores. Results show the new assessment measures provide an objective, reliable, and valid method of assessing students' physical examination techniques on the pelvic exam simulator.
View details for DOI 10.1197/jamia.M1107
View details for Web of Science ID 000178205000003
View details for PubMedID 12223497