ECLS Training and Simulation - Evaluation of the 8th Educational Corner of the EuroELSO Congress 2019 Held in Barcelona

Abstract

Introduction: Simulation-based learning and hands-on learning are popular in medicine, particularly in areas where life-saving manoeuvres and team skills are required. Simulations can be provided in different environments: directly in hospitals (in situ), in dedicated facilities (simulation rooms) or, on occasion, at scientific meetings, thus taking advantage of the delegates’ motivation. Simulation-based learning in extracorporeal life support is also increasingly relevant due to the inherent features of the often difficult and emergent decision-making, approaches and management involved, as well as to the challenging multidisciplinary teamwork. Aim: Based on these premises and on the constant rise in interest in starting new extracorporeal life support programmes, the EuroELSO organization has, since the beginning of its scientific activities, established an ‘ad hoc’ space (Educational Corner) for training and hands-on sessions with a limited number of attendees per session during its annual congress. Methods: Experienced trainers deliver repeated dedicated sessions on fundamental aspects of extracorporeal life support management. After several years of sessions, a questionnaire was prepared and delivered to the attendees at the 8th annual congress in Barcelona. Results: More than 90% of the responders indicated that they would recommend the workshop to their colleagues and that they received useful information during the workshops. Over 85% of the responders (85-97%) indicated that the workshops met the set educational goals and objectives and indicated that the simulation sessions would have a positive impact on their daily practice. Conclusion: The Educational Corner during the EuroELSO Congress has achieved great popularity, as shown by the number of attendees participating each year, and presumably improves many technical and behavioural skills among the attendees.

Keywords

simulation education educational corner extracorporeal membrane oxygenation extracorporeal life support

Introduction

Simulation-based learning is frequently used for medical education and skills training, especially in areas where complex teamwork is required, such as the management of patients with extracorporeal support.^1,2 The aim of such learning is to recreate specific clinical situations in a controlled environment where candidates can rehearse their responses without any negative consequences related to human error.³ The Educational Corner, an area dedicated to active learning and training, has been an integral part of the EuroELSO annual congress since the first meeting in Rome during 2012. It provides an opportunity for delegates who want to improve their extracorporeal life support (ECLS) knowledge during the congress to learn about dedicated topics and expand to new teaching topics. All of the workshops of the 8th edition of the EuroELSO congress have been fully sold out, highlighting the high demand and interest among ECLS users. Experienced trainers deliver repeated dedicated sessions on fundamental aspects of ECLS management. The Educational Corner was originally conceived to deliver education, training and hands-on facilities taking advantage of the congress participation and instituted to provide the registered attendees with a near-authentic, almost one-to-one training and enhanced learning experience through the use of simulations focusing on the acquisition of both technical and behavioural skills.^4–7

This publication should help to offer training, carry out feedback, debriefing and continuously development.⁸ The article is aimed towards responsible ECLS programme directors, coordinators and all healthcare professionals (e.g. physicians, ECLS specialists, perfusionists, nurses, respiratory therapists) involved in ECLS training. The active learning can be turned into effective improvements in the workplace and into beneficial changes in the methods for cannulating and managing patients on ECLS.^4–6

Methods

Access to the simulation sessions of the Educational Corner was only possible for delegates of the 8th EuroELSO Congress held in 2019 in Barcelona. To continuously improve the quality of the simulations provided to the delegates and to expand on new teaching topics, the learning experiences of all attendees during the 8th edition of the EuroELSO Congress were evaluated. The topics for the simulations were advertised in advance on the EuroELSO website with outlined learning objectives, allowing the congress delegates to select and sign up for specific simulations. The learning objectives included management of the patient on ECLS, indications and contraindications for respiratory and cardiac ECLS, cannulation strategies and techniques, cardiac physiology, patient-circuit interactions and anticoagulation. The learning objectives were also explained at the beginning of each session to ensure a high level of fidelity and attention to details for the attendees.

The sessions lasted between 60 and 90 minutes and covered one or two topics. They were built to cover not only technical skills but also behavioural skills (maintain professional behaviour, call for help, properly use all resources available etc.). All the simulations were prepared using the principle of the suspension of disbelief to help the attendees learn using scenarios similar to their clinical practice but in a controlled environment without any consequences for the patients.^7,9–11 At the end of each session, a debriefing was performed with the attendees to fix any concerns and improve both their technical and behavioural skills. Participant examination was not performed due to the lack of time. However, a questionnaire evaluating the quality of the simulation session was prepared by the Working Group for Education of the EuroELSO. Thus, our aim was to evaluate the impact of this learning strategy on the attendees using a dedicated questionnaire after each simulation session. The questionnaire (Table 1) included three open-ended questions (with an option for a free response for suggestions and ideas) and five closed-ended questions with response options of ‘yes’, ‘somewhat’ or ‘no’, referring to the educational goals that were set and achieved. After each session, all the data from the completed questionnaires were evaluated using an Excel form (Microsoft™ Office Standard Excel version 2016).

Table 1.

The content of the questionnaire.

Question number	Text	Possible answers
1	Have you received useful information during this workshop?	Yes/Somewhat/No
2	Will it change your current practice?	Yes/Somewhat/No
3	Did the workshop meet the set educational goals & objectives?	Yes/Somewhat/No
4	Do you have suggestions to improve the efficacy of the workshop you attended?	Free text
5	Would you recommend the workshop you participated to your colleagues?	Yes/Somewhat/No
6	Are there any new topics you would like to see included at the Educational Corner of the next EuroELSO Conferences?	Free text
7	Do you consider the Educational Corner – being a practical approach towards ECLS-related techniques – an important part of the EuroELSO annual meeting?	Yes/Somewhat/No
8	Do you have any other recommendations for future EuroELSO Educational Corner workshop?	Free text

ECLS: extracorporeal life support.

Results

In total, 395 conference delegates, from an overall attendance of approximately 1,500 delegates, participated in the Educational Corner’s activities. Five teams provided simulations covering five different topics (Table 2). Each topic was repeated four times (Figure 1). All the simulation sessions were conducted in English except one, which was held in Spanish (Fisiología del ECLS – Simulación para enfermeras/os). A total of 327 attendees participated at the simulation sessions, but only 140 (42.8%) participants completed the questionnaire. The distribution of the responses according to each session is illustrated in Figure 1.

Table 2.

Educational content with aims and learning goals.

Title and number of offered sessions	Trainers	Aims	Learning outcomes/objectives
The Thrills and Spills of delivering haemofiltration and plasma exchange to your ECMO patient (four sessions)	Margaret Farley, Jo-Anne Fowles	Technical challenges of deciding where to connect ‘Access’ and ‘Return’ lines for the haemofilter Working with the pressure limitations of your haemofiltration device Recognizing the potential risks associated with connecting the CRRT to the ECMO circuit	Programming the haemofilter for ECMO Programming and prescription for a plasma exchange Understanding the limitations placed by different CRRT machines This workshop will be very focussed on practical skills and asking those questions that have been troubling you
Circuit Factors: Pitfalls and Challenges of Hybrid ECLS (four sessions)	Emmanuel Devolder, Tim Jones, Leen Vercaemst	To provide the participants with an understanding of the appropriate hybrid cannulation strategy and flow management to meet the needs of the patient Indications for hybrid ECMO: The rationale behind the choice of cannulation size and sites The clinical and technical parameters used to assess adequacy of support The interventions required if support is inappropriate	Know when to decide on hybrid cannulation configuration for optimal support Understand where to cannulate, how to connect cannula into circuit and restart ECMO Understand the parameters used to assess adequacy of hybrid ECLS support Recognize whether or not the ECLS support is appropriate
ECLS in OHCA and IHCA – Simulation with Cannulation Training (five sessions)	Justyna Swol, Matthias Baumgärtel, Karin Buttler, Kathrin Emmrich, Steffen Nietzold	Insights how to perform cannulation via percutaneous vascular access during resuscitation of the arresting patient using mechanical circulatory support system	Basic training in advanced vascular access procedure to implement ECLS in order to cardiopulmonary resuscitation both in in-hospital (IHCA) and in out-of-hospital cardiac arrest (OHCA) Team logistics and all requirements for extracorporeal cardiopulmonary resuscitation (ECPR) will be discussed
Troubleshooting on paediatric ECMO (four sessions)	Mirjana Cvetkovic, Maura O’Callaghan	This course is designed for EuroELSO Participants – intensivists, anaesthetists, paediatricians, cardiologists, emergency physicians, physician assistants, advanced practice nurses, perfusionists and all other providers who provide care for patients treated on extracorporeal membrane oxygenation (ECMO) This immersive hands-on workshop provides the latest techniques and technology surrounding the clinical use of ECMO. Through clinical scenarios we will apply the knowledge gained towards the troubleshooting of ECMO circuit utilizing high-fidelity simulation lab in order to recognize routine and catastrophic ECMO problems	1. Routine ECMO problems: Access issues, flow fluctuations, kick-back of the venous line, haemodialysis and raised plasma-free haemoglobin, limb ischaemia, bleeding cannula sites 2. Catastrophic ECMO problems: Pump failure, ‘suck-down’, venous or arterial decannulation, circuit rupture, air embolism, cardiac arrest With VA ECMO: LV distension, cardiac chamber thrombosis Upon completion of this activity, participants should be able to identify the components of the ECMO circuit, recognize major indications and contraindications of VV and VA ECMO, recognize and address routine and catastrophic ECMO problems and differentiate the interaction ECMO has on various patient organ systems

CRRT: continuous renal replacement therapy; ECLS: extracorporeal life support; VA: venous arterial; LV: left ventricular; VV: venous venous.

A total of 100% of the responding participants considered the Educational Corner to be an important part of the EuroELSO annual meeting, as it provides a practical approach to ECLS-related techniques. More than 90% of responders indicated that they would recommend the workshop to their colleagues and that they received useful information during the workshops (Figure 2). Over 85% of the responders (85-97%) indicated that the workshops met the set educational goals and objectives. There were, however, differences in responders’ opinions about the impact of the simulation sessions on their clinical practice. A total of 45-70% of responders indicated that the simulation sessions would have a positive impact on their daily practice (Figure 2). The data showed that two workshops, ‘Trouble-Shooting in Paediatric ECLS’ and ‘ECPR in OHCA and IHCA’, were thought to change daily practice in less than 50% of responders (Figure 3).

The results from the analysis of evaluation questionnaires prepared for the 8th edition of EuroELSO showed how this modality of training is a possible way to improve attendees’ knowledge about ECLS using an active learning environment.

Discussion

Education about ECLS has been developed in parallel to bedside clinical practice with dedicated courses. Many of these courses, however, overemphasize factual knowledge and underemphasize technical and behavioural skills. Simulation-based training has emerged as a valuable tool in critical care education, offering the opportunity to improve technical skills and reduce the risk of human errors.^3,4 High-fidelity simulation training has gained popularity at scientific conferences and has been a constant element of the EuroELSO conferences since 2012. The results from the analysis of the evaluation questionnaires showed how this modality of training is an excellent way to improve attendees’ motivation and knowledge about ECLS using an active learning environment. Among all the sessions, those covering the practical aspects of ECLS management with simulations (circuit emergencies, cardiac physiology etc.) were the most recognized (90-100%).

Differences in the participants’ opinions about the impact of the simulation sessions on their clinical practice should be addressed. Changing practice takes time, and challenges and limitations remain that limit the universal adoption of key interventions. Both medical leadership and staff need to work together to achieve the effective implementation of changes. Quality improvement programmes that focus on processes and human factors lead to culture change, which, in turn, leads to demonstrable qualitative and quantitative results.^4,5,7

One of the challenges with delivering such training in a conference setting is making it accessible for as many attendees as possible. The EuroELSO Conference uses a model of short educational sessions repeated multiple times. This short exposure time presents problems with delivering meaningful training and education. This is overcome by writing concise educational aims and objectives for each session, enabling both the participants and the trainers to achieve effective training in the short time available. The survey confirms that the attendees identified the objectives and felt that those objectives were met during the training session.

The attendees reported the most positive feedback from the sessions about problem-solving and emergency management. This highlights the benefit of using simulation and experiential learning in a safe environment to explore and gain experiences. Adequate debriefing with feedback, the opportunity for reflection and the identification of learning points are the key to simulation-based training.

The results coming from this evaluation provided feedback for improving the efficacy of the workshops. The majority of the delegates expressed the wish to extend the duration of the offered simulation framework in order to demonstrate more types of circuits and their components, set up the scenarios and increase the number of scenarios. However, time-limited workshops are a compromise in providing as broad an educational offer to as many delegates as possible. It is important for organizers to be open with participants about the fact that the Educational Corner provides a compact focused outline and an introduction to the topic. The sessions cannot replace a full-day workshop. Furthermore, there needs to be a balance between small group workshops and the remainder of the educational offerings within the congress programme in its entirety. New topics suggested for future Educational Corners included anticoagulation in ECLS, training on communication with families and patients on ECLS and additional troubleshooting scenarios. Simulations and practical training are faculty-intensive, requiring one to two faculty members for every five to six participants, and often require industry support, raising the potential for conflicts of interest. Given the current focus on reducing potential conflicts of interest, particularly in Europe, the viability of sessions that are clearly thought to be valuable for participants is potentially at risk.

The data described above produced by the questionnaire are useful for programme designers and workshop providers. The participants did, however, report a low likelihood that current practice will change and the data do not give a clear reason for why this is the case. This standardized survey should continue to be administered annually at the upcoming annual congress to evaluate the needs and input of delegates as well as to record the quality of the conference.

Limitations

The main limitation of this study was the low response rate of 43%. Although this is a reasonable response rate in comparison with other types of studies, unfortunately, 57% of attendees did not share their thoughts on the workshops. The low return rate may have been due to the short time between sessions, overlap with activities in the main congress or the paper-based nature of the assessment form. We will endeavour to simplify the evaluation at future congresses, and we may link it to the receipt of a certificate of attendance.

Such workshops need to be led by both clinical and educational specialists to achieve high-quality training. An important limitation is the difficulty in linking these sessions with improved clinical practice or other outcomes.

Organizing such workshops is also very demanding with regard to logistics, as a substantial amount of educational and ECLS equipment, as well as preparation time, is required on site. Hence, support from the industry and congress organizers is indispensable in setting up an Educational Corner.

Conclusion

The Educational Corner during the EuroELSO Congress has achieved great popularity, as shown by the number of attendees participating each year, and gives an impulse to expand the knowledge in further full-day courses to improve their technical and behavioural skills.

Footnotes

Acknowledgements

We would like to acknowledge Victoria Schmitt and Christian Reim (both INTERPLAN, Congress, Meeting & Event Management AG, Kaiser-Wilhelm-Strasse 93, 20355 Hamburg, Germany), who distributed the survey form during the 8th EuroELSO Congress in 2019 in Barcelona and then carried out the statistical processing of the forms. The Educational Corner has been supported over the years by many trainers who performed excellent simulations during the past eight conferences free of any honorarium.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship and/or publication of this article: J.S. received ECLS equipment and disposables from Maquet and Biomed Simulation. L.V. received ECLS equipment and disposables from Xenios, Maquet and Medtronic, and the Califia ECLS simulator from Biomed.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: The shipment of institutional educational equipment was supported by EuroELSO.

ORCID iDs

Justyna Swol

Roberto Lorusso

Matteo Di Nardo

Simon J Finney

Nicholas A Barrett

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