Cite as: Burnett G, Park C. Five institutions tell us how they use simulation in regional anesthesia education. ASRA Pain Medicine News 2022;47. https://doi.org/10.52211/asra020122.010. 

Simulation is an Accreditation Council for Graduate Medical Education (ACGME) requirement for anesthesiology residency programs and has become a vital tool for training residents in anesthesiology fundamentals.¹ Based on survey data, approximately 80% of residents and 66.7% of fellows participate in anesthesiology residency programs that include regional anesthesia simulation.² With today’s work-hour and COVID-19 restrictions, simulation provides hands-on training to supplement traditional didactics and the apprentice model of training in regional anesthesia.

Regional anesthesia simulation involves numerous modalities, including task trainers or gel phantoms for low-stakes procedural training, live model scanning to learn relevant sonoanatomy, high-fidelity mannequin-based simulation for management of critical events such as local anesthetic systemic toxicity (LAST), and more. Because of the variety of modalities, developing a curriculum or organized method for integrating simulation into regional anesthesiology training can be difficult.

To aid in the creation of new training programs, we interviewed educators at five institutions across the United States about their use of simulation for regional anesthesia training. They described a variety of methods and curricula spanning stages from early development to established longitudinal curricula. The contributing experts and institutions are:

How are you using simulation for regional anesthesia training at your institution?

OHSU: We’ve incorporated it into our longitudinal curriculum. A critical component is a needle skills training session using a gel phantom on the very first day of a resident’s core regional anesthesia and acute pain medicine (RAAPM) rotation. This session emphasizes transducer movements and needle guidance skills, concepts that are constantly referred throughout the rest of the rotation. We also perform a complete simulated peripheral nerve catheter block on a torso simulator to review procedural steps. During the rest of the rotation, residents participate in weekly one- to two-hour sonoanatomy sessions with a standardized patient. In those, we practice patient positioning and scanning for a variety of regional anesthesia procedures. In the advanced resident rotation, we have simulated objective structured clinical examination (OSCE) sessions for LAST and peripheral nerve injury. We are in the process of evaluating additional OSCEs that are similar to what the residents experience during their board examinations.

Duke: We have a longitudinal simulation curriculum that covers progressively more advanced topics. First-year clinical anesthesia residents (CA-1s) participate in a regional anesthesia simulation with a case stem. In a small group setting, they perform a preoperative assessment, develop an anesthetic plan with specific regional anesthesia considerations, and select appropriate equipment and drugs. Residents then participate in a sonoanatomy scanning session to identify important landmarks and discuss how anatomical differences may require them to alter their approach. Next, they manage an intraoperative complication using a high-fidelity simulator and a discuss a postoperative complication in the classroom.

CA-2s and CA-3s participate in more advanced anesthesia crisis resource management high-fidelity simulation courses. The full-day experiences allow the learner to manage the patient as well as the environment; practice rare, critical situations they may not otherwise experience during training; and get exposure to regional anesthesia complications such as LAST. Our RAAPM fellows also participate in a crisis resource management simulation curriculum, which covers regional anesthesia and pain medicine–specific intraoperative emergencies, out-of-operating room scenarios, and simulated patient encounters. We use high-fidelity simulators to practice scenarios such as LAST, opioid overdose, advanced cardiac life support, tension pneumothorax, massive hemorrhage, and peripheral nerve injury. Our fellows also participate in and help proctor the mock OSCE, which includes an ultrasound station.

Stanford: Our RAAPM fellowship program has weekly dedicated teaching sessions with four elements: didactic lectures, cadaver workshops, ultrasound workshops, and quarterly simulation sessions. The first session is on ultrasound machine familiarization and needling practice using phantom models. The remaining three sessions use high-fidelity simulation to teach the principles of crisis resource management in the context of regional anesthesia and acute pain medicine. They cover perioperative, intraoperative, and postoperative events to prepare fellows for returning to the operating room after their fellowship is complete. Residents also have cadaver and live model scanning workshops throughout the year as part of their residency education curriculum and complete a LAST simulation during their annual anesthesia crisis resource management course.

Mount Sinai: Although we do not have a formalized longitudinal curriculum, we have integrated simulation into our training program at a variety of levels. Most of our RAAPM simulation focuses on learning techniques and relevant anatomy using live model scanning, task trainers, and high-fidelity simulations. More recently, we have developed a cadaver-based regional anesthesia course, which incorporates block performance and dissection as well as an OSCE-based regional anesthesia session.

Vanderbilt: Our RAAPM simulation is currently being developed. It will involve attendings, residents, fellows, and advanced practice providers and focus on everyday issues and crisis management. Our currently planned scenarios will use mannequins and live patients to train on thoracic epidural management, postoperative total shoulder management, and post-anesthesia care unit management of pain, hemodynamic instability, and respiratory difficulties, and we plan to create additional scenarios soon. Instructors will be trained on conducting simulator debriefing workshops. Rotators will have simulation opportunities in the middle of their rotation in two groups.

Is simulation for regional anesthesia used for summative or formative assessment at your institution?

OHSU: We use all simulations for formative assessment, not summative assessment.

Duke: Our program does not use most simulations for assessment. Rather, we emphasize debriefing to provide immediate feedback, reflection, and education in a low-stakes environment. However, one exception is our regional anesthesia simulation for RAAPM fellows. Conducted at approximately the midpoint of their fellowship, the simulation includes a formative assessment in which we evaluate fellows with a grading rubric based on a checklist for each scenario and a global holistic score on a four-point scale.

Stanford: We currently use simulation only for teaching and not for formative or summative assessment.

Mount Sinai: Our high-fidelity simulation, and more recently our OSCE-based regional anesthesia session, use formative assessment to facilitate individualized debriefs to improve our trainees’ skills. We do not currently use simulation for summative assessment in regional anesthesia.

Vanderbilt: We will not be using it for assessment (neither summative nor formative), only for educational purposes.

What challenges has your institution faced when implementing a simulation program for regional anesthesia training?

OHSU: Our greatest challenge has been integrating simulation into a busy service where clinical demands impinge on dedicated teaching time. Additionally, our regional service is distributed across two sites, which makes joint teaching and simulation sessions impossible.

Duke: Survey data from regional anesthesia programs have demonstrated that the biggest barriers to implementing simulation are time, cost, simulator availability, and curriculum development.² We are extremely fortunate to overcome many of those barriers with the Duke Human Simulation and Patient Safety Center and departmental support. In 2018, we invested faculty time to create a RAAPM simulation curriculum that has required only small updates. Therefore, our largest remaining challenge is time. Faculty have many competing clinical and nonclinical responsibilities, and time spent teaching in simulation is not always compensated. Furthermore, incentives to assist faculty development in simulation are limited.

Stanford: Although we offer weekly dedicated teaching sessions, we have not yet scheduled many educational topics, thus limiting the number of available sessions. Sessions also require two faculty members, a simulation technician to run the space, and space in the simulation center, which limit our abilities and offerings.

Mount Sinai: Our greatest challenge has been residents’, fellows’, and attendings’ availability to participate in training sessions because of the high clinical volume and other educational initiatives. We are fortunate that our department has a simulation center, which allows us to complete sessions in the morning or evening outside of clinical duties, but it can be difficult to coordinate participants’ time.

Vanderbilt: Developing our curriculum has been our biggest challenge, because many of our colleagues have little experience in creating simulation scenarios or leading debriefs.

What advice for low-resource programs would you have to integrate simulation into regional anesthesia training?

OHSU: Gel phantoms are relatively inexpensive and useful for needle skills training, and you only need one or two. Low-cost volunteers can be used for frequent scanning sessions to teach sonoanatomy. Many OSCE or simulations can be run as low fidelity, which does not require a formal simulation center. For example, a faculty member can pretend to have a nerve injury, or a mannequin and a simple rhythm generator can be used to simulate LAST.

Duke: Simulation allows for hands-on practice in an environment that eliminates potential harm to patients during the learning process, provides procedural skills practice, and allows for immediate feedback. Studies have shown that it improves procedural success in real-life clinical settings.³ Notably, low-fidelity models have been reported to be just as helpful as high-fidelity simulators.⁴ Learners can practice on task trainers, which can be made from a variety of low-cost materials. Advanced scenarios can be adapted and discussed with a faculty mentor without the use of an expensive mannequin-based system.

Stanford: You do not need to use high-fidelity models to add simulation to your regional program. Low-cost alternatives like ultrasound scanning workshops and simulated patient interactions with volunteers, phantom meat models, tabletop simulations, and trigger videos with guided debriefings can all be used.

Mount Sinai: Simulation can be conducted across a wide range of fidelity levels. Problem-based learning discussions require no specialized equipment and can be low-cost solutions when high-fidelity simulators or specialized task trainers are not available. Additionally, do-it-yourself gel phantoms using gelatin and fiber supplements or meat models have been described in the literature as low-cost alternatives to more expensive task trainers.^5,6

Vanderbilt: Developing a simulation curriculum can be difficult, given the need for many individuals and support staff as well as buy-in from all involved. Plan to spend six to nine months to activate the program and another three to six months to work through any kinks. Having a champion to lead the effort is key for integrating simulation into your regional anesthesia training. Moreover, success requires assistance in trainees’ and instructors’ schedules to free them from their clinical responsibilities. Be flexible, consider creative scheduling, and above all, do not get frustrated.

Where do you see the future of simulation in regional anesthesia going?

OHSU: If costs come down, advanced imaging simulators that simultaneously display the 3D anatomy, needle, and sonoanatomy could become an essential part of RAAPM training.

Duke: We believe that as patient safety benefits are highlighted, emphasis on simulation will increase. Simulation will become a core part of a regional anesthesia curriculum, allowing learners to practice, receive deliberate feedback, and address quality behaviors before inserting a needle into a real patient.

Stanford: If the ACGME moves toward a summative exam for regional anesthesia fellowships, simulations could be recorded and externally reviewed by trained evaluators.

Mount Sinai: We hope that virtual and augmented reality systems will be developed and applied for regional anesthesia training. Both the cost of hardware and availability of training software are currently limiting that use, but as hardware becomes more accessible, we hope more virtual and augmented reality regional anesthesia training software programs follow. We believe both technologies will allow for more realistic simulation experiences.

Vanderbilt: We see upward potential: not only to teach new techniques but also to troubleshoot blocks and epidurals.

References

1. Rochlen LR, Housey M, Gannon I, et al. A survey of simulation utilization in anesthesiology residency programs in the United States. A A Case Rep. 2016;6:335–42. https://doi.org/10.1213/xaa.0000000000000304
2. Burnett GW, Shah AS, Katz DJ, Jeng CL. Survey of regional anesthesiology fellowship directors in the USA on the use of simulation in regional anesthesiology training. Reg Anesth Pain Med. 2019;44:986–9. https://doi.org/10.1136/rapm-2019-100719
3. Chen XX, Trivedi V, AlSaflan AA, Todd SC, Tricco AC, McCartney CJL, Boet S. Ultrasound-guided regional anesthesia simulation training: a systematic review. Reg Anesth Pain Med. 2017;42:741-50. http://doi.org/10.1097/AAP.0000000000000639
4. Friedman Z, Siddiqui N, Katznelson R, Devito I, Bould MD, Naik V. Clinical impact of epidural anesthesia simulation on short- and long-term learning curve: high- versus low-fidelity model training. Reg Anesth Pain Med. 2009;34:229-32. http://doi.org/10.1097/AAP.0b013e3181a34345
5. Naraghi L, Lin J, Odashima K, Buttar S, Haines L, Dickman E. Ultrasound-guided regional anesthesia simulation: use of a meat glue in inexpensive and realistic nerve block models. BMC Med Ed. 2019;19:145. https://doi.org/10.1186/s12909-019-1591-1
6. Lahham S, Smith T, Baker J, Purdy A, Frumin E, Winners B, Wilson SP, Gari A, Fox JC. Procedural simulation: medical student preference and value of three task trainers for ultrasound guided regional anesthesia. World J Emerg Med. 2017;8:287-91. https://doi.org/10.5847/wjem.j.1920-8642.2017.04.007