Impact of emergency simulation training in primary care: a rapid review

Introduction

International healthcare trends suggest that the site of care for acutely ill and medically complex patients is increasingly shifting toward ambulatory offices,¹ such as general practice clinics and urgent care (UC) facilities. Six percent of all out-of-hospital cardiac arrests can occur in primary care.² Although emergencies occur relatively infrequently in primary care,³ general practitioners (GPs) have a responsibility to provide prompt and effective care when attending to life-threatening emergencies in their surgeries.⁴ The primary care provider plays an important role in the paediatric⁵ and adult emergency care services; however, due to the relative infrequency of emergencies in primary care, it can be quite daunting for those involved when emergencies occur.³ Primary care providers, particularly those who have worked outside of a hospital setting for a prolonged period, may feel ill-prepared to manage emergently ill patients.⁶

Simulation is one tool that can be used for education and systems testing for rare, but risky events⁷ such as emergency medical scenarios.^8,9 Simulation training could be particularly useful in primary care, given the minimal opportunities for health professionals to engage in multiprofessional emergency scenarios.¹⁰ Simulations can help develop psychomotor and critical decision-making skills, as well as training for the management of complex medical situations.¹¹ Classroom-based simulation is a well known teaching method and is often used for emergency life support courses;¹² however, in-clinic simulations can be particularly useful as clinicians should be encouraged to use their own equipment and medications during such simulations and develop confidence in managing emergencies within their surgeries.¹² High-fidelity simulation-based training programmes for managing emergencies, including cardiopulmonary resuscitation scenarios, have been successfully used in hospital settings and have been shown to improve knowledge and clinical skills.^13,14 Emergency simulations are well established as an efficacious education training tool for emergency medicine (EM) and intensive care unit (ICU) medical staff;^15,16 however, such emergency training simulation is less well evidenced in the education and training of primary care clinicians.¹⁷

In Aotearoa New Zealand (NZ), primary care clinicians work as general practitioners (GPs) with training through the Royal New Zealand College of General Practitioners (RNZCGP), as rural GPs with training through the Rural Hospital Medicine Training Programme (RHMTP), or as urgent care (UC) clinicians with training through the Royal New Zealand College of Urgent Care (RNZCUC). As part of these training programmes, registrars can be expected to complete courses such as Advanced Cadiac Life Support (ACLS), or Emergency Management of Severe Trauma (EMST) or Advanced Paediatric Life Support (APLS).^18,19 Although these courses can incorporate emergency simulations, none of the aforementioned training programmes mandate specific regular in-clinic simulation requirements for their trainees or fellows or respective clinics.^18,20 A reason why this is not regularly incorporated in the training of primary care specialties could be due to the lack of literature supporting the use of simulation for the wider primary care team including for non-clinical colleagues.³ There are relatively little data regarding the long-term value of simulation-based training in primary care.¹⁷

This research aimed to conduct a rapid literature review of studies looking at the use and impacts of emergency care simulation training in primary care,and to use this information to inform the use of such educational tools in the training of primary care clinicians.

Methods

Results

A PRISMA flowchart was used to record the data extraction process (see Fig. 1). From the initial search, 523 studies were identified; 10 duplicate articles were removed. Of the 513 remaining articles, the title and abstracts were screened to ensure they met the eligibility criteria of this review. The full texts of 26 potential studies were then further analysed to review eligibility. Initially, six studies met the final eligibility screening. The reference lists of all studies that underwent full-text analysis were then reviewed to identify further potential eligible studies. This identified two additional eligible studies, leading to a final number of eight studies being included in this literature review.

Fig. 1.

The PRISMA diagram outlining the data extraction process.

Seven of the studies evaluated the efficacy of simulation training for primary care providers. These were all prospective cohort studies. One of the eight studies was a proof-of-concept study to review the acceptability and barriers of emergency simulation training for primary care providers.

All studies were either based in the United Kingdom (UK), The United States (US) or Canada. Six of the studies involved participants that were from a range of clinical and non-clinical backgrounds, including administrative staff, nurse practitioners (NPs), practice nurses, healthcare assistants (HCAs) and primary care doctors. Two of the studies specifically reviewed the performances of junior medical doctors who had only recently started various training programmes, including family medicine residencies. Five of the studies mainly used surveys to record a combination of self-reported confidence using a Likert scale and collected qualitative information using free-text questions.^3,4,6,12,25 One study was a qualitative study that used semi-structured interviews and thematic data analysis.²⁶ Two studies incorporated independent assessments of performance during emergency simulations.^25,27 Ranger et al. specifically compared high-fidelity to low-fidelity simulation in emergency simulation training.²⁷ No previous literature reviews on this topic were found, and this probably reflects that this area has not been extensively researched in the past.

All studies demonstrated a positive effect on self-perceived confidence, competence and preparedness for the management of emergency cases in medical staff.^{3,4,6,7,12,25–27} GPs’ confidence in managing time-critical emergencies were often initially low, and significantly improved immediately after attending ‘real-world’, simulation-based training.¹⁴ These changes were applicable to all medical staff including non-clinical staff.^3,4,6,12 For example, one study reported confidence in managing emergencies improved significantly in all staff from a pre-course mean of 6.33 to a post-course mean of 8.52 (P < 0.0001). Further benefits were that there were significant improvements in understanding roles within the team (mean 7.37 vs 9.07, P < 0.001) and in awareness of protocols to be followed in an emergency (mean 7.07 vs 8.54, P < 0.01). There were also demonstrated benefits in developing emergency skills competence when measured by independent assessors,^25,27 and these changes have been shown to be sustained to at least 8 weeks post simulation training.⁴ Furthermore, there is a specific benefit that high-fidelity simulations can have when compared to low-fidelity simulations in emergency simulation training. For example, in one intervention cohort, 36% of participants who underwent high-fidelity simulations for transcutaneous pacing successfully completed all six tasks needed for transcutaneous pacing in comparison to 0% of the control group who underwent low-fidelity simulations (P < 0.001). And the intervention group completed most necessary emergency tasks under simulation pressure faster than the low-fidelity simulation group.²⁷

‘Real-life’, in-house, simulation-based training plays a key role in developing ‘practical preparedness’ in the context of resuscitation training.^4,28 Infrequent emergency events, the variety in management systems, lack of familiarity of code cart contents, varied layouts of primary care practices and a lack of standardisation of maintaining emergency carts can contribute to primary care staff feeling ill-prepared to handle emergencies.⁶ Staff valued the interactivity, teamwork and realism of in-house simulation-based training.³ This also helped learners recognise the crucial role that non-clinical staff play in the management of emergencies in primary care.³ Clinical staff particularly valued the opportunity to calculate drug doses and draw up medication under simulated pressure.³ In-house clinical simulation-based training can lead to clinics changing practices by standardising the availability of emergency medical equipment, protocols and the location of such resources within the clinic.^3,4 For example, in one study, all involved GP centres made changes to equipment and staff training after simulation training.²⁶

Barriers to staff participating in emergency care training in primary care can include an unwillingness to participate due to apprehension and anxiety prior to simulations, and having a fear of feeling assessed during simulations.²⁶

Table 1 presents a summary of the included studies.

Discussion

The studies included in this literature review consistently demonstrated that emergency care simulation training significantly impacts confidence, clinical practice and emergency management systems in primary care.^{3,4,6,7,12,25–27}

Developing clinicians’ confidence in managing medical emergencies and developing appropriate protocols to manage these in primary care is crucial. Most medical emergencies are peri-arrest situations, and this is an area where GPs lack confidence and competence.²⁹ Studies suggest that GPs feel that they know the theory of providing emergency care, but can lack the practical skills and confidence to manage these scenarios quickly and efficiently. This applies to both very experienced GPs and younger GPs who have recently undertaken hospital rotations, even for those with recent rotations in accident and emergency. Primary care providers and medical practices can be particularly ill-prepared to manage paediatric resuscitations.^30–32 This review showed the use simulations in primary care can have in developing confidence for staff to manage emergency cases. These results are consistent with the broader literature that suggests that the use of high-fidelity emergency simulations in primary care, including those for courses such as ACLS, is associated with improved skill performance after training.³³ Simulation-based medical education has consistently been shown to positively affect learner skills, knowledge and attitudes, and patient outcomes.^34,35 The findings from this literature review are also supported by a systematic review that concluded that simulation training improves several evaluation measures including self-efficacy (the degree of confidence in performing a procedure or providing patient care) and actual objective procedural competence.^36–40

This literature review has shown that hosting in-clinic emergency simulations can help improve the standardisation of medical equipment and policies. The lack of standardisation of emergency medical equipment, policies and training can be one of the reasons why primary care staff feel uncomfortable to manage emergencies.^6,31,32 Emergency simulation training should be run in the learners’ native clinical environments with only the equipment and resources that would normally be available.⁷ Real-life simulation in general practice surgeries highlights organisational, equipment and system issues that may prevent the delivery of rapid and effective care. For example, problems such as clinical staff struggling with equipment are best identified through actual use, and therefore it is paramount staff develop familiarity with equipment.²⁶

The other benefit to in-clinic simulation training is that targeted education and practice with teamwork and communication can lead to improved care from the real clinical team in a crisis.⁴¹ This literature review has shown that the benefits of in-clinic emergency simulations extend to both clinical and non-clinical staff.^3,4,6,15 Emergency management requires good teamwork, communication and effective use of available resources by the whole primary care team;¹⁷ however, teams are dynamic and require commitment to work and acknowledge that there is a need to understand other people’s roles,⁴² and there is a need to practice together. Hence, this is why there has been a growing interest in the application of simulation-based training for non-clinicians and organisations as a whole.⁴³ Simulated exercises have the potential to allow individuals to practise the management of emergencies within a team setting, and also allows teams to analyse and adapt their own performance.⁴⁴ It also allows non-clinicians to gain experience and appreciation for the demands of patient care,⁴³ emphasises the importance of defining team structures and processes,⁴⁵ and provides participants with the opportunity to develop non-technical skills such as effective teamwork and communication.⁴⁶ Furthermore, it is recommended that all staff participate in simulation training, as often a receptionist is the first person in a clinic to encounter a patient experiencing a medical emergency.⁶ Simulated waiting room emergencies provides a safe and supportive environment for staff to work together as a multi-disciplinary team (MDT) to manage infrequently occurring emergency scenarios.³ Team training has been identified as a high priority for the future of simulation.⁴⁷ ‘The best way to ensure readiness for an emergency is to practice regularly in the office setting, with as many office staff members as possible participating. Simulated exercises, or mock codes, provide a good opportunity for staff members to practice the steps of an emergency’ (American Academy of Pediatrics Committee on Pediatric Emergency Medicine 2007, p. 204).⁵

The findings of this literature review identified common barriers to implementing clinic-based or clinic-wide simulation training. Some of the barriers identified were that participants can be unwilling to participate due to apprehension and anxiety prior to simulations and having a fear of ‘feeling of being assessed or observed’. A major practical barrier is that staff may not attend training simulations unless mandated.⁶ And it can be impractical to either close a medical centre to ensure most staff can be available or to conduct it out-of-clinic hours.²⁶ However, there are practical advantages to hosting in-clinic simulation training. There can be lower training costs overall, no travel time or reduced personal expenses to participants, and it provides an opportunity for the entire inter-professional team to work together.²⁶

Conclusions

In-clinic emergency simulation education in primary care provides a valuable platform to improve the confidence of emergency management for clinical and non-clinical staff. It also can lead to improvement of clinical processes and systems. Mandated simulation training for primary care clinicians could be incorporated into relevant postgraduate training programmes.