Elsevier

Resuscitation

Volume 84, Issue 9, September 2013, Pages 1174-1183
Resuscitation

Review article
Simulation technology for resuscitation training: A systematic review and meta-analysis

https://doi.org/10.1016/j.resuscitation.2013.04.016Get rights and content

Abstract

Objectives

To summarize current available data on simulation-based training in resuscitation for health care professionals.

Data sources

MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, Web of Science, Scopus and reference lists of published reviews.

Study selection

Published studies of any language or date that enrolled health professions’ learners to investigate the use of technology-enhanced simulation to teach resuscitation in comparison with no intervention or alternative training.

Data extraction

Data were abstracted in duplicate. We identified themes examining different approaches to curriculum design. We pooled results using random effects meta-analysis.

Data synthesis

182 studies were identified involving 16,636 participants. Overall, simulation-based training of resuscitation skills, in comparison to no intervention, appears effective regardless of assessed outcome, level of learner, study design, or specific task trained. In comparison to no intervention, simulation training improved outcomes of knowledge (Hedges’ g) 1.05 (95% confidence interval, 0.81–1.29), process skill 1.13 (0.99–1.27), product skill 1.92 (1.26–2.60), time skill 1.77 (1.13–2.42) and patient outcomes 0.26 (0.047–0.48). In comparison with non-simulation intervention, learner satisfaction 0.79 (0.27–1.31) and process skill 0.35 (0.12–0.59) outcomes favored simulation. Studies investigating how to optimize simulation training found higher process skill outcomes in courses employing “booster” practice 0.13 (0.03–0.22), team/group dynamics 0.51 (0.06–0.97), distraction 1.76 (1.02–2.50) and integrated feedback 0.49 (0.17–0.80) compared to courses without these features. Most analyses reflected high between-study inconsistency (I2 values >50%).

Conclusions

Simulation-based training for resuscitation is highly effective. Design features of “booster” practice, team/group dynamics, distraction and integrated feedback improve effectiveness.

Introduction

The infrequency of resuscitation events limits the opportunities for on-the-job training. Such limitations may become more pronounced as duty hours reduce clinical exposures and as training shifts to ambulatory settings.1, 2, 3 Simulation training offers a potential solution that enables deliberate selection and sequencing of cases, practice (and error) without risking patient safety, and accommodation of training schedules. Given these proposed advantages, medical educators have been charged to develop and use simulation training models,4 and medical schools and teaching hospitals have invested heavily in simulation training technologies.5 However, the effectiveness and optimal design of resuscitation training remains unknown.6 A synthesis of available evidence would help educators and policymakers determine the appropriate role of simulation in resuscitation training and optimize instructional design.

Recent reviews have attempted to address this need by synthesizing results of empiric investigations of resuscitation training. However, these reviews had limitations including focus on a single provider type, lack of comprehensive search, or absence of quantitative synthesis.7, 8, 9, 10 A recent review of simulation-based education broadly found large benefits compared with no intervention and modest benefits compared with other instruction, but did not look specifically at resuscitation training.11, 12 We aimed to perform a comprehensive systematic review and meta-analysis focusing on simulation-based resuscitation training to determine effectiveness and best practices for instructional design.

Section snippets

Methods

This review was planned, conducted, and reported in adherence to PRISMA standards of quality for reporting meta-analyses.13 It is a planned sub-analysis of articles identified in general reviews of simulation-based education.11, 12, 14 Our general methods have been described in detail previously;11 we summarize them briefly below.

Trial flow

Our search yielded 10,903 articles. From these we identified 985 comparative studies of simulation-based training, and then 185 studies specific to resuscitation training (see Fig. 1). We identified two articles reporting on the same intervention; we selected the most detailed report for full review and excluded the other. We also excluded two studies without learning outcomes. This left 182 studies enrolling 16,664 participants included for full review, namely 114 comparisons with

Discussion

Meta-analysis of 114 studies indicates that simulation-based resuscitation training is highly effective when compared with no-intervention. Evidence from 21 studies further suggests that simulation-based training may be slightly more effective than non-simulation interventions for process skills, but not for knowledge or procedural speed.

Relatively few studies explored the elements that contribute to effective simulation-based instruction. However, these studies, when clustered by theme,

Funding source

This publication was supported by intramural funds, including an award from the Division of General Internal Medicine, Mayo Clinic.

Conflict of interest statement

No conflict of interest to disclose by any of the authors.

Acknowledgements

The authors acknowledge Stanley J. Hamstra, PhD, Rose Hatala, MD, MSc, Amy Wang MD, and Pat Erwin, MLS, for their efforts in initial study selection and data abstraction.

References (86)

  • W. de Vries et al.

    Self-training in the use of automated external defibrillators: the same results for less money

    Resuscitation

    (2008)
  • M.H. Oermann et al.

    Effects of monthly practice on nursing students’ CPR psychomotor skill performance

    Resuscitation

    (2011)
  • M. De Regge et al.

    Basic life support refresher training of nurses: individual training and group training are equally effective

    Resuscitation

    (2008)
  • C.C. Lee et al.

    Comparison of traditional advanced cardiac life support (ACLS) course instruction vs. a scenario-based, performance oriented team instruction (SPOTI) method for Korean paramedic students

    J Emerg Med

    (2010)
  • K.G. Monsieurs et al.

    Improved basic life support performance by ward nurses using the CAREvent® Public Access Resuscitator (PAR) in a simulated setting

    Resuscitation

    (2005)
  • S.E. Kardong-Edgren et al.

    Comparison of two instructional modalities for nursing student CPR skill acquisition

    Resuscitation

    (2010)
  • B.B. Spooner et al.

    An evaluation of objective feedback in basic life support (BLS) training

    Resuscitation

    (2007)
  • D.L. Isbye et al.

    Voice advisory manikin versus instructor facilitated training in cardiopulmonary resuscitation

    Resuscitation

    (2008)
  • H.C. Miotto et al.

    Advanced Cardiac Life Support Courses: live actors do not improve training results compared with conventional manikins

    Resuscitation

    (2008)
  • R.A. Cherry et al.

    The effectiveness of a human patient simulator in the ATLS shock skills station

    J Surg Res

    (2007)
  • H. Owen et al.

    Comparison of three simulation-based training methods for management of medical emergencies

    Resuscitation

    (2006)
  • B. Zendejas et al.

    Cost: the missing outcome in simulation-based medical education research: a systematic review

    Surgery

    (2013)
  • W.C. McGaghie et al.

    Translational educational research: a necessity for effective health-care improvement

    Chest

    (2012)
  • S.R. Moonesinghe et al.

    Impact of reduction in working hours for doctors in training on postgraduate medical education and patients’ outcomes: systematic review

    BMJ

    (2011)
  • J. Vozenilek et al.

    See one, do one, teach one: advanced technology in medical education

    Acad Emerg Med

    (2004)
  • G.T. McMahon et al.

    A simulator-based curriculum to promote comparative and reflective analysis in an internal medicine clerkship

    Acad Med

    (2005)
  • L.T. Kohn et al.

    (Institute of Medicine). To err is human: building a safer health system

    (2000)
  • D.L. Rodgers

    High-fidelity patient simulation: a descriptive white paper report

    (2007)
  • Passiment M, Sacks H, Huang G. Medical simulation in medical education: results of an AAMC survey;...
  • R. Hamilton

    Nurses’ knowledge and skill retention following cardiopulmonary resuscitation training: a review of the literature

    J Adv Nurs

    (2005)
  • J. Yeunga et al.

    The use of CPR feedback/prompt devices during training and CPR performance: a systematic review

    Resuscitation

    (2009)
  • C. Mosley et al.

    BEME guide: what is the impact of structured resuscitation training on healthcare practitioners, their clients and the wider service? A BEME systematic review: BEME Guide No. 20

    Med Teach

    (2012)
  • D.A. Cook et al.

    Technology-enhanced simulation for health professions education: a systematic review and meta-analysis

    JAMA

    (2011)
  • D.A. Cook et al.

    Comparative effectiveness of technology-enhanced simulation versus other instructional methods: a systematic review and meta-analysis

    Simul Healthc

    (2012)
  • D. Moher et al.

    Preferred reporting items for systematic reviews and meta-analyses: the prisma statement

    Ann Intern Med

    (2009)
  • D.A. Cook

    Randomized controlled trials and meta-analysis in medical education: what role do they play?

    Med Teach

    (2012)
  • D.A. Reed et al.

    Association between funding and quality of published medical education research

    JAMA

    (2007)
  • D.A. Cook et al.

    Internet-based learning in the health professions: a meta-analysis

    JAMA

    (2008)
  • J.P.T. Higgins et al.

    Measuring inconsistency in meta-analyses

    BMJ

    (2003)
  • J. Cohen

    Statistical power analysis for the behavioral sciences

    (1988)
  • S.L. Toback et al.

    Impact of a pediatric primary care office-based mock code program on physician and staff confidence to perform life-saving skills

    Pediatr Emerg Care

    (2006)
  • S.W. Wright et al.

    High fidelity medical simulation in the difficult environment of a helicopter: feasibility, self-efficacy and cost

    BMC Med Educ

    (2006)
  • S. DeMaria et al.

    Adding emotional stressors to training in simulated cardiopulmonary arrest enhances participant performance

    Med Educ

    (2010)
  • Cited by (170)

    • The effect of a structured ECPR protocol aided by specific simulation training in a quaternary ECMO centre: A retrospective pre-post study

      2022, Resuscitation Plus
      Citation Excerpt :

      Beyond this, the real-world effectiveness of simulation training for ECPR has not yet been clearly established. The implementation of simulation training for ECPR is largely informed by the proven benefit of simulation training in ACLS and resuscitation skill performance and patient outcomes.22,23 Though this study did not demonstrate an association between the intervention and ECPR utilisation, we speculate that the raw increase in ECPR numbers was likely due to both an increased awareness and the development of a clear protocol as opposed to a change in rates of refractory cardiac arrest.

    View all citing articles on Scopus

    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2013.04.016

    View full text