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The most important question concerning simulator-based training in anesthesia is its cost-effectiveness. This complicated question has two relatively independent components. The first component is the impact and benefit of the training on the performance abilities of participants, and the second is the cost to achieve that impact. In principle, simulation has many advantages as a training tool.[33]
| Cognitive Science of Dynamic Decision Making |
| What is the interaction of precompiled procedural knowledge versus deep medical knowledge and abstract reasoning? |
| How does supervisory control of observation relate to vigilance, data overload, and visual scanning patterns? |
| What is the information content of watching the surgical field? |
| How are optimal action planning and scheduling implemented? |
| How does re-evaluation fail and result in fixation errors? |
| Human-Machine Interactions |
| What is the distraction penalty for false alarms? |
| Is there an advantage to integrated monitors and displays versus multiple stand-alone devices and displays? |
| How easy to use are the controls and displays of existing anesthesia equipment in standard case situations and in crisis situations? Do they invite mode errors? |
| What is the mental workload imposed by a new diagnostic device such as transesophageal echocardiography? |
| Teaching Anesthesia in the Operating Room |
| How much teaching can be accomplished in the operating room without sacrificing the anesthesia crew's vigilance? |
| How well can faculty detect and categorize the performance of anesthesia trainees? |
| What teaching styles are best integrated with case management in the operating room? |
| Issues of Teamwork |
| How does the anesthesia crew (attending plus resident or certified registere nurse anesthetist pair) interact during case and crisis management? |
| How is workload distributed among individuals? |
| How do crew members communicate with each other, and how do they communicate with other members of the operating room team? |
| Effects of Performance-Shaping Factors on Anesthetist Performance |
| How do sleep deprivation, fatigue, aging, or the carryover effects of over-the-counter medications, coffee, or alcohol affect the performance of anesthetists? |
| Intelligent Decision Support |
| Can smart alarm systems or artificial intelligence provide correct and clinically meaningful decision support in the operating room or intensive care unit? |
| Development of new devices and applications (e.g., development of the telemedical Guardian Angel System, see Chapter 83 ). |
| Research Regarding the Technique of Simulation Itself |
| How well do simulators resemble the operating room and provoke the same actions as use in the operating room (ecologic validity of simulators)? |
| How does the setting of simulation scenarios influence aspects of perceived reality and how does it influence transfer issues into the real world? |
The fidelity required of the simulator and thus the choice between screen-only and realistic simulators depend on the intended goals of the training and the relevant target population. A spectrum of computer-based training is possible. Computer-assisted instruction programs and partial-task trainers can be used to teach basic concepts and technical material, such as the uptake and distribution of inhaled anesthetics or the pharmacokinetics of intravenous drugs. These uses are appropriate for students, novices, advanced residents, and experienced practitioners. Screen-only simulators are inexpensive and easy to use. They allow the presentation of and practice with the concepts and procedures involved in managing normal and abnormal case situations. They are also useful for a large number of user populations. Realistic simulators can be used to capture the full complexity of the real task domain, including human-machine interactions and the complications of working with multiple personnel. They are most appropriately used for residents and experienced practitioners. Regardless of the device used, the simulator is only a teaching tool that must be coupled with an effective curriculum for its use.
The evaluations conducted thus far suggest that simulator-based training is a powerful technique that both novice and experienced anesthetists believe to be highly beneficial and that participants and instructors alike believe may improve clinical performance. As the developers of Sim One pointed out, when simulation provides an opportunity to teach material that cannot be taught in another way, as for the systematic instruction of anesthesiologists in handling severe critical events such as cardiac arrest, anaphylaxis, or malignant hyperthermia, there is nothing with which to compare the simulator. Assessing whether the actual outcome of patients can be affected by this or any other training modality will be extremely difficult and expensive. Those investigating simulator-based training do not believe that such an outcome study is logistically feasible.[151] Determining the
Perhaps of even greater importance, no methodology is currently accepted for measuring the clinical performance of anesthetists either in the simulator or in actual practice.[66] Ironically, the simulator itself provides a tool for presenting the same calibrated situation to multiple anesthetists and may thus be a crucial tool in developing such performance measures. Many groups around the world are trying to refine performance measurement tools, * but no "gold standard" measurement is yet available to assess a simulations' effectiveness. [66] [161] See the earlier section on evaluation of performance.
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