Rural pediatric clinicians face barriers to accessing health care simulation, an educational standard to prepare for high-acuity, low-occurrence (HALO) events. Simulation is typically accessible in urban academic medical centers, as it is resource-intensive owing to the necessary equipment and expertise needed to implement training. Rural hospitals face geographic and financial barriers to providing simulation training. Paradoxically, rural clinicians may benefit from additional training owing to infrequent clinical HALO events in rural centers. Emerging simulation modalities, including mobile simulation, telesimulation, and extended reality, offer more accessible simulation alternatives for rural clinicians, addressing geographic and financial gaps in access.
Key points
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Access to health care simulation for rural clinicians is important for team-based training.
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There are many different types of simulation modalities to help address geographic and financial barriers to simulation in rural areas.
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Telesimulation and Augmented Reality simulation offer alternatives to traditional simulation for high-acuity, low-occurance (HALO) events.
Introduction
Ensuring access to high-quality neonatal and pediatric medical care, regardless of geographic location, is a critical component of public health with profound implications for the well-being of our youngest population. Recent data suggest that as much as 15% to 20% of the population, including 1 in 5 children, live in rural areas and encounter a higher burden of health care disparities compared with their urban counterparts. As rural health care providers struggle with constrained resources, geographic isolation, and a shortage of trained professionals, the delivery of timely and effective pediatric care becomes increasingly difficult. The repercussions are particularly dire for high-acuity, low-occurrence (HALO) events, such as acute resuscitation, where swift intervention can be the difference between life and death. Studies consistently highlight the disparities in health care delivery between rural and urban settings where pediatric volume and readiness for emergencies play a large role. For example, children who present to emergency departments with limited pediatric readiness have been found to have increased mortality, , and pediatric patients are twice as likely to die if they suffer a cardiac arrest in a rural hospital compared with in a specialty children’s hospital.
Access to structured pediatric training is critical in addressing health care disparities. Unfortunately, one of the persistent challenges in rural areas is the limited availability of specialized health care services. Almost half of all counties in the United States are without a general pediatrician, and 82% lack one in rural areas, with pediatric specialists being even more scarce. The American Hospital Association found that between 2008 and 2018, the number of pediatric inpatient units decreased by almost 20%, mostly affecting rural areas. These closures have led to a significant increase in distance to the nearest pediatric inpatient unit for almost one-quarter of US children. These rural challenges highlight the need to identify innovative educational opportunities to support hospitals in rural areas with lower pediatric volumes to maintain skills and readiness and address this rural/urban disparity.
Many physicians report lower confidence and skill with procedures as time away from residency increases. Iyer and colleagues showed that pediatricians reported feeling less prepared in procedural skills in practice than at graduation and would require additional training. Multiple studies have suggested that educational collaboratives between more general hospitals in rural areas and children’s hospitals can support access and quality of pediatric care. , Geography is often a barrier, as distance can limit education opportunities. However, the integration of technology in medical education has the potential to bridge this geographic gap.
One notable example of technology-driven medical education is health care simulation training. Simulation training is a widely accepted deliberate practice methodology to improve skills, including technical and task-related skills, communication, and team performance. Simulation programs allow health care providers in rural areas to practice for pediatric HALO events in a low-risk environment, honing their skills and building confidence. , Simulation programs have been shown to enhance clinical performance, reduce errors, and improve overall patient outcomes. Recent evidence has shown simulation-based training significantly impacted medical professionals’ competency and confidence levels, particularly in specialties like neonatology. Neonatal resuscitation simulation training decreases neonatal mortality and is an ideal method to train interprofessional teams. Furthermore, consensus statements from the International Liaison Committee on Resuscitation (ILCOR) and the American Heart Association (AHA) consistently recommend frequent simulation sessions to optimize skills.
Team-based training, such as those afforded by simulation and associated educational opportunities, can potentially improve hospital staff recruitment and retention. Engagement is crucial to maintaining the workforce and helping prevent hospital closures because of a lack of staffing. Hospital staff engagement has been shown to be directly related to patient safety, whereas hospitals with increased engagement have lower adverse safety events. ,
The existing disparities in pediatric infant and neonatal medical care in rural areas underscore the urgent need for innovative solutions. Integrating simulation technology in medical education and continuing medical education offers an approach to address these challenges, empowering rural health care providers with access to training opportunities to deliver high-quality care. This article reviews existing simulation modalities that play an important role in narrowing the gap between urban and rural pediatric health care outcomes. Specifically, it outlines the terminology, the application or implementation strategy of the technology, the benefits and limitations associated with the modality, and future directions.
Simulation technologies
Mobile Simulation
Traditional health care simulation typically occurs at or near simulation centers that are affiliated with academic medical centers (“center-based simulation”). Providing access to rural care teams presents logistical challenges (ie, distance traveled to the simulation center, limited clinical coverage during training). Building additional simulation centers across rural regions is not typically financially viable owing to construction and ongoing operating costs. Mobile simulation, however, is a solution to some of these challenges. It is defined as the “ability to move the simulator from one teaching location to another or teach a scenario on the move” ( Fig. 1 ). This transportable simulation allows simulation centers to bring training and technology to rural hospitals. Physically, this can be as a mobile simulation training unit in the form of a bus, trailer, or ambulance that replicates a clinical setting or by bringing simulators to train in the hospital’s actual clinical space, termed in situ simulation (ISS). The remainder of this section addresses mobile ISS simulation, including modalities, benefits, challenges, program implementation, and future directions.
Implementation of mobile simulation
ISS is defined as a simulation that takes place “in the actual patient care setting/environment in an effort to achieve a high level of fidelity or realism.” Different simulation modalities are used in mobile simulation training, including manikins and/or embedded simulated persons. Manikin-based simulation uses human-like manikins to create a patient encounter via heart and lung sounds, palpable pulses, voice interactions, vital signs monitoring, and limited movement. If financial resources are limited, more lower-fidelity manikins can be used effectively. Embedded simulated persons are individuals trained to portray either patients or family members. They can be used independently or as an effective adjunct in a mixed-method ISS.
Although training teams in communication, technical skills, and teamwork is necessary for improved patient safety, single or infrequent sessions are not sufficient to maintain skill levels. , Gains in cognitive, procedural, communication, and teamwork domains decay over time without regular reinforcement or refresher training. , To maximize potential gains from ISS, education should be more explicitly connected with health service priorities and patient outcomes. This has been coined “translational simulation,” a functional description of a subset of simulation activities that, in addition to training individuals and teams, is directly focused on improving health care processes and outcomes. Education and training are directed at a specific health care outcome target, with the goal of service improvements and a change in patient outcomes. Designing ISS events with this forethought can allow them to be tailored to specific rural health care needs, promoting relevance and applicability.
Several ISS programs have been able to show a translational impact of their training by explicitly integrating them into quality improvement projects. Abulebda and colleagues demonstrated an interventional study to measure and improve the community emergency department’s Pediatric Readiness Survey (PRS) scores, a composite readiness score shown to correlate with decreased mortality in critically ill children. , This program consisted of ISS, report-outs, access to online pediatric readiness resources, and content experts, which demonstrated significant improvement in pediatric readiness scores. The improvement was attributable to tailoring scenarios to focus on components of the PRS. The simulation-based performance of real-world teams applying their knowledge, using their equipment, and accessing their guidelines provided emergency department leaders with information on gaps in the care for sick children. Their simulation program demonstrated the value of strong communication and collaboration between community hospitals and academic medical centers.
Benefits of mobile simulation
Numerous benefits are obtained by providing rural care teams access to ISS. Realistic re-enactment of clinical scenarios can provide deliberate practice opportunities to improve teamwork and communication. Teamwork training is a specific recommendation by the Joint Commission, as communication issues top the list of identifiable root causes of infant death and injury during delivery and subsequent resuscitation. Although cost is often a barrier in creating large simulation centers and in high-fidelity (Hi-Fi) simulation, many task trainers and other low-cost options exist, which could be useful for ISS and mobile simulation in lower-resource settings. Most importantly, interprofessional in situ allows for a postsimulation reflective practice ( Fig. 2 ), termed “debriefing.” Debriefing, when led by skilled simulation educators, can serve as a forum for participants to identify areas of potential improvement in teamwork, medical knowledge, and their hospital system.
Limitations of mobile simulation
The use of ISS in rural settings has many drawbacks, including the availability of training spaces, scheduling challenges, and the cost of supplies. By using clinical spaces at the rural site, ISS can place strain on patient care. Rural hospitals may have limited space to care for patients, resulting in a higher rate of training cancellations if potential simulation space is needed for patient care. Sessions may be difficult to schedule, given the smaller pool of providers covering active clinical duties. Multiple ISS sessions may have to be scheduled to maximize participation, increasing the need for simulation experts to travel large distances. Improved operational efficiency may be gained from teams practicing with real supplies; however, the cost of using these supplies must be budgeted. ISS requires its own diligent safety practices to ensure patient readiness of clinical spaces if the need arises. Mitigation methods must be put in place to label supplies and medication effectively, ensuring they do not accidently get used for actual patient care. , Ultimately, ISS requires flexibility, as each hospital’s needs, resources, and limitations will vary ( Table 1 ).
| Advantages | Challenges |
|---|---|
| Interprofessional realistic re-enactment of scenarios | Increased probability of participants being distracted by patient care |
| Participants are more comfortable in their own clinical space | Higher rate of cancellations if clinical space is needed for patient care |
| Participants do not have to travel to simulation centers | Strain on the simulation center to bring equipment and trained facilitators to rural hospitals |
| Participants practice with real supplies and equipment | Cost of practicing with real supplies |
| Debriefing fosters team conversation to identify areas of potential improvement in teamwork, medical knowledge, and their health system | Use of clinical spaces strains resources for actual patients |
| The opportunity to maximize interdisciplinary participation | Safety threat of simulation materials being accidently used for actual patient care |
| Simulation events can more effectively integrate into a local quality improvement program | Safety threat of real clinical supplies and space being used for simulation and not adequately readied for patient care postsimulation |
| Hospital patients and family members may see simulation practice as confidence builder | Supportive audiovisual technology is harder to put in place |
Future directions of mobile simulation
Although health care simulation shows promise as an educational modality for rural health care teams, there is a need for further research on its long-term impact on service improvements, patient outcomes, and cost-effectiveness. Given the limited financial resources of rural hospitals, strategic funding support for the integration of simulation training into rural training will be critical. Increasing repeated accessibility of simulation is another frontier that merits further exploration. Given the finite simulation resources accessible to rural teams, cheaper, faster alternatives need to be explored. Although these methods may be considered “lower technology,” they can still maintain psychological fidelity, are thought to be essential for effective learning, and are associated with improved retention and long-term recall.
Telesimulation
Telesimulation, also known as “distance simulation,” provides an innovative solution to address disparities in access to simulation training for neonatal and pediatric care in rural hospitals. Telesimulation pairs simulation technology with audiovisual (AV) cameras allowing rural clinicians to participate in their own local environment while expert facilitators observe and provide feedback from a remote location. This enables teams to realize the benefits of ISS ( Table 2 ): improving procedural skills, clinical knowledge, teamwork, and communication and identifying systems issues and latent safety threats specific to that local environment. The use of telesimulation experienced rapid expansion during the COVID-19 pandemic and can be used deliberately to practice HALO events, including neonatal and pediatric resuscitations. This section explores the setup and implementation of telesimulation, focusing on benefits, challenges, and future directions.
| Accessibility and frequency of training |
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| Performance improvement |
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| Realistic scenarios with real-time feedback |
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| Affordability |
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| Team-based training |
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Implementation of telesimulation
Telesimulation requires a simulation manikin (ranging from task trainers to Hi-Fi manikins) and telecommunication equipment (ranging in capability and cost from smartphones to AV equipment designed specifically for simulation) at the local site with an Internet connection to remotely transmit audio and video data to simulation and content experts who facilitate ( Fig. 3 ) the simulation. The participants remain in their hospital and their clinical space with access to the same equipment and resources accessible during real HALO events. The manikin and AV equipment are within their clinical environment, live streaming to the remote facilitators, bridging any distance and reducing the cost of training. A local simulation champion can be used to operate the manikin and facilitate training onsite. The use of a remote simulation manikin controller is an alternative to having a local champion. , Communicating through the AV system, facilitators lead a debrief with participants following the simulation scenario ( Fig. 4 ). Successful implementation of a telesimulation program requires commitment from the local team, the remote simulation, and experienced clinical faculty, as well as administrative support. Furthermore, Simulation in Healthcare published the development of simulation educator guidelines for distance simulation, which is critical for standardization in continuing to advance the field.
