Proceedings of the Saudi Health Simulation Conference 2018

Fig. 2 (abstract A1). Respondents’ ratings in Perceptions of Teamwork Questionnaire (n = 1850). * The research IRB approval has been taken from the KAIMARC (King Abdullah International Medical Research Centre) A1 The impact of simulation-based training on teamwork and communication in the Emergency Department: a pre-test post-test evaluation Aida Darweish, Ali Alshareef, Shayma Millibary, Shahad Bafakeer, Malak BinShihon, Leen Othman Emergency Department, Jeddah, Saudi Arabia; Quality Department, National Guard Health Affairs Hospital (NGHA), Jeddah, Saudi Arabia; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia Advances in Simulation 2018, 3(Suppl 1):A1

Objective: The aim of this study is to present best practices of using simulation in high-stakes clinical assessment described in literature to provide guidance for stakeholders who are interested in such applications. Methods: This review of literature searched for articles discussing challenges, best practices and future directions of using simulation in high-stakes assessment. Studies included common modalities (standardized patients, high-fidelity mannequins, part-task trainers, virtual simulation and hybrid simulation). The search covered the following databases: PubMed, Education Resource Information Center (ERIC), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane library. Results: The initial screening for simulation assessment in the databases resulted in 19,292 articles. After the application of a refining search strategy, 40 articles were included for comprehensive evaluation. Most of the articles gave recommendations regarding best practices of implementing simulation in high-stakes assessments. Best practices were classified (based on the stage of the implementation) into three categories: planning, during the assessment and post-assessment (Table 1). Conclusion: The use of simulation for high-stakes assessment is promising. Assuring the application of best practices driven by previous experiences described in the literature is likely to assure the highest quality activities. Background: Role-play is used to enhance communication skills (CS) in medical students and has been proven to offer a level of pragmatism when incorporated with technical skills training, which lead to improved patient-doctor interaction. In order to achieve the CanMED competency, the communicator, we have small group teaching on CS at our College. It comprises role-play among peers with simulated patients who are students chosen from each CS group. We use two types of role-play, Round Robin and Relays or Carousel method. The Round Robin method includes three students; a doctor, a patient and an observer and Relay method comprises four doctors, four observersone for each doctor -and a patient. This study explored the effectiveness of different methods of role-play to support the development of CS by working with peer students as simulated patients. Methods: The study was conducted in May 2017 at College of Medicine, King Faisal University, Al-Ahsa. All first-year students and trainers were included in the study. A structured questionnaire was distributed among students and trainers at the end of the teaching block. The comparison of two methods was evaluated at the end of all sessions. The questionnaire included 15 statements related to the role-play methods based on Likert scale ranging from 1=strongly disagree to 5=strongly agree. Questions were formulated from a previous study however; the study had a different context and method. Therefore, the questions were modified and more items were added by CS experts based on the teaching of CS sessions and according to the competencies relevant to CS. Data was collected and entered to SPSS version 20.00. Descriptive statistics were computed for all the items. Wilcoxon signed-rank test was applied to compare different items for both methods and to obtain p-value. A P-value of <0.05 was considered as significant.
Results: A total of 246 students and trainers participated in the study. The results of statistical test for comparing both methods suggest that there is significant difference in Round Robin and Relay method for most of the questions P-value < 0.05. However, there was no significant difference on role-play as an interesting mode of learning (P-value= 0.062 (CI=0.052-0.061)), role-play generates better attention span (P-value=0.138 (CI=0.129-0.142)) and role-play helps in developing self-confidence (P-value=0.178 (CI=0.170 -0.185)). Conclusion: Overall, the results suggest that there is a difference between role-play methods and students and trainers perceive the Round Robin method as more effective. Background: The literature of simulation in healthcare education indicates insufficient information regarding the effect of different levels of simulation fidelity on student satisfaction. Objectives: The study was conducted to evaluate students' perceptions of Low-Fidelity Simulation (LFS) and High-Fidelity Simulation experiences (HFS). Methods: A descriptive, cross-sectional, retrospective post-test study was approved by the Education/Nursing Research Ethics Board (ENREB). Fourth-year nursing students at the University of Manitoba, enrolled in fall term 2014 were invited to complete a survey electronically using Fluid Survey. The survey includes the Satisfaction with and Clinical Learning (CL). The data input and analyses were conducted using SPSS version 22.
Results: Thirty-five eligible students participated. A paired t-test analysis revealed a significant difference in CL subscale means between LFS (M=4.09) and HFS (M=3.78), p = 0.008. The ranking question revealed that the opportunities to practice new skills, and to apply clinical reasoning and decision-making were among the top three ranked features for both LFS and HFS. Also the LFS's preparation and orientation and HFS's engagement and realism were top ranked. Discussion: The findings from the SSE provides evidence that students valued simulations of low and high fidelity, and that clinical learning was found to be preferable for LFS. Clinical learning is enhanced and transferred to clinical practice through practice in engaging and realistic environments, and by reflection on this practice during debriefing [1,3]. The top ranked "apply new skills," for both low and high fidelity simulations suggests that simulation could provide safe and controlled environments to practice. The students highly ranked "apply CR and DM," for both simulations indicates the students were able to think through the case scenarios and provide appropriate care. The students top ranked LFS "orientation and preparation". Also, they ranked highly HFS's "engagement and realism," which suggest the authentic learning environment in HFS allows engagement. Eight-four per cent graduate without running a code during their training. This will likely have a profound impact on their first Code Blue event as a senior resident (Code leader). Although the rate of paediatric Code Blue is low (9 codes in 2016), the residents' chances to run a code is low. Impact on clinical outcome has been demonstrated in many studies that observed increased survival rates correlated with increased number of mock codes [1][2][3][4].
Objectives: To evaluate our program to enable residents to manage simulated Code Blue in situ. Methods: Our goal was to help Code teams learn. We conducted unscheduled simulation Codes in real settings. Each resident led one simulated Code during second-year, and one during their third-year of residency. Evaluation data was collected in each Code for the team leader including knowledge assessment, and Critical Recourse Management (CRM) score. Scores were analysed to evaluate improvements after the second Code. Other data related to team members' performance was also collected, including: CPR initiation time and first epinephrine dose timing.
Results: A pilot group of six paediatric residents involved in simulated Codes twice, with 12±3 month intervals, revealed improvement in knowledge and CRM scores (Fig. 1). Data also showed the adherence to AHA guidelines was 33% in paediatric codes for team leaders not involved in simulation, and 100% for those who underwent simulation. Other data showed CPR initiation time by first nurse responder improved from an average of 58 seconds in first opportunity to 30 seconds in the fifth opportunity.
Discussion: Results showed improvement in paediatric residents' performances in simulated Codes by their second session. These simulation sessions have also had a positive impact on other team members' performance and patient safety including AHA guidelines adherence and CPR initiation time. Although there are limitations with our small sample size and the measurement tools, this simple evaluation points to the key role of simulation in supporting residents in managing a Code Blue in paediatric settings.  SaudiMED, communication and collaboration is the core domain [1]. Literature shows that repeated practice followed by feedback is mandatory for behavioral changes. We live in an era of "digital natives" generation. Different technologies can be used to support their experiential learning [2] such as Virtual Reality (VR). Methods: Experimental study was conducted where 4th year medical students participated in a workshop to address the core competence. They were divided into two groups according to the educational tool: group one received 360 VR videos and group two received lectures.
The outcome factors were all quantitative variables: Perception level (a questionnaire was given before the session), MCQs score (20 MCQs pre-and post-session to assess knowledge retention), OSCE score (to assess skill acquisitions), satisfaction level (a questionnaire was given after VR session). All the 169 medical students were included in the study.  Background: Simulation is considered a safe training method. Simulation training technology is a popular method of learning for healthcare professionals worldwide [1]. It includes performing a medical procedure on simulators to increase the confidence and skills of trainees before conducting the procedures on humans [2]. Cupping therapy (Hijama) is a widely used traditional healing therapy which is performed by applying cups on selected body points by sucking air to induce sub-atmospheric pressure inside the cup either by heat or suction [3]. The use of simulation in cupping therapy training was an innovation developed by National Center for Complementary and Alternative Medicine (NCCAM), Ministry of Health (MOH), Saudi Arabia [4]. There is no available validated evaluation tools for assessment of cupping simulation learning due to the novelty of this method. An internal committee of NCCAM, Saudi Arabia developed this questionnaire, as a part of the evaluation process of their training courses.

Results
Objectives: To discuss the development of a new tool which can be used for evaluation of cupping therapy simulation-based learning.
Methods: Fifteen items in the questionnaire were divided into three scales. The three scales were confidence, expectations/satisfaction, and performance. Each scale included five questions and used 5 Likert scale responses from 1 to 5 [ Fig. 1]. Statistical Package for Social Sciences (SPSS) Software Version 20 was used for data entry, management and analysis. Internal reliability of the questionnaire and scales was evaluated by Cronbach's alpha test.
Results: 50 healthcare professionals participated in the study. They were selected from the trainees of the simulation courses provided by NCCAM as a part of the program's evaluation. Cronbach's alpha of items deleted were ranged from 0.91 to 0.92 for each item. Cronbach's alpha of confidence scale was 0.85, expectations/satisfaction scale was 0.81, performance scale was 0.94, and total evaluation was 0.92. These values showed good internal consistency of the scales. Conclusion: Cupping Simulation Training Evaluation Questionnaire (CSTEQ) is a promising new tool for evaluating self-reporting of confidence, expectations/satisfaction and performance of trainees. It may be used as a tool for improvement of cupping simulation training programs. Further large scale trials, and validation studies should be conducted.

A10
The current status of using simulation based learning in integrative and complementary medicine training programs Tamer  Background: Simulation-based learning in medicine and surgery is a training approach where new practitioners can practice and acquire clinical skills in a safe, risk free environment similar to the real clinical situation [1]. The history of using simulation in the field of complementary medicine is dated to 1027 when Ancient Chinese physician Wang Wei-Yi used two bronze real-size statutes for teaching acupuncture and surface anatomy [2].

Fig. 1 (abstract A9). See text for description
Objectives: The aim of this review is to give a brief overview of the current status of simulation-based learning in integrative and complementary medicine training programs. Methods: The relevant literature published in English prior to December 2017 was retrieved from PubMed, Cochrane, and ScienceDirect databases to identify articles on the use of simulation in integrative and complementary medicine training programs. Two reviewers evaluated the results based on predefined inclusion, and exclusion criteria.
Results: Seven articles met inclusion criteria. A virtual reality simulator for acupuncture training providing trainees' with realistic feeling of touch was developed [3]. The phantom acupoint tool significantly improved students' manipulation skills in acupuncture simulation training [4]. Virtual reality haptic back (VHB) was designed by two colleges (osteopathic and engineering) in Ohio University to help in the training of osteopathic students and related therapies in clinical palpatory diagnosis method [5,6]. A hospital based massage learning course was developed and offered by Midwest academic medical centre, USA. The simulation-based practice in the simulation centre was a basic part of the course [7]. Chapman et al. showed that using simulation in the training of cervical spine manipulation for early trainees of chiropractic was beneficial. Early trainees acquired the basic skills initially and gained the confidence to proceed to training on real patients [8]. Cupping therapy simulation learning was an innovative idea developed by the National Center for Complementary and Alternative Medicine (NCCAM), Ministry of Health, Saudi Arabia ( Fig. 1) [9]. Discussion: Benefits of using simulation-based learning were reported in the field of integrative and complementary medicine training. Haptic simulation was used in the fields of acupuncture (Fig. 2), massage, osteopathy, and chiropractic learning. However, the parttask mannequin simulators were used in cupping therapy training and cervical manipulation as a part of chiropractic training. We recommend introducing simulation-based learning in the field of complementary medicine training to help trainees gain confidence and basic clinical skills. Future large scale studies to evaluate the simulation based learning programs and trainees' performance are encouraged.
Conclusion: This review identified the introduction of simulationbased learning in five integrative and complementary therapies which were: acupuncture, osteopathy, massage, chiropractic, and cupping therapy.
Background: The incidence of pressure ulcers in ICU ranges from 8.8% to 23% [1]. System integration utilizes the principle of system engineering and risk management to improve patient care [2]. CRE-SENT system integration model uses the acronym of CRESENT to describe the various stages of system integration.
Objectives: The aim of this study is to apply the newly described CRE-SENT system integration model to the prevention of pressure ulcers in ICU.
Methods: The steps for CRESENT system integration model include: Clarify, Review, Examine, Simulate, Execute, Notify and Track. This model is applied for a project on prevention of pressure ulcers in ICU at KFMC.
Results: The CRESENT model is applied as follows: 1) Clarify the problem that prompted system integration: Head of ICU is concerned about an increase in pressure ulcers rate. 2) Review of the current data shows pressure ulcers rate in ICU around 10 pressure ulcers/1000 patient days, while the target is < 5 (Fig. 1). 3) Examine the possible causes and identifies areas of improvements through simulation. 4) Simulate by using system modeling to develop applicable SBE activity. An 8-hour SBE  workshop on pressure ulcer prevention in ICU is developed by a simulation educator (FS). 5) Execute: A total of 92 inter-professional simulation (IPS) are conducted between March and April 2017. Around 82 (60%) ICU staff nurses attended these activities. 6) Notify the stakeholders (Chairman of Critical Care Department) through detailed report on the SBE activities, attendance, evaluations and assessment. 7) Track the impact of the system integration by following the preset indicator(s) to evaluate the outcome of the SBE. The rate of pressure ulcer was reduced by 50% from the 1 st & 2 nd quarters of 2017 (Fig. 1). Discussion: System integration is an effective modality to identify areas of potential threats and improvement strategies. The SBE activity on prevention of pressure ulcer in ICU provided knowledge and skills to the ICU staff, as well as defined responsibilities and collaboration among the treating team in ICU. The following categories of healthcare givers are trained together: Nurses, physicians, respiratory therapists, physiotherapists, wound care team, pharmacists, risk management and dietitians.
Conclusion: The CRESENT model for system integration provides a framework that can be used to apply the principles of risk management in health care facilities. Results: The peer simulated debriefing training is an exercise that takes 90 to 110 minutes depending on the number of participants. It includes assigning two learners to watch a video recording of a simulation scenario twice. The learners are asked to pick up key actions based on agreed objectives, assume frames for debriefing and document these actions on a special forms. The two learners will assign and play the role of important characters in the scenario. A third learner joins the group and practice pre-briefing, introduction of the session and building a safe environment. The whole team then watches the video once again followed by a debriefing. After the debriefing, the actors reflect on the debriefing by describing their feeling and debriefing the debriefer. An expert watches the whole process and gives final feedback. Conclusion: Simulated debriefing training allows peers to practice debriefing in a safe environment with regular feedback, promotes training on scenario analysis and identifies learning gaps, provides an opportunity for participants to practice "debriefing the debriefing" method and presents a structured method that tracks participants' progress and areas for development.

A14
The feasibility of using the Grounded Theory to analyze qualitative mock code data Background: Unannounced simulated mock codes are used to assess the readiness of medical teams and the institution to manage cardiopulmonary arrests [1]. Large amounts of quantitative and qualitative data are usually collected. The analysis and meaningful translation of qualitative data from mock codes can be challenging. Grounded theory can provide a framework to generate concepts through analysis of qualitative data from mock codes [2].
Objective: The aim of this study was to determine the feasibility of using Grounded Theory to analyze data generated from mock codes. Methods: The mock code program at the Brigham & Women Hospital is sponsored by the Emergency Response Committee. Locations are selected on a rotational basis to ensure uniform assessment of the three separate code teams that respond to designated areas. Two mock codes per month are conducted without forewarning of time or location; the majority during normal working hours. Each mock code is followed by 5-7 minutes of debriefing. A report of the drill is provided to local and hospital lead clinicians and administrators. Quantitative data are collected such as time to arrival of first responder, time to first chest compression, and so on. Qualitative data is collected by a single faculty member who leads the mock codes and/or as reported by the respondents during the debriefing. This includes administrative and clinical protocol deviations, quality of CPR, articulation of an exit strategy, equipment failures, staffing deficiencies, misuse of equipment, access issues among others. All debriefing comments and observations were clustered by one of the authors (UA) based on similarity. We stratified the data into two broad categories: training gaps (gaps to be addressed by educational interventions) and systems gaps (gaps to be addressed through changes in processes). Results: One hundred and fifty sessions with 994 debriefing comments and observations were collected between September 2003 and July 2015. After exclusion of 96 positive comments, of the 898 gaps identified, 777 (87%) were related to training gaps and 121 (13%) were related to system gaps. The frequency of these comments are plotted over time (Fig. 1). We identified a decrease in the frequency of training gaps over time, while there was no change in the system gaps. Discussion: Employing Grounded Theory, we were able to cluster performance gaps of observed, unannounced mock codes into two categories: training-related gaps and system-related gaps [3,4]. We found that over time, educational gaps decreased but there was no change in the frequency of system-related gaps. Based on this, allocation of resources to improve system-related performance gaps appears to be indicated. Conclusion: Grounded Theory can be used to analyze the qualitative data generated from mock codes and can provide administrators information on strategies to improve key performance indicators (KPIs).

A15
Simulation-based teaching and didactic lecture in gaining and retaining knowledge among undergraduate medical students: a randomized controlled trial Marwa M. R. Tawfik  Background: Most medical teaching is still delivered by traditional face-to-face interaction [1]. However, simulation-based teaching (SIM) is growing as an effective technique in medical education which can be used as alternative to lectures [2].
Objectives: The aim of our study was to evaluate the effectiveness of SIM versus traditional lectures in improving and retaining knowledge. Methods: A randomized controlled trial was conducted among 72 medical students at Princess Nourah bint Abdulrahman University (PNU). Using random number sequence, students were randomized into two groups, 36 each. Each group received the same scientific information about the diagnosis and management of bronchial asthma by the same instructor but through different teaching techniques. In one group the instructor used didactic lecture with video recording while in the other group, mannequin simulation with role-play session was used. Knowledge testing immediately before and after the teaching sessions and 4 months later was done using 30 multiple-choice questions. A questionnaire was distributed to students to assess their satisfaction with the teaching methods.
Results: There was no significant difference between the two groups regarding their scores in the pre-test; the simulation group scored 41.2 ±10.6 and the lecture group scored 38.8±7.2, p-value =0.3. The simulation group scored higher than the lecture group in the post-test and in the second post-test, however, this difference was not statistically significant (p-value =0.50 and 0.40 respectively). Both groups showed an improvement in the average score from the pre-test to post-test but the improvement in the simulation group was higher than that in the lecture group (8.4±10.7 and 7.1±11.8 respectively) though this difference was not statistically significant (p-value =0.61). Additionally, students in the simulation group were significantly more satisfied by the teaching modality than students in the lecture group as reflected by the higher satisfaction score (42.4± 11.7 versus 29.7±9.3, p-value <0.01) Conclusions: SIM was as effective as the didactic lecture in immediately improving and retention of knowledge. SIM is a more satisfactory and interesting way of teaching as reported by students. If it is integrated in undergraduate program, it may help to overcome obstacles of clinical training and the lack of proper medical students' exposure to real patients because of ethical considerations.   Fig. 1 (abstract A16). Age groups of participating SCFHS Trainees   Background: Non-technical skills (NTS) have been incorporated into many undergraduate medical schools' curricula and identified as important skills for healthcare workers. The best available evidence showed that the communication skills training should use experiential methods. Simulation-based scenarios followed by debriefing will give the chance for healthcare workers to have the experience followed by feedback.
Objectives: The aim of this study was to assess if team debriefing after a simulation-based scenario improved NTS; and to identify the elements of debriefing that lead to improvement of these skills. Methods: The study design was randomized, pre-test post-test, control group, experimental design. The sample size was calculated using Openepi sample size calculation tool. The teams were randomized into two arms, the debriefing group and the control group. Each team attended a 4-hour simulation activity consisting of an interactive lecture about NTS followed by two high fidelity scenarios on myocardial infarction resuscitation and anaphylaxis resuscitation. The order of the two cases in each course was variable based on concealed randomization. All teams in the intervention group received the debriefing immediately after the first case by a certified simulation educator. All the events within the simulation centre were video recorded. Four performance raters blinded to the grouping and the order of the cases reviewed and rated all 66 videos using the global rating scale of TEAM assessment tool [1]. The rating scale for the 11 elements ranged from 0 to 4. The main variables included are: leadership, teamwork, situation awareness and task management.
Results: A total of 136 nurses and 34 physicians from the emergency department at King Fahad Medical City (KFMC) were randomized into 34 teams. Each team consisted of 4 nurses and a physician. One group was excluded from the data analysis due to an issue with video recording. Debriefing after the simulation-based scenario significantly improved NTS TEAM assessment total mean score in the study group compared to controls, 4.8 points with p = 0.015 vs. 3.9 points with p = 0.11 respectively (Fig. 1). The detailed scores are shown in Table 1.
Conclusion: Simulation based scenario followed by debriefing and feedback is an effective teaching tool to improve NTS. The improvement is mainly noted in leadership, communication and team work. Future studies are needed to explore how long those skills are maintained and their application to real practice.
Background: The growth of health simulation in Saudi Arabia necessitated skilled technical staff to assist educators in the design, Fig. 1 (abstract A17). Pre and post-performance mean scores in the two study groups Objective: The aim of this project is to propose a job description and career pathway for simulation technologists.
Methods: A review of the literature was made to look for publications regarding characteristics, job descriptions and career pathways for simulation technicians, operation specialists and/or technologists. After appraising various models and experiences and the benchmark in the market, a draft job description was made in accordance to the rules and regulations of the Ministry of Health (MOH) and Ministry of Civil Service in Saudi Arabia. The simulation team worked with experts from talent acquisition and human capital departments at KFMC to come up with a proposed career pathway using a three-step modified Delphi method to establish consensus.

Results:
Terminology: The consensus of the simulation and human resources experts is to use the term "simulation technologist" over "simulation technician" or "simulation operation specialist". The "technologist" term is more inclusive than technician, and "specialist" has specific connotation in the MOH lists for medical career paths.
Educational background: A degree (diploma, bachelor, masters or PhD) in nursing, respiratory therapist, emergency medical services, allied health, biomedical sciences or engineering or information technology.
Job description: -Prepare setup, allocate and provide all requirements for skills training activities and OSCE exams. operating procedures and instructions so that work is carried out in a controlled and consistent manner. -Contribute to the identification of opportunities for continuous improvement of systems, processes and practices taking into account leading practices, improvement of business processes, cost reduction and productivity improvement. -Promote the implementation and adherence to policies, processes and operating procedures to others within the mother institution.
Career Pathway: the proposed career path is presented in the figure below.

Conclusion:
The simulation technologist is a new addition to the healthcare workforce in Saudi Arabia. We hope it will be officially recognized by the Saudi Commission of Health Specialties (SCFHS) in the near future. Background: Simulation system integration can be defined as consistent, planned, collaborative, integrated, and iterative application of simulation-based assessment, research, and teaching activities with systems engineering, and risk management principles to achieve excellent bedside clinical care, enhanced patient safety, and improved outcome metrics across the healthcare system(s) [1].
Objective: The aim of this project is to develop a practical model for simulation system integration.
Methods: A panel of 5 experts in health simulation used a three-step modified Delphi method to establish consensus. The first round was a face-to-face meeting where the essential steps of the simulation system integration were agreed. Round 2 consisted of defining three items for each step. The members of the expert panel marked "agree" or "disagree" beside each statement, and provided comments. Eighty percent agreement was used to determine acceptance or rejection of a statement. Statements that did not meet consensus from round 2 were emailed to all 5 members. In round 3, the experts used the same voting method, but with the knowledge of the scores and comments.
Results: The developed simulation system integration model is a seven step model that follows the acronym of CRESENT. The first step "Clarify" involves: 1) Capture the needs, problems or concerns.
2) Characterize the impact and priority of the problem. 3) Classify involved stakeholders. The second step "Review" involves: 1) Review available data/metrics on the concerns. 2) Relate to planned or ongoing projects on the concerns. 3) Recommend metrics that can be tracked. The third step "Examine" involves: 1) Employ root-cause analysis, 2) Evaluate potential causes and 3) Estimate areas of simulation intervention. The fourth step "Simulate" involves: 1) Set system modeling (2) to simulate vital characteristics. 2) Select simulation modalities and environments. 3) Sketch simulation-based interventions. The fifth step "Execute" involves: 1) Employ simulation-based interventions. 2) Extend simulation intervention/model to involve all stakeholders. 3) Evaluate as you simulate. The sixth step "Notify" involves: 1) Navigate detailed report of outcomes. 2) Name stakeholders to receive the report. 3) Note feedback from stakeholders. The seventh step "Track" involves: 1) Tune new data to metrics that can be tracked. 2) Transform metrics/KPIs to a dashboard. 3) Troubleshoot deviation from norms.
Conclusion: The CRESENT model provides a well-defined stepwise approach for simulation system integration.

A21
The elements of eye tracking that differentiate user experience on laparoscopic virtual reality simulator Nada Almohaimeed Background: Virtual reality (VR) surgical simulation provides safe and realistic learning environment and can improve trainees' skills and performance [1]. Eye movements' measurements such as fixation (moments when eyes are relatively stationary, taking in or encoding information) and saccade (quick eye movements occurring between fixations) can reveal the amount of information processing applied to interface elements by individuals [2].
Objective: The aim of this study is to determine what elements in eye tracking during VR surgical performance can segregate novices from experts. Methods: The subjects performed the clipping module ( Fig. 1) on LapVR surgical simulator (CAE Healthcare). This skill required appropriate traction to correctly place four clips to stop blood flow, and then cut between the clips. Subjects can navigate and change the angle of the view by moving the camera handle. Eye movements were recorded via Tobii X120 (Stockholm, Sweden). A full HD video recording was captured via a Logitech C920 HD webcam (Fig. 2). The electrodermal activity (EDA) signal was obtained for the whole session including the baseline for each participant.
There was no significant effect on the total fixation duration (E=126 seconds and N = 144, p = 0.115). No significant differences in the mean fixation duration was observed (E=444ms ±100 vs. N = 368ms±121, p = 0.240). There was no significant difference in the fixation rate (E=121±28 vs. N = 122±18, p = 0.873). By investigating areas of interest (AOIs), novices fixated longer on the tools menus which means that they had greater uncertainty selecting the appropriate tool than experts. Gazeplots and clusters revealed that the intensity of fixations and the spatial distribution of fixations are different among the two groups where novices show more of scattered saccades. Experts performed the task significantly faster than novices (E=146 ±13 vs. N = 207±64 seconds, p = 0.005). EDA level for novices was significantly higher than experts during the performance, p = 0.009. Aggregate gaze data showed a contrast in the spatial and temporal features of gaze-plots of experts when compared to novices. The number fixations, intensity of fixations and the spatial distribution of fixations were higher for novices than experts. When comparing clusters, novices tend to adjust camera handle to show the vessel in closer angle to their dominant hand, whereas experts place it to a wide angle showing the vessel in the middle of the screen. Figure 4 shows the number of mistakes done in each performance measure by each group. Experts made an average number of mistakes of 0.83, whereas novices made an average of 3.92. Conclusion: The performance results of our experiments showed that experts were quicker and generally exhibited fewer errors than novices. The eye gaze analysis did not show marked differences between experts and novices. However, spatial density of fixation was different.  Background: Studies have shown that there is an increase in survival rate from cardiac arrest (CA) when the knowledge and skills learnt in Basic Life Support (BLS) courses are administered [1]. Nurses in Saudi Arabia are the first responders when patients experience CA. It is mandated that they obtain the BLS certificate to work in any healthcare facility [2]. Objectives: The study aimed to assess the knowledge of BLS guidelines and the relationship between nurses' knowledge of BLS and their professional profile. Methods: The study is a non-experimental, quantitative, crosssectional design. Sampling method was a non-probability, purposive. The data collection tool was a questionnaire. The study targeted all registered nurses in the hospital. The significance level was set at p <0.05, while the level of confidence was set at 95 per cent.
Results: A total of 172 nurses were included in the study, 32 (18.6%) got their BLS training via high fidelity simulation courses. They scored higher grades than others in each aspect of BLS knowledge.
As the results of the Kruskal-Wallis test indicate that, the significance level computed for the assessment's knowledge (p = 0.016), effective chest compression knowledge (p = 0.023), the effective cardiac defibrillation knowledge (p = 0.014) and the air way management knowledge (p < 0.005). Nurses aged 21-30 years (n = 58, 33.7%) scored higher grades than other age groups in the assessment's knowledge (p = 0.014) and in correct chest compression (p = 0.021). Surgical nurses (n = 42, 24.4%) had a higher score in the BLS knowledge in comparison with nurses in the medical and outpatient departments. The significance levels computed for the assessment knowledge (p = 0.020), effective chest compression knowledge (p = 0.034) and the effective cardiac defibrillation knowledge (p = 0.023). Nurses (n = 40, 23.3%) who were updated on evidence-based nursing practices in BLS in the last 6 months were more knowledgeable in effective chest compression (p = 0.006) and the airway management (p = 0.025). Conclusion: Nurses' professional profiles appear to have an impact on their BLS knowledge. Using high fidelity simulation technique in BLS courses is the preferred choice when training the nurses [3]. A refresher evidence-based BLS course every six months will be beneficial for clinical nurses [4]. Nurses who work in the surgical department may be the best choice to be a resuscitation team member.
Background: There are integral faults that can be faced upon starting new departments in a healthcare facility. These errors can affect patient safety and lead to medical errors. Medical simulation can be used to diagnose these potentials errors so the can be corrected prior to commissioning of the new service.
Objectives: The objective of this study is to utilize simulation-based system integration methodology to identify areas of improvement prior to starting a new Emergency Department (ED) at King Fahad Medical City (KFMC). Methods: A new ED was constructed to improve emergency medicine services and meet the expanding demands at KFMC. The new ED has a capacity of 50 beds with complete radiology, pharmacy and laboratory services. Prior to commissioning, a simulation drill was performed to identify latent safety threats and potential weaknesses and potential errors in the system. A total of 12 scenarios were written and 3 SPs and 2 high fidelity manikins were utilized in the drill. Complete moulage was performed on SPs and manikins as needed.
The outcome measures were classified as major and minor. Major weaknesses are defined as defects that may compromise patient safety, while minor ones are those related to resource allocation, patient flow and other administrative issues not affecting the quality of care and patient safety. A team of 3 ED physicians with special expertise in simulation recorded the observations. who did not attend this course (n = 21). The chi-square test revealed a significant difference in dressing done with completely aseptic techniques among participants who attended the wound management course (p = 0.02). In general, among all nurses the mean score for nurses' adherence to correct wound management techniques was 77.6%. Compliance was lower in the pre-phase, confirming the dressing order: n = 27 (66.7%), conducting client verification n = 29 (71.8%), and explaining the procedures to the client N = 24 (59%). Compliance was higher during the performance phase (n = 36; 90%). However, the least compliance was shown in the post-phase in the area of educating patients and family by only 33.3% (n = 13). Conclusion: Integrating simulation-based teaching in a wound management workshop was found to be effective and was reported to improve clinical practice. The simulation has been integrated in other KAUH nursing workshops and courses based on these findings.