Manikin fidelity in resuscitation education: EIT 6410 TF SR

Conflict of Interest (COI) Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none recused as no COI declared.

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees:

• Donoghue and A. Cheng were first and/or co-authors on two of the included studies and they were not involved in the data extraction or risk of bias assessment for those studies.^{1, 2}
• A. Cheng and A. Lockey were co-authors on the published manuscript summarizing the 2015 ILCOR systematic review on this topic³; the quality assessment of this review for inclusion (AMSTAR-2⁴) was conducted by two other review team members (A. Donoghue, K. Allan).

CoSTR Citation

Donoghue A, Allan K, Cortegiani A, Schnaubelt S, Cheng A, Lockey A, Greif R on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force (EIT). Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR), 2024 October 16. Available from: http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic literature search of higher fidelity manikin use vs. lower fidelity manikin use conducted by an information specialist with involvement of clinical content experts. Evidence collected from the literature was reviewed and considered by the EIT Task Force. These data were taken into account when formulating the Treatment Recommendations.

Systematic Review

Publication in progress

PICOST

Prospero Registration: CRD4202453504

Consensus on Science

Details of the screening process are shown in the PRISMA diagram (Figure 1).

21 studies were included^{1, 2, 5-23}; study details are shown in the data extraction table (Table 1). EIT 6410 Tables 1 data extraction and 2 ROB Final Risk of bias assessments are shown in Table 2. The studies included 14 studies from a previously published ILCOR systematic review.³ This publication was evaluated by two reviewers using AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews)⁴ and found to be of sufficient quality to directly extract data and risk of bias assessments on these 14 studies from the review. In addition to these 14 studies, seven additional studies published between 2015 and 2024 were included.^{13, 14, 18, 20-23}

All studies involved healthcare providers and/or healthcare trainees. 15 studies were performed in North America^{1, 2, 6-12, 17, 19-23}; 4 in Asia^{5, 14, 16, 18}; one in Europe¹³; and one in Australia.¹⁵ 12 studies used adult scenarios^{5, 7, 10-13, 15-19, 23}; 4 used pediatric scenarios^{1, 2, 20, 22}; 4 used neonatal scenarios.^{6, 8, 9, 14}

Skill at course conclusion (scenario-based assessment)

For the important outcome of skill at course completion, we included eight RCTs with 279 intervention subjects and 271 controls.^{1, 2, 7, 9, 10, 12, 14, 19} Four RCTs assessed performance in an adult scenario^{7, 10, 12, 19}; two in a pediatric scenario^{1, 2}; and two in a neonatal scenario.^{9, 14} On meta-analysis, a significant effect favoring higher fidelity manikins was found (standard mean difference 0.66, 95% CI 0.08 – 1.25)(Figure 1)

Figure 1: Forrest plot of RCTs reporting scenario-based skill assessment at course conclusion EIT 6410

In addition to the eight RCTs included in the above meta-analysis, two additional RCTs with 51 intervention subjects and 56 controls compared skill at course conclusion but did not report sufficient measures of variance for inclusion in meta-analysis. Both RCTs found no difference in skill performance at course completion.^{8, 15}

Four RCTs measured and reported skill performance before and after training in addition to comparing low- and higher-fidelity manikin groups.^{1, 2, 14, 15} All four studies demonstrated improvement in performance post-training when compared with pre-training irrespective of the level of manikin fidelity.

Knowledge at course completion

For the important outcome of knowledge at course completion, we included seven RCTs with 511 intervention subjects and 505 controls.^{1, 5, 7, 10, 13, 14, 19} Five RCTs assessed performance in an adult scenario^{5, 7, 10, 13, 19}; one in a pediatric scenario¹, and one in a neonatal scenario.¹⁴ On meta-analysis, no effect favoring higher fidelity manikins was found (standard mean difference 0.24, 95% CI -0.23 – 0.71) (Figure 2)

Figure 2: Forrest plot of RCTs reporting knowledge at course conclusion EIT 6410 figure 2

In addition to the seven RCTs included in the above meta-analysis, three additional RCTs with 72 intervention subjects and 112 controls and one observational study of 34 subjects compared knowledge at course conclusion but did not report sufficient measures of variance for inclusion in metaanalysis.^{11, 15, 17, 20} One RCT found improved knowledge at course completion¹⁵; two RCTs and one observational study found no difference.^{11, 17, 20}

Skill – time to task performance at course conclusion

For the important outcome of time to task completion during simulated resuscitation, we included three randomized controlled trials (RCTs) with 71 intervention subjects and 108 controls.^{6, 20, 23} Two RCTs found faster time-to-task completion (EMS activation)²³ and intervention/reassessment cycle.²⁰ One RCT found no difference in time to intubation during NRP training.⁶ No meta-analysis was attempted due to small study number and heterogeneity in outcomes between studies.

Skill – teamwork at course conclusion

For the important outcome of teamwork performance at course conclusion, we included three randomized controlled trials (RCTs) with 96 intervention subjects and 97 controls.^{1, 15, 21} One RCT found improved teamwork behaviors following training with higher fidelity manikins compared with lower fidelity²¹; one RCT found improved teamwork behavior during one of three assessment scenarios following training with higher fidelity¹⁵; one RCT found no difference in teamwork scores between groups.¹ No meta-analysis was attempted due to small study number and heterogeneity in outcome measures between studies.

Skill – clinical performance at 3 months or greater

For the important outcome of clinical performance 3 or more months after training, we included three randomized controlled trials (RCTs) with 163 intervention subjects and 159 controls.^{5, 12, 19} One RCT in nursing students found better clinical performance in a CPR scenario 3 months after training with higher fidelity manikins⁵; two studies of ACLS skills found no difference at 3 months post training or at one year post training.^{12, 19} No meta-analysis was attempted due to small study number and heterogeneity in outcomes between studies.

Knowledge at 3 months or greater

For the important outcome of knowledge 3 or more months after training, we included three randomized controlled trials (RCTs) with 146 intervention subjects and 184 controls.^{5, 19, 20} Two RCTs found improved knowledge following higher fidelity manikin training (3 months after BLS training⁵; 6 months after PALS training²⁰); one RCT found no difference in ACLS knowledge at 6-9 months post training.¹⁹ No meta-analysis was attempted due to small study number and heterogeneity in outcomes between studies.

Skill – CPR parameters at course conclusion

For the important outcome of CPR performance at course conclusion, we included two RCTs with 80 intervention subjects and 80 controls. One RCT found a greater degree of improvement as measured at course completion by the American Heart Association CPR skills checklist among subjects trained on higher fidelity manikins⁵; one RCT found better compression depth and compression fraction immediately post training among subjects trained on higher fidelity manikins.²³ No meta-analysis was attempted due to small study number and heterogeneity in CPR parameters reported as outcomes between studies.

Affective responses

For the important outcome of learner preference and confidence following training, we included 10 RCTs with 347 intervention subjects and 471 controls.^{6-10, 13, 16, 18, 19, 22} Seven RCTs found subjects reporting higher effectiveness of training with higher fidelity manikins^{6-8, 13, 16, 18, 22}; three RCTs found no difference.^{9, 10, 19} No meta-analysis was attempted due to heterogeneity in outcomes between studies.

Treatment Recommendations

We suggest the use of high-fidelity manikins when training centers/organizations have the infrastructure, trained personnel, and resources to use them (weak recommendations, very-low quality evidence).

If high-fidelity manikins are not available, we suggest that the use of low-fidelity manikins is acceptable for life support training in an educational setting (weak recommendations, low-quality evidence).

Justification and Evidence to Decision Framework Highlights

In making this suggestion, the EIT taskforce considered the following:

A majority of studies found a positive impact on skill and/or knowledge at course conclusion. The meta-analysis of 8 RCTs found a significant association between the use of high-fidelity vs. low fidelity manikins and improved skill at course conclusion. There were no studies that demonstrated a negative effect of higher fidelity manikins on educational outcomes. Given that resource utilization and cost were not directly studied, along with the fact that higher fidelity manikins are likely more expensive to obtain and maintain, we limit our recommendation to centers where these resources are available.

The recommendation for use of low-fidelity manikins when higher-fidelity manikins are not available is based on four of the included studies which found improved performance in post-training versus pre-training assessment in all groups irrespective of level of manikin fidelity.

No studies reported on cost or resources needed to implement higher fidelity manikins. Our recommendation is predicated on the higher fidelity manikins being used in a setting with appropriate space, infrastructure, personnel, and resources to use them properly. Educational settings where these resources are less available might make implementation difficult.

Knowledge Gaps

We identified several knowledge gaps in the literature:

• Cost-effectiveness and implementation studies
• Studies examining longer term educational outcomes (skill and/or knowledge retention and/or decay)
• Specific simulation features that are most associated with improved learning
• Translational research from simulation to actual patient care processes and patient outcomes

EtD Table: EIT 6410 Et Ddocx

References

1. Cheng A, Hunt EA, Donoghue A, et al. Examining pediatric resuscitation education using simulation and scripted debriefing: a multicenter randomized trial. JAMA Pediatr 2013; 167: 528-536. DOI: 10.1001/jamapediatrics.2013.1389.

2. Donoghue AJ, Durbin DR, Nadel FM, et al. Effect of high-fidelity simulation on Pediatric Advanced Life Support training in pediatric house staff: a randomized trial. Pediatr Emerg Care 2009; 25: 139-144. DOI: 10.1097/PEC.0b013e31819a7f90.

3. Cheng A, Lockey A, Bhanji F, et al. The use of high-fidelity manikins for advanced life support training--A systematic review and meta-analysis. Resuscitation 2015; 93: 142-149. 20150414. DOI: 10.1016/j.resuscitation.2015.04.004.

4. Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 2017; 358: j4008. 20170921. DOI: 10.1136/bmj.j4008.

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6. Campbell DM, Barozzino T, Farrugia M, et al. High-fidelity simulation in neonatal resuscitation. Paediatrics and Child Health 2009; 14: 19-23. DOI: 10.1093/pch/14.1.19.

7. Conlon LW, Rodgers DL, Shofer FS, et al. Impact of levels of simulation fidelity on training of interns in ACLS. Hosp Pract (1995) 2014; 42: 135-141. DOI: 10.3810/hp.2014.10.1150.

8. Curran V, Fleet L, White S, et al. A randomized controlled study of manikin simulator fidelity on neonatal resuscitation program learning outcomes. Adv Health Sci Educ Theory Pract 2015; 20: 205-218. DOI: 10.1007/s10459-014-9522-8.

9. Finan E, Bismilla Z, Whyte HE, et al. High-fidelity simulator technology may not be superior to traditional low-fidelity equipment for neonatal resuscitation training. J Perinatol 2012; 32: 287-292. DOI: 10.1038/jp.2011.96.

10. Hoadley TA. Learning advanced cardiac life support: a comparison study of the effects of low- and high-fidelity simulation. Nurs Educ Perspect 2009; 30: 91-95.

11. King JM and Reising DL. Teaching advanced cardiac life support protocols: the effectiveness of static versus high-fidelity simulation. Nurse Educ 2011; 36: 62-65. DOI: 10.1097/NNE.0b013e31820b5012.

12. Lo BM, Devine AS, Evans DP, et al. Comparison of traditional versus high-fidelity simulation in the retention of ACLS knowledge. Resuscitation 2011; 82: 1440-1443. DOI: 10.1016/j.resuscitation.2011.06.017.

13. Massoth C, Röder H, Ohlenburg H, et al. High-fidelity is not superior to low-fidelity simulation but leads to overconfidence in medical students. BMC Med Educ 2019; 19: 29. DOI: 10.1186/s12909-019-1464-7.

14. Nimbalkar A, Patel D, Kungwani A, et al. Randomized control trial of high fidelity vs low fidelity simulation for training undergraduate students in neonatal resuscitation. BMC Res Notes 2015; 8: 636. DOI: 10.1186/s13104-015-1623-9.

15. Owen DD, McGovern SK, Murray A, et al. Association of race and socioeconomic status with automatic external defibrillator training prevalence in the United States. Resuscitation 2018; 127: 100-104. DOI: 10.1016/j.resuscitation.2018.03.037.

16. Rishipathak P, Hinduja A and Sengupta N. A comparative analysis of self-efficacy in low fidelity vs high fidelity simulation post advanced cardiac life support (ACLS) sessions on cardiac arrest algorithm amongst EMS students of Pune, India. Indian Journal of Public Health Research and Development 2020; 11: 415-419. DOI: 10.37506/v11/i1/2020/ijphrd/193853.

17. Rodgers DL, Securro S, Jr. and Pauley RD. The effect of high-fidelity simulation on educational outcomes in an advanced cardiovascular life support course. Simul Healthc 2009; 4: 200-206. DOI: 10.1097/SIH.0b013e3181b1b877.

18. Roh YS. Effects of high-fidelity patient simulation on nursing students' resuscitation-specific self-efficacy. Comput Inform Nurs 2014; 32: 84-89. DOI: 10.1097/cin.0000000000000034.

19. Settles J, Jeffries PR, Smith TM, et al. Advanced cardiac life support instruction: do we know tomorrow what we know today? J Contin Educ Nurs 2011; 42: 271-279. 20110322. DOI: 10.3928/00220124-20110315-01.

20. Stellflug SM and Lowe NK. The Effect of High Fidelity Simulators on Knowledge Retention and Skill Self Efficacy in Pediatric Advanced Life Support Courses in a Rural State. J Pediatr Nurs 2018; 39: 21-26. DOI: 10.1016/j.pedn.2017.12.006.

21. Thomas EJ, Williams AL, Reichman EF, et al. Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations. Pediatrics 2010; 125: 539-546. DOI: 10.1542/peds.2009-1635.

22. Tufts LM, Hensley CA, Frazier MD, et al. Utilizing High-fidelity Simulators in Improving Trainee Confidence and Competency in Code Management. Pediatr Qual Saf 2021; 6: e496. DOI: 10.1097/pq9.0000000000000496.

23. McCoy CE, Rahman A, Rendon JC, et al. Randomized Controlled Trial of Simulation vs. Standard Training for Teaching Medical Students High-quality Cardiopulmonary Resuscitation. West J Emerg Med 2019; 20: 15-22. DOI: 10.5811/westjem.2018.11.39040.