Empirical Investigations

Evaluating the Impact of Classroom Education on the Management of

Septic Shock Using Human Patient Simulation
Geoffrey K. Lighthall, MD, PhD; Background: Classroom lectures are the mainstay of imparting knowledge in a
structured manner and have the additional goals of stimulating critical thinking, lifelong
Dona Bahmani, MD; learning, and improvements in patient care. The impact of lectures on patient care is
difficult to examine in critical care because of the heterogeneity in patient conditions and
personnel as well as confounders such as time pressure, interruptions, fatigue, and
David Gaba, MD
nonstandardized observation methods.
Methods: The critical care environment was recreated in a simulation laboratory using
a high-fidelity mannequin simulator, where a mannequin simulator with a standardized
script for septic shock was presented to trainees. The reproducibility of this patient and
associated conditions allowed the evaluation of ‘‘clinical performance’’ in the man-
agement of septic shock. In a previous study, we developed and validated tools for the
quantitative analysis of house staff managing septic shock simulations. In the present
analysis, we examined whether measures of clinical performance were improved in
those cases where a lecture on the management of shock preceded a simulated exercise
on the management of septic shock. The administration of the septic shock simulations
allowed for performance measurements to be calculated for both medical interns and for
subsequent management by a larger resident-led team.
Results: The analysis revealed that receiving a lecture on shock before managing a
simulated patient with septic shock did not produce scores higher than for those who did
not receive the previous lecture. This result was similar for both interns managing the
patient and for subsequent management by a resident-led team.
Conclusions: We failed to find an immediate impact on clinical performance in
simulations of septic shock after a lecture on the management of this syndrome. Lectures
are likely not a reliable sole method for improving clinical performance in the man-
agement of complex disease processes.
(Sim Healthcare 11:19Y24, 2016)

Key Words: Lecture, Teaching methods, Resuscitation, Clinical competence, Simulation,

Medical education

S eptic shock is the leading cause of mortality in the in-

tensive care unit (ICU) with more than half a million new
cases per year in the United States; with an aging population,
this figure will only increase.1 Clinical guidelines for the
management of severe sepsis are structured around in-
terventions that have reduced its morbidity.2,3 Despite
attempting to standardize the treatment of severe sepsis and
shock through the dissemination of such treatment guide-
lines by the Society of Critical Care Medicine and others,3Y5
little attention has been directed to the decision making and
performance of individuals or teams in the act of managing
sepsis. Likewise, the degree to which different educational
strategies can facilitate uptake and deployment of best
practices has not been adequately examined.
Experiential learning, considered broadly, includes ac-
tivities that actively engage learners in aspects of or related to
From the Department of Anesthesia Stanford University School of Medicine, Stanford, CA.
Reprints: Geoffrey K. Lighthall, MD, PhD, Anesthesia and Critical Care Stanford
University School of Medicine, 300 Pasteur Drive, H3580 Stanford, CA, 94305,
(e<mail: geoffl@stanford.edu).
Supported by the Foundation of Anesthesia Education and Research (FAER).
The authors declare no conflict of interest.
Copyright * 2016 Society for Simulation in Healthcare
DOI: 10.1097/SIH.0000000000000126
the concepts and material to be learned or their application
to real-world situations. In addition to technology-based
simulation, experiential learning includes role playing,
problem-based learning, storytelling, encounters with stan-
dardized patients, and psychomotor task training. Generally,
even when experiential learning is planned as a critical ele-
ment of teaching clinical care, it is combined with traditional
modalities of learningVtypically a lecture (in person or by
video) targeting the levels in Miller’s pyramid of ‘‘knows’’ or
‘‘knows how.’’6 The effectiveness of a lecture in embedding
knowledge can be measured with a written test (knows) but
that cannot determine the degree to which such knowledge
becomes ‘‘deployable’’ (knows how).
Because we have created high-fidelity simulations of
critical illness, including septic shock, to train house staff in
the management of patient care emergencies7 and later de-
veloped a scoring tool to assess the quality of teamwork and
medical management in these scenarios,8 we know that
statistically distinguishable categories of performance can be
identified.8 Although many investigators had previously
attempted to use simulation to impart knowledge to
learners, we turned this paradigm around to use simulation
to study whether knowledge had become deployable and

Vol. 11, Number 1, February 2016 19

Copyright © 2016 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
useful. In this study, we make use of the scoring rubric to
evaluate the impact of classroom instructionVa lectureVon
performance when managing simulations of septic shock.
The intensive care clinical rotation includes a recurring
lecture series, 1 day of which is replaced by a 4-hour simu-
lation session. Because the scheduling of specific lectures
varies according to the availability of faculty, the lecture on
sepsis preceded the simulation of septic shock approximately
half of the time. Therefore, we first performed a retrospective
analysis of whether receiving the classroom lecture on septic
shock before the simulation of septic shock was associated
with higher performance on this scenario. We then conducted a
prospective investigation of whether a redesigned lectureVone
that was geared more toward improving clinical performance
than to discussion of physiologic conceptsVwould lead to
better performance on subsequent simulations of septic shock.
METHODS
The experiment presented here consisted of 2 phases. In
phase I, data presented in our initial report on assessing the
management of septic shock simulations were analyzed in
terms of whether the simulation runs that followed a lecture
were associated with higher management scores. Phase II
analyzed performance in simulations after a redesign of the
lecture to a more deliberate focus on a widely accepted algo-
rithm of managing septic shock.2 Cards with the printed al-
gorithm were distributed to those attending the lecture, and a
quiz was administered before and after the lecture to assess
comprehension of information presented in the lecture.
Setting and Participants
The human subjects committee at Stanford University
School of Medicine approved the protocol; informed consent
was waived for the use of videotapes made originally for
debriefing and teaching purposes. Study subjects were in-
ternal medicine interns and postgraduate year 2 to 4 resi-
dents in surgery, anesthesiology, and internal medicine who
were rotating for 1 month in the medical/surgical ICU. The
critical care unit is a 15-bed semiclosed unit at the Veterans
Affairs Palo Alto Health Care System. Structured activities
consist of 2 hours of morning multidisciplinary bedside
rounds, afternoon sign-out rounds, and a lecture adminis-
tered each weekday by the critical care faculty. Lectures are
mandatory for interns and residents, and topics are those
particular to intensive care, including management of re-
spiratory failure, shock, sepsis, and postoperative patients.
The lecture series was constant in content from month to
month, and the same faculty member gave the lecture on
septic shock during the duration of this experiment. In
addition, a 4-hour course on critical care crisis management
is conducted in a dedicated simulation center each month
where standardized scenarios of septic shock and respiratory
failure are managed by teams of house staff and allied personnel.
Although timing of lectures sometimes varied according to
faculty availability, the simulation course took place on the
second Wednesday of each month. We attempted to schedule
the shock lecture earlier in the month to be before the simu-
lation session, but this could be accomplished only approxi-
mately half of the time.
20 Impact of Lectures on Management of Septic Shock
Copyright © 2016 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
Educational Intervention
In phase I, simulator performance was compared be-
tween house staff who received a lecture before the simula-
tion with those who had the simulation first. Phase II
involved an educational intervention for which a 2-part
lecture on the pathophysiology of shock was changed to a
single-hour clinically focused discussion of septic shock that
was altered in the following ways.
1. Minimized discussion of the finer physiologic and
biochemical details of organ dysfunction.
2. Emphasized ‘‘early goal-directed therapy’’ for severe
sepsis and septic shock, as advocated by treatment
guidelines2Y4; pocket cards with an algorithm for
early goal-directed therapy were distributed.
3. Presented an interactive problem-based learning
discussion regarding severe sepsis and septic shock,
where the patient’s vital signs are projected on a
screen and changed according to interventions re-
quested by trainees.9 This ‘‘hypothetical patient’’ was
nearly identical to the scenario encountered in the
simulation, but this was never stated.
In phase II, a quiz was administered to trainees both
before and immediately after the lecture and was used to
evaluate: (1) the acquisition of knowledge resulting from the
lecture and (2) a general approximation of the knowledge
that each team had before the simulation. Participants placed
a self-generated identification code on both quizzes, so they
could be matched for before-and-after comparisons while
assuring anonymity. No attempt was made to evaluate the
impact of the time interval between the lecture and simulation.
A scoring system that quantitatively rates the manage-
ment of a simulated patient with septic shock was developed
and validated previously.8 The scenario called for a period in
which the ICU interns were the sole physicians managing the
patient (first 10 minutes) and a later period where residents
directed patient management. This allowed for the formu-
lation of management scores for both interns and residents.
In addition to the main hypothesis that a revised lecture would
improve performance in sepsis management, we also hy-
pothesized that the internsVbeing relatively new to clinical
medicine and having the most to learnVmight be influenced
to a greater extent by an improved educational strategy.
Simulation Exercise
All participants were naive to the scenario content and
were asked to preserve the novelty for others and to sign
confidentiality agreements. The sepsis scenario follows a
standard script of signs, symptoms, and vital signs at baseline
and for patient deterioration or improvement according to
clinician interventions. The scenario begins with 2 interns
along with a critical care nurse who are called in as first
responders. Senior residents, fellows, subspecialty physi-
cians, respiratory therapists, and pharmacists could be
summoned if desired; senior physician help was invariably
requested but, by design, was kept out of the simulation
room until the 10-minute point. Thus, for each scenario, 2
groups of physicians were evaluated: (1) the interns present
during the first 10 minutes and (2) residents who took over
the management of the scenario at the 10-minute time point.
Simulation in Healthcare
Data Sources and Analysis
Video recordings of scenarios were analyzed by 2 trained
raters, and averages of the 2 scores were used for the com-
parisons described. Nontechnical ratings were based on skills
such as leadership, communication, contingency planning,
and resource use. These skills may dictate success in dynamic
environments and have been described by a number of
studies in the literature.7,10Y15 Previous analysis demon-
strated a high degree of interrater reliability for both tech-
nical and nontechnical rating systems (J = 0.96 and J = 0.88,
respectively).8 Comparisons between ‘‘lecture first’’ and
‘‘simulation first’’ for technical and nontechnical scores for
the septic shock scenarios were made by analysis of variance
(ANOVA). For all tests, P G 0.05 was taken as statistically
significant.
Quizzes covering the key findings and therapy of septic
shock were administered before and after the redesigned lecture
in phase II; comparisons of scores used Student t test for paired
samples. The association between quiz scores and simulation
scores was assessed by Spearman test for correlation.
Postcourse surveys covering perceived educational value
of simulation, realism, likes and dislikes, as well as sugges-
tions for improvement were administered to participants, as
is customary for all courses in our simulation center.
Temporal trends were examined to assess whether simu-
lation scores were influenced by timing within the academic
year or simply by time, as may be expected if ambient or
collective knowledge were to naturally increase during the
study period. Scores during different time intervals within the
academic year were analyzed by ANOVA and during the course
of the experimental period by Spearman test for correlation.
RESULTS
In the present study, we analyzed intern and group
scores in relation to whether a lecture on shock was presented
before or after the simulation session. A total of 56 scenarios
were analyzed in this experiment; 23 were from phase I.
Phase II produced 33 scoreable scenarios during a 41-month
period; scenarios from 8 courses scattered throughout the
study period were not scoreable when technical problems,
illnesses, and other unforeseen events prevented the scenario
from being conducted according to experimental standards.
Averages of all scores from phases I and II were compared
and showed a statistically significant higher score in phase II
(interns 6.8 vs. 9.6 and residents 8.5 vs. 11.2; P G 0.0001 for
both). Because of this difference, ‘‘lecture first’’ and ‘‘simula-
tion first’’ scores were compared separately within each phase
of the experiment. Data from the ‘‘technical’’ (medical man-
agement) scoring system is presented for both interns and full
care teams led by subsequently arriving residents. Phase I data
presented in Table 1 indicate that neither technical scores nor
nontechnical scores were significantly different when the sim-
ulation session was before the lecture versus after the lecture.
When comparing scores of ‘‘lecture first’’ versus ‘‘sim-
ulation first’’ groups in phase II, we again found no statis-
tically significant benefit of the lecture but surprisingly a
higher average score for groups who completed the simu-
lation without the previous lecture (Table 2). The modest
17% improvement in score was statistically significant for
Vol. 11, Number 1, February 2016
Copyright © 2016 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
TABLE 1. Impact of a Classroom Lecture on the Management
of Simulations of Septic Shock
Lecture First Simulation First Significance
Interns’ technical 6.6 (1.9) 6.9 (2.5) n.s.
score, mean (SD)
Residents’ technical 8.2 (2.2) 9.0 (1.4) n.s.
score, mean (SD)
Residents’ nontechnical 23.75 27.2 n.s.
score, mean (SD)
Phase I data; n.s., not significant.
only the ‘‘resident’’ group (not for interns). Nontechnical
scores were not significantly different in phase II (Table 2,
lower row of data).
Prelecture quiz scores correlated with level of training as
shown in Figure 1, where significant differences were noted
between medical students and all levels of house staff. Most
items on the quiz were directly relevant to the elements on
our technical rating scale for simulations.
Significant improvement in postlecture quiz scores was
seen for subjects at all levels of training. No significant differ-
ences existed between training-level groups when postcourse
test scores were compared (dark bars in Fig. 1). All groups had
average scores of approximately 7.5 of 10; thus, students
showed the greatest overall improvement in scores, followed by
interns and residents.
To complete the inquiry into the relationship between
knowledge and clinical performance, we compared the
simulation scores to the covariate of quiz scores at the time of
the simulation course (this score provides a rough estimate
of the subject’s knowledge about sepsis). Thus, for the group
participating in the simulation before the lecture, the average
of their ‘‘prelecture’’ quiz scores was used to estimate subject
knowledge, whereas the average of ‘‘postlecture’’ quiz scores
was used to estimate knowledge of groups receiving the
lectures before simulator participation. With data paired in
this manner, we found no correlation between test knowl-
edge and simulation performance. However, caution should
be exercised in interpreting this finding. This analysis looked
at only groups of individuals, not the actual pairing between
individuals managing the sepsis scenario and their scores.
Our commitment to administering quizzes with anonymity
prevented us from making the more accurate pairing be-
tween quiz and video performance.
The influence of time on the scenario scores was also
assessed. Figure 2 presents the simulation scores when sorted
into successive quarters of the academic year and when the
scenario scores are plotted sequentially during the course of
the experiment. There seems to be no significant improve-
ment during the course of the academic year for either
interns or residents. When all scores throughout the ex-
perimental period are viewed in sequence, the scores gen-
erated by interns steadily decline during the 41-month
period, whereas the average resident scores were unchanged.
On surveys administered at the conclusion of the simu-
lation workshop, a mean (SD) of 90% (0.1%) recorded either
‘‘agree’’ or ‘‘strongly agree’’ to the question of whether they
‘‘felt the simulation environment and scenarios prompted
realistic responses.’’ Responses regarding the realism of the
* 2016 Society for Simulation in Healthcare 21
TABLE 2. Impact of a Classroom Lecture on the Management
of Simulations of Septic Shock
Lecture First Simulation First
Interns’ technical 9.2 (1.6) 10.3 (1.6)
score, mean (SD)
Residents’ technical 10.5 (1.6) 12.3 (1.2)
score, mean (SD)
Residents’ nontechnical 23.58 26.95
score, mean (SD)
Phase II data; n.s., not significant.
scenarios did not differ between the groups with the highest
(top 5) and lowest (bottom 5 of 23) levels of performance for
both interns or for resident teams. Likewise, responses re-
garding realism did not differ between ‘‘simulation first’’ or
‘‘lecture first’’ groups.
DISCUSSION
Simulation techniques have created exciting opportu-
nities for the enhancement of medical education; however,
their use as a tool to evaluate aspects of traditional medical
education is relatively novel. This is an important goal be-
cause the ultimate purpose of providing medical knowledge
to trainee clinicians is in fact to allow them to conduct pa-
tient care effectively.
Veracity of Findings
From the survey data after simulations and voluntary
comments concerning the quality of lectures, it seems that
the data are a fairly credible representation of participants’
behavior. We therefore believe that the results require con-
sideration of a number of factors related to lectures and
classroom instruction including quality, context, and cog-
nitive processing. The results also prompt consideration of
our own goals for such instruction and how realistic it is to
expect behavioral change from these lectures.
Could the results be explained by a lecture poor in quality
or content? All items present on the technical scoring checklist
were discussed in the corresponding lecture and queried on the
quiz. Residents have repeatedly identified the lectures as being
a high quality, relevant, and valued component of the ICU
rotation. However, it is interesting that no group was able to
achieve an average of 10/10 on the postlecture quiz.
Could temporal trends influence results? Our expectation
that collective knowledge increases over time or increases by
the number of months into internship year seems to be un-
founded (Fig. 2). The latter is somewhat surprising because we
assumed that there was some exposure to the management
concepts under question in other rotations before an intern’s
ICU rotation and that such experiences were likely to accu-
mulate during the course of the academic year.
Is it possible that the performance seen in the simulation
underrates true clinical performance? This is certainly a
concern of many programs offering clinical simulation ex-
ercises and is the reason we go to great lengths to familiarize
the participants with the simulator, to use the same equip-
ment used in the ICU, and to have a ‘‘facilitator nurse’’ who
knows where supplies are, so that participants will not be
frustrated by an unfamiliar environment. What we cannot
replicate are the skin, motor movements, and affects of true
22 Impact of Lectures on Management of Septic Shock
Copyright © 2016 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
patients. Participants can address questions about skin color
and warmth, capillary refill, pupils, neck veins, and mucus
Significance membranes to the simulation operators and receive the in-
n.s. formation via an overhead speaker. Nonetheless, we grant
that some may use these and other clues to form a sub-
P G 0.05 conscious picture of a patient and his clinical course that may
not be possible with a mannequin.
n.s.
Our scoring rubric presents a list of ideal actions and
behaviors, but even executing them perfectly cannot guar-
antee a good outcome in all cases. Similarly, the sequence of
actions (such as provision of fluids before vasopressors)
could be important in real life, whereas our scoring system
did not distinguish between order of interventions. Although
we hold the belief that simulation approximates real-life
behavior, it is still true that physicians, patients, and the
health care system in general probably behave differently
when real lives are at stake. Although we make great efforts to
recreate the ‘‘motivational structure’’ of the real world in
simulations, it is impossible to really know whether this has
been achieved.
Implications of Findings
In phase II, all trainees at multiple levels demonstrated
an increase in theoretical knowledge on the quiz, so the lack
of transfer to the simulated patient was completely unex-
pected. We assumed that the lecture would have a positive
impact on the technical scores of the interns. This as-
sumption was based on the idea that interns would have had
the least experience managing critical illness, and therefore,
their management of sepsis would be influenced by in-
struction to a degree greater than that of more senior resi-
dents. Supporting this notion is the fact that quiz scores
showed the greatest improvement in lower levels of training
(Fig. 1). Our finding is not a unique observation. For ex-
ample, Rodgers et al16 rated performance of nursing stu-
dents during simulations of cardiac arrests and found no
association between simulator performance and score on
FIGURE 1. Average prelecture and postlecture quiz scores are
shown for each level of training. Light bars indicate prelecture
scores, and dark bars are the postlecture tests. All groups showed
improvement in score as a result of the lecture (*P G 0.05 by
Student t test for paired samples). Intergroup comparisons showed
a trend toward higher prelecture scores according to the level of
training, with all postgraduate scores significantly different from
the medical students’ scores (**P G 0.05 by ANOVA with
Bonferroni correction for multiple samples). No statistical differ-
ences existed amongst the posttest scores.
Simulation in Healthcare
FIGURE 2. A, Technical scores were sorted for interns (dark bars) and residents (light bars) according to successive quarters of the
academic year. B, Intern and resident scores were arranged in sequential months of the 41-week study period to assess for nonspecific
increases in knowledge or performance over time. For interns, the trend toward lower scores with time was statistically significant
(Spearman r = j0.56, P G 0.001).

previously administered tests. The present study adds to the
latter work by showing a similar disconnection between
acquired and deployable knowledge in multiple levels of
postgraduate trainees. The degree of standardization of the
scenarios for all participants and consistency of content
among the lecture, quiz, simulation and rating tool are
unique to this study and improve the credibility of the ex-
perimental findings.
We have no clear explanation as to why apparent uptake of
clinically relevant material did not manifest itself by higher
simulation performance. A number of explanations exist and
may be reasonable targets for further investigation. Perhaps,
the knowledge gained needs time to be processed, consoli-
dated, and compared with existing mental models of disease
management before becoming deployable. It is possible that
the conditions presented to the trainees during the simulation
were sufficiently stressful that a slower, more deliberate
method of processing the new information was required but
not easily accessible.17Y19 As postcourse surveys and discus-
sions do reveal that the trainees consider the simulations in-
tense and challenging,20 this explanation seems plausible.
A contrasting explanation is that the day or two sepa-
rating the lecture and the simulation was too great of an
interval and that more immediate practice and hands-on ex-
perience with newly learned material is a requisite for reliable
incorporation into practice. For example, ‘‘just in time’’ and
‘‘booster’’ training provided immediately before simulations
improves the efficacy of chest compressions in simulated
pediatric arrests.21,22 Unfortunately, it is hard to predict what
type of patient problem will present at a given moment, so
pairing training to immediate clinical need is impractical.
Nonetheless, the sequence of instruction followed by guided
practice may provide superior training over separation of these
components and deserves further evaluation.
We started this experiment hoping to show that the con-
tent of lectures could be altered to create improvements in
clinical care and ended up questioning the value of lectures in
general. Lectures, both in the traditional in-person form and
in the video-based ‘‘flipped classroom’’ paradigm, have been
thought to have significant value in conveying ‘‘knows’’ and
‘‘knows how’’ information at a rather low cost. Hundreds of
learners can be in the audience in person; an unlimited number
might view the lecture on video. Yet, if such activities do not
result in deployable knowledge and skill, this leverage is useless.
If lectures do not work, then what does? Trainees may
need to be ‘‘shown the way’’ to a greater degree than we are

Vol. 11, Number 1, February 2016 * 2016 Society for Simulation in Healthcare 23
Copyright © 2016 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
willing to admit. In either event, with resident work hour
limitations in place, there is an added premium on under-
standing the impact of educational programs on patient care
and finding the most efficient means to increase the effec-
tiveness of physicians. Future work in this area should use
focused interviews and other qualitative techniques to better
understand the behaviors and cognitive processes that un-
derlie performance at the different ends of the spectrum.
Educational programs should then be shaped around the
factors associated with high performance. Measurement
systems, such as the one presented here, may help evaluate
performance of education programs and with further re-
finement might predict clinical outcomes. For example,
some actions may prove to have greater impact than others
in managing certain clinical problems, and any rating system
would need to weigh these accordingly. In addition, as
mentioned earlier, the sequence of actions is often important
and so might need to be more closely evaluated.
CONCLUSIONS
This study used a standardized simulation as a surrogate
for clinical performance and hypothesized that a carefully
designed lecture would lead to quantitative improvements
in clinical performance. Instead, we showed that perfor-
mance scores of intensive care interns and residents man-
aging a simulated case of septic shock were no better when a
lecture/workshop on the same disease process preceded the
simulationVdespite demonstrating uptake of the lecture
content. Lectures and group discussions are the de facto
standard for imparting medical knowledge. Despite such
status, the transfer of knowledge between lecture and bedside
care has not been formally proven. Ironically, proof of effi-
cacy is a burden placed on the proponents of simulation and
immersive learning as these techniques attempt to find a
niche in the instructional repertoire. It is difficult to com-
pletely discard the value of classroom instruction; however,
this and future studies may prove it to be more effective as
a complimentary technique rather than the sine qua non of
health care education.
REFERENCES
1. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky
MR. Epidemiology of severe sepsis in the United States: analysis of
incidence, outcome, and associated costs of care. Crit Care Med
2001;29:1303Y1310.
2. Rivers E, Nguyen B, Havstad S, et al; Early Goal-Directed Therapy
Collaborative Group. Early goal-directed therapy in the treatment of
severe sepsis and septic shock. N Engl J Med 2001;345:1368Y1377.
3. Dellinger RP, Carlet JM, Masur H, et al; Surviving Sepsis Campaign
Management Guidelines Committee. Surviving Sepsis Campaign
guidelines for management of severe sepsis and septic shock.
Crit Care Med 2004;32:858Y873.
4. Dellinger RP, Levy MM, Carlet JM, et al; International Surviving
Sepsis Campaign Guidelines Committee; American Association of
Critical-Care Nurses; American College of Chest Physicians; American
24 Impact of Lectures on Management of Septic Shock
Copyright © 2016 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
College of Emergency Physicians; Canadian Critical Care Society;
European Society of Clinical Microbiology and Infectious Diseases;
European Society of Intensive Care Medicine; European Respiratory
Society; International Sepsis Forum; Japanese Association for Acute
Medicine; Japanese Society of Intensive Care Medicine; Society of
Critical Care Medicine; Society of Hospital Medicine; Surgical Infection
Society; World Federation of Societies of Intensive and Critical Care
Medicine. Surviving Sepsis Campaign: international guidelines for
management of severe sepsis and septic shock: 2008. Crit Care Med
2008;36:296Y327.
5. Dellinger RP, Levy MM, Rhodes A, et al; Surviving Sepsis Campaign
Guidelines Committee including the Pediatric Subgroup. Surviving
sepsis campaign: international guidelines for management of severe
sepsis and septic shock: 2012. Crit Care Med 2013;41:580Y637.
6. Miller GE. The assessment of clinical skills/competence/performance.
Acad Med 1990;65:S63YS67.
7. Lighthall GK, Barr J, Howard SK, et al. Use of a fully simulated intensive
care unit environment for critical event management training for
internal medicine residents. Crit Care Med 2003;31:2437Y2443.
8. Ottestad E, Boulet JR, Lighthall GK. Evaluating the management of
septic shock using patient simulation. Crit Care Med 2007;35:769Y775.
9. Lighthall GK, Harrison TK. A controllable patient monitor for
classroom video projectors. Simul Healthc 2010;5:58Y60.
10. Gaba DM. Improving anesthesiologists’ performance by simulating
reality. Anesthesiology 1992;76:491Y494.
11. Flin R, Maran N. Identifying and training non-technical skills for teams
in acute medicine. Qual Saf Health Care 2004;13(suppl 1):i80Yi84.
12. Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R.
Anaesthetists’ Non-Technical Skills (ANTS): evaluation of a behavioural
marker system. Br J Anaesth 2003;90:580Y588.
13. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of Crew Resource
Management training in commercial aviation. Int J Aviat Psychol
1999;9:19Y32.
14. DeVita MA, Schaefer J, Lutz J, Dongilli T, Wang H. Improving medical
crisis team performance. Crit Care Med 2004;32:S61YS65.
15. Davis D, Evans M, Jadad A, et al. The case for knowledge translation:
shortening the journey from evidence to effect. BMJ 2003;327:33Y35.
16. Rodgers DL, Bhanji F, McKee BR. Written evaluation is not a predictor
for skills performance in an Advanced Cardiovascular Life Support
course. Resuscitation 2010;81:453Y456.
17. Stiegler MP, Gaba DM. Decision-making and cognitive strategies.
Simul Healthc 2015;10:133Y138.
18. Croskerry P. Clinical cognition and diagnostic error: applications of a
dual process model of reasoning. Adv Health Sci Educ Theory Pract
2009;14(Suppl 1):27Y35.
19. Kahneman D. Thinking Fast and Slow. New York: Farrar, Straus and
Giroux; 2011.
20. Lighthall GK, Barr J. The use of clinical simulation systems to train
critical care physicians. J Intensive Care Med 2007;22:257Y269.
21. Cheng A, Brown LL, Duff JP, et al; International Network for
Simulation-Based Pediatric Innovation, Research, & Education
(INSPIRE) CPR Investigators. Improving cardiopulmonary
resuscitation with a CPR feedback device and refresher simulations
(CPR CARES Study): a randomized clinical trial. JAMA Pediatr
2015;169:137Y144.
22. Sutton RM, Niles D, Meaney PA, et al. ‘‘Booster’’ training: evaluation
of instructor-led bedside cardiopulmonary resuscitation skill training
and automated corrective feedback to improve cardiopulmonary
resuscitation compliance of Pediatric Basic Life Support providers
during simulated cardiac arrest. Pediatr Crit Care Med
2011;12:e116Ye121.
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