Original research
Impact of repeated simulation on learning curve
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1
Anaesthesiology, Sri
Ramachandra Medical College
and Research Institute, Chennai,
Tamil Nadu, India
2
Hull and East Yorkshire
Hospitals NHS Trust, Hull, UK
3
Anaesthesiology, Sri
Ramachandra Medical College
and Research Institute, Chennai,
Tamil Nadu, India
Correspondence to
Dr Sree Kumar E J,
Anaesthesiology, Sri
Ramachandra Medical
College and Research
Institute, Chennai, TN
600116, India;
sreekumardr@gmail.com
Accepted 4 December 2019
© Author(s) (or their
employer(s)) 2019. No
commercial re-use. See rights
and permissions. Published
by BMJ.
To cite: E J SK, Purva M,
Chander M S, et al. BMJ
Simul Technol Enhanc Learn
2020;6:351–355.
E J SK, et al. BMJ Simul Technol Enhanc Learn 2020;6:351–355. doi:10.1136/bmjstel-2019-000496
characteristics of residents exposed to rare life
threatening situations
Sree Kumar E J ,1 Makani Purva,2 Sarat Chander M,1 Aruna Parameswari3
ABSTRACT
Background Little is known about the learning curve
characteristics of residents undertaking simulation-based
education. It is important to understand the time for
acquisition and decay of knowledge and skills needed to
manage rare and difficult clinical situations.
Method Ten anaesthesiology residents underwent
simulation-based education to manage a cannot intubate
cannot ventilate scenario during general anaesthesia for
caesarean section. Their performance was measured
using an assessment tool and debriefed by two
experienced anaesthesiologists. The parameters against
which the performance was judged were grouped into
preoperative assessment, preoperative patient care,
equipment availability, induction sequence,
communication and adherence to airway algorithm
protocol. The scenario was repeated at 6 and 12 months
thereafter. The residents’ acquisition of knowledge,
technical and non-technical skills were assessed and
compared at baseline, 6 months and end of 12 months.
Result The skills of preoperative assessment,
preoperative care and communication quickly improved
but the specific skill of managing a difficult airway as
measured by adherence to an airway algorithm required
more than 6 months (CI at 6 vs 12 months: −3.4 to –0.81,
p=0.016). The skills of preoperative assessment and
preoperative care improved to a higher level quickly and
were retained at this improved level. Communication (CI
at 0 vs 6 months: −3.78 to −0.22, p=0.045 and at 6 vs
12 months : −3.39 to −1.49, p=0.007) and difficult
airway management skill were slower to improve but
continued to do so over the 12 months. The compliance to
machine check was more gradual and showed an
improvement at 12 months.
Conclusion Our study is unique in analysing the
learning curve characteristics of different components of
a failed obstetric airway management skill. Repeated
simulations over a longer period of time help in better
reinforcement, retention of knowledge, recapitulation and
implementation of technical and non-technical skills.
INTRODUCTION
General anaesthesia (GA) for caesarean section (CS)
is a rare event.1 Resident anaesthesiologists may
encounter this situation for the first time while on
call during out of hours especially when senior help
may not be readily accessible. Failed intubation dur-
ing GA is more likely in the obstetric population and
the consequences could be life threatening to the
mother and baby.2 Simulation education can prepare
trainees for this rare and potentially serious event
(Royal College of Anaesthetists curriculum)3 4 and
teach them the technical and non-technical skills
needed to manage a difficult airway. Little is known
about the length of time needed for uptake of these
skills and even less on how long they are retained
following the uptake and even fewer studies have
addressed the complexity of teaching these skills in
a novice population.5–8 We believe that our study is
the first to explore uptake and retention of technical
and non-technical skills in the arena of obstetric
anaesthetic training.
METHODOLOGY
We conducted the study as a single arm, prospective,
interventional, pre and post design study. Ten first-
year anaesthesiology postgraduates resident trai-
nees, at the end of their first year of training, were
recruited (figure 1). None of the residents had pre-
viously participated in a simulation and had not
experienced a cannot intubate cannot oxygenate
(CICO) situation. All 10 residents were followed
up after 6 months. At the 12th month, 9 residents
participated in the exercise with one dropping out of
the study due to being on maternity leave. Of the 9
residents, 7 residents had provided 1 to 2 GA for
a CS in the 12 months, with none having experi-
enced a CICO and with 3 residents in two situations
and 4 residents in one scenario each.
The residents were provided prebriefing and an
introduction to the simulation environment. The
simulation scenario incorporated a GA for CS cul-
minating in a CICO situation. The performance of
the residents was assessed remotely by two anaes-
thesiologists against an assessment tool. The tool
comprised of the steps to be undertaken while
undertaking GA for CS (online supplementary
material9) and managing a difficult airway as per
Difficult Airway Society (DAS) protocol which
refers to management of unanticipated failed
intubation.2 The checklist suggested by Scavone
et al9 was modified (with equal weightage given to
each variable) and additional steps were included to
provide a greater purview of the resident’s manage-
ment of a difficult airway. These included preopera-
tive assessment of vital parameters and checking for
the presence of supraglottic and nasopharyngeal air-
way, the required drugs and intravenous fluids. The
assessors were senior anaesthesiologists with 10 and
25 years’ experience in obstetric anaesthesiology.
At the end of the scenario, the participants were
provided debriefing with an opportunity to reflect
on their performance. The participants were fol-
lowed up after 6 and 12 months. Each of the
351
 Original research

Table 2 Scores achieved against the assessment tool (mean±SD

(median))
Factors assessed At 0 month At 6 months At 12 months
Preoperative assessment 1.7±1.3 (1) 4.3±1.95 (4.5) 5.22±2.44 (5)
Preoperative patient care 1.6±1.3 (1) 2.9±1.66 (4) 3.56±1.24 (4)
Equipment check 1.1±2.1 (0) 4.3±3.59 (3.5) 6.11±3.3 (8)
Induction sequence 6±2.5 (4) 6.8±1.48 (6.5) 8±2.06 (8)
Communication 2.2±1.8 (2) 4.2±1.75 (3.5) 6.56±1.88 (6)
DAS protocol 0.6±0.5 (1) 1.2±1.23 (1) 3.22±0.83 (3)
Total 13.2±6.1 (12.5) 23.7±5.29 (21.5) 32.66±7.68 (36)
DAS, Difficult Airway Society.

Figure 1 Flow chart of participants in the study

DISCUSSION
Simulation is now an established educational modality in healthcare
education. While its value is increasingly being realised, less is
participants were exposed to the same scenario and the same known about how to structure the simulation-based education in
process was repeated on all three occasions. Their retention of curricula and plan the frequency of offering, such that technical and
knowledge, recapitulation and implementation of their acquired non-technical skills are not only acquired but maintained without
skills were evaluated. The parameters against which the perfor- decay. Our study is unique in analysing the learning curve charac-
mance was judged were grouped into preoperative assessment, teristics of different components of a failed obstetric airway man-
preoperative patient care, equipment availability, induction/intu- agement skill. We analysed the performance of our
bation sequence, communication and adherence to DAS proto- anaesthesiologists in six areas of failed airway management in an
col. Communication was assessed as a composite score of the first obstetric scenario (online supplementary material). We believe that
six components of preoperative assessment along with the ver- lessons learned from our study can be extrapolated to the wider
ification of obstetric readiness and the call for help. educational arena and influence future training programmes in
other specialties.
RESULTS The first area of preoperative assessment involved undertaking
Individual performance and the total score obtained against the a rapid relevant history of key information under time pressure.
assessment tool (online supplementary material) were compared at Our study participants demonstrated an improvement in overall
0, 6 and 12 months (table 1). The mean±SD and the median value performance, from a poor baseline of 18.9% to 58% at 12 months
with lower and upper quartile were calculated (tables 2 and 3). We (table 1). This was also noted in another simulation study,10 where
used Wilcoxon signed-rank test to compare between two median lowest baseline scores were observed in preoperative assessment.
time points. The CI of the difference and the p value were calcu- Key elements of the preoperative assessment include the elucida-
lated. p<0.05 was considered significant (table 3). tion of the allergy status and airway examination and this improved
The results show an overall improvement in the performance of from 0% and 10% to only 55.6% and 44.4%, respectively, at 12
the residents in the management of an obstetric difficult airway months (table 1). Residents in our institution are provided adequate
between baseline and 12-month scores with significant improve- training and should have the knowledge to undertake a competent
ment in the areas of preoperative assessment, preoperative care, history taking. But our results illustrate that this may not be the case
communication and adherence to DAS protocol noted at 6 months demonstrating the urgent need for repeated simulation especially
(figures 2 and 3). Machine check performance improved signifi- during the early stages of anaesthesiology training.
cantly at 12 months when compared with 0 month (table 3). There The second area of assessment involved preoperative prepara-
was no significant improvement (table 3) in the adherence to induc- tion of the patient for an obstetric GA and included undertaking
tion and intubation sequences even at the end of 12 months. a machine check and ensuring a working intravenous cannula.
Various case reports of patient harm due to intravenous cannula
failure have been reported.11–13 Our residents did not improve in
Table 1 Percentage scores achieved against the assessment tool this critical step and achieved only 22% compliance at 12 months
Factors assessed At 0 month At 6 months At 12 months
Preoperative assessment 18.8% 47.7% 58.0%
History of allergy 0% 20% 55.6% Table 3 Scores achieved against the assessment tool (CI)
Airway assessment 10% 20% 44.4% 0 vs 6 months 6 vs 12 months 0 vs 12 months
Preoperative patient care 32% 58% 71.11% Assessed variable (95% CI) (95% CI) (95% CI)
100% oxygen 100% 100% 100% Preoperative −3.91 to −1.29* −2.67 to 0.89 −5.48 to −1.41*
Ensure working intravenous catheter 0% 10% 22.2% assessment
Equipment availability 12% 47.77% 67.90% Preoperative care −2.37 to −0.23* −2.15 to 0.60 −2.94 to −0.84*
Machine check 0% 77.8% 77.8% Equipment availability −6.48 to 0.08 −5.83 to 3.17 −7.24 to −2.54*
Induction sequence 37.50% 42.50% 50% Induction sequence −3.45 to 1.85 −3.17 to 0.73 −4.69 to 0.69
Left uterine displacement 0% 0% 0% Communication −3.78 to −0.22* −3.39 to −1.49* −6.10 to −2.35*
Communication 22% 42% 65.55% DAS protocol −1.50 to 0.30 −3.4 to –0.81* −3.23 to −1.88*
DAS protocol 15% 30% 80.55% Total −17.45 to −3.55* −15.92 to −1.63* −25.16 to −12.84*
Total 24.90% 44.71% 61.66% *A p value of <0.05 is considered significant.
DAS, Difficult Airway Society.
DAS, Difficult Airway Society.

352 E J SK, et al. BMJ Simul Technol Enhanc Learn 2020;6:351–355. doi:10.1136/bmjstel-2019-000496

Figure 2 Performance of residents - assessment, care and equipment check
(table 1). Recognising the potential patient risk to our patients,
we made changes to our airway management protocol and intro-
duced a checklist emphasising the need for checking cannula
patency. We believe that checklists are valuable adjuncts to
improve memory,14–16 will act as a timely reminder for the anaes-
thesiologist having to undertake a CS under time-pressured situa-
tions and believe that this should be adopted by other institutions
as well.
The third area of assessment involved checking for equipment
availability and the performance of a machine check. In our study,
most of the residents failed to perform the machine check.
Disconnections and malfunctioning of the anaesthetic machine
have led to serious maternal harm and are discussed with resi-
dents regularly.17 It was surprising, therefore, to not observe this
basic expected behaviour. We believe that this error is possibly
a rule-based error.18 We believe that these factors are particularly
pertinent to a CICO situation and this needs to be carefully
addressed in anaesthesiology training programmes. Evidence
suggests that checklists are also useful adjuncts to address rule-
based errors and this now being routinely introduced in obstetric
theatres to improve anaesthesiologists’ compliance with
protocols.19–21 Kuduvalli et al8 noted an improvement in
machine check in a similar simulation study, on practicing
Figure 3 Performance of residents - induction sequence, communication, DAS protocol and overall total
E J SK, et al. BMJ Simul Technol Enhanc Learn 2020;6:351–355. doi:10.1136/bmjstel-2019-000496
Original research
anaesthesiologists, by 6 weeks and was sustained up to 6 months.
However, their study did not follow-up residents beyond 6
months. In our study, although we also noted an improvement
throughout our study, significant improvement was only noted at
12 months, emphasising the need for regular top up simulation
education in the curriculum. In view of the critical nature of this
step, in our institution we have introduced a machine check
proforma for our residents to ensure that this step is not
forgotten.
The fourth area of assessment involved checking compliance
with the induction and intubation sequence. Previous simulation
studies have demonstrated that tasks such as left uterine displace-
ment, verifying obstetric team readiness and notifying the obste-
tric team to proceed are commonly overlooked.5 In our study, left
uterine displacement was not performed even at the end of 12
months despite providing feedback to the residents during the
debriefing. We realised that the failure to improve was because in
our institution, the left uterine displacement is performed by the
obstetrician and not the anaesthesiologist. This underlines the
importance of ensuring that teaching in the simulated environ-
ment is contextually connected to the real world. Only then it
will lead to gainful positive reinforcement and positive impact on
patient outcomes22 and is a timely reminder to educationalists to
353
 Original research
design scenarios relevant to the learner and the environment they
work in.
The fifth element of assessment involved measuring commu-
nication during the scenario. Evidence suggests that communi-
cation failure accounts for 43% of errors in the workplace23 and
is especially relevant in difficult airway situations. Our study
demonstrated that communication skills improved significantly
but only reached 65.6% at 12 months (table 1). We believe that
this has been borne out by other studies and this may be due to
the difficulties in inculcating a complex behavioural skill change
such as is seen in team communication.24 25 Improving team
communication may require more time for reflection, training
at work, dedicated teaching of communication or more inten-
sive simulator training. This will need to be factored in while
designing multidisciplinary training and the importance of
team-based simulation education at regular intervals cannot be
overemphasised as decay in communication skills is highly
likely.
The sixth component of the assessment tool measured adherence
to an airway algorithm (DAS society-ref), and this showed signifi-
cant improvement from a baseline of 30% to 80% at 12 months.
This is in contrast to other studies,8 26 where the adherence
increased from higher baseline to 100% by 6 months. We believe
that this may be due to the relatively junior grade of anaesthesiolo-
gists in our study and a different model of simulation education.26
Hubert et al employed an intensive 2-day airway training postsimu-
lation exposure, which may have contributed to a better compliance
at 6 months and thereafter. During this training, the participants had
an opportunity to practice repeatedly the CICO scenario contribut-
ing to an attainment of a mastery standard earlier than in our study.
On the contrary, the assessment process in the Hubert et al study
used a global score for assessing compliance unlike our study where
we assessed more rigidly the compliance to individual steps of the
airway algorithm. This may have resulted in the harsher lower
scores in our study.
Long-term retention of decision-making skills requires frequent
reinforcement. Focused training on a patient simulator has been
shown to improve resident performance that involved GA for
emergencies.5 27 Repeated exposure to a scenario improves reten-
tion, as shown in our study. McGaghie et al3 suggest that skill decay
depends on the specific skill acquired, the degree of skill learning
and the time allowed to elapse between learning and follow-up
measurement. The study by Ortner et al5 reported competencies
equal to an experienced anaesthesiologist at 5 weeks and a retention
of up to 8 months in a study on performance of GA in emergency
CS. Their study differed from ours, in that some of the residents had
a prior exposure to simulation education and the study did not
include a CICO scenario. In our study, resident anaesthesiologists
were involved, who had similar experience and practice and had no
prior exposure to simulation education. The need to focus on the
behaviour of different components of the check list at each repeated
simulation scenario is stressed in our study. Our study observed that
the skills of preoperative assessment, preoperative care and com-
munication were quickly acquired, while the adherence to DAS
protocol required more than 6 months. The skills of preoperative
assessment and preoperative care were retained, while communica-
tion skill and adherence to DAS protocol continued to improve at
12 months. The compliance to machine check was more gradual
and showed an improvement at 12 months. The adherence to the
induction sequence was much more gradual but increased, though
not significantly, over 12 months. This is especially noteworthy as
our residents’ exposure to an obstetric GA situation in the clinical
environment was minimal (averaging only 1.2 per resident per year)
354 E J SK, et al. BMJ Simul Technol Enhanc Learn 2020;6:351–355. doi:10.1136/bmjstel-2019-000496
and therefore the impact of the simulation education was even more
evident.
Limitations
The absence of video recording may have influenced the capture
of information noted during the scenario as the assessors may
have been distracted and not captured the adherence to the
assessment protocol in a consistent and rigorous manner. We
believe that the presence of two raters during the scenario may
have reduced effects of distraction. Further, as the scores were
arrived at by consensus between the two raters, there was less
chance of variability or bias between the raters. Further, the same
raters were used during the three sittings ensuring consistency
and reliability.
We acknowledge that the improvement in learning demon-
strated during the study cannot be attributed purely to our simu-
lation-based education and could be attributed to similar
exposure in the clinical environment over the 12-month study
period. However, from the information provided by the resi-
dents, their exposure to emergency CS during the same period
of time was minimal. Therefore, we believe that as the exposure
to a similar scenario in the real world was limited, the improve-
ment in performance noted during our study should be attributed
to our simulation education.
CONCLUSION
Repeated simulation delivered over a longer period of time leads
to better retention of knowledge, communication skills and
adherence to airway protocols in the management of a failed
obstetric intubation.
Contributors The following are the contributions by the authors to this article. SKEJ:
design of the work, acquisition, analysis or interpretation of data, drafting, revision,
final approval and accountable for all aspects of the work. MP: design of the work;
acquisition, analysis, drafting, revision, final approval and accountable for all aspects
of the work. SCM: design of the work; acquisition, drafting, revision, final approval
and accountable for all aspects of the work. AP: design of the work; drafting, revision,
final approval and accountable for all aspects of the work.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Ethics approval The study was approved by the Institutional Ethics Committee of Sri
Ramachandra Institute of Higher Education and Research, Chennai.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request.
ORCID iD
Sree Kumar E J http://orcid.org/0000-0002-1057-8530
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