The change in curriculum and increasing need for active healthcare professionals providing quality patient care has emphasised simulation-based regular training, reskilling and simulation centres to deliver these. However, there is limited literature on how to establish a simulation centre and overcome the challenges relating to developing faculty and maintaining the financial viability of these centres. Our review focuses on this gap in the current literature. The findings are presented as 1) identification of the methods of establishing a simulation centre, 2) setting up the resource in a simulation centre and 3) faculty development and curricular integration in a simulation centre. The space of a simulation centre depends on the organisation's or training body's needs. There is no single design which is recommended. Establishing a simulation centre should consider the needs of the organisation, educators and learners along with the available resources and ensure that curriculum integration and standards are met.

Even in the presence of established institutional guidelines, failure of compliance by the clinical teams plays an important role in the control of diabetes. The identified gaps include contextual and biomedical knowledge, attitudes, clinical inertia, confidence and familiarity with existing hospital resources and guidelines with regards to hospital diabetes care We wanted to demonstrate the efficacy of low-dose high-frequency The exercise was a 15-minute session, delivered during working hours to individual nurses. This consisted of a 5-minute scenario, involving a standardized patient followed by a 10-minute debrief. Modified Diamond-model debrief with an advocacy-inquiry model was used by the debriefer, a trained fellow in simulation, and overseen by an expert. The scripted scenario involved a patient with Diabetic Ketoacidosis (DKA), with learning outcomes of recognizing DKA, managing the patient and adhering to the institutional guidelines including management of hypoglycaemia. The scenario was individualized based on the roles of the participants. Pre- and post-questionnaires were given to the participants. The simulation was repeated twice in the second week and once in the third week. This mixed-method study was conducted in a UK teaching hospital, in a ward designated for patients with diabetes, as a part of a quality improvement programme. In the first week, patients with diabetes, admitted for DKA, were chosen and their blood sugar recordings, dysglycaemic episodes and adherence to guidelines were noted. Every week data were collected as in the first week. GNU pspp 1.0.1 [version 3] free software was used. The confidence scores were given as mean and standard deviation with confidence interval (CI) of 98.75%. A p-value of <0.0125 was considered significant based on the number of data points. The Dysglycemic episodes and protocol adherence from medical records Considering the T2 (increased recognition of diabetic emergencies and adherence to protocol) and T3 (improved patient outcomes) outcomes, the methodology was recommended as a modality of training the nursing staff involved in inpatient care of patients with diabetes. Future programmes including multi-disciplinary teams, to explore teamwork and communication, are planned.

Background Interprofessional education can provide better professional outcomes in areas like professionalism, empathy, and communication.1 2 Simulation is one of the best ways for interprofessional health care training. Summary of Work The session was planned as a 90-minute session on empathy which was relevant to the undergraduate curriculum followed by a session on reflection for 60 minutes. The participants were 250 students comprising both medical and nursing undergraduate students. The students were asked to sit in pairs – with a Student nurse with a medical student. They were divided into 10 groups and 2 spokespersons-one medical and nursing in each group were assigned. All the students were asked to fill the pre-course questionnaire and then had an introduction to each other so that all knew their partners’ details. The activities to promote interprofessional activities included, to discuss what qualities or behaviors a professional doctor or nurse will have, to Critique the behavior of doctor and the behavior of nurse, The interprofessional simulation education included professionalism; demonstrate the ability to communicate to patients in a patient, respectful, nonthreatening, non- judgmental and empathetic manner; reflective practice. Following it, the groups were asked to reflect on the breaking bad news session, they were given 15 minutes to write and 15 minutes to exchange and critique. The post-course questionnaire was then submitted online. Summary of Results Analysis of the questionnaire showed that the students’ understanding of reflection (26.2% to 42.1%) and their confidence to reflect (22.6% to 37.8%) had increased post-session. Most of them enjoyed the session (76.9%) and their confidence in defining the qualities of a professional person (26.2% to 49.4%) and breaking bad news (16.3% to 32.9%) had increased. Discussion and Conclusion Large group simulation-based education is a major challenge in tertiary hospitals of countries like India. This inter-professional education shows the feasibility of providing simulation-based training for essential healthcare aspects of professionalism, empathy, and communication Recommendations Healthcare education should be reorganized to include interprofessional simulation-based education for essential healthcare behaviors. References Margaret Costello, et al. Simulation as an effective strategy for Interprofessional education. Clinical Simulation in Nursing 2017;13(12):624–27. Moyer, Susan. ( 2016). Large group simulation: using combined teaching strategies to connect classroom and clinical learning. Teaching and learning in nursing. 10.1016/j.teln.2016.01.002.

Background Simulation-based education is a novel method of Healthcare education in India. With a dearth of experts in our country, we implemented a novel method of training the trainers,1 2 with a foreign expert, to bridge this gap in this field. Summary of Work The training program was done for the faculty of Sri Ramachandra Institute of Higher Education and Research, Chennai, India. The program Coordinators included an International expert in Simulation from Hull University teaching Hospital and Head of the Medical Education Unit, SRIHER. The facilitators included faculties trained in Simulation. The target group included the faculties from Medical college, Dental college, Pharmacy college, Nursing college, and Allied health sciences of SRIHER. The training program was planned as 3 Tiers. In Tier 1, 24 participants, who were interested in Medical education, volunteered for a 5-hour Tele Video session delivered by the International faculty and facilitated by local experts. Tier 2, 1 week later, included 24 observers in addition to the initial 24 participants. The observers had the previous week’s session as Tutored Video Instruction (TVI), with local experts present in a blended learning session. Tier 3 included an inter-professional Simulation by the participant groups observed by the observers. Similar workshops are planned with observers becoming participants in the forthcoming sessions. Summary of Results The outcome of the sessions was assessed with Pre and Post questionnaire. 61.1% did not have any previous simulation experience. We observed an increase in the confidence levels for delivering a simulation course in healthcare. The session resulted in the use of hybrid simulation by the participants. The confidence in debriefing and running a simulation course may require a longer time. Discussion and Conclusion The ability to provide training in a resource-limited setting can be done by this method. A large number of faculty can get exposed to simulation-based education. These can also help in identifying core groups and leadership for simulation-based inter-professional education in Hospitals. Recommendations Resource limited countries can opt for TVI for training a large number of faculty in a short period of time. References Adrianne J. Lane, et al. Using a Train the trainer model to prepare educators for Simulation instruction. The journal of continuing education in nursing 2013; 44. doi:10.3928/00220124-20130515-33 Mormina and Pinder. A conceptual framework for training of trainers(Tot). Globalization and Health 2018;14:100; doi.org/10.1186/s12992-018-0420-3

Background With the spread of Simulation-based education (SBE) to newer countries like India, there is a need for large scale and rapid implementation of training in debrief techniques. We present one method of training the trainers in a debrief workshop. Summary of Educational Programme A two hour workshop on the basics of debriefing was planned. The learning objectives of this workshop were to develop an understanding of the importance of debrief, the ability to plan a debrief session, Use of Advocacy- Inquiry model during debrief and to analyse a debrief session.1 During the workshop the why, who, when and how of debrief was discussed. The workshop addressed the participant-debriefer relationship and also on debriefing on human factor and for closing performance gaps.2 Construct of sentences based on this model was done during the course of this workshop. Some of the challenges, at various stages of debriefing, were also be discussed. A scenario video was shown and was followed by debriefing session as small group activity and presentation. Step by step debrief by diamond model with advocacy-Inquiry model was done. All the queries of participants on debriefing were clarified by Simulation experts. Following this an ideal debriefing session for the same scenario was shown to participants for better understanding. All the participants filled pre and post workshop questionnaire. Summary of Results The analysis of the questionnaire showed that the understanding of debriefing by the participants had increased post-workshop and their confidence in the Advocacy-inquiry model had also improved. But most of the participants preferred longer sessions on debriefing. Discussion and Conclusion This fast and short duration workshop did have an impact on the understanding of debriefing by the participants, but it is definitely not adequate, and we need to have longer sessions for better results. A fixed framework is essential while introducing the concept of debriefing to novices in SBE. Recommendations Short duration workshop is appropriate to introduce debrief techniques and to provide confidence for novices in the field of SBE. References Jenny W. Rudolph, et al. There’s no such thing as ‘Nonjudgmental’ Debriefing: a theory and method for debriefing with good judgment. Simulation in Healthcare 2006;1:49–55. Pocketbook for Simulation debriefing in Healthcare. Dennis Oriot, Guillaume Alinier, Springer 2018.

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.

Background Learning through simulation has gained momentum in India. Knowledge of establishing and maintaining a simulation center has become a prerogative for health care professionals.1 Summary of the Educational Programme The objectives of this interactive workshop using an open-ended survey was to (1) understand the targeted needs and related design of a Simulation Centre that is required, (2) enlist the resources required in setting up the Centre (3) discuss the need to develop Simulation Programs & Centre Policies and (4) to describe the challenges in sustaining a Simulation Centre. Summary of the Results The survey was conducted among 29 health care professionals of different disciplines as -medicine 16(55.17%), dental5(17.24%), nursing 3(10.34%), and pharmacy 5 (17.24%). The participants were divided into three groups with an equal number from each discipline. The session involved brainstorming among the group and the themes that emerged for each objective were as follows: The first objective for the need for Simulation-Based Education(SBE) gave rise to the following themes as learner needs, regulatory body requirement, reduction of errors, safe environment for learning, and quality patient care. The themes under the resource were budget, infrastructure in terms of manpower and material, equipment- high fidelity, low fidelity, or task trainers based on utility value, virtual reality devices, simulation tools. There was a uniform consensus among the participants regarding the need to improve on existing infrastructure. The need for simulation programs was to train the students, update skills for practitioners, Improve patient care, and enhance patient safety and enhance confidence. The probable challenges in implementing a Simulation Centre included Financial inputs, Resource, and training of faculty, assigning roles, technical issues, Coordination between courses in terms of scheduling classes in the simulation Centre, effective utilization need-based expansion of the center, policies, rules and regulation to meet accreditation, strategies to overcome these challenges included revenue generation as a long term objective, creation of a pool of instructors, periodical evaluation and feedback from all participants.2 Conclusion The survey enabled us to determine the facilitatory as well as inhibitory factors that were common among all health care professionals in the development of a Simulation Centre and implementation of simulation-based training to facilitate learning in order to provide quality care for patients. Recommendation In countries where simulation is introduced for healthcare education, training sessions, for setting up a simulation Centre, should address these concerns. Conflict of Interest Nil References Viggers S, Østergaard D, Dieckmann P. How to include medical students in your healthcare simulation centre workforce. Advances in Simulation 2020;5(1). Dias J. Establishing a Simulation Centre in Karachi, Pakistan. COJ Nursing & Healthcare 2018;1(4).

Background In November 2018 the Hull Institute of Learning and Simulation (HILS) became the first centre within the United Kingdom to be awarded the ASPiH Accreditation. Here we share the experience of that journey with intentions of helping others with their applications. Summary of work The initial stage was ensuring that HILS fulfilled the criteria for the organisation accreditation. The standards framework and guidance from the ASPiH website lists the criteria - four modules; Faculty, Technical Personnel, Activity, Resources Once confident that the requirements could be met, the application form was completed. The application requires the organisation to justify how they meet the criteria for each area, backed up with evidence. Some evidence included with the application is listed below: 2 Years of Activity Course Programmes Scenario Design Templates Sample Scenarios Faculty Training Statistical Reports–Footfall, Usage Following submission of the application, it was reviewed by ASPiH panel members before arranging an audit of the centre. HILS were tasked with arranging a room for the visit. The panel ask that the centre arranges delegates, faculty and staff members who could be interviewed by the panel, this was challenging as most of the interviewees work clinically but the panel were very flexible in how and when the interviews took place. Following the audit the panel gave the management team some recommendations for HILS to consider. This was very useful for HILS as it provided an external point of view of the service. Summary of results A week following the visit; HILS were notified that we had been successful in gaining the centre accreditation having met the required standards for the organisational accreditation. The report stated ‘HILS is a well-run centre with excellent administrative, technical and managerial support’ Areas of commendation are in innovation and new technologies. Areas for development are branding, continued faculty development and clarity over strategy. Discussion The process is very much formative. HILS are now working on the recommendations from the report and are accredited for 3 years. Conclusions The accreditation, application and audit was a rigorous process but the panel were very supportive and helpful throughout the process. Recommendations To ensure a smooth process we would recommend checking off the guidance criteria and start collecting evidence required to support the application as that can be time consuming. References HILS www.heyhils.co.uk ASPIH www.aspih.co.uk

Introduction The relation between dysglycaemia and morbidity, cost of hospitalisation and mortality is well established.1 Even in the presence of established guidelines, human factors may play an important role in the insufficient control of diabetes. The identified gaps include contextual and biomedical knowledge, attitudes, clinical inertia, confidence, and familiarity with existing hospital resources and guidelines with regards to hospital diabetes care.2 Adherence to guidelines for inpatient diabetes management has shown to be greater with repeated training.3 Management of blood glucose in an in-patient requires basal-bolus insulin therapy, regular glucose monitoring, as well as enhancing healthcare provider’s role and knowledge.4 Implementation of training in practice is challenging, mainly due to increasing workload burden on staff and fear of hypoglycaemia. We seek to demonstrate the efficacy of multiple, short duration in-situ simulation; a pilot study in a ward to improve outcomes in patients with diabetes. Methodology This study will be conducted in the Ward 70 of the Hull University Teaching Hospital. In the first week, 6 patients with diabetes on insulin will be chosen and their blood sugar recordings will be noted. The insulin therapy and adherence to guidelines will be noted. Also noted will be the number of hypoglycemic episodes. This will serve as the baseline-our current data suggests that there is inadequate adherence in this area. In the second week an in-situ simulation will be delivered replicating hypoglycemia and diabetic ketoacidosis. This will be repeated twice a week for 3 weeks. Every week data will be collected on the adherence to guidelines in the ward from the medical records of patients with diabetes on insulin. Data will be analysed for number of episodes of dysglycaemia (< 4 mmol/L and > 14 mmol/L) and deviation from the hospital protocol. This is an ongoing study and is expected to be completed in 8 weeks. Discussion Continuing education to health care professionals is essential to improve patient outcomes and can be provided as in-situ simulation.2 We believe that this study will form the basis for further research in using low dose high frequency methodology of in-situ simulation for improving ward based care. We believe that our project is unique in identifying whether this methodology can be used for medical patients in a busy tertiary care hospital. If found effective and feasible we hope to share our results widely and replicate this model in other wards and other hospitals in our region. References Schmeltz LR, Ferrise C. Glycemic management in the inpatient setting. Hosp Pract1995. 2012 Apr;40(2):44–55. Pichardo-Lowden A, Haidet P, Umpierrez GE. Perspectives on learning and clinical practice improvement for diabetes in the hospital: a review of educational interventions for providers. Endocr Pract Off J Am Coll Endocrinol Am Assoc Clin Endocrinol. 2017;23(5):614–26. Alkhiari R, Alzayer H, Aljazeeri J, Vanniyasingam T, Punthakee Z. Adherence to Guidelines for Inpatient Pharmacologic Management of Type 2 Diabetes in Adults and Glycemic Outcomes. Can J Diabetes. 2018 Apr;42(2):158–62. Thabit H, Hovorka R. Glucose control in non-critically ill inpatients with diabetes: towards closed-loop. Diabetes Obes Metab. 2014 June;16(6):500–9.

Introduction The literature is sparse on the effect of repeated simulation on the confidence levels of residents in achieving non-technical skills. Methodology Ten first year anaesthesiology residents underwent a simulation scenario of difficult airway situation during general anaesthesia for Caesarean section. Pre and Post questionnaires, were collected for self-reported confidence levels on seven parameters. The residents were assessed based on a preformed check list and debriefed by two experienced anaesthesiologists. The same scenario was repeated at 6 and 12 months and confidence scores were collected. Results The overall collated confidence scores showed significant increase from pre to post simulation at 0 and 12 months (p of 0.021 and 0.004 respectively) but not at 6 months. At 0 months, significant improvement between pre and post confidence scores were noted in the parameters of communication (p=0.016), recognising error at work place (p=0.031) and acknowledging limits of competence (p=0.016). At 6 months, there was no change between pre and post scores in any parameter. At 12 months, the significant improvement was noted again in communication(p=0.031) and also in ability to lead a team (p=0.031) and work as a team member (p=0.016). Up till 12 months, the two parameters where there was improvement but did not reach significance was in the confidence l to delegate and to manage a sick patient. Discussion Learner specific training includes the understanding of the self confidence levels in the performance during a simulation scenario. The difference observed in the variables could suggest the hierarchical goals set by the residents to solve the problem.1 As per the conscious-competence model,2 acknowledging the limits of knowledge and a less complex communication skill preceded achievement of confidence in the more complex psycho-motor skill of leading a team and working as a team. Confidence in a more complex metacognitive knowledge like delegation of work would require more time. Conclusion Debriefing during simulation for resident training should factor in the stages of competency hierarchy of the resident. Recommendation Debriefing should be targeted to guide the residents through these phases of learning References Anderson JR. Skill acquisition: Compilation of weak-method problem situations. Psychol Rev 1987;94:192–210. doi:10.1037/0033-295X.94.2.192 Cannon H, Hale Feinstein A, Feinstein D. Managing Complexity: Applying the Conscious-Competence Model to Experiential Learning. Dev Bus Simul Exp Learn 2010;37:172–82.

Introduction In 2015 the Joint Royal Colleges of Physicians Training Board (JRCPTB), acting on behalf of the three UK Royal Colleges of Physicians, launched a set of quality criteria designed to improve the educational experience of Core Medical Trainees (CMTs). Another major aim of the criteria was to ensure the CMT curriculum was systematically covered by the training programme, whilst helping to build trainee confidence in performing the role of General Internal Medicine Registrar, which requires being confident in practical procedures such as thoracentesis, abdominal paracentesis and in emergency presentations such as cardiac arrest. The implementation of the criteria would be monitored on a UK-wide basis using the General Medical Council’s annual National Training Survey (GMC NTS). In addition, a UK-wide survey of CMT training programme directors was held in 2015 and 2016 to obtain their feedback (via an online survey with free-text responses) on local implementation. Methods Following discussions at the joint JRCPTB/Health Education England (HEE) Expert Group on Simulation in CMT, amongst wider consultation, a simulation-specific ‘quality criterion’ was included and reflected in the GMC NTS from 2015 onwards: Skills laboratory and/or simulation training for all mandatory procedural skills to be provided at least once a year to supplement clinical training. Summary of results There was a sequential increase in trainees’ reported attendance at simulation training events with time (63%, 2015; 73%, 2016; 82%, 2017; 86%, 2018). Trainers consistently reported attendance at 90% and stated this training should be mandatory. Discussion, conclusions and recommendations The findings demonstrate that centrally co-ordinated efforts to improve the provision of, and attendance at, curriculum-relevant simulation training can be effective, despite not being mandated in the curriculum and with no additional resources available for implementation. It is believed that the improvements reported by trainees were achieved through the co-ordinated efforts of the central promotion and drive for change arising from the three UK Colleges of Physicians together with a network of key stakeholders operating at a local level, including Heads of UK postgraduate schools of medicine, CMT training programme directors, supervisors, College tutors and their equivalents plus the support of the GMC to include relevant questions in their annual training survey. References Joint Royal Colleges of Physicians Training Board. Quality criteria for core medical training. 2015. https://www.jrcptb.org.uk/cmtquality [Accessed 3 June 2019]. General Medical Council. National training surveys. https://www.gmc-uk.org/education/how-we-quality-assure/national-training-surveys [Accessed 3 June 2019].

Introduction In 2014 a literature review was undertaken on behalf of the Expert Group on Simulation in Core Medical Training (CMT), hosted by the Joint Royal Colleges of Physicians Training Board (JRCPTB) and Health Education England (HEE), to evaluate the use of simulation-based education (SBE) in CMT. The review aimed to identify where SBE might be utilised to improve the quality of CMT and to make recommendations for implementation. Methods Searches were conducted in MEDLINE (English language texts published from 1996–2015 inclusive) to identify SBE evidence applicable to the 2009 CMT curriculum. Concurrently an online survey of UK-wide CMT training programme directors was conducted by Dundee University to assess current and potential future practice. Summary of results Evidence supporting training using SBE in CMT was found in 90 individual studies. The main findings were: There is good evidence that certain CMT practical procedures (central venous catheterisation, thoracentesis, abdominal paracentesis) and emergency presentations (cardiorespiratory arrest) improve patient safety if taught by SBE. There is no reason why additional CMT procedures should not also be taught using SBE, indeed evidence suggests this is desirable. There is reasonable evidence that non–technical and human factors CMT skills can be effectively taught using SBE. That the teaching of CMT procedures and non–technical skills using SBE is already widespread within the UK and training programme directors support its use. Discussion, conclusions and recommendations Based on these findings the JRCPTB recommended the following to the General Medical Council in 2017: That all essential and desirable practical procedures listed in the CMT curriculum should be taught by simulation as early as possible in Year One, with further simulation teaching, involving human factors and scenarios training, carried out in either Year One or Year Two. The latter should also include refresher training for procedural skills, where necessary. These recommendations have now been incorporated into the Internal Medicine curriculum being implemented from August 2019 and will be considered for inclusion into higher specialties. References Joint Royal College of Physicians Training Board & Health Education England. Enhancing UK Core Medical Training through simulation-based education: an evidence-based approach. A report from the joint JRCPTB/HEE Expert Group on Simulation in Core Medical Training. 2016. https://www.jrcptb.org.uk/news/enhancing-uk-core-medical-training-through-simulation-based-education-sbe-evidence-based [Accessed 3 June 2019].

BackgroundThe Civil Contingencies Act (2004) requires organisations such as the emergency services, councils and hospital trusts to prepare for emergencies by undertaking ‘live’ Major Incident exercises every three years¹. In the summer of 2017 our organisation took part in ‘Operation Orange Falcon,’ a multiagency live Major Incident Exercise. This involved teams from Hull and East Yorkshire Hospitals, Yorkshire Ambulance Service, Humberside Fire and Rescue, Humberside Police and the Royal Logistics Corps and more than 60 casualty volunteers. Hull Institute of Learning and Simulation (HILS) led the debriefing element of the exercise.Project summaryThe challenge in debriefing such a large-scale exercise came in providing meaningful immediate feedback to participants while also providing useful feedback to the involved organisations as a whole. We approached this by using two forms of debriefing; a ‘hot debrief’ on closing the exercise and a ‘cold debrief’ several weeks later. It was impractical to deliver a hot debrief to all of the participants in the exercise together. We agreed within the participating organisations to establish key areas of focus and placed debriefing teams in each of those key areas. They could then provide immediate feedback to participants on close of exercise. The debriefing teams consisted of a content expert, with expertise in the particular area being observed and an experienced debriefer from HILS. The agreed areas of focus included: Decontamination at the scene of the incident. The incident command team on–site. Decontamination at the hospital. Triage at the Hospital. Hospital control room. Casualty volunteers were debriefed separately by a team that included a psychologist from the Humber Mental Health Trust. The cold debrief was held eight weeks after the exercise and all participants were invited to attend. It focused on the same key areas, with the addition of video footage of the day to illustrate key points and revisited the issues raised in the hot debriefings.ResultsThe feedback from the other agencies was very positive. They reported that the standard debriefings they had attended before focused on finding fault or assigning blame. Use of on-site hot debriefing provided a deeper understanding of how the Trust’s Major Incident Plan worked in practice.DiscussionThe skills of debriefers from a healthcare background can be transferred outside of the healthcare environment when paired up with content experts in the field. Debriefing teams improved the experience of participants in a multiagency Major Incident Exercise.ReferencesCabinet Office. ‘Emergency Preparedness: Guidance on Part 1 of the Civil Contingencies Act 2004, its Associated Regulations and Non-statutory Arrangements.’ (2005).

Background Little is known about the learning curve characteristics following simulation based training for airway management. Method Ten residents, at the end of their first year of training, underwent a simulation based training in a cannot intubate cannot ventilate scenario during general anaesthesia for Caesarean section. They were assessed based on a preformed check list and debriefed by two experienced anaesthesiologists. The scenario was repeated at 6 and 12 months. Result The skills of preoperative assessment and preoperative care improved by 6 months and having reached a high score were retained ie maintained with no further improvement after 6 months (table 1). Communication skill (0 vs 6 months p= 0.045 and at 6 vs 12 months p=0.007) although was learnt quickly, it was only at 12 months it was significantly improved. The adherence to the airway algorithm (p = 0.016 and 0.007 at 0 vs 6 months and 6 vs 12 months respectively) improved significantly at 6 months and again at 12 months but took the longest to reach the highest score. Discussion McGaghie 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 measurement1 Our study demonstrates that learners achieve competence of technical and non-technical skills at varying rate. Failed airway is an important complication for anaesthesiologists to manage.2 Our study suggests that repeat simulation scenarios preferably at six monthly intervals will be needed to maintain competence. Conclusion Repeat simulation training help in better reinforcement, retention and recapitulation of technical and non-technical skills Recommendation Simulation educationalists should design scenarios relevant to the learning curve of the residents with ample opportunities to refresh and repeat learning. Conflict of interest: None References McGaghie WC, Issenberg SB, Barsuk JH, et al. A critical review of simulation-based mastery learning with translational outcomes. Med Educ 2014;48:375–85. doi:10.1111/medu.12391 Ortner CM, Richebé P, Bollag LA, et al. Repeated simulation-based training for performing general anesthesia for emergency cesarean delivery: long-term retention and recurring mistakes. Int J Obstet Anesth 2014;23:341–7. doi:10.1016/j.ijoa.2014.04.008Abstract P77 Table 1 Percentage of maximum achievable score of factors Percentage of maximum achievable score of factors Factors assessed At 0 months At 6 months At 12 months Preoperative assessment 18.88% 47.77% 58.02% History of Allergy 0% 20% 55.6% Airway assessment 10% 20% 44.4% Preoperative patient care 32% 58% 71.11% 100% oxygen 100% 100% 100% Ensure working intravenous catheter 0% 10% 22.2% Equipment availability 12% 47.77% 67.90% Machine check 0% 77.8% 77.8% Induction sequence 37.50% 42.50% 50% Left Uterine displacement 0% 0% 0% Communication 22% 42% 65.55% DAS protocol 15% 30% 80.55% Total 24.90% 44.71% 61.66%

Background HILS has faced challenges over the years with the growing service and activity, evolving with the latest technologies and training curriculums for our health care professionals. Simulation relies heavily on faculty to deliver it, they are the backbone in delivering our courses. As funding is scarce for faculty and we rely heavily on our clinicians who give up their free time to teach, we have had to develop alternative faculty models. Summary of Work We have been privileged to work with Health Education England (HEE) Leadership Fellows from a variety of specialties who helped us to develop and deliver courses. We have secured a further 2 fellows commencing August 2019; focusing on developing Virtual Reality and enhancing Human Factors training. In house, we have developed an ‘Associate Simulation Fellowship’, which was implemented in 2015. A 12 month programme which runs August to August, for which we have created a job description. The successful candidates are selected from an application and interview process. The programme is voluntary and in return for teaching days the fellows are rewarded with training and development opportunities such as participating in research projects and attending courses and conferences. The Fellows are supervised and have induction meetings, mid-term meetings and end of placement meetings. A log book of activity is maintained so that we are able to track the activities carried out through the programme and the fellows are able to use this as evidence for their own development. Summary of results Figure 1 shows results, 28 Associate Fellows to date, 31 HEE fellows, Courses developed. Discussion Advantages have been; Varied backgrounds and clinical areas, Embed a simulation workforce locally, Opportunities for collaborative projects, Awareness and profile in wider organization, Trust recruitment and retention. Disadvantages; Oversight and mentoring, Dilution of experience?, Variable output – difficult to enforce commitment, Impact on core clinical training, Negotiating study leave, Time to competence and independence, How do they maintain activity after year finished? Conclusions In recent years funding is challenging within the NHS and it is more difficult to obtain grants for fellows, who in the past have created and delivered courses for HILS. The creation of the Associate programme has helped to build the faculty and reputation for the centre, helping to ensure the delivery of its activities. Recommendations Continue to strengthen the programme, recruiting a manageable number of fellows for supervision. Continue to look for other faculty programmes. References HILS -www.heyhils.co.uk HEE -https://www.yorksandhumberdeanery.nhs.uk/education/future_leaders_programme

Background The group has been in collaboration since 2016, with the aim of ensuring partnership working across our region, sharing best practice, knowledge and resources. The group is represented by a number of organisations across the patch including Hull University Teaching Hospitals, York Teaching Hospitals and Northern Lincolnshire and Goole (NLAG) who meet quarterly to share projects and ideas. We are now three years in and well underway with planning our third annual conference ‘Quality’. Summary of work Over the past 12 months we have welcomed nine new members to our group who have joined in at our meetings. Reviewed documentation from each organisation to ensure that it was in line with the new GDPR guidance and developed ideas to make this consistent across the organisations. Finalised the Regional Simulation Audit – Which contains information on each centre, its facilities and resources. Website is currently be redesigned to enhance ease of use for followers, which is intended to be a resource platform. The new website will have discussion forums and a resource section where simulation scenario templates and course programmes, manuals, Newsletters and publications can be found. The SPARK Twitter page is consistently updated with latest news and events from the organisations Launched our annual newsletter in December 2018 which showcased the highlights of 2018 for the SPARK group. Planning of the third annual conference ‘Quality’ to be held at NLAG on 15th July 2019. Application to Health Education England for a SPARK Leadership Fellow. Group created from their existing programmes, 2 courses Chest Drain and CVC ensuring these were standardised across the group. Summary of results We now have over 40 members contributing to the group Communications in progress through various mediums; website, twitter, newsletter, presenting at conferences. Third conference now being planned and will take place in July (Evaluations will be shared on poster) In August 2019 we have our SPARK Fellow (Nurse) commencing in post for 12 months (following successful application) Two SPARK badged courses – Cathether Insertion and Chest Drain for Core Medical Trainees Conclusion The group has grown over the past 3 years and the group is proving to be productive in standardising the courses on offer at the regional centres and enhancing quality. The meetings are a useful platform for sharing ideas and the reputation of SPARK is growing year on year. References Website: www.spark-neynl.org.uk Twitter: @SparkNEYNL

Introduction Immersion in simulation scenarios is usually measured by subjective questionnaires of self-reported anxiety levels. We present a novel method of measuring immersion, objectively using the surrogate marker of heart rate changes. Summary of work Nine anaesthesiology residents wearing a heart rate monitoring watch underwent a simulation scenario of a difficult airway situation during Caesarean section. Pre and Post simulation questionnaires was provided for self-reported anxiety levels. The residents were assessed based on a preformed check list and debriefed by two experienced anaesthesiologists. Summary of results The median heart rate was 88 bpm pre simulation(PrS) (± 12.05 bpm) and post simulation (PoS) was 96 bpm (Standard deviation ± 9.83) [p = 0.004]. The median self-reported anxiety scales in both PrS and PoS was 3 with SD of ± 0.7 and 0.5 respectively (p=1). There was no correlation between PrS and PoS perceived anxiety and heart rate changes (R2 = 0.01 and 0.13 respectively). Discussion Studies suggest that a higher degree of immersion in a simulation scenario are more likely to improve memory and learning.1 However, increased perceived stress may also produce underperformance and scar the participant, negatively influencing further engagement with simulation programmes.2 Therefore, it is important to measure stress and various methods including heart rate variability, salivary cortisol and blood pressure have been used but these have been found to be intrusive methods, which could themselves reduce the immersion in the scenario. We believe that a watch with heart rate monitoring ability could be a less intrusive measurement of stress. It is interesting to note that the self- reported anxiety scores pre and post simulation did not match the heart rate changes which were statistically significant suggesting that there was some stress although perhaps not acknowledged by the participants. Conclusion Self-reported anxiety scores may not be an accurate measure of true immersion. Further work may be needed to validate the use of a watch to measure stress during simulation. Recommendation Consideration should be given to measuring stress levels of learners routinely during simulation teaching to gauge the immersion of the scenario and its impact on the performance of the learner. References Maheu FS, Joober R, Lupien SJ. Declarative memory after stress in humans: differential involvement of the beta-adrenergic and corticosteroid systems. J Clin Endocrinol Metab 2005;90:1697–704. doi:10.1210/jc.2004-0009 Pluyter JR, Rutkowski A-F, Jakimowicz JJ. Immersive training: breaking the bubble and measuring the heat. Surg Endosc 2014;28:1545–54. doi:10.1007/s00464-013-3350-4

Background SPARK is a regional collaborative involving Hull and East Yorkshire Hospitals NHS Trust, York Teaching Hospitals NHS Foundation Trust and Northern Lincolnshire and Goole NHS Foundation Trust, the partnership was formed in 2016 with the aim of ensuring course delivery within the region was to the same standards regardless of where the course was being attended. Summary of work The group meet quarterly to agree and action priorities. This year it was agreed to: Plan an annual conference to be held at York Ensure the website was fully functional and informative Standardise courses, starting with the Core Medical Trainee (CMT) Procedural Skills Programme. At the start of year 2, SPARK focused on updating their website www.spark-neynl.org.uk to ensure that it was useful and accurate for our followers. The group agreed on adding course material to the website so that facilitators across the region could easily access the resources. Tim Hunt (York) set off with building the website and populating it with the required information. The next step was to begin with standardising our course material ready for uploading to the website, we commenced with the chest drain course which is being delivered to CMT’s across the region as mandatory training. The organisations brought to the meetings their programmes and all course documentation. Ian Millard (Scarborough) then merged all programmes into one taking best practice from each. The group then sought approval from College Tutors and Health Education England. Summary of results SPARK now has a fully functional website in which followers can access news, resources including course documentation and a discussion forum where members can communicate and find or offer useful advice/tips. The partnership, has a SPARK badged course – Chest Drain for CMT which is the standard template being delivered across the region. In keeping with the CMT programme, the group are close to finalising the next course which has followed the same method as the Chest Drain and is the Central Venous Catheterisation (CVC)course. The annual conference is being hosted by Anne Waddington (York) and is now in the final planning stages, which is to be held on Monday 25th June 2018. Conclusion The partnership has had a productive first 2 years since launching and the meetings have provided a useful arena for sharing advice/tips and concerns. The group has grown and now has 35 individuals actively attending meetings and contributing to projects. Reference www.spark-neynl.org.uk

Introduction Human factors awareness within the NHS is becoming established due to its association with cultural change and empowerment of staff for patient safety and clinical excellence (National Quality Board, 2013). Add to this the need for inter-professional leaning due to the increase of silo working and tribalism between separate professions (Bleakley, 2006). Therefore HILS developed a human factors course for Obstetrics and Gynaecology ST1s and local midwives to promote inter-professional learning. HALO was first established in September 2015 by Dr Kathleen Merrick who was a simulation fellow at HILS; the course has now become an established part of the curriculum for ST1 doctors in the region as well as for midwives in the local trust with a total of 86 candidates taught. Method The course is facilitated by Obstetrics and Gynaecology specialists and midwives with the use of lectures, scenarios and group activities. The topics below were explored and discussed for approximately one hour: Personality Types – Insights Training Bullying/Undermining – Communication Scenario of a handover Errors – Martin Bromley video Stress/Distraction – Simulated scenario of a PPH in theatre Root Cause Analysis – Group work relating to PPH scenario, patient retained swap Debriefing – Pre-recorded scenario of a mother collapsing during a pool birth Pre and post-course questionnaires using a 5-point Likert scale were completed by all candidates to measure confidence levels and self-awareness of the topics above. Open ended questions were used to gain qualitative feedback on the course. Results All areas showed at least 1.05 improvements on the post-course Likert scale. The mean awareness of influences of candidates own behaviour increased from 3.61 to 4.47.While understanding of the root cause analysis improved the most from an average of 2.87 to 4.40. Full mean score of results are shown in the table: Example of qualitative feedback: ‘Really appreciated the experiences of other area’s practices and training with multi-disciplinary teams’ Discussion As the qualitative feedback shows integration of human factors and inter-disciplinary learning is positively received, efforts should be made expand this form of training to other courses and specialities who work regularly in multi-disciplinary teams. All quantitative data showed increased confidence which suggests they felt better equipped to challenge detrimental clinical situations. However longitudinal feedback from previous candidates could be beneficial to determine if the skills learnt on the course have been acted upon in the work environment. References Bleakley A, Boyden J, Hobbs A, Walsh L, Allard J. Improving teamwork climate in operating theatres: The shift from multiprofessionalism to interprofessionalism. Journal of Interprofessional Care2006;20(5):461–70. https://www.england.NHS.uk/wp-content/uploads/2013/11/nqb-hum-fact-concord.pdfAbstract P29 Table 1 Mean Question Pre Post Managing human factors 3.27 4.34 Managing situational awareness 3.25 4.30 Managing authority gradients 3.00 4.18 Managing team dynamics 3.28 4.30 Challenging undermining behaviour 2.76 4.11 Understanding root cause analysis 2.87 4.40 Aware of influences on own behaviour 3.61 4.47