PROGRESSIVE CLINICAL PRACTICE Technology-enhanced Simulation in Emergency Medicine: A Systematic Review and Meta-Analysis

Objectives: Technology-enhanced simulation is used frequently in emergency medicine (EM) training programs. Evidence for its effectiveness, however, remains unclear. The objective of this study was to evaluate the effectiveness of technology-enhanced simulation for training in EM and identify instructional design features associated with improved outcomes by conducting a systematic review. Methods: The authors systematically searched MEDLINE, EMBASE, CINAHL, ERIC, PsychINFO, Scopus, key journals, and previous review bibliographies through May 2011. Original research articles in any language were selected if they compared simulation to no intervention or another educational activity for the purposes of training EM health professionals (including student and practicing physicians, midlevel providers, nurses, and prehospital providers). Reviewers evaluated study quality and abstracted information on learners, instructional design (curricular integration, feedback, repetitive practice, mastery learning), and outcomes. Results: From a collection of 10,903 articles, 85 eligible studies enrolling 6,099 EM learners were identified. Of these, 56 studies compared simulation to no intervention, 12 compared simulation with another form of instruction, and 19 compared two forms of simulation. Effect sizes were pooled using a random-effects model. Heterogeneity among these studies was large (I 50%). Among studies comparing simulation to no intervention, pooled effect sizes were large (range = 1.13 to 1.48) for knowledge, time, and skills and small to moderate for behaviors with patients (0.62) and patient effects (0.43; all p < 0.02 except patient effects p = 0.12). Among comparisons between simulation and other forms of instruction, the pooled effect sizes were small ( 0.33) for knowledge, time, and process skills (all p > 0.1). Qualitative comparisons of different simulation curricula are limited, although feedback, mastery learning, and higher fidelity were associated with improved learning outcomes. Conclusions: Technology-enhanced simulation for EM learners is associated with moderate or large favorable effects in comparison with no intervention and generally small and nonsignificant benefits in comparison with other instruction. Future research should investigate the features that lead to effective simulation-based instructional design. ACADEMIC EMERGENCY MEDICINE 2013; 20:117–127 © 2013 by the Society for Academic Emergency Medicine From the Division of Emergency Medicine, Department of Medicine, University of Washington School of Medicine (JSI), Seattle, WA; the Division of Emergency Medicine, Department of Medicine, McMaster University (JS), Hamilton, Ontario, Canada; the Office of Education Research, Mayo Medical School (DAC), Rochester, MN; and the Division of General Internal Medicine, Mayo Clinic (DAC), Rochester, MN. Received July 26, 2012; revision received August 27, 2012; accepted August 27, 2012. This work was supported by intramural funds, including an award from the Division of General Internal Medicine, Mayo Clinic. The authors have no potential conflicts of interest to disclose. Consensus Conference Follow-up 2008: Editor’s Note: Academic Emergency Medicine highlights articles that follow up on the research agendas created at the journal’s annual consensus conferences. This article relates to the 2008 AEM consensus conference, “The Science of Simulation in Healthcare: Defining and Developing Clinical Expertise.” All prior consensus conference proceedings issues are available open-access at www.aemj.org, and authors interested in submitting a consensus conference followup paper should consult the author guidelines. http://onlinelibrary.wiley.com/journal/10.1111/%28ISSN%291553-2712/homepage/