A novel simulation enhanced education for osteopathic manipulation of hospitalized patients

Methods

This study was a pilot quality improvement project with a survey-based protocol. The project was reviewed by the OhioHealth Institutional Review Board and deemed to not meet the criteria for formal review as a quality improvement project. Therefore, informed consent was not necessary. Costs incurred with the lab, including supplies, rental of hospital beds, and an honorarium for the speaker, were supported by the hospital’s medical education department. Participants in the survey response were solicited among those learners in attendance of the event in a voluntary fashion. There was no identified risk to the survey respondents because information was gathered anonymously through the Research Electronic Data Capture (REDCap) system.

Prior to the start of the 2022–2023 academic year, the leadership from the hospital’s 10 osteopathic-focused programs met with the Program Director for Osteopathic Medical Education to discuss the curriculum. They were informed of the intent for an SBME OMM lab focused on hospital-based OMM in the subsequent academic year and given an option to participate. Those choosing to participate included the following programs: the cardiology and pulmonary-critical care fellowships and the general surgery, internal medicine, and family medicine residencies. Residents and fellows of all postgraduate training years and medical students rotating with these programs were invited to attend. Six faculty from internal medicine, general surgery, and family medicine acted as table trainers and were assigned to different portions of the room to facilitate questions.

For the simulation, learners alternated between the role of physician (practicing technique) and the patient (wearing the specialized simulation gown). Simulation hospital gowns were created to simulate the lines, drains, and airways potentially seen in hospitalized patients. These hospital gowns consisted of a standard gown with a central line sutured to the neckline, cardiac monitor leads, a Foley catheter, a chest tube tucked underneath the patient, ventilator tubing that was attached to an elastic band around a participant’s neck, and IV tubing bandaged to the participant’s wrist (Figure 1). Each learner was encouraged to pair with another from a different program while practicing the techniques on their partner. All participants were given the opportunity to practice these techniques in the simulated environment with gowns and rented hospital beds.

Figure 1:

Demonstration of a hospital bed and simulation gown utilized for the simulation-based medical education (SBME) osteopathic manipulative medicine (OMM) lab.

The 2 h SBME lab consisted of lecture content in Osteopathic Principles and Practice (OPP), demonstration of OMM techniques, and time to practice the techniques on each other. Lecture instruction was provided by a single neuromuscular specialist with experience in the osteopathic technique for hospital patients. Objectives for the experience included the following:

1. List the anatomical considerations when treating a patient with hospital conditions (surgical ileus, chronic obstructive pulmonary disease [COPD]/acute respiratory distress, congestive heart failure [CHF]/edema)

2. Recite the autonomic influences for the above conditions

3. Outline the challenges that present when approaching hospital patients with OMT

4. Apply the three areas/3 min approach to providing OMT to a hospitalized patient in a simulated experience

5. Demonstrate the following techniques utilizing this approach in a simulated experience: OMT treatment of surgical ileus, effective rib raising, and Dalrymple pump

Participants were asked to complete a survey (Table 1) prior to the start of the lab providing a self-assessment of knowledge surrounding the objectives given. Following completion of the lab, learners were then asked to complete a post-lab survey with the same knowledge-based assessment, along with questions regarding the effectiveness of the lecturer and effectiveness of the simulated experience (Table 2). The unique survey tool utilized had not been previously validated but followed the Phillips and Phillips “Return on Learning” protocol [7], with a 5-point Likert scale to standardize the responses.

For survey analysis, data were reported utilizing frequencies and percentages for categorical variables and means and standard deviations for continuous variables. While most results were limited to descriptive analysis only, the success of the lecture instruction was evaluated pre- and postevent utilizing the chi-square test. The p-value was set at 0.05 for significance. For the remainder of the survey data collected, the combined number of positive survey responses (agree + strongly agree and knowledgeable + very knowledgeable) were calculated and compared to the negative responses (neutral + disagree or strongly disagree) and presented in a descriptive manner.

Results

The SBME OMM lab took place on November 23, 2022 in the hospital’s medical education space. In total, 35 out of 68 possible learners attended. A total of 32 of these learners participated and completed the survey in its entirety. The average answers for the presimulation self-assessment of knowledge survey ranged from a low of 2.5 (for the three areas/3 min approach) on the 5-point Likert Scale to the high of 3.5 (for the anatomical considerations of hospital-based patients). Despite these above-average baseline knowledge scores in most areas, there was a statistically significant increase in knowledge surrounding all objectives vs. the postsimulation survey (Table 1).

When considering the remaining data, the survey results from the additional questions gathered on the postsimulation survey can be described in three areas: the effectiveness of the OMM lab, the simulation experience, and the lecturer, as detailed below.

Discussion

The unique challenges that come with incorporating OMM on hospitalized patients include environmental (navigating around tubes, lines, or drains that also impact patient care), equipment-related (performing OMM on patients in larger, softer beds), and patient-specific barriers (the acuteness of the illness, the lack of mobility of the patient, or the ability for the patient to fully partake in some of the treatments). There is also the added challenge of protecting patient modesty with techniques while they lie in hospital gowns. However, given the responses on the surveys in this study, the SBME lab seemed to deliver a favorable method for learners to acquire the skills to handle these challenges and become more comfortable in utilizing OMM on hospitalized patients.

This result is noteworthy given the positive beneficial effects that OMM can have on hospitalized patients, as demonstrated in the literature [8]. Perhaps the most influential and largest study on hospitalized patients was the Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) trial [8]. In this study, 387 patients (>50 years old) admitted for pneumonia were randomized to conventional care, light-touch treatment (sham), or OMM treatment (consisting of twice-daily treatments while hospitalized) [8]. OMM was found both to statistically reduce the length of stay in younger patients and to reduce mortality in the older, more severe patients with pneumonia [8]. Institutions that train a variety of osteopathic learners could capitalize on the successes found in these studies to provide better holistic care through SBME.

The SBME experience also allows for learners to troubleshoot how to address scenarios in a real-world practice setting [1]. SBME is a real-world experience that gives a “positive behavioral norm.” [1] It allows for visualization and practice of possible real-time scenarios, reduces anxiety, improves expectations, and enables the space to practice the handling of difficult situations with simulations prior to handling real patient encounters [1]. The incorporation of simulated experiences in osteopathic postgraduate training may be a novel way to target the decline of OMM use in practice. Having curriculum that is structured to teach OMM in a variety of settings or environments allows for increased use of OMM in the future as the learners become more comfortable navigating the various possible challenges and learn the relevant techniques or methods [9]. In the SBME, it was quite clear from the results how learners not only felt engaged by the content and delivery, but also and most importantly, felt more comfortable in providing OMM on hospitalized patients in the future. It is important to note the discrepancy of mixed responses on the likelihood of learners utilizing the OMM techniques in the future, as demonstrated in the lab. This response received one of the largest distributions of responses in the study, which could have been related to the mix of primary and surgical/specialty care residents. The difference in responses indicates that future labs may have to better demonstrate how OMM techniques may be applied to each individual specialty for potential improvement of this measure.

Some strengths in this study included the organization of the lecture, experience of the lecturer, novelty of the lab, and manner in which real-time data collection/feedback took place. The novelty of this learning experience allowed for significant engagement with hands-on learning. On the other hand, it should be noted that all participants were either residents/fellows from an osteopathically recognized program or osteopathic medical students. This study group composition could have a pre-experience positive bias that confounded the data. Other weaknesses include the timing of the lab: it took place the day before a holiday, with a significant reduction in participation secondary to vacations. Also, acquiring more hospital beds for a similar future lab would enable learners to participate throughout, preventing the need for groups to switch between OMM tables and hospital beds during the lab. The other concern was the cumbersome nature of changing gowns between partners, which slowed the learning experience. Having designated simulation patients would mitigate this limitation in the future study, but it would also add to the cost. Finally, it would have been good to have more specialty-focused attendings for table training, because they could provide more tailored feedback for learners in their various specialties.

Future studies should include a follow-up survey of participants on the actual use of techniques in the hospital setting after attending the osteopathic SBME event. Some additional ideas include an evaluation of the use of obstetrical gowns to mimic pregnancy, or simulation suits to mimic the altered anatomy of scoliosis, anatomical short leg, or gait/posture abnormalities. Of note, simple studies of simulation could also utilize living simulation ‘patients’ (such as obstetrical, geriatric, or pediatric persons) in case scenarios to assist learners in enhancing their skills of palpation and treatment for common conditions pertinent to practice [10].

Conclusions

This study highlights the utility of SBME in enhancing the perception and comfort of performing OMM in the inpatient environment for a variety of osteopathic learners. It provided an avenue for further OMM training beyond the outpatient setting and allowed individual learners to become accustomed to navigating the specific challenges associated with the inpatient setting. The event in this study brought together learners from a variety of specialties who overwhelmingly responded favorably toward the effectiveness of the OMM lab, the simulation environment, and the lecturer involved. Further research could consider exploring the use of SBME to enhance the OMM learning experience in other healthcare areas, bringing OMM more prominently into a variety of settings.