Background: Advanced practice providers play a significant role in hospital medicine across the country. The 2018 State of Hospital Medicine report from the Society of Hospital Medicine found that 75% of hospital medicine groups include advanced practice providers. At our urban, tertiary care, public hospital, physician assistants (PAs) comprise forty percent of internal medicine ward teams and are often the first responders to acute clinical events. PAs have a wide variation in clinical experience. As a result, an assessment of their confidence and competence in providing initial management is necessary to develop targeted education programs. Simulation is frequently used to educate physicians in internal medicine residency programs, but comparable evidence to guide simulation education is limited for advanced practice providers. The purpose of this study is to assess and improve PA knowledge and confidence in addressing acute clinical events using simulation.
Methods: Monthly simulations focused on the management of acute clinical events on the internal medicine wards. The topics covered to date were bradycardia and seizures. We used a previously validated survey with a five-point Likert scale to assess confidence in initiating management [1]. In addition, we created four question tests to assess critical knowledge and piloted the tests with a group of medical students and residents. The PAs completed the topic specific survey and test before and after each education session. The sessions consisted of a case-based discussion followed by a one-hour simulation exercise. Pre and post test scores were compared using a two sample t-test assuming unequal variances. Likert scale results from the confidence survey were compared using a one-tailed Mann-Whitney U test.
Results: There was a statistically significant increase in PA confidence in addressing stable bradycardia (U=47, p=0.04, r=0.44), unstable bradycardia (U=20.5, p<0.01, r=0.55), pacing (U=20.5, p<0.01, r=1.01), seizure (U=67, p=0.03, r=0.46), and status epilepticus (U=37, p<0.01, r=0.77). From the critical knowledge test, differences in knowledge scores between pre and post-intervention were statistically significant for the bradycardia simulation (pretest mean 72.5%, posttest mean 90.0%, p=0.02, g=0.91) and seizure simulation (pretest mean 62.9%, posttest mean 91.5%, p<0.01, g=1.45). Subjective comments showed the PAs valued the education exercises: “They helped me feel confident when approaching a sick patient and/or rapid response.”
Conclusions: Simulation exercises paired with case-based discussions significantly improved both the knowledge and confidence of the PAs in addressing acute clinical events. The study supports that simulation education is an effective tool for APP education. Future directions for research include assessing whether the improvements in knowledge and confidence are sustained over time and translate to performance in clinical practice.