IJCS | Volume 32, Nº2, May/June 2019

228 Souza-Silva et al. Simulation training for myocardial infarction Int J Cardiovasc Sci. 2019;32(3)227-237 Original Article Simulation-based techniques are well-established means to improve both individual and teamwork performance by increasing awareness of current protocols, development of practical skills and enhancing clinical reasoning. 7-9 Issenberg et al., 10 reviewed studies to evaluate the features of simulation techniques onmedical education and observed that it is an effective learning technique that complements bedsidemedical education. 10 However, studies evaluating the use of simulation education in LMICs are limited. There is a lack of permanent education programs and restrained funds to invest in simulations. 11 We hypothesize that using simulations in LMICs can improve the healthcare team’s performance and knowledge on ACS, leading to a more effective care to be delivered to the patients. 12,13 Thus, the purpose of this study is to evaluate the implementation of a two-phased, large-scale ACS training program across multiple learners in resource- limited areas. Furthermore, we provide preliminary data on knowledge acquisition, learner confidence, and impact on medication prescription after the strategy to foster further use of the program. Methods Participants Physicians and nurses from public hospitals, emergency care units ( Unidades de Pronto Atendimento , UPA) and the ambulance service ( Serviço de Atendimento Médico de Urgência, SAMU) of Belo Horizonte and 89 municipalities in the north of Minas Gerais state, Brazil, were invited to join the training, focusing mainly on professionals responsible for the care of patients with ACS. Also, professionals from institutions belonging to the Telehealth Network of Minas Gerais (TNMG) were also invited to participate. The TNMG is a large public telehealth service launched in 2005 by seven public universities in Minas Gerais state. At first, TNMG focused on telecardiology and assisted primary care settings of remote municipalities in Minas Gerais state, Brazil. The initiative has expanded to other municipalities (covering 813 of the 853 municipalities of the state) and also to emergency services. 14,15 Furthermore, the service participated in the development of the acute myocardial infarction (AMI) system of care in Belo Horizonte and in the north of Minas Gerais, and this training was part of the implementation of those care systems. 16,17 Intervention design The training consisted of four sections: (1) pre- assessment, (2) lectures, (3) simulation-based stations and (4) post-assessment. Firstly, the participants’ previous knowledge on the subject was assessed through a pre-test, which consisted of 10 multiple-choice questions related to diagnosis, management and treatment of ACS patients based on standard protocols. Afterwards, they had lectures about those topics, based on current ACS protocols. 18-24 At the end of the section, the lecturer dedicated a moment to listen to and answer queries from the audience. Then, they participated in a simulated environment to perform what they had learned in a practical setting. Lastly, they completed the same test taken at the beginning of the training. The goal was to determine knowledge acquisition. Simulation setting The simulation-based session comprehended five stations to practice the following situations: (1) ST-elevation myocardial infarction (STEMI) with thrombolysis indication, (2) STEMI with indication of referral for primary angioplasty, (3) AMI with cardiogenic shock and respiratory failure, (4) Non-ST-elevation myocardial infarction (NSTEMI) and (5) Recording and transmitting the digital electrocardiogram. Each situation was reproduced in a simulated scenario guided in real- time by a facilitator. The simulation stations used one high-fidelity mannequin, one low-fidelity mannequin and three actors simulating patients (Figures 1 and 2). The facilitator followed a simulation plan that included: 1) primary and secondary objectives of each station; 2) case description; 3) response plan to the simulator depending on the participants’ possible actions; 4) scripts for the actors responsible for voice simulator and other participants; and 5) a debriefing plan. All scenarios were previously tested. In each station, two individuals created the learning environment and 6-7 others watched the two first ones. The simulation followed the consecutive sequence: (i) participants were welcomed by the facilitator; (ii) explanation of basic simulation techniques; (iii) introduction of the simulator and simulation environment; (iv) separation in two groups: “hot seats” and observers (v) introduction of the scenario; (vi) performance of the scenario; (vii) facilitateddebriefing, stage inwhich the facilitatormediatedconstructive feedback