IJCS | Volume 32, Nº2, May/June 2019

234 Souza-Silva et al. Simulation training for myocardial infarction Int J Cardiovasc Sci. 2019;32(3)227-237 Original Article In both phases, the performance of healthcare practitioners in the post-test was better than in the pre- test. More than 66.0% of the professionals achieved better results in the post-test in the first phase and 78.0% in the second phase. There was a significant improvement in 8 out of the 10 questions with statistical significance (p < 0.05) in the first phase. It shows that, after training, professionals had an increase in the theoretical domain regarding managing ACS patients, which contributes to better use of these lessons in clinical practice. In the second phase, the number of right answers increased for physicians and nurses, but nurses achieved greater improvement. Nurses improved their performance in all questions with statistical significance and the median number of correct answers increased significantly. Meanwhile, physicians improved their performance in 9 out of 10 questions, yet therewas no statistically significant difference in 5 of them, due to sample size limitations (it was not possible to apply theMcNemar Test in 2 questions, as the entire sample answered correctly in the post-test). As it was evident when looking at the pre-test results, medical doctors tended to have better previous knowledge about ACS than nurses. Considering that, we hypothesize that the trainingwas especially valuable for professionals with less previous knowledge on the subject. As for medical doctors, a huge disparity in medical education was also evident, as the result of pre-test varied significantly among participants: the pre-test IQR of correct answers was 2-9 in the pre-test and decreased to 7-9 in the post-test. The training also impacted on the participants’ self-confidence, as 95% reported feeling very secure when performing fibrinolysis after the training. Even though participants did not have previous experience with simulation during graduation, they accepted and adapted well to the training model. They participated in the simulated scenarios, debriefing and in the feedback sessions. This simulation experience had strengths and barriers. A specific characteristic that contributed to the success of our training was the fact that physicians and nurses were trained together. It was based on the idea that effective collaboration between these professionals can lead to a reduction in morbidity and mortality, fewer medical errors and enhance job satisfaction. 27 Recently, training models have been recognized as important tools to improve teamwork and communication skills across the healthcare staff. 28,29 Thus, we developed a framework that emphasized teamwork and communication. In each station, two participants (one physician and one nurse) worked together to respond to the clinical scenario and all participantswere engaged in the debriefing. Furthermore, our training was also helpful to increase awareness of current guidelines. As Sussman et al., 30 points out, lack of familiarity of practitioners with the presenting literature is one of the causes leading to the bridge between research and clinical routine. 30 For instance, the use of pre-hospital electrocardiogram (ECG) to diagnose and manage patients is accepted in the literature as an effective method to reduce morbidity and mortality of ACS. 24,31 Nevertheless, this recommendation is not always followed in clinical practice. 32,33 This divergence between scientific knowledge and its implementation reinforces the importance of strategies to increase awareness of the guidelines and their application. On the other hand, despite the common use of simulation in high-income countries (HIC) 34 , its use in LMICs are still scarce. 11,35 In these countries, restrained funding remains an obstacle to the implementation of simulation training programs. 11 Building a simulation center involves the acquisition of equipment, trained personnel and adequate facilities, thus the costs are high. 36 In our experience, funding was a great barrier to turn this program into a continued education program. The professionals underwent a similar training session for only one additional time and the program is current on hold due to lack of resources. Looking at successful simulation trainings in LMICs, they usually involve a collaborative network between various departments and institutions andwe believed that it could be an alternative to our scarcity of funding. 11 As for other barriers, it is important to mention the lack of employers’ support, in the sense that the hours healthcare professionals spent on training were not paid. In the second phase, we can highlight the distance from the workplace to the simulation center, which increased transportation costs and precluded the participation of physicians and nurses who lived far from the city where the training was being held (Montes Claros). This experience was part of the implementation of the AMI care system in Belo Horizonte and in the northern region of Minas Gerais state. This initiative encompassed a multifactorial intervention across multiple institutions to improve the quality of treatment, which also included tele-electrocardiogram implementation and AMI care reorganization. Previous studies concluded that to achieve success in the implementation of care systems, the action plan has to be defined not only considering established guidelines, but also taking into consideration