IJCS | Volume 32, Nº2, May/June 2019

235 Souza-Silva et al. Simulation training for myocardial infarction Int J Cardiovasc Sci. 2019;32(3)227-237 Original Article the regional differences. 37,38 Several studies performed in developing countries highlighted the existence of obstacles related to poor infrastructure to the establishment of a care system. 38,39 In those situations, the training strategy might be even more important, since any improvement in health represents significant benefits in patient care. Although using the same test to evaluate the participants makes it difficult to appraise the influence of the pre-test on the post-test performance, the increase in medication prescription within the first 24 hours after admission and at discharge is an evidence of the impact of the training strategy. The fact that the benefit decreased aftertime following the training (the prescription increased in the nine months after the two training sessions but decreased after this period) showed the importance of continued education for healthcare professionals. Due to the high turnover of emergency professionals, training sessions need to be repeated periodically to increase effectiveness. The use of simulation-based education has increased gradually in recent years and it has been considered an important method to improve professional development, patient safety 25,40 and to enable team work practice. 8 It is a student-centered learning process that enables students to build their own knowledge from mistakes. A basic assumption is that learning from mistakes in a simulated environment can reduce the occurrence of errors in clinical practice and increase the practice of the correct attitudes. 40 In a systematic review by Issenberg et al., debriefing was considered the most important step to determine effectiveness in simulation-based learning. 10 We considered that the use of these principles had an important role for our training success. The feedback from the health professionals showed a positive impact on their daily tasks, as most participants submitted to the training stated that the strategy added confidence and safety to their clinical practice. Corroborating our findings, the BRIDGE-ACS study (Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes) performed in Brazilian public hospitals, demonstrated the effectiveness of a multifactorial intervention to improve quality of treatment. This intervention included the use of reminders, checklists, distance and presential training using simulation techniques. There was a significant increase in the proportion of patients who received the recommended therapies (aspirin, P2Y12 inhibitors, anticoagulants and statins) within 24 hours after admission and at discharge. 41 Thus, there is evidence of an impact on the increase in adherence to the ACS guidelines. Another gain that is not possible to be measured is the impact on physicians’ and nurses’ motivation, which was very important for the success of the MI care system. The study has limitations. Knowledge acquisition was assessed immediately after training. We tried to assess the long-term impact of the training by collecting data on medication prescription (and there was no other intervention to improve it), but further studies should perform a thorough assessment of the impact on clinical outcomes. Conclusion This study showed how a theoretical educational intervention, associated with simulation-based training strategy, in the context of the implementation of MI care systems in resource-limited areas, showed an impact on learners’ knowledge acquisition in two different scenarios, with evidence of impact on the health providers’ confidence in performing thrombolysis in STEMI patients and medication prescription within 24 hours after admission and at discharge. These experiences can be used to guide future programs that can be expanded to the rest of the country. Author contributions Conception and design of the research: MarcolinoMS, Ribeiro AL; acquisition of data: Dias TD, Machado GSB, Carvalho EAS, Rocha GAS, Marino BCA; analysis and interpretation of the data: Marcolino MS, Souza-Silva MVR, Passos PFOP, Lemos TR, Carvalho EAS, Rocha GAS; writing of the manuscript: Marcolino MS, Souza- Silva MVR, Passos PFOP, Lemos TR; and all authors participated in critical revision of the manuscript for intellectual content. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding This studywas fundedby Fundação de Amparo a Pesquisa do Estado de Minas Gerais (RED061-11 AND RED018-14), ConselhoNacional de Desenvolvimento Cientifico e Tecnológico (309073/2011-1), Coordenação de Aperfeiçoamento de Pessoal