Livestreamed cross-institutional hybrid simulations on healthcare inequality: a time, cost and environmentally friendly opportunity for large group learning?
Authors: Keitley James , Garland-Lo Simon , Azher Saad , Parr Tim , Nelmes Pam , Pascoe Rachel , Graham Blair 
Published: November 2022

Students intercalating in BSc Urgent and Emergency Care/BSc Critical Care degrees undertake placements in 32 NHS Trusts across the UK. A collaborative simulation day was planned between the University and a geographically distant hospital, aiming to explore bias within healthcare. Inequality has been examined through simulation previously and recommendations exist on maximising simulation effectiveness [1].

A hybrid simulation day took place with 11 students present ‘in-situ’ and 49 remote students across the UK joining a livestream. High-definition cameras provided multi-angle simulation views plus a patient monitor with separate audio from ceiling-mounted boundary microphones. A webcam and cardioid microphone captured the debriefing. The free programme OBS Studio controlled the livestream as a single ‘virtual camera’, with test results overlaid as appropriate. Scenarios involved an atypical myocardial infarction, sickle cell crisis, and female genital mutilation/trauma in pregnancy.

Feedback from learners (n=21) rated the content most useful for ‘trauma in pregnancy’ (2.95/5) and ‘teamworking’ (2.90/5), whilst ‘networking with peers’ was lowest rated (2.21/5). Scenarios were realistic (75%) and appropriate for training level (86%). However, the audio-visual system was rated adequate by only 57%. Comments described difficulty with simultaneous speech during the simulation. Satisfaction with reflective debriefing was 76%, however free-text comments revealed verbal feedback delivered to simulation teams by ‘remote’ peers was perceived more critically than feedback received from local faculty.

A novel technological setup with OBS Studio was used for a collaborative simulation event viewed across the UK. Scenarios were rated positively. There was difficulty discerning multiple audio streams during the simulation. We plan to provide team leaders with dedicated microphones for overall commentary. We recognised the lack of diversity in simulation manikins within the host hospital and, as recommended [1], are now arranging representative manikins that can be used routinely and not for stereotypical scenarios. Feedback from a remote group to a smaller ‘in-situ’ participant group can feel daunting and direct. This may reflect the challenging topics explored, but also difficulties recognising the nuances of nonverbal cues in a virtual space. As such, care must be taken with ground rules, and facilitating appropriate exploration of learning points. Although feedback has identified areas for improvement, hybrid simulation can deliver immersive experiences to geographically-dispersed learners which are time- and cost-effective, with reduced environmental impact from travel. Alongside allowing physical-distancing, it may support distance-learning and facilitate cross-institutional collaborations. We recommend exploring OBS Studio for livestreaming simulations [2].

1. Vora S, Dahlen B, Adler M, Kessler DO, Jones VF, Kimble S, Calhoun A. Recommendations and Guidelines for the Use of Simulation to Address Structural Racism and Implicit Bias. Simulation in Healthcare. 2021;16(4):275–294.

2. Gumble E. Setting up for remote simulation using OBS Studio. 2021.