Development and usability testing of a fully immersive VR simulation for REBOA training

Abstract

Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving procedure for bleeding trauma patients. Being a rare and complex procedure performed in extreme situations, repetitive training of REBOA teams is critical. Evidence-based guidelines on how to train REBOA are missing, although simulation-based training has been shown to be effective but can be costly and complex. We aimed to determine the feasibility and acceptance of REBOA training using a fully immersive virtual reality (VR) REBOA simulation, as well as assess the confidence in conducting the REBOA procedure before and after the training.

Methods Prospective feasibility pilot study of prehospital emergency physicians and paramedics in Bern, Switzerland, from November 2020 until March 2021. Baseline characteristics of trainees, prior training and experience in REBOA and with VR, variables of media use (usability: system usability scale, immersion/presence: Slater-Usoh-Steed, workload: NASA-TLX, user satisfaction: USEQ) as well as confidence prior and after VR training were accessed.

Results REBOA training in VR was found to be feasible without relevant VR-specific side-effects. Usability (SUS median 77.5, IQR 71.3–85) and sense of presence and immersion (Slater-Usoh-Steed median 4.8, IQR 3.8–5.5) were good, the workload without under-nor overstraining (NASA-TLX median 39, IQR 32.8–50.2) and user satisfaction high (USEQ median 26, IQR 23–29). Confidence of trainees in conducting REBOA increased significantly after training (p < 0.001).

Conclusions Procedural training of the REBOA procedure in immersive virtual reality is possible with a good acceptance and high usability. REBOA VR training can be an important part of a training curriculum, with the virtual reality-specific advantages of a time- and instructor-independent learning.

Keywords

REBOA, Virtual reality, Trauma resuscitation, Medical education

Study Design, Setting, and Ethical Approval

This is a prospective feasibility pilot study involving pre-hospital emergency physicians and emergency paramedics of the “Schutz und Rettung Bern”. The study was conducted at the University Emergency Department (Universitätsklinik für Notfallmedizin) at the Inselspital, Bern, Switzerland. This study was exempt from full ethical review by the local institutional review board (Kantonale Ethikkommission Bern). Written informed consent for study participation was obtained from all participants.

Participants

The local prehospital emergency medical services are carrying out about 23,000 preclinical medical emergency operations annually. There are 17 emergency physicians and 108 paramedics (50% female) working in a rendezvous system. All participants were offered and attended the training on a voluntary basis.

Baseline Data

Sociodemographic data (gender, age, profession (physician/paramedic), working experience in years, need to wear eyeglasses, right/left-handedness), prior training and experience in REBOA as well as prior experience with VR, were collected in a survey.

Intervention

Initially, three peer teachers were introduced to the VR set-up and the correct operation of the REBOA VR module by the development and study team of the University Emergency Department in a 2-h training session, who then passed on their knowledge and were able to train their peers (“teach the teacher”).

Acceptance of the VR Simulation (Usability)

Overall, the VR REBOA simulation was well received by the participants. Usability measured with the SUS was clearly above the average of 68 (median 77.5, IQR 71.3–85). The simulation was very well tolerated. Sense of presence and immersion, as measured by Slater-Usoh-Steed, was also good (median 4.8, IQR 3.8–5.5).

Confidence

Subjective confidence of the participants in using the REBOA procedure correctly before training was low and significantly increased after the VR simulation (p < 0.0001).

Limitations

These results must be interpreted with some limitations. This was a study of a single population with a limited number of participants who may be subject to selection bias due to voluntary participation.

Conclusion

The procedural training of the REBOA catheter procedure in immersive virtual reality is possible with a good acceptance and high usability indicated by the trainees.