Abstract
We conducted a randomized controlled study to compare conventional lectures with tele-education for delivering wound care education. Education was delivered by the two methods simultaneously to two classes. Forty-eight paramedics received a live didactic presentation and 41 paramedics received the same lecture via videoconferencing. The participants were evaluated by a multiple-choice examination and a practical test of their wound closure skills. There were no significant differences in any category of the practical skills test, and no difference in the results of the written examination: the mean total score was was 109.0 (95% CI 105.7–112.4) in the conventional lecture group and 110.3 (95% CI 106.2–114.3) in the video group (P = 0.63). In a survey at the end of the study the live lecture group rated the overall effectiveness of teaching significantly higher than the video-based group: the median scores for effectiveness of teaching were 6.0 (IQR 5.5–6.0) in the live lecture group and 4.0 (IQR 3.0–5.0) in the video group (P < 0.001). Videoconferencing was at least as effective as live didactic presentation.
Introduction
In a previous study, we assessed the feasibility of evaluating an acute wound via web-based videoconferencing by comparing it to a bedside evaluation. 1 We found that the evaluation and treatment of wounds were almost identical via the two modalities. Telemedicine could expand the educational tools available in rural areas and potentially allow the teaching of medical skills remotely. 2,3 However, there is little published information in which tele-education has been compared to conventional lecturing. 4–9
The purpose of the present study was to determine if particular knowledge and wound management skills, including suturing, stapling and liquid tissue adhesive use, could be learned by novice paramedics as effectively via tele-education as by conventional face-to-face teaching.
Methods
We conducted a randomized controlled study using participants who were undergoing wound closure training. The participants were paramedics from the Orlando area who volunteered to participate in the study. They were randomly divided into two groups. The control group was given a live wound management lecture, followed by hands-on training in clinical skills. The experimental group participated in the same wound management lecture and skills training via videoconferencing.
Study setting
The study setting was the multipurpose classrooms and auditorium at the Orlando Regional Medical Center, a tertiary-care teaching hospital. The medical centre houses several graduate medical education training programmes, including emergency medicine and general surgery. The centre's wireless network was utilized for computer communication for this study. The paramedics who participated in the study were certified by the Florida Department of Health and were employed by one of the agencies operating within the Orange County (Florida) EMS System. The study was approved by the appropriate ethics committee.
Study design
The lecturer in the live class was filmed during the entire lecture and this video was transmitted via the Internet using iChat (Apple Inc., Cupertino, CA, USA) to the tele-education class. Thus the participants in both groups received the same lecture at the same time. If anyone in the tele-education class had a question, they could go to a camera in the classroom and ask the lecturer. Once the lecture and skills training had been completed, both groups were evaluated together in one classroom.
Outcome measures
Two methods were used for the evaluation. The first method was a written examination to assess comprehension, which included 11 multiple-choice questions; the total possible score was 25. The second was a skills test of wound closure and suturing techniques. During the skills test, the participants demonstrated their wound closure techniques in 13 categories. Each category was evaluated using a Likert scale (0 = unable to 10 = mastered the category). The evaluation was performed by four blinded emergency medicine physicians who used a standardized worksheet to assess each paramedic on wound preparation, simple interrupted skin suturing, skin stapling and liquid tissue adhesive (Dermabond) application. The physician assessors were trained to perform the evaluation using the same scoring sheet. Each participant had a single evaluation.
For the wound preparation category, paramedics were evaluated on appropriate sterile technique, effectiveness of irrigation, effectiveness of anaesthetic administration and overall performance. For the simple interrupted skin suturing category, paramedics were evaluated on suturing technique, ability to approximate wound edges and overall performance. For the skin stapling category, paramedics were evaluated on stapling technique, ability to approximate wound edges and overall global performance. For the liquid tissue adhesive category, paramedics were evaluated on suturing technique, ability to approximate wound edges and overall performance.
At the conclusion of the examinations, the participants evaluated the lecture and skills training (which had been supplied either by tele-education or live) and provided feedback. Effectiveness of teaching was scored on a Likert scale (0 = ineffective; 7-effective).
Data analysis
Comparisons between the two groups was performed using Fisher's Exact test and the independent sample t-test with pooled or separate variance as appropriate. Sample size was determined a priori using data from a previous telemedicine wound care study. 1 Sample sizes of 40 in each group achieved a 90% power to detect non-inferiority with a margin of equivalence of 1.0 point on the technical evaluation and a SD of 1.5. Significance was set at an alpha of 0.05.
Results
A total of 89 participants completed the study: 48 received a live lecture and 41 viewed a video of the lecture. The mean age of participants was 39 years (SD 8) and 88% were male. They had a mean of 12 years of experience as a paramedic (SD 7). Seventeen participants (19%) reported having previous suture experience. This prior wound management experience may have been assisting with wound care in the military or acting as a medical assistant. However, detailed information about prior experience was not collected. The participants' demographic information is shown in Table 1.
Characteristics and skill acquisition for the live lecture and video lecture groups
Overall, the mean total score for all participants was 109.6 (out of a total score of 130). The mean total score in the conventional lecture group was 109.0 (95% CI 105.7–112.4) and the mean score in the video group was 110.3 (95% CI 106.2–114.3) (P = 0.63), see Table 1.
The scores for the written examination were almost identical for the two groups with a mean difference between them of −0.1 points (95%CI −1.0, −0.8) (P = 0.89), see Table 1.
The participants rated the live lecture higher than the video lecture. The median scores for effectiveness of teaching were 6.0 (IQR 5.5–6.0, n = 15) in the live lecture group and 4.0 (IQR 3.0–5.0, n = 23) in the video group (P < 0.001). In addition, some of the video lecture group participants rated the technical quality of the video, see Table 2.
Technical ratings of the video lecture (score 0–7) by 23 participants
Discussion
The results of the present study confirm those of previous studies which have demonstrated no difference in knowledge acquisition between tele-education and face-to-face education. 4–9 The two groups had similar characteristics except for previous suturing experience. Although there was a significant difference in prior experience (29% in the video group vs. 10% in the live lecture group, P = 0.03), the results were the same with and without the inclusion of the subjects who reported prior suturing experience (see Table 1). Definitive wound management training is not a component of the National Standard Curriculum for paramedics. 10
In addition to demonstrating the effectiveness of tele-education, we also evaluated satisfaction and course effectiveness according to the study participants. Although the video-based teaching was rated slightly lower than the live lecture, it was still considered to be an adequate and effective means of learning. This is consistent with the previous studies. 11–13 Participants in the telemedicine (video) group assessed the image quality and sharpness as average (median score ratings of 4 and 3.5 out of 7, respectively). They assessed the audio quality as excellent (median score 6 out of 7). Based on these results, it appears that knowledge and skills in wound care can be effectively learned via telemedicine. Tele-education may also be useful in other areas of medicine.
A limitation of the present study was that the technical skills were evaluated subjectively. Without a validated wound closure tool, there is the potential for bias on the part of the evaluators. Nonetheless, the results suggest that tele-education may be an effective means of delivering education in wound care, and that it is at least as effective as conventional lecturing.
Footnotes
Acknowledgements
We thank the paramedics for volunteering to participate in the study. The research was supported in part by an EMS Awards grant from the state of Florida, which was issued by the Orange County government.