Physicians and nurses from public hospitals, emergency care units (Unidades de Pronto Atendimento, UPA) and the ambulance service (Serviço de Atendimento Médico de Urgência, SAMU) of Belo Horizonte and 89 municipalities in the north of Minas Gerais state, Brazil, were invited to join the training, focusing mainly on professionals responsible for the care of patients with ACS. Also, professionals from institutions belonging to the Telehealth Network of Minas Gerais (TNMG) were also invited to participate.

The TNMG is a large public telehealth service launched in 2005 by seven public universities in Minas Gerais state. At first, TNMG focused on telecardiology and assisted primary care settings of remote municipalities in Minas Gerais state, Brazil. The initiative has expanded to other municipalities (covering 813 of the 853 municipalities of the state) and also to emergency services.14^,15 Furthermore, the service participated in the development of the acute myocardial infarction (AMI) system of care in Belo Horizonte and in the north of Minas Gerais, and this training was part of the implementation of those care systems.16^,17

The training consisted of four sections: (1) pre-assessment, (2) lectures, (3) simulation-based stations and (4) post-assessment.

Firstly, the participants' previous knowledge on the subject was assessed through a pre-test, which consisted of 10 multiple-choice questions related to diagnosis, management and treatment of ACS patients based on standard protocols. Afterwards, they had lectures about those topics, based on current ACS protocols.18^-24 At the end of the section, the lecturer dedicated a moment to listen to and answer queries from the audience. Then, they participated in a simulated environment to perform what they had learned in a practical setting. Lastly, they completed the same test taken at the beginning of the training. The goal was to determine knowledge acquisition.

The simulation-based session comprehended five stations to practice the following situations: (1) ST-elevation myocardial infarction (STEMI) with thrombolysis indication, (2) STEMI with indication of referral for primary angioplasty, (3) AMI with cardiogenic shock and respiratory failure, (4) Non-ST-elevation myocardial infarction (NSTEMI) and (5) Recording and transmitting the digital electrocardiogram. Each situation was reproduced in a simulated scenario guided in real-time by a facilitator. The simulation stations used one high-fidelity mannequin, one low-fidelity mannequin and three actors simulating patients (Figures 1 and 2).

Figure 1

Figure 2

The facilitator followed a simulation plan that included: 1) primary and secondary objectives of each station; 2) case description; 3) response plan to the simulator depending on the participants' possible actions; 4) scripts for the actors responsible for voice simulator and other participants; and 5) a debriefing plan. All scenarios were previously tested.

In each station, two individuals created the learning environment and 6-7 others watched the two first ones. The simulation followed the consecutive sequence: (i) participants were welcomed by the facilitator; (ii) explanation of basic simulation techniques; (iii) introduction of the simulator and simulation environment; (iv) separation in two groups: “hot seats” and observers (v) introduction of the scenario; (vi) performance of the scenario; (vii) facilitated debriefing, stage in which the facilitator mediated constructive feedback in order to stimulate critical reflection about the simulation; (viii) summarizing of the most important topics.25

This phase was developed in Belo Horizonte, Brazil. Physicians and nurses from emergency care units and SAMU were invited to join the training, focusing mainly on professionals responsible for the care of ACS patients.

This phase was developed in Montes Claros, Brazil. It was part of a quasi-experimental study, Minas Telecardio 2 project, a three-phase study (baseline, implementation and post-implementation phases) which assessed the impact of the implementation of the myocardial infarction care system in the north of Minas Gerais state. The training reported here was part of the implementation phase.17^,26

In this region, the health system is divided into nine micro-regions, covering 89 municipalities in an area consisting of 128,000 km² and comprising a population of 1.6 million inhabitants. There are 18 public hospitals in the area, but 9 of those are concentrated in Montes Claros, the main municipality of the region. SAMU has 47 ambulances (7 with doctors and 40 with nurse technicians).26

There were two training sessions. The first one, on April 2014, was carried out in Montes Claros, and physicians and nurses from emergency services of the 18 public hospitals and ambulance services (SAMU) of the north region of Minas Gerais were invited to participate.

The model and duration of the training were similar to the first phase, except for the test applied to nurses, which included specific questions about their role in the management of ACS patients. All professionals were invited to answer a feedback survey. It included questions about the participant's clinical practice, how often they had managed chest pain in the last month and how secure they felt when performing thrombolysis (when indicated) after the course.

The second training session was carried out in August/September 2014. This one took place in five different municipalities distributed throughout the region, to make it easier for professionals who lived far away from Montes Claros to participate. Physicians and nurses from the emergency services of the 18 public hospitals and ambulance services (SAMU) of the north region of Minas Gerais were invited to participate. For this one, no pre and post-tests were applied.

Data about medication prescription was collected in three different moments: baseline (June 19^th, 2013 to March 31^st, 2014); post-implementation phase, just after the training sessions happened (September 1^st, 2014 to May 31^st, 2015); and eight months after the end of the Minas Telecardio 2 project (June 1^st, 2015 to January 31^st, 2016). Data on the prescription of aspirin, P2Y12 inhibitor, heparin and statin medication within the first 24 hours after admission and at discharge were collected from STEMI patients admitted to hospitals in Montes Claros.

The data were analyzed using the program Statistical Package for the Social Sciences, version 20.0 (SPSS Inc, Chicago, IL, EUA). The evaluation of the distribution of continuous variables was performed using the Kolmogorov-Smirnov test. The continuous variables were expressed as mean and standard deviation or median and interquartile range, as appropriate, while categorical variables were expressed as absolute number and percentage. The test questions were classified into different categories depending on the subject: diagnosis, treatment or both. This classification was used to analyze the results of both tests stratified by the subject. The results of the pre- and post-tests were compared using McNemar test. In order to evaluate the influence of workplace and years since graduation on the participants' performance in the test, the non-parametric Spearman's correlation coefficient was calculated. The p value considered significant was set at 0.05.

A total of 189 professionals participated in the training, of which 86 were doctors and 103 nurses. Most were females (68.0%), and there was a predominance of professionals from the emergency care units (50.8%), hospitals (29.5%) and ambulance services (17.2%). Additionally, 18.9% of them had graduated up to 1 year before, 24.6% had graduated 2 to 5 years before, 16.4% had graduated 6 to 10 years before and 38.5% had been working for more than ten years in the profession.

One hundred and fifty-six professionals answered both tests, which corresponds to 82.5% of the total (Figure 3). In the comparative data analysis, it was observed an improvement in the participants' performance in the post-test, since 66.0% of the professionals achieved better scores.

Figure 3

To highlight the improvement in the professionals' knowledge acquisition, a comparative analysis of the total number of correct answers in both tests was performed and is shown in Table 1. An increase in the number of correct answers was observed in the post-test when compared to pre-test, with a median of 6 right answers in the pre-test (interquartile range [IQR] 5-7) and 7 in the post-test (IQR 6-9) (p < 0.0001). In addition, the lowest score comprised two correct answers to questions in the pre-test and increased to four in the post-test. Based on the type of question, an individual analysis showed an increase in the number of correct answers in 8 out of 10 questions (p < 0.05). As for the remaining questions, in one of them the number of right answers in the pre-test was high (97.4%) and remained high in the post-test results (99.4%). In the last question, the number of correct answers remained low in both tests, as shown in Table 2. No correlation was observed between years of work experience (Spearman -0.058, p = 0.53) or workplace (Spearman -0.034, p = 0.71) and knowledge acquisition. These results were similar when assessing only medical doctors (occupation time Spearman's = -0.041, p = 0.75; workplace Spearman's = -0.10 p = 0.42).

A total of 252 professionals participated in the first training session, of which 81 were doctors and 171 nurses. Two-hundred and forty-two professionals (75 doctors and 167 nurses) answered both tests, which corresponded to 96% of the total (Figure 3). The profile analysis of physicians (n = 75) revealed that most were males (76.0%). There was a predominance of the ambulance service professionals (51.0%), followed by hospital employees (45.0%) and 21.0% had graduated up to one year before, 41.0% had graduated 2 to 5 years before, 20.0% had graduated 6 to 10 years before and 17.0% had been working for more than ten years in the profession. As for nurses, the analysis of their profile (n = 167) indicated that most were women (58.0%), with a predominance of professionals working in hospitals (73.1%) followed by those working in ambulance services (25.7%). Ten percent had graduated up to one year before, 42.0% had graduated 2 to 5 years before, 42.0% had graduated 6 to 10 years before and 5.0% had been working in the profession for more than ten years.

In the comparative data analysis shown in Table 1, an improvement in the results was observed in the post-test, since 78.0% of the sample (58.0% of physicians and 83.0% of nurses) obtained better results. Medical doctors reached a median of 7 correct answers in the pre-test (interquartile range [IQR] 2-8) and 8 in the post-test (IQR 7-9) (p < 0.0001). Nurses had a median of 6 right answers in the pre-test (interquartile range [IQR] 4-7) and 9 in the post-test (IQR 7-9) (p < 0.0001). Furthermore, as shown in Table 2, the lowest score for physicians was two questions in pre-test and increased to four in post-test and for nurses it went from zero to five questions. Table 3 shows the individual analysis of each question, for physicians and nurses.

One-hundred and thirty-seven healthcare professionals filled out the survey, of which 58 were nurses (29.9% of the total) and 76 were physicians (93.8% of the total). Most of the sample (52.6%) had had less than 5 years of work experience since graduation. A total of 58 physicians (76.3% of the respondents) informed having treated at least five patients with chest pain during the last month, while 26 (34.2%) reported having treated 5 to 10 patients and 32 (42.1%) professionals treated over 10 patients. After the training, 128 professionals (95.5%) reported feeling “very secure” when performing fibrinolysis.

A total of 24 physicians and 119 nurses participated in the second training session.

Regarding the impact on medication prescription,, the results are shown in Table 4.