Using Rapid Cycles Deliberate Practice in a Status Epilepticus Simulation Scenario: A Teaching Strategy for Neurology Education

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We investigated the applicability of RCDP for Status Epilepticus (SE) Emergency Approach training, a time-sensitive condition with high morbidity. Methods In a workshop during the Brazilian Neurology Congress, 111 participants underwent an adapted RCDP session. Simulations were video-recorded and evaluated for time to critical actions and stratification of errors. Participants answered an online perception survey. Results All teams administered benzodiazepines; only 10.8% succeeded on the first attempt. Mean time to first benzodiazepine dose decreased from 42.3s to 33s. Errors related to general procedures were most frequent (48%). Conclusions RCDP seems to be a feasible, adaptable method for SE simulation training. It improved time-critical decisions and was well accepted by participants. Trial Registration: not applicable Medical Education Clinical Simulation Rapid Cycle Deliberate Practices Neurology Figures Figure 1 Figure 2 BACKGROUND Epilepsy is a neurological condition defined by the occurrence of two unprovoked epileptic seizures more than 24 hours apart or one seizure with a high risk of recurrence in next ten years¹. It is one of the most common neurological diseases, with a prevalence of more than 70 million people worldwide², causing also a high economic burden³. A critical condition related to epilepsy is status epilepticus (SE), defined as epileptic seizures lasting longer than five minutes or re-entrant seizures without return to baseline consciousness level 4 . Historically, definitions of SE varied, with intervals of 20 to 60 minutes being considered 5 . Analyzing the clinical and electrographic epileptic phenomenon, a seizure lasting longer than 6 minutes could lead to nonspontaneous resolution of the seizure 7 . In addition, the longer a seizure lasts, the more refractory to treatment it becomes 4 and therefore, reducing epileptic seizures duration became a critical point to avoid SE development 5 . SE has variable mortality rates with an average of 20% 4 . Seizure control within the first hour of patient admission is a major determinant of clinical outcome 8 . There are several guidelines for managing SE and a similar treatment sequence is defined, starting by patient’s monitoring and stabilization, followed by the infusion of first-line drugs, such as benzodiazepines and, if necessary, second-line IV drugs, such as fosphenytoin, levetiracetam, valproate and phenobarbital. In addition, depending on the refractoriness, measures such as continuous sedation can be used 8 . Even though, SE remains not well recognized and not promptly treated 9 . A diagnostic high-fidelity simulation study carried out between 2017 and 2018 revealed that most participants were able to perform first-line therapy, but only 54% of participants rated airway protection. Regarding checking vital signs, neurologists had worse performance than other participants 9 . Health workers’ practice is strongly based on the performance of complex tasks and demands, and it is often necessary to mobilize psychosocial resources, clinical reasoning and critical thinking, communication skills, empathy, team collaboration, conflict resolution, and technical-scientific skills 10 .To be able to provide quality care, and to reduce morbidity and mortality of critical conditions, such as SE, the physician who works in the emergency department must undergo specific training to develop adequate proficiency especially when considering time-sensitive health conditions 10 . In neurology, literature presents successful reports of simulation training in clinical scenarios, in a formative and evaluative way, regarding performance, and interpretation of complementary exams 11 . Simulation methodologies also can vary depending on the clinical problem in question. Repetition of the same clinical scenario may be an interesting educational approach, especially for situations where a standardized procedure is demanded. Thus, in 2014, a paper described a new simulation-based strategy that allows multiple repetitions of the same predetermined task associated with microfeedbacks, called Rapid Cycle Deliberate Practice (RCDP) 12 , 13 . In RCDP, a clinical scenario is simulated, with a checklist based on predetermined objectives, as in traditional methods. When the first error occurs, the simulation is interrupted and the participant is provided with an immediate microfeedback regarding what was not appropriate and is invited to restart the station, "rewinding" a few seconds of the attempt 12 . Thus, the clinical situation is simulated until a proposed competence is achieved. Even with mastery demonstrated in previous task, it is necessary to perform it again to continue the simulation. This allows the learned knowledge to be revisited in a short period of time within a controlled and safe environment for participants. The use of cases with multiple correct choices may not be suitable for this methodology, however, as linearity and reproducibility may be impaired 14 . This simulation methodology has already been applied in wide emergency scenarios, mainly pediatric, normally related to cardiopulmonary resuscitation procedures, but not restricted to this 15 . In 2019, a RCDP simulation for death notification training in a group of 22 first-year residents of emergency medicine was published 16 . During the COVID-19 pandemic, a study described an adaptation of the methodology in which the facilitators could apply a simulation based on RCDP without the students needing to be in the same physical environment as the instructors, showing that it is possible to apply the methodology at a distance, with some adaptations, to preserve the safety of participants in a period of social distancing 17 . There are few studies in literature on the use of the RCDP strategy including neurological cases scenarios. Due to the epidemiological importance of SE in the medical departments worldwide and the need for a reproductible and efficient training methodology in this area, we aimed to study if RCDP was applicable to SE approach training, not restricted to participants with a neurology formation background, and our primary outcome was the time to administer the first dose of benzodiazepine. METHODS This was an educational intervention study carried out at the XXX Brazilian Congress of Neurology, during the workshop "Approaching the Status Epilepticus using Rapid Cycle Deliberate Practices", which took place at Fortaleza, Brazil, on September 2022.The workshop team used an adapted version of RCDP, aiming large group training, for SE approach, enrolling a total of 111 participants. The workshop team, composed of three epileptologists, two general neurologists, a neurology resident and a nurse, built a check list for SE approach at an emergency scenario department. Undergraduate medical students and neurology residents were invited to participate in the RCDP workshop for validation of the scenario Regarding the RCDP final practice, it was set up in a large room, where two stations were built, using a hospital bed, vital signs monitors and emergency medical supplies. Participants chose one of the 1-hour workshops at their convenience (2–3 pm, 3–4 pm and 4–5 pm), where they received a briefing on the rules of RCDP before starting the practice. At each workshop, they were divided in teams of three participants and waited for their turn in line and were instructed to alternate roles at each practice (leading doctor, nurse and auxiliar doctor). At the beginning of workshop session, participants received the following vignette instruction: A 43-year-old man (75 kg) was brought to emergency room by his neighbor. He was found at the door of his house, with fever and involuntary movements (repetitive shaking) in his arms and legs. The patient is maintaining these movements for the last 10 minutes. At each SE station, a previously instructed patient-actor performed motor paroxysms in four limbs as needed. Two facilitators supervised each station. As a trio of participants approached the case, facilitators, using a checklist, were responsible for interrupting the station if a step of SE approach was missing or performed inappropriately, which was called “station blockage”. Facilitators then gave micro feedback, and the next trio of the line assumed the case from the start. The dismissed trio, then, waited for their next opportunity to repeat the scenario. After the end of each workshop session, all groups received a debriefing regarding main learning objectives that were developed in the intervention. All stations were video recorded for analysis of selected parameters. Five main aspects were analyzed: time taken to decision of first dose (outcome 1) and second dose (outcome 2) of benzodiazepines, time taken to decision of first dose (outcome 3) and second dose (outcome 4) of phenytoin and completion of the station (outcome 5). In addition, the checklist items related to station blockage were analyzed, and these errors were grouped into three categories: category 1 (General Procedures Skills), category 2 (Specific Knowledge Skills) and category 3 (Communication Skills) Data were collected using four instruments: (1) performance evaluation instrument using the stations’ checklist (Supplementary Material 1); (2) video recording of the simulation sessions; (3) sociodemographic data retrieved from the official registration database of the congress; and (4) intervention perception questionnaire. Video analysis was performed by four researchers who were not involved as station facilitators. The perception questionnaire was developed specifically for this study by the research team, based on formats from previous RCDP perception surveys. The full English version of the questionnaire is provided as Supplementary Material 2. DATA MANAGEMENT AND ANALYSIS Data was processed in a Microsoft Excel spreadsheet and were analyzed using Stata software, version 13. Univariate statistics were used to describe the variables. Numerical variables were described using measures of central tendency and dispersion (mean and standard deviation) as well as separators (median and interquartile range). To identify the difference between the groups, Student's T test was used for paired groups to compare means, and the Sign Test was used to compare medians. Workshop facilitators didn’t participate in data analysis. ETHICAL ASPECTS The research complied with the norms defined in Resolution n° 466 of December 2012, of the Brazilian National Health Council/Ministry of Health and the Declaration of Helsinki, which regulates research involving human beings and ensures the rights and duties, being submitted and approved by the Research Ethics Committee of the University of Fortaleza under registration 59539722.0.0000.5052. All participants signed an informed consent form prior to participation. RESULTS A total of 111 participants from the five Brazilian regions participated in the study, with a predominance of the Northeastern region, where the event took place. There was a similar proportion between men and women (54% women), with a median age of 31 years. More than half of the participants (58.6%) had a specialization in neurology, 30.6% were neurology residents, 2.7% were internists and 8.1% were undergraduate medical students (Table 1 ). Table 1 Participants description N % Participants 111 100% Median Age (IQI) 31(28–39) Sex Female 59 53% Brazillian Region Northeast 51 46% Southeast 37 33.3% North 1 0.9% Middlewest 12 10.8% South 10 9% Formation Neurologist 65 58.6% Neurology Residents 34 30.6% Internal Medicine 3 2.7% Undergraduate Medical Students 9 8.1% IQI: Interquartile Interval Data from video records analysis are stratified in Tables 2 and 3 . All teams reached the primary outcome, but only 35 of the 37 teams completed all steps of the station within the proposed time. Most of them needed three attempts to complete all steps, in an average time of 75.1 seconds. No team completed the station on the first attempt. All groups achieved the first three outcomes (first and second doses of benzodiazepine and first dose of phenytoin). The first outcome took an average of 42.3 seconds and only 10.8% performed the first dose of benzodiazepine in a first attempt. Table 2 Time to achieve study outcomes Outcome Mean Time ± SD (in seconds) Median Time(IQI) Benzodiazepine first dose 42.3 ± 17.9 40 (30–50) Benzodiazepine second dose 50.6 ± 17.0 49 (37–58) Phenytoin first dose 59.6 ± 16.0 57 (49–69) Phenytoin second dose 67.7 ± 16.8 67 (57–75) Stage Completion 75.1 ± 18.2 75 (62–125) SD: Standard Deviation; IQI: Interquartile Interval. TMIN: minimal time to achive. TMAX: maximum time to achieve Table 3 Outcome attempts distribution Outcome Median (IQI) Benzodiazepine first dose 3 (2–3) Benzodiazepine second dose 3 (2–4) Phenytoin first dose 3 (2–4) Phenytoin second dose 3 (3–4) Stage Completion 3 (3–4) IQI: Interquartile Interval . Comparatively, there was a reduction of 9.3 seconds (22%) in time related to administration of benzodiazepine between the first and the last attempt in which the station was successfully completed (Table 4 and Fig. 1 ). When necessary to perform the second dose of benzodiazepine, teams took an average of 50.6 seconds, and 38% were successful in second attempt. Only 5 of the 37 teams (13.5%) did not administer the two benzodiazepine doses in the same attempt, immediately starting the second-line drug after failure of the first dose of benzodiazepine in overcoming the epileptic seizure. Table 4 Comparison between mean and median time of benzodiazepine first dose in first and last attempt SD: Standard Deviation; IQI: Interquartile Interval; a: T Student test; b: Sign Test First Attempt Last Attempt p-valor Mean ± SD 42.3 ± 17,9 33 ± 13.4 < 0.001 a Median (IQI) 40 (30–50) 31 (24–40) 0.002 b Regarding the first dose of phenytoin, it took 59.6 seconds for the teams to reach this goal. The majority (38%) of the teams achieved on their third attempt. Participants demonstrated less accuracy in dosing and inadequacy in defining infusion speed of the drug, resulting in more errors. Even though they were not necessary for skill achievement, these errors were considered station blocking items by the evaluators. The fourth objective (second dose of phenytoin) was not achieved by all teams. Approximately 87% of teams were successful in this goal, mostly on the third attempt, with an average of 67.7 seconds. Alternatively, some teams that did not readministered phenytoin offered responses that were not foreseen in the checklist, such as the use of phenobarbital (6%) and sedation with airway protection (2%). Teams that simulated the administration of other drugs, such as lacosamide, levetiracetam or a third dose of benzodiazepine, did not advance in the station because these drugs are not yet approved in Brazil for use in SE. Only two teams did not reach the completion of the station. During simulation, the stations were blocked 87 times. The average time for first block was 25 seconds, with checklist items 1 and 2 (physician identification and hand hygiene, respectively) being the most prevalent errors, with approximately 21.6% of the first errors. The checklist item with the highest number of errors throughout the intervention was item 8, related to the request for capillary blood glucose and specific action in view of its result, with 19.5% of errors, followed by item 2, hand hygiene, with 13.8% (Table 5 ). Regarding group’s categories, the most prevalent (48%) is category 1 (Fig. 2 ). In general, there was a tendency for the number of errors to decrease with each attempt by the teams. Only 2 teams repeated errors related to feedback that had already been provided. Table 5 Checklist error distribution by attempt Checklist item First attempt Second attempt Third attempt Fourth attempt Fifth attempt Total 1 8(21.6%) 1(3.4%) 1(6.2%) 0 0 10(11.5%) 2 8(21.6%) 3(10.4%) 1(6.2%) 0 0 12(13.8%) 3 2(5.4%) 4(13.9%) 0 0 0 6(6.9%) 4 5(13.5%) 1(3.4%) 3(18.8%) 0 0 9(10.3%) 5 0 0 0 0 0 0 6 5(13.5%) 2(6.9%) 2(12.5%) 0 0 9(10.3%) 7 0 0 0 0 0 0 8 6(16.2%) 7(24.2%) 3(18.8%) 1(25%) 0 17(19.5%) 9 0 1(3,4%) 2(12,5%) 0 0 3(3,4%) 10 0 0 0 0 0 0 11 2(5.4%) 2(6.9%) 0 0 0 4(4.6%) 12 0 0 0 0 0 0 13 0 6(20.7%) 0 2(50%) 0 8(9.2%) 14 0 0 0 0 0 0 15 0 2(6.9%) 4(25%) 1(25%) 1(100%) 8(9.2%) Total Errors 37* 29 16 4 1 87 * One of station blockages was due to an error that was not in checklist Only 35 (31.5%) of participants answered the perception survey sent by email. Of these, 91.5% believed that the RCDP method facilitated learning the station's programmed content, without any embarrassment or discomfort related to the simulation (88.6%). In addition, for 91.4% the feedback immediately after the error facilitated the acquisition of skills, and, for 94.3%, there was a positive perception regarding the repetition of the task right after the feedback. DISCUSSION The use of an adapted RCDP methodology in a neurological emergency scenario for SE approach may be effective in training health professionals. Our results show that all teams were able to achieve the primary outcome of the study, administering the first dose of benzodiazepines drug in a shorter interval when compared to other studies 9 . The administration of a benzodiazepine drug as first-line treatment is considered superior to the use of other anti-seizures drugs, as it is more effective for this purpose and has a better safety profile 18 , however, it needs to be administered as quickly as possible, as status persistence mechanisms can decrease the drug efficiency 4 . There was a statistically significant decrease in the relative time to administer the first dose of benzodiazepine between the first attempt and the attempt at the last performance of the station. This information may be an indicator of the learning process related to the proposed goals of the intervention, as repetitive execution of tasks allows consolidation of protocol’s sequence, reducing time needed to perform critical actions. Several studies show a decrease in time for critical actions when comparing groups with RCDP intervention and control group 13 ; 19 . In this trial, however, due to the methodological design, this type of evaluation was not possible, limiting a better determination of the educational potential of the methodology. It is noteworthy that, despite the familiarity of most participants with the problem situation of the simulated scenario, as approximately 89.2% had some training in neurology, no team was successful in completing the stations on their first attempt, and only four teams reached the first dose of benzodiazepine on their first attempt. Although physicians with some kind of affiliation with neurology achieved more frequently the use of second-line anti-seizure drugs in a simulation study, actions related initial care of critical patients, such as requesting vital signs or checking the airways, were less performed when compared to other subgroups 9 . Although the methodology recommends that stations do not have more than one possible answer for a given task 12 , the instructors who participated in the study accepted answers that were not foreseen in the checklist, a fact observed in the item related to the second dose of phenytoin. Such alternatives were accepted, as they suited the routine of an emergency room and didn’t change the established workflow of SE approach of this simulation. We believe that this methodological flexibility may be acceptable once the primary outcome of a station is achieved and didn’t change station course. The category of errors referring to general care procedures was the most prevalent, corresponding to 48%, corroborated data already published in other studies 9 . Approximately 94% of the teams did not repeat the same error during their attempts, showing the use of overlearning by allowing multiple opportunities for repetition of tasks, a core characteristic of RCDP 13 . Although most participants did not respond to the intervention perception questionnaire, it was noticeable that the RCDP was well accepted as a simulation methodology, mainly in its main characteristic, which is the repetition of the station after feedback, without causing emotional discomfort in the simulation run. The moment of feedback among peers can be embarrassing and it can be harmful or viewed as flawed when perceived as treat to individual self-esteem or conflitant with self assessment 20 . Non-individual feedback may be a negative characteristic of this adapted version of RCDP, since it uses peers mistakes for learning. This finding is important, since one of the pillars of RCDP is to provide a “psychologically safe” environment so that feedback can be received without hindering the teaching-learning process 18 . However, participants stated that the feedback was important in the acquisition of the skills proposed in the intervention. We believe that this immediate feedback must be maintained, but a specific methodological approach may be better developed, so it will prevent mental distress for participants. Logistical organization for well-functioning stations, such as determining the time required for training teams and material available for simulation, is fundamental for applying the methodology RCDP. Based on the number of attempts and time that teams took to accomplish the learning objectives, there was enough time to apply the proposed methodology, with approximately one hour of training for each session of 36 participants. In the literature, there is a variation in the time available for the application of simulation, as the first description of RCDP study used approximately two hours per training session with groups of 34 residents 13 and some studies using four hours between preintervention, intervention and postintervention evaluations for a group of 22 residents 16 . This study has some other limitations. Participants were not evaluated on their previous knowledge on SE treatment before participating in the workshops. Workshops had a limited time schedule, and so not every participant completed all steps of the station. Another important point is that a non-validated checklist was used. Finally, it is important to emphasize that, regarding the impact of SE occurrence in emergency departments all over the world, teaching its approach may require methods that are easy for large groups and reproductible in every environment, as shown in our results. RCDP has been shown to be an effective methodology for training health care protocols, with high capillarity, since it was possible to train many participants in a short period of time, with the main educational outcomes being achieved by all participants. This perception is corroborated by other studies, considering the RCDP to be a good tool for teaching skills that follows a well-defined protocol 16 . CONCLUSIONS RCDP seems to be a feasible, versatile, adaptable and reproducible simulation method when approaching SE in an emergency department scenario. Time to administer high impact drugs were improved during this training and all participants were able to accomplish the primary outcome needed to reduce damage when assisting a patient presenting SE. More studies are needed to better define the efficiency of RCDP compared to traditional simulation methods in Neurology teaching and its impact on real life learning skills. Declarations Ethics Approval and Consent to Participate: Approved by the University of Fortaleza Ethics Committee (59539722.0.0000.5052). Clinical Trial Registration: not applicable. All participants signed informed consent. Consent for Publication: Not applicable. Competing Interests: The authors declare no competing interests. Funding: No external funding was received. Author Contribution MCB: conceptualization, methodology, data curation, writing – original draft.MC, LOC, JPA,SCM: scenario development, facilitation, manuscript review.AVGD, VCAFR, JGF: data analysis, logistics, literature review.SCM, FMMC: supervision, writing – review & editing. Data Availability Available from the corresponding author upon reasonable request. References Fisher RS, Acevedo C, Arzimanoglou A, Bogacz A, Cross JH, Elger CE, et al. ILAE official report: a practical clinical definition of epilepsy. Epilepsia. 2014;55(4):475–82. Thijs RD, Surges R, O'Brien TJ, Sander JW. Epilepsy in adults. Lancet. 2019;393(10172):689–701. SAÚDE. Ministério da Saúde (BR). DATASUS: Departamento de Informática do SUS. Brasília, Ministério da Saúde; 2024. Betjemann JP, Lowenstein DH. Status epilepticus in adults. Lancet Neurol. 2015;14(6):615–24. Shorvon S, Sen A. What is status epilepticus and what do we know about its epidemiology? Seizure. 2020;75:131–6. Gastaut H. 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Prática Deliberada em Ciclos Rápidos: uma estratégia moderna de simulação (Rapid Cycle Deliberate Practice: a modern simulation strategy). Sci Med. 2018;28(1):ID28849. Hunt EA, Duval-Arnould JM, Nelson-McMillan KL, Bradshaw JH, Diener-West M, Perretta JS, Shilkofski NA. Pediatric resident resuscitation skills improve after rapid cycle deliberate practice training. Resuscitation. 2014;85(7):945–51. Peng CR, Schertzer K. Rapid Cycle Deliberate Practice in Medical Simulation. StatPearls. Treasure Island (FL)2023. Ng C, Primiani N, Orchanian-Cheff A. Rapid Cycle Deliberate Practice in Healthcare Simulation: a Scoping Review. Med Sci Educ. 2021;31(6):2105–20. Ahmed R, Weaver L, Falvo L, Bona A, Poore J, Schroedle K, et al. Rapid-cycle deliberate practice: death notification. Clin Teach. 2020;17(6):644–9. Balmaks R, Auzina L, Gross IT. Remote rapid cycle deliberate practice simulation training during the COVID-19 pandemic. BMJ Simul Technol Enhanc Learn. 2021;7(3):176–7. Treiman DM, Meyers PD, Walton NY, Collins JF, Colling C, Rowan AJ, et al. A comparison of four treatments for generalized convulsive status epilepticus. Veterans Affairs Status Epilepticus Cooperative Study Group. N Engl J Med. 1998;339(12):792–8. Lemke DS, Young AL, Won SK, Rus MC, Villareal NN, Camp EA, Doughty C. Rapid-cycle deliberate practice improves time to defibrillation and reduces workload: A randomized controlled trial of simulation-based education. AEM Educ Train. 2021;5(4):e10702. Watling C, Driessen E, van der Vleuten CP, Vanstone M, Lingard L. Beyond individualism: professional culture and its influence on feedback. Med Educ. 2013;47(6):585–94. Additional Declarations No competing interests reported. Supplementary Files suppmat1.pdf suppmaterial2.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 14 Sep, 2025 Reviewers agreed at journal 28 Aug, 2025 Reviewers invited by journal 22 Aug, 2025 Editor assigned by journal 20 Aug, 2025 Editor invited by journal 31 Jul, 2025 Submission checks completed at journal 30 Jul, 2025 First submitted to journal 30 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Cantídio","correspondingAuthor":false,"prefix":"","firstName":"Samir","middleName":"Câmara","lastName":"Magalhães","suffix":""},{"id":507343809,"identity":"b7a7b90b-0d6a-4845-b29f-f469e7e17261","order_by":8,"name":"Fernanda Martins Maia Carvalho","email":"","orcid":"","institution":"Universidade de Fortaleza","correspondingAuthor":false,"prefix":"","firstName":"Fernanda","middleName":"Martins Maia","lastName":"Carvalho","suffix":""}],"badges":[],"createdAt":"2025-07-16 20:23:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7143134/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7143134/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90317926,"identity":"c13ff13c-c52e-45d4-a6bc-35dc49d4ff31","added_by":"auto","created_at":"2025-09-01 10:29:27","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":300418,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"FIgure1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7143134/v1/e353d941ea38cfda51c48903.jpeg"},{"id":90320446,"identity":"216dac70-0463-486f-b203-e5e0e26b4911","added_by":"auto","created_at":"2025-09-01 10:45:27","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":228276,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7143134/v1/186962cbff6138e88d1994c8.jpeg"},{"id":90320452,"identity":"f4a5b73b-2749-4705-a64d-eab9509f4775","added_by":"auto","created_at":"2025-09-01 10:45:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1250630,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7143134/v1/ccf44194-75e8-4594-ac23-c08ff81f613f.pdf"},{"id":90316475,"identity":"a05177f2-793a-41e8-8265-cafe43dc09ce","added_by":"auto","created_at":"2025-09-01 10:21:27","extension":"pdf","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":77693,"visible":true,"origin":"","legend":"","description":"","filename":"suppmat1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7143134/v1/6455e19aae078bbb9f483d3f.pdf"},{"id":90316474,"identity":"458615de-4fb5-4521-8208-bd0e65c3c4de","added_by":"auto","created_at":"2025-09-01 10:21:26","extension":"pdf","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":48776,"visible":true,"origin":"","legend":"","description":"","filename":"suppmaterial2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7143134/v1/7fab72d782c977ec1d379b69.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Using Rapid Cycles Deliberate Practice in a Status Epilepticus Simulation Scenario: A Teaching Strategy for Neurology Education","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eEpilepsy is a neurological condition defined by the occurrence of two unprovoked epileptic seizures more than 24 hours apart or one seizure with a high risk of recurrence in next ten years¹. It is one of the most common neurological diseases, with a prevalence of more than 70\u0026nbsp;million people worldwide², causing also a high economic burden³.\u003c/p\u003e\u003cp\u003eA critical condition related to epilepsy is status epilepticus (SE), defined as epileptic seizures lasting longer than five minutes or re-entrant seizures without return to baseline consciousness level\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Historically, definitions of SE varied, with intervals of 20 to 60 minutes being considered \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Analyzing the clinical and electrographic epileptic phenomenon, a seizure lasting longer than 6 minutes could lead to nonspontaneous resolution of the seizure\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. In addition, the longer a seizure lasts, the more refractory to treatment it becomes\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e and therefore, reducing epileptic seizures duration became a critical point to avoid SE development\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eSE has variable mortality rates with an average of 20%\u003csup\u003e4\u003c/sup\u003e. Seizure control within the first hour of patient admission is a major determinant of clinical outcome\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. There are several guidelines for managing SE and a similar treatment sequence is defined, starting by patient’s monitoring and stabilization, followed by the infusion of first-line drugs, such as benzodiazepines and, if necessary, second-line IV drugs, such as fosphenytoin, levetiracetam, valproate and phenobarbital. In addition, depending on the refractoriness, measures such as continuous sedation can be used\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eEven though, SE remains not well recognized and not promptly treated\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. A diagnostic high-fidelity simulation study carried out between 2017 and 2018 revealed that most participants were able to perform first-line therapy, but only 54% of participants rated airway protection. Regarding checking vital signs, neurologists had worse performance than other participants\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eHealth workers’ practice is strongly based on the performance of complex tasks and demands, and it is often necessary to mobilize psychosocial resources, clinical reasoning and critical thinking, communication skills, empathy, team collaboration, conflict resolution, and technical-scientific skills\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.To be able to provide quality care, and to reduce morbidity and mortality of critical conditions, such as SE, the physician who works in the emergency department must undergo specific training to develop adequate proficiency especially when considering time-sensitive health conditions\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. In neurology, literature presents successful reports of simulation training in clinical scenarios, in a formative and evaluative way, regarding performance, and interpretation of complementary exams\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eSimulation methodologies also can vary depending on the clinical problem in question. Repetition of the same clinical scenario may be an interesting educational approach, especially for situations where a standardized procedure is demanded. Thus, in 2014, a paper described a new simulation-based strategy that allows multiple repetitions of the same predetermined task associated with microfeedbacks, called Rapid Cycle Deliberate Practice (RCDP)\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn RCDP, a clinical scenario is simulated, with a checklist based on predetermined objectives, as in traditional methods. When the first error occurs, the simulation is interrupted and the participant is provided with an immediate microfeedback regarding what was not appropriate and is invited to restart the station, \"rewinding\" a few seconds of the attempt\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Thus, the clinical situation is simulated until a proposed competence is achieved. Even with mastery demonstrated in previous task, it is necessary to perform it again to continue the simulation. This allows the learned knowledge to be revisited in a short period of time within a controlled and safe environment for participants. The use of cases with multiple correct choices may not be suitable for this methodology, however, as linearity and reproducibility may be impaired \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis simulation methodology has already been applied in wide emergency scenarios, mainly pediatric, normally related to cardiopulmonary resuscitation procedures, but not restricted to this\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. In 2019, a RCDP simulation for death notification training in a group of 22 first-year residents of emergency medicine was published\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. During the COVID-19 pandemic, a study described an adaptation of the methodology in which the facilitators could apply a simulation based on RCDP without the students needing to be in the same physical environment as the instructors, showing that it is possible to apply the methodology at a distance, with some adaptations, to preserve the safety of participants in a period of social distancing\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThere are few studies in literature on the use of the RCDP strategy including neurological cases scenarios. Due to the epidemiological importance of SE in the medical departments worldwide and the need for a reproductible and efficient training methodology in this area, we aimed to study if RCDP was applicable to SE approach training, not restricted to participants with a neurology formation background, and our primary outcome was the time to administer the first dose of benzodiazepine.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis was an educational intervention study carried out at the XXX Brazilian Congress of Neurology, during the workshop \"Approaching the Status Epilepticus using Rapid Cycle Deliberate Practices\", which took place at Fortaleza, Brazil, on September 2022.The workshop team used an adapted version of RCDP, aiming large group training, for SE approach, enrolling a total of 111 participants.\u003c/p\u003e\u003cp\u003eThe workshop team, composed of three epileptologists, two general neurologists, a neurology resident and a nurse, built a check list for SE approach at an emergency scenario department. Undergraduate medical students and neurology residents were invited to participate in the RCDP workshop for validation of the scenario\u003c/p\u003e\u003cp\u003eRegarding the RCDP final practice, it was set up in a large room, where two stations were built, using a hospital bed, vital signs monitors and emergency medical supplies. Participants chose one of the 1-hour workshops at their convenience (2–3 pm, 3–4 pm and 4–5 pm), where they received a briefing on the rules of RCDP before starting the practice. At each workshop, they were divided in teams of three participants and waited for their turn in line and were instructed to alternate roles at each practice (leading doctor, nurse and auxiliar doctor).\u003c/p\u003e\u003cp\u003eAt the beginning of workshop session, participants received the following vignette instruction:\u003c/p\u003e\u003cp\u003eA 43-year-old man (75 kg) was brought to emergency room by his neighbor. He was found at the door of his house, with fever and involuntary movements (repetitive shaking) in his arms and legs. The patient is maintaining these movements for the last 10 minutes.\u003c/p\u003e\u003cp\u003eAt each SE station, a previously instructed patient-actor performed motor paroxysms in four limbs as needed. Two facilitators supervised each station. As a trio of participants approached the case, facilitators, using a checklist, were responsible for interrupting the station if a step of SE approach was missing or performed inappropriately, which was called “station blockage”. Facilitators then gave micro feedback, and the next trio of the line assumed the case from the start. The dismissed trio, then, waited for their next opportunity to repeat the scenario. After the end of each workshop session, all groups received a debriefing regarding main learning objectives that were developed in the intervention.\u003c/p\u003e\u003cp\u003eAll stations were video recorded for analysis of selected parameters. Five main aspects were analyzed: time taken to decision of first dose (outcome 1) and second dose (outcome 2) of benzodiazepines, time taken to decision of first dose (outcome 3) and second dose (outcome 4) of phenytoin and completion of the station (outcome 5). In addition, the checklist items related to station blockage were analyzed, and these errors were grouped into three categories: category 1 (General Procedures Skills), category 2 (Specific Knowledge Skills) and category 3 (Communication Skills)\u003c/p\u003e\u003cp\u003eData were collected using four instruments: (1) performance evaluation instrument using the stations’ checklist (Supplementary Material 1); (2) video recording of the simulation sessions; (3) sociodemographic data retrieved from the official registration database of the congress; and (4) intervention perception questionnaire. Video analysis was performed by four researchers who were not involved as station facilitators. The perception questionnaire was developed specifically for this study by the research team, based on formats from previous RCDP perception surveys. The full English version of the questionnaire is provided as Supplementary Material 2.\u003c/p\u003e\u003cp\u003eDATA MANAGEMENT AND ANALYSIS\u003c/p\u003e\u003cp\u003eData was processed in a Microsoft Excel spreadsheet and were analyzed using Stata software, version 13. Univariate statistics were used to describe the variables. Numerical variables were described using measures of central tendency and dispersion (mean and standard deviation) as well as separators (median and interquartile range). To identify the difference between the groups, Student's T test was used for paired groups to compare means, and the Sign Test was used to compare medians. Workshop facilitators didn’t participate in data analysis.\u003c/p\u003e\u003cp\u003eETHICAL ASPECTS\u003c/p\u003e\u003cp\u003e The research complied with the norms defined in Resolution n° 466 of December 2012, of the Brazilian National Health Council/Ministry of Health and the Declaration of Helsinki, which regulates research involving human beings and ensures the rights and duties, being submitted and approved by the Research Ethics Committee of the University of Fortaleza under registration 59539722.0.0000.5052. All participants signed an informed consent form prior to participation.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 111 participants from the five Brazilian regions participated in the study, with a predominance of the Northeastern region, where the event took place. There was a similar proportion between men and women (54% women), with a median age of 31 years. More than half of the participants (58.6%) had a specialization in neurology, 30.6% were neurology residents, 2.7% were internists and 8.1% were undergraduate medical students (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipants description\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParticipants\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e111\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMedian Age (IQI)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31(28\u0026ndash;39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBrazillian Region\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNortheast\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSoutheast\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNorth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddlewest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.8%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFormation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeurologist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeurology Residents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInternal Medicine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUndergraduate Medical Students\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eIQI: Interquartile Interval\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eData from video records analysis are stratified in Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. All teams reached the primary outcome, but only 35 of the 37 teams completed all steps of the station within the proposed time. Most of them needed three attempts to complete all steps, in an average time of 75.1 seconds. No team completed the station on the first attempt. All groups achieved the first three outcomes (first and second doses of benzodiazepine and first dose of phenytoin). The first outcome took an average of 42.3 seconds and only 10.8% performed the first dose of benzodiazepine in a first attempt.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTime to achieve study outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean Time\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003cp\u003e(in seconds)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedian Time(IQI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBenzodiazepine first dose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e42.3\u0026thinsp;\u0026plusmn;\u0026thinsp;17.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40 (30\u0026ndash;50)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBenzodiazepine second dose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e50.6\u0026thinsp;\u0026plusmn;\u0026thinsp;17.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (37\u0026ndash;58)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhenytoin first dose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e59.6\u0026thinsp;\u0026plusmn;\u0026thinsp;16.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57 (49\u0026ndash;69)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhenytoin second dose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e67.7\u0026thinsp;\u0026plusmn;\u0026thinsp;16.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67 (57\u0026ndash;75)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStage Completion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e75.1\u0026thinsp;\u0026plusmn;\u0026thinsp;18.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75 (62\u0026ndash;125)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eSD: Standard Deviation; IQI: Interquartile Interval. TMIN: minimal time to achive. TMAX: maximum time to achieve\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOutcome attempts distribution\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedian (IQI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBenzodiazepine first dose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (2\u0026ndash;3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBenzodiazepine second dose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (2\u0026ndash;4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhenytoin first dose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (2\u0026ndash;4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhenytoin second dose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (3\u0026ndash;4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStage Completion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (3\u0026ndash;4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003eIQI: Interquartile Interval .\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eComparatively, there was a reduction of 9.3 seconds (22%) in time related to administration of benzodiazepine between the first and the last attempt in which the station was successfully completed (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). When necessary to perform the second dose of benzodiazepine, teams took an average of 50.6 seconds, and 38% were successful in second attempt. Only 5 of the 37 teams (13.5%) did not administer the two benzodiazepine doses in the same attempt, immediately starting the second-line drug after failure of the first dose of benzodiazepine in overcoming the epileptic seizure.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison between mean and median time of benzodiazepine first dose in first and last attempt SD: Standard Deviation; IQI: Interquartile Interval; a: T Student test; b: Sign Test\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFirst Attempt\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLast Attempt\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-valor\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42.3\u0026thinsp;\u0026plusmn;\u0026thinsp;17,9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33\u0026thinsp;\u0026plusmn;\u0026thinsp;13.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian (IQI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (30\u0026ndash;50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31 (24\u0026ndash;40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.002\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eRegarding the first dose of phenytoin, it took 59.6 seconds for the teams to reach this goal. The majority (38%) of the teams achieved on their third attempt. Participants demonstrated less accuracy in dosing and inadequacy in defining infusion speed of the drug, resulting in more errors. Even though they were not necessary for skill achievement, these errors were considered station blocking items by the evaluators.\u003c/p\u003e\u003cp\u003eThe fourth objective (second dose of phenytoin) was not achieved by all teams. Approximately 87% of teams were successful in this goal, mostly on the third attempt, with an average of 67.7 seconds. Alternatively, some teams that did not readministered phenytoin offered responses that were not foreseen in the checklist, such as the use of phenobarbital (6%) and sedation with airway protection (2%). Teams that simulated the administration of other drugs, such as lacosamide, levetiracetam or a third dose of benzodiazepine, did not advance in the station because these drugs are not yet approved in Brazil for use in SE. Only two teams did not reach the completion of the station.\u003c/p\u003e\u003cp\u003eDuring simulation, the stations were blocked 87 times. The average time for first block was 25 seconds, with checklist items 1 and 2 (physician identification and hand hygiene, respectively) being the most prevalent errors, with approximately 21.6% of the first errors. The checklist item with the highest number of errors throughout the intervention was item 8, related to the request for capillary blood glucose and specific action in view of its result, with 19.5% of errors, followed by item 2, hand hygiene, with 13.8% (Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Regarding group\u0026rsquo;s categories, the most prevalent (48%) is category 1 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In general, there was a tendency for the number of errors to decrease with each attempt by the teams. Only 2 teams repeated errors related to feedback that had already been provided.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eChecklist error distribution by attempt\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eChecklist\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eitem\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFirst attempt\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSecond\u003c/p\u003e\u003cp\u003eattempt\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eThird\u003c/p\u003e\u003cp\u003eattempt\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFourth\u003c/p\u003e\u003cp\u003eattempt\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFifth\u003c/p\u003e\u003cp\u003eattempt\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(21.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1(3.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1(6.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e10(11.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(21.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3(10.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1(6.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e12(13.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(5.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4(13.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6(6.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5(13.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1(3.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3(18.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e9(10.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5(13.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2(6.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2(12.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e9(10.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(16.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7(24.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3(18.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1(25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e17(19.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1(3,4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2(12,5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3(3,4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(5.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2(6.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4(4.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6(20.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2(50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e8(9.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2(6.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4(25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1(25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1(100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e8(9.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Errors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e87\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e* One of station blockages was due to an error that was not in checklist\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOnly 35 (31.5%) of participants answered the perception survey sent by email. Of these, 91.5% believed that the RCDP method facilitated learning the station's programmed content, without any embarrassment or discomfort related to the simulation (88.6%). In addition, for 91.4% the feedback immediately after the error facilitated the acquisition of skills, and, for 94.3%, there was a positive perception regarding the repetition of the task right after the feedback.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe use of an adapted RCDP methodology in a neurological emergency scenario for SE approach may be effective in training health professionals. Our results show that all teams were able to achieve the primary outcome of the study, administering the first dose of benzodiazepines drug in a shorter interval when compared to other studies\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. The administration of a benzodiazepine drug as first-line treatment is considered superior to the use of other anti-seizures drugs, as it is more effective for this purpose and has a better safety profile\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e, however, it needs to be administered as quickly as possible, as status persistence mechanisms can decrease the drug efficiency\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThere was a statistically significant decrease in the relative time to administer the first dose of benzodiazepine between the first attempt and the attempt at the last performance of the station. This information may be an indicator of the learning process related to the proposed goals of the intervention, as repetitive execution of tasks allows consolidation of protocol\u0026rsquo;s sequence, reducing time needed to perform critical actions. Several studies show a decrease in time for critical actions when comparing groups with RCDP intervention and control group\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. In this trial, however, due to the methodological design, this type of evaluation was not possible, limiting a better determination of the educational potential of the methodology.\u003c/p\u003e\u003cp\u003eIt is noteworthy that, despite the familiarity of most participants with the problem situation of the simulated scenario, as approximately 89.2% had some training in neurology, no team was successful in completing the stations on their first attempt, and only four teams reached the first dose of benzodiazepine on their first attempt. Although physicians with some kind of affiliation with neurology achieved more frequently the use of second-line anti-seizure drugs in a simulation study, actions related initial care of critical patients, such as requesting vital signs or checking the airways, were less performed when compared to other subgroups\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAlthough the methodology recommends that stations do not have more than one possible answer for a given task\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e, the instructors who participated in the study accepted answers that were not foreseen in the checklist, a fact observed in the item related to the second dose of phenytoin. Such alternatives were accepted, as they suited the routine of an emergency room and didn\u0026rsquo;t change the established workflow of SE approach of this simulation. We believe that this methodological flexibility may be acceptable once the primary outcome of a station is achieved and didn\u0026rsquo;t change station course.\u003c/p\u003e\u003cp\u003eThe category of errors referring to general care procedures was the most prevalent, corresponding to 48%, corroborated data already published in other studies\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Approximately 94% of the teams did not repeat the same error during their attempts, showing the use of overlearning by allowing multiple opportunities for repetition of tasks, a core characteristic of RCDP\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAlthough most participants did not respond to the intervention perception questionnaire, it was noticeable that the RCDP was well accepted as a simulation methodology, mainly in its main characteristic, which is the repetition of the station after feedback, without causing emotional discomfort in the simulation run. The moment of feedback among peers can be embarrassing and it can be harmful or viewed as flawed when perceived as treat to individual self-esteem or conflitant with self assessment\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Non-individual feedback may be a negative characteristic of this adapted version of RCDP, since it uses peers mistakes for learning. This finding is important, since one of the pillars of RCDP is to provide a \u0026ldquo;psychologically safe\u0026rdquo; environment so that feedback can be received without hindering the teaching-learning process\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. However, participants stated that the feedback was important in the acquisition of the skills proposed in the intervention. We believe that this immediate feedback must be maintained, but a specific methodological approach may be better developed, so it will prevent mental distress for participants.\u003c/p\u003e\u003cp\u003eLogistical organization for well-functioning stations, such as determining the time required for training teams and material available for simulation, is fundamental for applying the methodology RCDP. Based on the number of attempts and time that teams took to accomplish the learning objectives, there was enough time to apply the proposed methodology, with approximately one hour of training for each session of 36 participants. In the literature, there is a variation in the time available for the application of simulation, as the first description of RCDP study used approximately two hours per training session with groups of 34 residents\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e and some studies using four hours between preintervention, intervention and postintervention evaluations for a group of 22 residents\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis study has some other limitations. Participants were not evaluated on their previous knowledge on SE treatment before participating in the workshops. Workshops had a limited time schedule, and so not every participant completed all steps of the station. Another important point is that a non-validated checklist was used.\u003c/p\u003e\u003cp\u003eFinally, it is important to emphasize that, regarding the impact of SE occurrence in emergency departments all over the world, teaching its approach may require methods that are easy for large groups and reproductible in every environment, as shown in our results. RCDP has been shown to be an effective methodology for training health care protocols, with high capillarity, since it was possible to train many participants in a short period of time, with the main educational outcomes being achieved by all participants. This perception is corroborated by other studies, considering the RCDP to be a good tool for teaching skills that follows a well-defined protocol\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eRCDP seems to be a feasible, versatile, adaptable and reproducible simulation method when approaching SE in an emergency department scenario. Time to administer high impact drugs were improved during this training and all participants were able to accomplish the primary outcome needed to reduce damage when assisting a patient presenting SE. More studies are needed to better define the efficiency of RCDP compared to traditional simulation methods in Neurology teaching and its impact on real life learning skills.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e\u003cp\u003e Approved by the University of Fortaleza Ethics Committee (59539722.0.0000.5052). Clinical Trial Registration: not applicable. All participants signed informed consent.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting Interests:\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eNo external funding was received.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMCB: conceptualization, methodology, data curation, writing \u0026ndash; original draft.MC, LOC, JPA,SCM: scenario development, facilitation, manuscript review.AVGD, VCAFR, JGF: data analysis, logistics, literature review.SCM, FMMC: supervision, writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAvailable from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFisher RS, Acevedo C, Arzimanoglou A, Bogacz A, Cross JH, Elger CE, et al. ILAE official report: a practical clinical definition of epilepsy. Epilepsia. 2014;55(4):475\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThijs RD, Surges R, O'Brien TJ, Sander JW. Epilepsy in adults. Lancet. 2019;393(10172):689\u0026ndash;701.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSA\u0026Uacute;DE. Minist\u0026eacute;rio da Sa\u0026uacute;de (BR). DATASUS: Departamento de Inform\u0026aacute;tica do SUS. Bras\u0026iacute;lia, Minist\u0026eacute;rio da Sa\u0026uacute;de; 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBetjemann JP, Lowenstein DH. Status epilepticus in adults. Lancet Neurol. 2015;14(6):615\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShorvon S, Sen A. What is status epilepticus and what do we know about its epidemiology? Seizure. 2020;75:131\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGastaut H. Clinical and electroencephalographical classification of epileptic seizures. Epilepsia. 1970;11(1):102\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJenssen S, Gracely EJ, Sperling MR. How long do most seizures last? A systematic comparison of seizures recorded in the epilepsy monitoring unit. Epilepsia. 2006;47(9):1499\u0026ndash;503.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCrawshaw AA, Cock HR. Medical management of status epilepticus: Emergency room to intensive care unit. Seizure. 2020;75:145\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSutter R, Tisljar K, Opic P, De Marchis GM, Bassetti S, Bingisser R, et al. Emergency management of status epilepticus in a high-fidelity simulation: A prospective study. Neurology. 2019;93(19):838\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhan K, Pattison T, Sherwood M. Simulation in medical education. Med Teach. 2011;33(1):1\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlbin CS, Greene JP, LaHue SC, et al. Reviews in medical education: advances in simulation to address new challenges in neurology. Neurol Educ. 2023;2(1):e200042.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCastro LD, Couto TB. Pr\u0026aacute;tica Deliberada em Ciclos R\u0026aacute;pidos: uma estrat\u0026eacute;gia moderna de simula\u0026ccedil;\u0026atilde;o (Rapid Cycle Deliberate Practice: a modern simulation strategy). Sci Med. 2018;28(1):ID28849.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHunt EA, Duval-Arnould JM, Nelson-McMillan KL, Bradshaw JH, Diener-West M, Perretta JS, Shilkofski NA. Pediatric resident resuscitation skills improve after rapid cycle deliberate practice training. Resuscitation. 2014;85(7):945\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePeng CR, Schertzer K. Rapid Cycle Deliberate Practice in Medical Simulation. StatPearls. Treasure Island (FL)2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNg C, Primiani N, Orchanian-Cheff A. Rapid Cycle Deliberate Practice in Healthcare Simulation: a Scoping Review. Med Sci Educ. 2021;31(6):2105\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAhmed R, Weaver L, Falvo L, Bona A, Poore J, Schroedle K, et al. Rapid-cycle deliberate practice: death notification. Clin Teach. 2020;17(6):644\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBalmaks R, Auzina L, Gross IT. Remote rapid cycle deliberate practice simulation training during the COVID-19 pandemic. BMJ Simul Technol Enhanc Learn. 2021;7(3):176\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTreiman DM, Meyers PD, Walton NY, Collins JF, Colling C, Rowan AJ, et al. A comparison of four treatments for generalized convulsive status epilepticus. Veterans Affairs Status Epilepticus Cooperative Study Group. N Engl J Med. 1998;339(12):792\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLemke DS, Young AL, Won SK, Rus MC, Villareal NN, Camp EA, Doughty C. Rapid-cycle deliberate practice improves time to defibrillation and reduces workload: A randomized controlled trial of simulation-based education. AEM Educ Train. 2021;5(4):e10702.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWatling C, Driessen E, van der Vleuten CP, Vanstone M, Lingard L. Beyond individualism: professional culture and its influence on feedback. Med Educ. 2013;47(6):585\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Medical Education, Clinical Simulation, Rapid Cycle Deliberate Practices, Neurology","lastPublishedDoi":"10.21203/rs.3.rs-7143134/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7143134/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eRapid Cycle Deliberate Practices (RCDP) is a simulation method, in which participants receive feedback immediately after an error in a task, repeating the same scenario until mastery in an ability is acquired. We investigated the applicability of RCDP for Status Epilepticus (SE) Emergency Approach training, a time-sensitive condition with high morbidity.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eIn a workshop during the Brazilian Neurology Congress, 111 participants underwent an adapted RCDP session. Simulations were video-recorded and evaluated for time to critical actions and stratification of errors. Participants answered an online perception survey.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAll teams administered benzodiazepines; only 10.8% succeeded on the first attempt. Mean time to first benzodiazepine dose decreased from 42.3s to 33s. Errors related to general procedures were most frequent (48%).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eRCDP seems to be a feasible, adaptable method for SE simulation training. It improved time-critical decisions and was well accepted by participants.\u003c/p\u003e\u003ch2\u003eTrial Registration:\u003c/h2\u003e\u003cp\u003enot applicable\u003c/p\u003e","manuscriptTitle":"Using Rapid Cycles Deliberate Practice in a Status Epilepticus Simulation Scenario: A Teaching Strategy for Neurology Education","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-01 10:21:22","doi":"10.21203/rs.3.rs-7143134/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-09-15T01:52:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"183986134860692517994460882952363973132","date":"2025-08-28T22:34:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-22T10:30:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-20T08:30:09+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-31T06:10:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-30T20:26:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-07-30T20:23:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"27105767-1701-4d3b-9d95-c1f5c17e03e9","owner":[],"postedDate":"September 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-01T10:21:22+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-01 10:21:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7143134","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7143134","identity":"rs-7143134","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}