 Hello, everyone, and welcome to the 5.30 to 6.00 p.m. session of the 2019 Open Simulator Community Conference. In this session, we are happy to introduce a presentation called Real-World Applications of Virtual Reality, Saving Newborn Lives. Our speaker is Rachel Eumoren. Rachel is an Associate Professor of Pediatrics and Adjunct Associate Professor of Global Health at the University of Washington, where she is Director of the Neonatal Education and Simulation-Based Training, better known as NEST, program. Today's presentation traces a path from the Global Health Island on Second Life and the Africa Traveler Islands on Open Sim to the Gates Foundation-funded project, the EHBB Mobile Virtual Reality Training on Neonatal Resuscitation for Healthcare Workers in Resource Scare Settings. To learn about her work, please see nestprogram.org. Now, we would normally ask you to check the conference for the rest of our events, but after this, we have a party. So I want to say welcome, everyone. You can send tweets to add OpenSimCC with the hashtag pound OSCC19. And now, let's begin our session. Rachel, over to you. Thank you so much, there, for that wonderful introduction. And thank you, everyone, for staying to the bitter end. I can't wait for the party either. So we'll make this as quick as possible. All right. So I'm speaking today on a really wonderful application of virtual reality that I've been involved with. It's about saving newborn lives. And for those of you that know me, my practice involves saving newborn lives every day. But I do that one at a time in a newborn intensive care unit here in the US. Meanwhile, around the world, there are babies who are dying every day because healthcare workers don't have a vital education that they need to be able to resuscitate them if they don't breathe at birth. So that is what this presentation is about. For the past two years, I've been developing and testing a virtual reality application called EHBB. And its goal is to train healthcare workers in low resource settings like Africa on how to perform newborn resuscitation. It's a million dollar project funded by the Bill and Melinda Gates Foundation. But this work really started back in 2012. And many of you were part of it. So the question is, how did we get here? And I want to take you with me back on this journey. I learned a lot. And I want to share my experiences, which date back to Second Life, like many of us. We had a global health island. It was a small parcel that was attached to the Indiana University Second Life Island on Second Life, which I believe is still there. There I learned the basics of virtual world building. I remember every year there was a threat that the island would go away. But I went, I moved away from the institution and the island was still there. So I believe it's still there. You should visit it one day and take, there's a little survey at the center of the island. It's a well, if you're interested in global health, click on it and let me know. But moving on, we made the jump with the help of the Vibe Group, which was led by Steven Zuclay to open Sim in 2013. That was very exciting. The Africa Traveler Sim focused on experiential learning about health. For students who were on global health electives, we had elements of communication, and we had safety issues. Many of you visited. Some of you got sick there, virtually, caught various virtual bugs. But then we had medication that you had in your backpack that you could take and feel better. Yes, I know. She definitely got sick. So working in open Sim was a huge expansion from that little parcel on Second Life, and we were able to build out the whole island with many interactive learning activities and with lots and lots of NPCs. Then we had this whole Ebola crisis and that prompted the development of West Africa Traveler, which was on the Moses spread, which many of you may have been aware of back then. However, we ended up not actually using that Sim because this Ebola crisis passed so quickly, we didn't really have time to finish it. So one of the challenges is time. It takes a while to put together these activities and make them interactive and interesting. But the original Africa Traveler Sim was used for medical students training in global public health. It continued to be used by Professor Gossett, my collaborator in Indiana for her nursing classes for many years. And then I moved to the West Coast. I started to think about the work that we were doing in virtual worlds and how it might have a greater impact around the world. So this slide shows the impact of neonatal mortality. If you look at the areas that are in blue, like the U.S., neonatal mortality rates are pretty low. But those areas that are yellow and red are what account for an estimated 2.5 million babies who die in the first month of life. And if you think that's a crazy number, look up the child mortality rates of children who die under five. Many of these babies are dying on the first day. The first day, which is supposed to be the happiest day for that family, is the day that they lose something very precious to come. And while a third of them may die on the first day, three quarters will die in the first week. So that first week of life is a critical period for targeted interventions to improve newborn outcomes. And so this slide shows the fraction of babies that die because they're not breathing at birth. And if a baby is born not breathing at birth, there's lack of, and the provider that's there, the health care worker of whatever level, doesn't know what to do, how to resuscitate that baby, then that baby can have injury to his organs, so brain injury, injury to the liver and other organ systems. And that's what then leads to death. So it's one of the three commonest causes of newborn deaths globally. Now, there are maternal and newborn education programs that are being used for health care worker training. And these programs use a model called the training of the trainers. They focus on getting a group of people together in a room, teaching them really, really well, and then sending them off to train other people. It's a cascade. And the goal is to see how many people they can train. So kind of like a pyramid scheme. Unfortunately, like many pyramid schemes, this doesn't work very well. Because as time goes on, the original people that you train have forgotten some things, the way that they train other people tends to be less precise and lacks the fidelity that you use to train them. And so as time goes on, things degrade. There are a lot of barriers to implementation using this form of training. And so one of the things that we've noticed is that there's this lack of standardization and there's that can be no objective feedback. They tend to emphasize like doing like you need to learn how to do the bag and mask ventilation, just learn how to do that, learn how to create a good seal, but not the thinking part. So if things are not working, the healthcare worker needs to be critically assessing how's this baby doing, how's what I'm doing affecting the baby. And that piece is where there can be a disconnect. There's high staff turnover. People move from one unit to the other very routinely. And so you have to keep training them. Retraining is expensive. It's time consuming. Instructors can always cover all the material. And there's a lack of follow up after the training, which means that learners don't consolidate their knowledge and skills. In addition, the bottom line always comes in, there's there are funding constraints. And that means that not everyone can be taught this way. So we thought, why not use mobile virtual reality? After all, smartphones are common. They're everywhere you go, there's cellular connectivity in many of these low resource settings. It's a flexible option. It can be quite interactive. It can be very consistent. And so it would save the time and cost of mannequin based training. Especially important is the standardized feedback. There's a lot of hierarchy in medicine. And so it can be hard for someone to tell someone who they perceive to be more senior to them. So like a senior nurse or an older matron, that they're doing it the wrong way. But a software program wouldn't recognize that. It would give standardized feedback. And so while we don't believe that this will completely take away the need for our hands on mannequin based training, we felt that it could supplement the in person training and particularly to be used for refresher training and to reinforce what they had initially learned. So we surveyed 279 healthcare workers in Nigeria about using simulation for education. And they identified, as we had imagined, that there is a lack of awareness, potentially lack of equipment, and lack of standardized training modules as barriers to using virtual reality. While we knew that the equipment they were talking about could just be their smartphone. So we weren't worried about that. But we did also know that there weren't really any training modalities out there. So they said that if facilities were available, they would like to use online simulation. So a huge opportunity opened up here. And so we set out to develop a standardized training module in newborn resuscitation. And we call it EHBP, helping babies breathe in virtual reality. It featured three scenarios with step by step guidance and performance based feedback. And it was intended for healthcare workers who resuscitate babies but have little or no experience with virtual reality. Some of them have little or no experience with using their own smartphone. And a few of them had no smartphones. So again, we had to plan for all of these things. So the software itself is designed in Unity. It works on a wide range of smartphones. And it uses step by step guidance and performance based feedback. I can go into more details if anyone's interested on the design and why we chose that particular approach to the design. But at the end, there will be a link that you can use to go to a short screen capture that shows the various features of the software. So here's one of our usability testers. And we had a group that worked with us really closely to feed the information back to the development team and ensure that we were going through cycles of iterative development that led to improved usability testing results. So our testers were very enthusiastic. They said they were very likely to use the activity and to recommend it to a colleague. And we had the same response with our focus group discussions. So they had positive impressions of EHVB. They described it as interesting, providing education on best practice, helping them to remember and very importantly, enabling learning without stress. And for folks that are more, I wouldn't say, I think the American approach definitely tends to emphasize learning without stress. But around the world and I grew up in a setting that was more of the UK persuasion where, you know, there is a lot of stress involved in learning. So this seemed to be something that really resonated with them and that they found potentially helpful. So we are conducting a randomized controlled trial with these healthcare workers to look at the performance of neonatal resuscitation skills and comparing ER with video-based training. And that is ongoing. We have about 290 healthcare workers participating from 20 facilities in Nigeria and Kenya. And so the results of this will be available in early 2020 and I look forward to sharing them with you. I also want to acknowledge that this has been a huge effort with lots and lots of individuals involved, lots of collaborators from different facilities and of course the team from Nigeria and Kenya who have done a lot of the heavy lifting on the ground. And I would like to thank all of you here for being here, first of all, and for those of you that I know personally through VR and in the physical world. You've really helped me in various ways on this journey. And I want to echo what Val said. This is not just VW versus VR or AR. Virtual worlds are virtual reality. They're just a different way of experiencing it. So everyone that's here, thank you all very much. And I'm happy to take any questions either now or if you're heading out to the party. Just email me if you're interested in global health issues. And I know that avatars from around the world visited the Global Health Island Second Life, so here in healthcare. Join the Society for Simulation in Healthcare. There's a section on serious games and virtual environments and here's the link to view some of the features of the HPV. Thank you, Rachel. That's a fantastic session. Are there any questions for Rachel? Last year you may have recalled that she gave a session on how she gets grant funding for programs like this because often we're thinking not everyone gives you a million dollars even when the mission is important. They have to believe that the technology will help produce the kind of data and the kind of results that save lives. What are your reporting requirements, Rachel? Maybe that's what interests us is what do you have to do to validate the use of VR and some of the other technologies you're using? That's a really good question. That is a big part of the grant, right? You have to talk about your evaluation and how you're going to test this in the real world. We set up this randomized controlled trial and we actually have three groups participating. We have a group that's randomized to receive the VR training, a group that receives a video. It's a neonatal resuscitation video. It's actually featuring me, so happy to send a link to that. And then we have a control group that gets neither of those things, but all groups get the material that's the standard material on neonatal resuscitation. It's a standard curriculum. So I think the components that made this grant and project successful are that we use the standard curriculum, something that was recognized and has been used in 80 countries around the world, so there was potential for scaling. We also use devices that were readily available to healthcare workers and we did budget in case healthcare workers didn't have their own device, that we would be able to give them one to ensure that they could actually access the curriculum. We partnered with institutions in country as well as senior foreign investigators who had the skills and the ability to help implement the project on the ground. And we also worked with people that had the expertise to conduct these studies on the ground, like the usability testing that I mentioned. So really being very close to the people who would be the end users was a very important part of this, not just developing it here and in the U.S. and then taking it somewhere else, but working collaborative and putting together this proposal that ended up being successful and project that we'll see what the results are, but we certainly had a lot of fun doing it. That's great. Well, we had a couple of comments and questions in the chat. One of them was from Lisa Laxton on what can we do to help? And before you answer that one, Delightful's Barbara Truman's is what is next for your research endeavors. Those may be related questions. Lisa, by the way, member presented on the scene gate viewer and the echo voice viewer. So she's thinking about the interfaces to the virtual world. So we are working closely with these institutions to build out their simulation programs. And I firmly believe that virtual simulation needs to be an integrated part of simulation based training for institutions, particularly those in low resource settings. So that is how you can help Lisa. Let's talk about what's available for various devices, what could be used by institutions in low resource settings. And Spiff is not here. I think he left, but I was going to give him a shout out as well, that if things are drying up on this side of the Atlantic, they're definitely opening up on the other. And then from the same point of what's next. Well, we are eagerly awaiting the results of this study, but we're already planning our next steps, being expanding the curriculum of modules that are available, because that is a huge need. And working with health care workers at different levels. So we worked with health care workers who are at what we call the secondary and tertiary institutions. So general hospitals and teaching hospitals, we'd like to work with health care workers who are at the primary care level. So even closer to the families that have this need. Thank you, Rachel. And that was a fantastic session. Please give her a round of applause. Here is the link to her program at nestprogram.org. And now, I have the honor to say that, hey, this was our last conference session, but we're not done yet. Next up is the OSCC 2019 after party on Tiki Beach at Pirates of Tull in Digi Worlds, starting at 6pm. Now we do have a photo, so don't run off. This dream pop rave can be reached can be reached via your hyper grid capable map by entering the following. And I'm going to paste this into the chat, but it's of course login.digiworlds.com colon 8002 and colon Pirates ATOLL. After arriving in the main station, there will be a poster there that has a link and you can click on it to get to the Tiki Beach subway stop to get to the party. As a reminder to our audience, we encourage you to visit the OSCC 19 poster Expo in the OSCC Expo 3 region to find accompanying information on presentations and explore the hyper grid tour resources in OSCC Expo 2 region, along with the sponsor and crowd funder booths located throughout all of the OSCC Expo regions. They remain open all year, so please check them out. And thank you again to our speakers and the audience for participating in OSCC 2019. Many thanks to our organizing team, our stream team, our wonderful volunteers, and our speakers. Thank you.