Preparing for the Clinical Simulation Exam (CSE)

  • Overview of the 2015 NBRC Clinical Simulation Examination

In the early 1960’s, the NBRC began using a two-part oral examination to evaluate the knowledge and competency of respiratory therapists. Since the oral exam was conducted live with each examinee facing four examiners (2 examiners in 2 separate rooms), the oral exam was not considered a truly “objective” exam. Many issues were raised in regard to the subjectivity and consistency of the testing method and exam results. In 1979, the oral exam was replaced with the current clinical simulation exam.

The clinical simulation examination (CSE) consists of two parts – information gathering (IG) and decision making (DM). Until the end of 2014, the candidate must pass both parts (each part has its own minimal passing score) of the same exam. If the candidate fails the IG or DM part of the CSE, he/she must re-take the entire CSE exam (both parts).

  • 2015 Brings 22 problems, 4 hours and 1 passing score

Starting in 2015, the Clinical Simulation Examination contains a total of 22 patient management problems (20 scored and 2 pretest problems). The time allowed is 4 hours (240 minutes) or about 10 minutes per problem. The IG and DM scores are combined with a single passing score. For example, one form of the 2015 CSE has a passing score of 72% (cut score 272 / maximum score 376).

  • The CSE Point System

In traditional written objective exams (e.g., multiple-choice), each correct answer earns one point. No points are deducted for incorrect answers. In the CSE, the total score is determined by “right minus wrong.” The points earned for selecting the correct answers are reduced by the points for incorrect answers. For example, if a candidate gets 8 correct choices and 3 incorrect choices in the “Information Gathering” section, 5 (8-3) points are earned for the section. In terms of testing strategy, it would be better to have 6 correct choices and 0 incorrect choices.

The strategy to earn maximal number of points in the CSE, therefore, is to avoid selecting too many incorrect choices.

This strategy becomes more important in the “Decision Making” sections because DM sections have very few choices (5 to 6) to pick from. More importantly, each section usually has only one best (correct) choice. For this reason, the point distribution does not favor making “bad” decisions. For example, if a candidate gets 1 correct choice after making 2 incorrect choices in a “Decision Making” section, the candidate may earn 0 point for this section (assuming correct choice = 2 points and incorrect choices = 1 point each).

The sections below highlight some strategies to maximize your points in the CSE. Of course, you must have a comprehensive knowledge in all aspect of respiratory care. But the “know how” will definitely enhance your ability to do better in the CSE.

  • Opening Scenario

The opening scenario is the first paragraph of each new patient management case. This sets the stage of the remaining case. When you read the opening scenario, you should come up with a good idea what you are dealing with – patient’s age, gender, weight or height, brief history (and possibly a diagnosis). This information will become important for the rest of case later on. For example, selecting an ET tube or determining the initial ventilator settings would depend on the age, gender, weight and height of the patient. For these reasons, you should write down the information on the piece of paper provided to you. Cross this out with a big “X” after you have completed this case. Since you will have 22 different patients (perhaps more if you get into a critical care rounds situation), it can get confusing after a few patients.

After eading the opening scenario, you should try to come up with a preliminary diagnosis. You preliminary diagnosis can be confirmed after one or two IG sections. See the example below.

The opening scenario reads “A 4-year-old girl comes to the Emergency Department with her parents at 11 p.m. The girls weights 44 lbs (20 kg) has mild cyanosis and breathing is fast and labored. Inspiratory and expiratory stridors are heard without a stethoscope. The physician asks you to assess the respiraotry status of this patient.” What should the preliminary diagnoses include? Epiglottitis, croup, asthma, foreign body aspiration, bronchiolitis? Based on the stridors alone, it is an supra- or sub-glottic condition. If you select “lateral neck radiograph” in the IG section, you should be able to “confirm” your choices between epiglottitis and croup. You should not select “chest radiograph” because it is not specific to “stridor.” In addition, asthma (wheezing), foreign body aspiration (wheezing and history), bronchiolitis (consolidation) do not collaborate the presence of “stridors.”

  • Information Gathering

The Information gathering (IG) sections in a CSE allow you to make more than one choices. In fact, you should make as many choices as possible – as long as the choices are reasonable and pertinent to the patient at that particular time and setting.  After you select a choice, the response will be shown to you immediately. For example, if you select “breath sounds” the response “vesicular breath sounds bilaterally” will be shown. Once you select a choice, it is yours to keep. You cannot change your selection as you would be able in a multiple-choice exam. You do not have to select the choices in a top-to-bottom fashion. You may select the choices in random order – from basic to advanced information. More on this later.

IG mainly deals with obtaining patient or clinical data – the information needed to provide optimal patient management. For example, IG for a patient with shortness of breath may include vital signs (heart rate, respiration, blood pressure), pulse oximetry, signs of cyanosis or diaphoresis, breathing pattern, patient’s sensorium. Another example, IG for mechanically ventilated patients with ARDS may include ventilator graphics compliance (volume/pressure) loop, static and dynamic compliance, peak inspiratory pressure, plateau pressure, FIO2, PaO2, chest auscultation, PEEP level, breathing pattern, hemodynamic data.

Other than patient or clinical data, IG may require you to gather the required supplies for certain procedures. For example, IG for an intubation procedure may include size of ET tube, water soluble lubricant, stylet, manual resuscitation bag and mask, large volume syringe, sedative, depolarizing neuromuscular blocking agent, analgesic. Another example, IG for weaning readiness may include information on weaning mechanics – VC, MIP, respiratory frequency, minute ventilation, RSBI, ABG, use of sedatives.

To prepare for the IG sections of the CSE, you should put yourself into the clinical scenario and ask the question “what type of information do I need at this time”?  Generally speaking, information that can be easily obtained, is readily available and non-invasive are safe bets. Vital signs, SpO2, breathing pattern, presence of cyanosis are standard “brownie points” in most non-emergency settings. Procedures that are invasive, difficult to obtain or costly should be avoided unless there is a specific indication. For example, a CT (computerized tomogram)  scan and ICP (intracranial pressure) are not relevant for a patient with shortness of breath and they should be avoided in almost all cases. However, CT and ICP would become crucial information to have when the patient has a closed head injury.

One strategy for the IG section is to review the entire list of options available to you and then select the simple choices first (e.g., breath sounds, vital signs, SpO2). For example, if the breath sounds reveal “normal breath sounds on right and absent on left,” you may then use this information to select “trachea deviation,” “mediastinum shift,” or “chest radiograph.” In other words, selecting “trachea deviation” before selecting “breath sounds” is risky because the breath sounds could turn out to be “normal bilaterally.”

  • Decision Making

The Decision Making (DM) sections allow you to make ONLY ONE choice unless you are directed to “make another selection in this section.” You should take you time in the DM section because the point system is very tight in DM sections (i.e. one choice with positive points and 4 to 6 choices with negative points). The choice you make must be the best choice under the current setting and patient condition.

Do not panic if you see this response after making a selection in the DM section “Physician disagrees. Make another selction in this section). In most cases, “make another selction in this section” is not a good message. But it helps you to determine what to avoid in the remaining choices. You should go back one or two sections and clarify the clinical information and patient condition before making another selection. Take your time in the DM sections.

DM is “what would you do next”? Each decision must be based on the information you have gathered. Using the same example from an earlier discussion, the information obtained are as follows: heart rate 100/min, respiration 16/min, blood pressure 110/68 mm Hg, pulse oximetry 88%, mild cyanosis and signs of diaphoresis, breathing pattern is shallow and fast, patient’s sensorium shows mild disorientation. What would you do next? Incentive spirometer, oxygen therapy, IPPB, mechanical ventilation, vibratory PEP, or percussive vest? Based on the information, oxygen therapy should be the choice because of desaturation and presence of cyanosis.

Another example. The information gathered from an IG section shows: MIP -12 cm H2O, VC 0.7 L, spontaneous VT 0.2 L, frequency 32/min, SpO2 of 88% at the end of a 30-minute spontaneous breathing trial. What would you do for a weaning decision? Proceed to extubation, delay weaning and continue with current ventilator settings, increase the ventilator pressure support, initiate CPAP or perform tracheotomy?  Based on the information, delay weaning and continue with current ventilator setting is the best choice because of inadequate or poor respiratory weaning mechanics.

One more example on DM is the extubation criteria. You should be able to use the data from extubation criteria (e.g., VC, VT, RSBI, gag reflex, leak test, SpO2, FIO2) to make a decision on the readiness for extubation.

You should remember that many similar decisions may be required for different patient settings (adult, pediatric, neonatal patients). CPR algorithm, ventilator settings, selection of ET tubes are some examples that require patient specific decisions.

  • Taking Notes and Time Management During CSE

For each patient problem, you should write down the main problem (croup, post-op, COPD etc). This will help you focus on the main problem until you are done with the problem. You must also slow down because each of the 22 problems are relatively short – 5 to 6 IG and DM sections.  Take a break or two to regroup about 5 or 6 problems.

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