Planning and Implementation of a Simulation Laboratory Design

1. Planning and Implementation of a Simulation Laboratory Design Roberta Wattleworth, D.O., MHA, MPH, FACOFP Professor and Chair, Department of Family Medicine Director, Simulation Laboratory

2. The Question • Why Build a Simulation Lab? • Increase preparedness of second-year students before they go out on rotation • Introduce physiology/ pharmacology/microbiology, etc. into medical cases for first-year students • Complement cases 3rd and 4th year students receive on rotation

3. Increase positive outcomes for high-stakes crises • Entice well-qualified undergraduate students to enter our program • Demonstrate the value of team-building and collaboration as we incorporate EMS, pharmacy students, nursing students, etc. into our scenarios with the medical students

4. Location • Preferably ground level with elevator access • Tank switch-out • Easy access for complex scenarios (ER, OR, etc.) • Consider “garage door” on one side to simulate an ER ambulance bay • Depending on which gases are used in the lab, the tanks have to be protected from vandalism, theft, risk of explosion, etc.

5. Simulation Room Design • Give yourself room to maneuver • At times more than one scenario can take place (mother delivering baby becomes unresponsive from blood loss while infant is being resuscitated) • Consider a retractable divider that can be used to make the room resemble a large trauma room or a small individual ER room

6. Appropriate ventilation • Scavenger system if anesthesia is used • Rooms heat up quickly between equipment and fear! • Ceiling height is critical if you will be installing surgical lights • Flooring – “fake” blood loss can be copious at times (post-partum hemorrhage, vascular trauma) – linoleum can become slippery and pose a hazard; carpeting will become quickly soiled

7. Rooms should have one-way viewing glass on two sides to allow control room and observation room a clear view • Cameras should be directed from several angles for maximum viewing • Microphones should be in close proximity yet not be in the way • Include computer terminal to pull up lab, x-ray reports.

9. Debriefing Room Design • Large viewing windows into simulation room • Large table with computer ports and comfortable chairs • Base the size of the room/table on the number of participants per group – six students is the recommended maximum • Smart board to view video of just-completed scenario, an example of the same scenario run differently, or for discussion of post-encounter questions

10. Dry erase board • Duplicate patient monitor with tracings identical to tracings in simulation room • Video taping capability of debriefing sessions • Storage rooms – often overlooked. Must be large enough to allow you to buy in bulk and store

11. Funding • Existing sources • Grants • Collaborators • Do they bring funds or expertise to the mix? • Often want to see copies of policy and procedure documents, job descriptions of key employees, etc.

12. Financial Analysis • Plan an initial budget for five years • Expect to lose money for the first three years • Outline start-up costs as well as ongoing operating expenses • Be sure to include depreciation of simulators!

13. Ideally stagger large purchases so replacement costs don’t hit you at once • Include a large travel allotment initially to allow for visits to existing simulation centers • Training program for key faculty is a must!

14. Metrics to collect • Occupation rate (by room or by hour) • Number and type of learners (students, residents, nursing, EMTs, attending physicians) • Net loss/income • Faculty time allocated to time in labs vs. case development • Number of scenarios that have been developed • Satisfaction from learners – increased confidence, competence • Document how competencies are tied into scenarios for accreditation

15. Developing Performance Standards • Must be developed for each scenario to allow for more consistent scoring • “Weight” of standard may be higher as to the time to critical decision-making or failure to act – reflects patient safety issue

16. Example • Information below is presenting information provided to participant prior to entering the room Previously healthy 8 year-old male arrives in the ER department approximately 30 minutes after being struck by a car while riding his bike. He was wearing a helmet; EMTs report witnesses did not note loss of consciousness prior to arrival of ambulance. The child complains of left leg and left rib pain Vitals: H 140 R 24 BP 78/58 T 99o F O2 sat 98% Ht 130 cm wt 30 kg

17. Scoring 5 pts_____ Brief confirmation of history from patient 20 pts____ Conducts primary survey within 60 seconds (airway, breathing, circulation, disabilities, exposure). One point deducted for every 10-second interval past 60 seconds until survey is started) 10 pts____ Order given to administer fluids as bolus 5 pts_____ Successful starting of IV with minimum size of 18 g needle

18. 10 pts _____ Request to type and cross blood should be made within two minutes after completing primary survey. One point deducted per minute of delay. 10 pts_____ Secondary survey – failure to note increased heart rate, decreased blood pressure and distended abdomen will trigger code due to hypovolemia 10 pts_____ Surgical Consult must be done – one point lost per minute delay after secondary survey completed 10 pts_____ Team Leadership if in group setting Total case value 80 points Earned score ____points

19. Debriefing • Takes longer for medical students than residents since more in-depth discussion of anatomy and physiology should take place • Have participants use laptops to investigate answers to questions posed after the scenario yet before debriefing. • What is the most likely source of blood loss in this patient? • Why are children more prone to injury in this area? • Discuss the physiology behind the elevation of heart rate while blood pressure was dropping.

20. What volume of blood does this child have circulating and how much can he lose before critical loss is reached? • What long-term consequences will this patient likely experience as a result of the proposed surgery? • Once answers have been typed in along with their reference source, they are printed off for scoring and will become part of the participant’s permanent chart • Discussion of the case, scenarios, and possible review of the videotape now takes place along with discussion of the post-encounter questionnaire

21. Evolution of our Lab • Initial discussion for creation of the simulation lab took place February ‘06 • Appointment of director of the sim lab, chair of the simulation committee, and committee members • Meetings took place with members of various colleges to confirm where simulation exercises could be incorporated into their curricula

22. Decisions were made as to faculty • Full time lab coordinator • Full time clinical coordinator • Part-time director (.4 FTE) • Part-time secretarial support • Job descriptions were created • Search committee interviewed candidates for both positions – lab coordinator started February 1, 2007 and clinical coordinator started March 1, 2007.

23. Site visits to existing simulation labs • Attendance at training programs • International Meeting on Simulation in Healthcare January 07 • METI training program Feb. 07 and Mar 07 • Harvard Institute for Medical Simulation Comprehensive Workshop May 07

24. Simulators • METI HPS • METI child • Laerdal adult • Laerdal baby • Gaumard birthing simulator (Noelle)

25. METI HPS

26. METI child

27. Laerdal adult

28. Laerdal baby

29. Gaumard birthing simulator (Noelle)

30. Future Plans • Formation of the Center for Clinical Skills Development • Harvey Heart Sounds Simulator • Standardized Patient Assessment Laboratory • Surgical Skills Lab • Simulation Lab

31. For the first two years we will concentrate on incorporating simulation into the first two years of curricula • As our third year students are brought in closer to Des Moines for core rotations, they will be brought back for scenarios in a format resembling their COMLEX-PE experience. Those students felt to be at risk for failure will be given intensive instruction and remediation

32. We eventually want to “sell” time to area hospitals for resident training, area nursing and paramedic schools, and Drake College of Pharmacy • Using analysis of data, we hope to convince outside funders of our goal to improve patient safety, and apply for grants to help with ongoing expenses.