SIMULATION IN MEDICAL EDUCATION

1. SIMULATION IN MEDICAL EDUCATION Professor Harry Owen and Val Follows Flinders University School of Medicine simulation@flinders.edu.au

2. Simulation in Medical Education • Simulation technologies used in Medical Education in Australia, the US and Europe • Setting up the Flinders University Medical School Clinical Skills and Simulation Unit • Fundamentals of high-fidelity simulation • Where do we go from here? Some observations on the future of simulation

3. Who’s who in medical education • Basic medical education • Medical students • Pre-vocational medical education • Interns, RMOs, PGY 1&2 • Specialist training (discipline-based) • Registrars/Senior registrars/Fellows • Specialists and GPs (life-long learning) • CME, MOPS, IRM, etc • Teachers and trainers

4. (1) AdelaideSouth Australia (1) 1 1 1 2

5. Source: Jones A (BMSC)

6. Simulation centres 11 9 10 20 195 25 2 10 6 5 2 2

7. Publications on ‘patient simulation’ in clinical care Year

8. Simulation technologies used in medical education • Computer-based simulations (micro-worlds, micro-simulation) • Virtual environments +/- haptics • Part-task trainers • Low-fidelity simulators/manikins • Simulated or standardised patients • Hybrid simulations • High-fidelity (full mission) simulation

9. Knowledge/Skills/Attitudes • Individual psychomotor skills • Appropriate application of skills • Communication / Team performance / Leadership skills (CRM) • Supervision/teaching • Assessment

10. Knowledge/Skills/Attitudes • Teaching best practice • learner centred • appropriate use of technology • Assessment best practice • Valid and reliable • Reproducible

11. The Flinders Clinical Skills and Simulation Unit • Grew from a project to improve airway management teaching to medical students • Value to teaching other health professionals and other skills recognised • Funding generated from teaching outside the medical school

12. Endotracheal intubation • Learnt on patients under anaesthesia • No special consent • Duty of care to protect patient from harm • Increased risk when performed by a student or trainee

13. ETI needed by many health professionals, including anesthesiologists, paramedics/EMTs, rural GPs, emergency physicians, ICU staff, respiratory therapists, etc. Competence requires practise Endotracheal intubation

14. When and how should ETI be taught? • Animals • Small, e.g. cats • Large, e.g. dogs or monkeys • Unconscious patients • In the OR • In ICU • Newly dead/recently deceased • Cadavers • Simulators

15. The learning environment • Quiet, few distractors • Clinical equipment • Expert tutors • Realistic models • Many different models • Easy  difficult very difficult

16. Actar D-Fib® (Armstrong) Adult A-A Female ® (Nasco) CPR Prompt ® (Compliant) Fat Old Fred ® (Lifeform) David/Adam ® (Nasco) Little Anne™ (Laerdal) CPR Pal® (Ambu) Economy Saniman® (Nasco) Basic Buddy™ (Lifeform)

17. Computer-based Teaching ResusSim CathSim PA simulator ECG Local anaesthesia Part-task trainers BLS & ALS IVI & CVC Trauma Adult Gynae & Obstetric Neonatal Premature (28wks) Paediatric (age range) The Flinders Clinical Skills and Simulation Unit

18. Several whole body manikins including: ResusciBaby ALS baby ResusciAnne with SkillReporter Mr Hurt Nursing Anne Megacode Kid etc SimMan UPS Postoperative care modules Trauma modules Severe Trauma modules Local produced dental trauma modules The Flinders Clinical Skills and Simulation Unit

19. Components Student/trainee/health professional Procedure/task/skill/test/treatment or equipment Patient and/or disease process Trainer/supervisor Anatomy of a simulation (1)

20. Function of components Passive Enhance setting for realism Active Change in a programmed way Interactive Responds to action or event Anatomy of a simulation (2)

21. Trainees learning cricothyrotomy on a part-task trainer (Note educational aids in background) Trainee performing an emergency cricothyrotomy in a full-mission simulation. (Note more realistic setting)

22. High fidelity simulation (1) • Determine educational needs and choose most efficient and effective • Need to balance resource availability and student demand • May need to ‘promote’ low-tech solutions

23. High fidelity simulation (2) • Confirm teaching goals can be achieved using simulation • Develop scenario, acquire equipment needed and prepare associated materials • Test and validate the simulation

24. Options for running simulations • Free-form • Easy but poor learning • ‘On the fly’ • Scripted but intensive for the ‘controller’ and some variables may appear discontinuous • Programmed trends • More sophisticated simulations possible • Trends and event handlers • Facilitates high-fidelity simulation with most realistic response to interventions

25. Resources needed • Equipment: • Simulators, monitors, defibrillator, trolleys, etc • Disposables: • Appropriate for scenario, setting and participants, re-use w/o compromising fidelity • Faculty: • Trained, available, practised • Support staff: • Technician/bio-medical engineer essential!

26. Before and after simulations... • Set-up scenario • eg. make blood, set up area, X-rays, notes, etc • Load simulation program • Check everything works • Cameras, VCR, communicators Afterwards... • Check simulator (replace or repair parts) • Clean everything used and put away • Replace/reorder all used items

27. High fidelity simulation (3) • Allow time for briefing and familiarisation with the patient simulator and equipment • Brief participants on: • Broad objectives • The scenario • How to get help

28. High fidelity simulation (4) Always follow the script but... …have alternative outcomes planned and rehearsed Simulation control room

29. High fidelity simulation (5) Using simulation situations can be re-run to explore outcome with different treatments Mission critical tasks can be performed by learners without putting patients at risk

30. High fidelity simulation (6) Facilitated debriefing with an expert practitioner. Participants reflect on their own performance and discuss this with the group

31. Anaesthesia Emergency medicine Family Medicine/GP CCU/ICU Trauma/retrievals Paramedics/EMT Specialist nurses Medical Imaging Paediatrics Rural health workers Sim Centre settings OR, PACU, ER, Imaging suite, post-op ward, clinic, aircraft, ambulance, home, roadside, terrorist incident, etc Outreach settings Regional hospitals, rural settings, etc How we use the SimMan UPS

32. Medicine: A High-Risk Industry • Harvard Medical Practice Study (1991) identified a ‘serious error’ rate of 3.7% • (serious error leads to prolonged hospital stay or disability) • Vincent (2001) NHS ~11% error rate with 50% preventable • ~50,000 patients pa die from medical error or accident. Litigation cost £44billion • Australian data - adverse event rate of ~17%

33. Successful strategies for crisis management: • Use of written checklists to help prevent crises • Use of established procedures in responding to crises • Training in decision making and resource co-ordination • Systematic practise in handling crises including part-task trainers and full-mission realistic simulation

34. The future of simulation... • Skills training tool for all disciplines • Acute care • Try new techniques and/or equipment • Patient safety initiatives • Retraining • Multi-disciplinary training • inter-professional communication • team performance • Training in decision-making/resource co-ordination

35. Simulation technologies used in medical education • Computer-based simulations (micro-worlds, micro-simulation) • Virtual environments +/- haptics • Part-task trainers • Low-fidelity simulators/manikins • Simulated or standardised patients • Hybrid simulations • High-fidelity (full mission) simulation

36. Simulation research must address healthcare training needs • Improved outcomes • Fewer adverse events, fewer preventable incidents, fewer ‘near miss’ events • Increased efficiency of training • Improved outcomes in same or (preferably) less training time • Improved use of resources • Fewer failures, more efficient training, quicker performance