MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY
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MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY

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MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY Presentation Transcript

  • MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY Professor Harry Owen Director, Clinical Skills and Simulation Unit Flinders University Adelaide, South Australia [email_address]
  • MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY
    • Background to simulation
    • Simulation technologies used in Medical Education in Australia, the US and Europe
    • Fundamentals of high-fidelity simulation
    • How simulation can improve patient safety
    • Emerging trends in simulation
  • Why simulation?
    • Simulation is valuable when ‘on-the-job’ training is expensive or risky
    • Simulation has been adopted for training where consequences of error expose many people to risk or the cost of error is high, for example:
      • Aerospace
      • Military
      • Nuclear power plants
  • 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%
  • How simulation can improve patient safety
    • Fewer errors
    • Better error trapping
    • Improved recognition of error and/or consequences of error
    • Develop capacity to manage consequences of error
  • Advantages of Simulation
    • Structured learning
    • Guaranteed and scheduled opportunities for teaching learning
      • Uncommon situations can be presented
      • Teacher can model process, give feedback, repeat process, modify process
    • Repetition as often as needed
  • 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
  • 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
  • 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
  • Cost and benefit in simulation Increasing level of fidelity and exclusivity $$$$$ Manikin training Part-task trainers Full mission simulation CBT
  • Medical Education includes Knowledge/Skills/Attitudes
    • Individual psychomotor skills
    • Appropriate application of skills
    • Communication / Team performance / Leadership skills (CRM)
    • Supervision/teaching
    • Assessment
  • Knowledge/Skills/Attitudes
    • Teaching best practice
      • integrated
      • learner centred
      • appropriate use of technology
    • Assessment best practice
      • valid and reliable
      • reproducible
  • 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 quickly recognised
    • Now involved in teaching across disciplines and outside the medical school
  • Endotracheal intubation
    • Learnt on patients under anaesthesia
    • No special consent
    • but
    • Duty of care to protect patient from harm
    • Increased risk when performed by a student or trainee
  • Endotracheal intubation
    • ETI needed by many health professionals, including anesthesiologists, paramedics/EMTs, rural GPs, emergency physicians, ICU staff, respiratory therapists, etc.
    • Competence requires practise
    • Animals
      • Small, e.g. cats
      • Large, e.g. dogs or monkeys
    • Unconscious patients
      • In the OR
      • In ICU
    • Newly dead/recently deceased
    • Cadavers
    • Simulators
    When and how should ETI be taught?
  • The learning environment
    • Quiet, few distractors
    • Clinical equipment
    • Expert tutors
    • Realistic models
    • Many different models
      • Easy  difficult  very difficult
  • Outcomes of the ETI program
    • Goal of reducing patient risk of trauma has been achieved
    • Improved confidence of students and trainees
    • Trainees receive more teaching
    • Improved trainer satisfaction
  • The Flinders Clinical Skills and Simulation Unit
    • CBT
      • ResusSim
      • CathSim
      • PA simulator
      • ECG
      • Local anaesthesia
    • Part-task trainers
      • BLS & ALS
      • IVI & CVC
      • Trauma
      • Adult
      • Gynae & Obstetric
      • Neonatal
      • Premature (28wks)
      • Paediatric (age range)
  • CPR Prompt ® (Compliant) Little Anne™ (Laerdal) CPR Pal ® (Ambu) Basic Buddy™ (Lifeform) Economy Saniman ® (Nasco) Adult A-A Female ® (Nasco) Fat Old Fred ® (Lifeform) David/Adam ® (Nasco) Actar D-Fib ® (Armstrong)
  • The Flinders Clinical Skills and Simulation Unit
    • 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
  • Anatomy of a simulation (1)
    • Components
    • Student/trainee/ health professional
    • Procedure/task/skill/test/ treatment or equipment
    • Patient and/or disease process
    • Trainer/supervisor
  • Anatomy of a simulation (2)
    • Function of components
    • Passive
      • Enhance setting for realism
    • Active
      • Change in a programmed way
    • Interactive
      • Responds to action or event
    • 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)
  • 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
  • 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
  • Resources
    • 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
      • Bio-medical technician essential! Also clerical.
  • Before and after simulations...
    • Set-up scenario
      • eg. make blood, set up OR, X-rays, etc
    • Load up simulation program
    • Check everything works
      • Cameras, VCR, communicators
    • Afterwards...
    • Check simulator
    • Clean everything used and put away
    • Replace/reorder all used items
  • High fidelity simulation (3)
    • Allow time for familiarisation with the simulator & equipment
    • Brief participants on:
      • The scenario
      • Educational objectives
      • How to get help
  • High fidelity simulation (4)
    • Always follow the script but...
    … have alternative outcomes planned and rehearsed Simulation control room
  • 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
  • High fidelity simulation (6)
    • Facilitated debriefing with an expert practitioner. Participants reflect on their own performance and discuss this with the group
  • How we use the SimMan UPS
    • 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
  • Source: Jones A (BMSC)
  • Simulation centres 2 20 9 5 25 10 195 6 11 2 10 2 May 2003 Flinders Uni
  • Publications on ‘patient simulation’ in clinical care Year
  • Research needed on simulation in healthcare training
    • 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
  • 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
  • The future of simulation...
    • Skills training tool for all disciplines
      • Acute care
      • New techniques and/or equipment
      • Managing complications
      • Retraining
    • Multi-disciplinary training
      • inter-professional communication
      • team performance
    • Training in decision-making/resource co-ordination