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  1. 1. The Integrated Simulation Center: Lessons Learned Tony Errichetti, Patty Myers, Tom Scandalis American Association of Colleges of Osteopathic Medicine 4 th Annual Meeting – “Challenges and Opportunities” Baltimore, MD - June 24, 2006
  2. 2. Objectives <ul><li>Describe the state-of-the-art simulation center </li></ul><ul><li>Discuss curricular , political and logistical issues in setting up a simulation center </li></ul><ul><li>What are the key issues, decisions? </li></ul><ul><li>Review major simulations technologies, and their integration </li></ul>
  3. 3. Simulation = reality substitution
  4. 4. Increased use of simulations because…. <ul><li>Shrinking patient base, shorter stays </li></ul><ul><li>COMLEX-PE, USMLE-CS </li></ul><ul><li>DO School Sim Center Program Surveys </li></ul><ul><li>- 2001 - SP Programs: 62% </li></ul><ul><li>- No robotic sim programs (JAOA) </li></ul><ul><li>- 2006 - SP programs: 82%, 8% under development </li></ul><ul><li>- Robotic sim programs: 57% </li></ul><ul><li>(submitted to JAOA) </li></ul>
  5. 5. Increased use of simulations because…. <ul><li>Simulation industry (SPs, patient simulators, virtual reality) </li></ul><ul><li>High medical error rates, lawsuits and public demands for higher quality - </li></ul><ul><li>Patient safety! </li></ul>
  6. 6. Classroom Work How do simulations “work”?
  7. 7. Childhood Training Through Simulation
  8. 8. Childhood Training Through Simulation
  9. 9. How do simulations “work”? <ul><li>Practice / repetition in a patient- and trainee-safe environment (sim center) </li></ul><ul><li>“ Confidence builds competence” </li></ul><ul><li>Arousal, increase of productive anxiety , “ nightmare” scenarios </li></ul><ul><li>Feedback / debriefing </li></ul><ul><li>– the essential element </li></ul>
  10. 10. Simulations …. <ul><li>… solve training logistical problems </li></ul><ul><li>“ We prescribe illnesses” </li></ul><ul><li>… provide control of the clinical training and skills assessment </li></ul><ul><li>… do not harm or leave patients untreated as a bi-product of medical education </li></ul>
  11. 11. Simulation Center Elements <ul><li>Simulation Technologies </li></ul><ul><li>Simulation Connectivity System </li></ul>
  12. 12. Simulation Technologies SPs VR Simulation Triad Simulators
  13. 13. Simulated and standardized patients: What’s the difference? Simulated Standardized More realistic More standardized Less standardized Less realistic Training Assessment SPs
  14. 14. Early Mechanical Simulator
  15. 15. 1700s “Venus M é dica” La Specola Collection, Firenze
  16. 16. 1700s “Venus M é dica” La Specola Collection, Firenze
  17. 17. Gross Anatomy Animal Models e.g Suturing Practice Simulators
  18. 18. <ul><li>Part-task / Part body trainers </li></ul><ul><li>Basic concepts </li></ul><ul><li>Psychomotor skills training </li></ul>Simulators
  19. 19. <ul><li>Patient simulators (manikins) </li></ul><ul><li>Teamwork, procedures e.g. codes, ACLS </li></ul><ul><li>Procedure simulators </li></ul><ul><li>Psychomotor skills, e.g. </li></ul><ul><li>laproscopic surgery </li></ul>Simulators
  20. 20. <ul><li>Virtual Reality and Computer-Based Programs </li></ul><ul><li>PC/Mac – Patient “in the computer” </li></ul><ul><li>(DxR) </li></ul><ul><li>Haptic – Feel and touch </li></ul><ul><li>Full immersion – Haptic plus virtual </li></ul><ul><li>environment </li></ul>VR
  21. 21. Full-Immersion Virtual Reality VR Diana – University of Florida                                                                                                          
  22. 22. Simulation Connectivity System
  23. 23. <ul><li>Easy storage </li></ul><ul><li>Users (trainees, faculty) retrieve videos through the web </li></ul><ul><li>SP / Sim training / quality assurance </li></ul><ul><li>Debriefing / precepting / feedback – locally and remotely </li></ul>Digital AV
  24. 24. <ul><li>Paperless PC / PDA data collection </li></ul><ul><li>- ROI: saves time and human resources </li></ul><ul><li>Data analysis / scoring / score reporting </li></ul><ul><li>Evaluation of trainees, faculty </li></ul><ul><li>Longitudinal studies of competency </li></ul><ul><li>acquisition </li></ul>Data Collection
  25. 25. <ul><li>Managing schedules (e.g. students, SPs) </li></ul><ul><li>- ROI: saves time and human resources </li></ul><ul><li>Exam management </li></ul><ul><li>Automated announcements </li></ul><ul><li>Automated DV camera movements </li></ul>Program Management
  26. 26. Planning / Financial Issues
  27. 27. Training areas (rooms) Permanent Mobile Simulators , equipment (stuff) Faculty Staff (people) Curriculum SPs, trainers,techs, coordinators $ im Center Element $
  28. 28. # 1 Problem Building first, then planning
  29. 29. Problems <ul><li>Budgeting and purchasing out of synch with planning and operations. </li></ul><ul><li>Users aren’t consulted in design process. </li></ul>
  30. 30. Lesson Learned <ul><li>Planning = </li></ul><ul><li>Really good planning = </li></ul>
  31. 31. # 2 Problem Buying more manikin than what’s needed, and / or not budgeting for other simulation equipment
  32. 32. Lesson Learned <ul><li>Manikin just one of hundreds of pieces of equipment needed </li></ul><ul><li>Develop a program first (planning again) before committing to a manikin </li></ul>
  33. 33. Lesson Learned <ul><li>Sim Centers are expensive! </li></ul><ul><li>“ We’re in a medical education arms race!” </li></ul><ul><li>- Ken Veit, D.O. - PCOM </li></ul><ul><li>Collaborate when possible </li></ul><ul><li>Establish regional sim centers </li></ul><ul><li>Sell your services </li></ul>
  34. 34. # 3 Problem Decentralized management of simulation services
  35. 35. Administrative Problem Family Medicine SPs VR Surgery / ED MIS Simulators
  36. 36. Lesson Learned <ul><li>Centralized management of all sim services, under a dean (vs. e.g. family medicine), to maximize efficiency, and program integration </li></ul>
  37. 37. Lesson Learned <ul><li>Program director = an expert in performance test development (usually a Ph.D.) who can work with and develop clinical faculty to: </li></ul><ul><li>create formative and summative assessment </li></ul><ul><li>set pass-fail standards </li></ul><ul><li>design research </li></ul><ul><li>Have a consultation line in your budget to bring in experts </li></ul>
  38. 38. How Simulations Are Changing Clinical Learning
  39. 39. Physiology Anatomy Histology Cardiology Hematology Urology From Learning Silos…
  40. 40. To integrated curriculum Basic Sciences / Clinical Knowledge / Skills Because the work requires integration of knowledge, skills, attitudes
  41. 41. … and integrated health care delivery DOCTORS NURSES, PAs PTs … because healthcare requires team work
  42. 42. SPs Sims VR Simulation Integration
  43. 43. “ Cardiology” Scenario Students encounter a cardiology complaint (manikin) and discuss physiology / pharmacology issues with a science teacher Simulation Integration - e.g. Basic Science Sims
  44. 44. “ Gross anatomy - SP” Scenario Students in gross anatomy dissect the abdomen and then watch a video, in the lab, of a patient (SP) presenting with abdominal complaints. Simulation Integration - e.g. SPs Sims
  45. 45. “ Suturing” Scenario Students practice suturing (p/task trainer) attached to a “conscious patient” (SP) Simulation Integration - e.g. SPs Sims
  46. 46. “ Conscious - Comatose” Scenario Students encounter a hospital patient (SP), then that same patient in a comatose state (manikin) Simulation Integration - e.g. SPs Sims
  47. 47. “ Pre-Encounter” Scenario Students prepare for a sim encounter by meeting a web-patient (PC-VR), then meet the “actual patient” (manikin) in an ED setting, and / or live patient (SP) Simulation Integration - e.g. SPs Sims VR
  48. 48. “ Patient Management” Scenario Students encounter a patient (SP), then that same patient in a acute state (manikin), then manage the patient’s treatment post-discharge (PC-VR) Simulation Integration - e.g. Sims VR SPs
  49. 49. “ Simulator-Audience Response” Program Students encounter a patient in an acute state (manikin), and through a live DV feed, an audience participates via an audience response system Simulation Integration - e.g. Sims ARS
  50. 50. “ Death and dying” Scenario Students encounter “dying patient” (manikin), then counsel “grieving family member” (SP) Simulation Integration - e.g. SPs Sims
  51. 51. Death and Dying Scenatio: Objectives <ul><li>Combine clinical training and behavioral medicine </li></ul><ul><li>Verisimilitude : Using the manikin to get students (MS1) into the “death and dying” scenario, to practice couseling </li></ul><ul><li>Integrate PA, DO and psychology faculty </li></ul>
  52. 52. Steps <ul><li>Developed manikin case </li></ul><ul><li>Developed 5 SP cases, i.e. 5 SPs representing 5 different grief reactions </li></ul><ul><li>Trained SPs </li></ul><ul><li>Ran the program </li></ul><ul><li>Debriefed the students </li></ul>
  53. 53. Videos
  54. 54. Summary: State-of-the-Art Sim Center <ul><li>Integrates the Simulation Triad </li></ul><ul><li>Integrates knowledge and skills </li></ul><ul><li>Simulation connectivity system that integrates everything together </li></ul><ul><li>Plan before you build - </li></ul><ul><li>Consult the users! </li></ul><ul><li>Faculty development – the hardest job </li></ul>
  55. 55. For Information Tony Errichetti, Ph.D. Chief of Virtual Medicine Director, Institute For Clinical Competence [email_address] 516.686.3928