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Applications of Simulation in Anesthesiology


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Applications of Simulation in Anesthesiology

  1. 1. <ul><li>David M. Gaba, M.D. </li></ul><ul><ul><li>Director, Patient Safety Center of Inquiry at VA Palo Alto HCS </li></ul></ul><ul><ul><li>Professor of Anesthesia, Stanford University School of Medicine </li></ul></ul>Applications of Simulation in Anesthesiology
  2. 2. Why Use Patient Simulation? <ul><li>Regardless of the application, there is never a risk to a patient </li></ul><ul><li>Simulators allow the presentation at will of a wide variety of scenarios, including uncommon but critical events </li></ul><ul><li>The underlying (medical) causes of each situation are known </li></ul>
  3. 3. Why Use Patient Simulation? <ul><li>The same events can be presented to different clinicians or teams </li></ul><ul><li>Errors can be allowed to occur and play-out that in a real patient would require immediate intervention by the investigator/instructor </li></ul>
  4. 4. Why Use Patient Simulation? <ul><li>Clinicians can be required to interact with actual medical equipment and a variety of clinical personnel (and personalities) </li></ul><ul><li>Intensive and archival recording of clinician performance is facilitated, e.g. </li></ul><ul><ul><li>Multiple video views and audio </li></ul></ul><ul><ul><li>ECG, EEG </li></ul></ul>
  5. 5. Diverse Applications of Patient Simulation in Anesthesiology <ul><li>Education </li></ul><ul><li>Training </li></ul><ul><li>Research </li></ul><ul><li>Risk management and public relations </li></ul><ul><li>Performance Assessment (covered later) </li></ul>
  6. 6. Distinction Between “Education” and “Training” <ul><li>Education </li></ul><ul><ul><li>The goal is to improve knowledge and conceptual understanding </li></ul></ul><ul><li>Training </li></ul><ul><ul><li>The goal is to improve the performance of tasks or functions </li></ul></ul>
  7. 7. Applications of Simulators in Anesthesiology EDUCATION <ul><li>Example Target Groups: </li></ul><ul><ul><li>University students </li></ul></ul><ul><ul><li>Pre-clinical medical students </li></ul></ul><ul><li>Example Target Curriculum: </li></ul><ul><ul><li>Applied physiology or pharmacology </li></ul></ul>
  8. 8. Applications of Simulators in Anesthesiology EDUCATION <ul><li>Example Target Group: </li></ul><ul><ul><li>2nd year medical students in “Preparation for Clinical Medicine” Course </li></ul></ul><ul><li>Example Target Curriculum: </li></ul><ul><ul><li>“ Introduction to the Integrated Management of the Ill Patient” </li></ul></ul><ul><ul><ul><li>Interleaving of Dx, Monitoring, Rx </li></ul></ul></ul>
  9. 9. Applications of Simulators in Anesthesiology EDUCATION <ul><li>Example Target Group: </li></ul><ul><ul><li>2nd year medical students in basic anesthesiology classroom course </li></ul></ul><ul><li>Example Target Curriculum: </li></ul><ul><ul><li>Early exposure to clinical anesthesia </li></ul></ul>
  10. 10. Applications of Simulators in Anesthesiology EDUCATION <ul><li>Example Target Group: </li></ul><ul><ul><li>Anesthesiology clerkship students </li></ul></ul><ul><li>Example Target Curriculum: </li></ul><ul><ul><li>Introduction to anesthesiology </li></ul></ul><ul><ul><ul><li>Complements OR experience </li></ul></ul></ul>
  11. 11. Applications of Simulators in Anesthesiology EDUCATION <ul><li>Example Target Group: </li></ul><ul><ul><li>Pharmaceutical or device manufacturer representatives or executives </li></ul></ul><ul><li>Example Target Curricula: </li></ul><ul><ul><li>Introduction to clinical environments </li></ul></ul><ul><ul><li>“Anesthesia for Amateurs” (Boston CMS) </li></ul></ul>
  12. 12. Applications of Simulators TRAINING <ul><li>Training is targeted at specific professional groups </li></ul><ul><li>Training curricula focus on skills & behaviors required for tasks on the job </li></ul>
  13. 13. Applications of Simulators TRAINING <ul><li>Example target group </li></ul><ul><ul><li>Novice anesthesia residents </li></ul></ul><ul><li>Example training curricula </li></ul><ul><ul><li>Basic airway management skills </li></ul></ul><ul><ul><li>Techniques for induction of anesthesia </li></ul></ul><ul><ul><li>Managing routine abnormalities during anesthesia; calling for help </li></ul></ul>
  14. 14. Applications of Simulators TRAINING <ul><li>Example target group </li></ul><ul><ul><li>Experienced anesthesia residents </li></ul></ul><ul><li>Example training curricula </li></ul><ul><ul><li>Preparation for anesthesia specialty rotations </li></ul></ul><ul><ul><li>Advanced airway management skills </li></ul></ul><ul><ul><li>Anesthesia Crisis Resource Management (ACRM) </li></ul></ul>
  15. 15. Applications of Simulators TRAINING <ul><li>Target Population: </li></ul><ul><ul><li>Experienced Anesthesia Personnel </li></ul></ul><ul><li>Example training curriculum: </li></ul><ul><ul><li>Hands-on experience with the use of a new pharmaceutical agent (e.g. remifentanil): </li></ul></ul><ul><ul><ul><li>Familiarity: Mixing, dosing, infusion set-up </li></ul></ul></ul><ul><ul><ul><li>Safety: Recognition of and response to side-effects and complications </li></ul></ul></ul>
  16. 16. Applications of Simulators TRAINING <ul><li>Example target group </li></ul><ul><ul><li>Non-anesthesia physicians and nurses </li></ul></ul><ul><li>Example training curriculum: </li></ul><ul><ul><li>Principles and practice of safe conscious sedation </li></ul></ul><ul><ul><ul><li>Credentialing requirement in some institutions </li></ul></ul></ul>
  17. 17. Applications of Simulators TRAINING <ul><li>Example target group </li></ul><ul><ul><li>Experienced anesthesiologists (CME) </li></ul></ul><ul><li>Example training curricula </li></ul><ul><ul><li>Advanced airway management skills </li></ul></ul><ul><ul><li>Use of new techniques or technologies (e.g. drugs, monitors) </li></ul></ul><ul><ul><li>Anesthesia Crisis Resource Management (ACRM) </li></ul></ul>
  18. 18. Many Centers Run “Anesthesia Crisis Resource Management - ACRM” -- Why? <ul><li>Crises or challenging situations occur frequently </li></ul><ul><li>Major gaps exist in training and performance concerning decision making and teamwork </li></ul><ul><li>Patient safety may be improved by targeting these issues more than medical/technical issues </li></ul>
  19. 19. Crisis management behaviors have been studied extensively in aviation Resulting in special training: Crew Resource Management (CRM)
  20. 20. Crisis Management <ul><li>Successful crisis management requires BOTH: </li></ul><ul><ul><li>Sound technical skills of individuals </li></ul></ul><ul><ul><li>Sound crisis management behaviors and teamwork </li></ul></ul>
  21. 21. Principles of Dynamic Decision Making and Teamwork <ul><li>Cognitive Components: </li></ul><ul><ul><li>Know the Environment </li></ul></ul><ul><ul><li>Anticipate and Plan </li></ul></ul><ul><ul><li>Use All Available Information & Cross Check </li></ul></ul><ul><ul><li>Prevent/Manage Fixation Errors </li></ul></ul><ul><ul><li>Use Cognitive Aids </li></ul></ul>
  22. 22. <ul><li>Team Management Components: </li></ul><ul><ul><li>Leadership & followership </li></ul></ul><ul><ul><li>Communication </li></ul></ul><ul><ul><li>Distributing the workload </li></ul></ul><ul><ul><li>Calling for help early </li></ul></ul>Principles of Dynamic Decision Making and Teamwork
  23. 23. Approach of Anesthesia Crisis Resource Management (ACRM) & Its Derivatives <ul><li>Training “Philosophy”: </li></ul><ul><ul><li>Single-Discipline, Discipline-Specific: “Training Crews to Work in Teams” </li></ul></ul><ul><ul><ul><li>Example: Training anesthesiologists to work with with each other & in teams </li></ul></ul></ul><ul><ul><ul><li>Ideally to be complemented with multidisciplinary combined team training </li></ul></ul></ul>
  24. 24. Approach of Anesthesia Crisis Resource Management (ACRM) & Derivatives <ul><li>Training “Philosophy”: </li></ul><ul><ul><li>Primary emphasis on decision making and teamwork behaviors but embedded within technically challenging situations </li></ul></ul><ul><ul><ul><li>Typically aim for > 60% emphasis on these behaviors, <40% on medical/technical details </li></ul></ul></ul>
  25. 25. Approach of Anesthesia Crisis Resource Management (ACRM) & Derivatives <ul><li>Training “Philosophy”: </li></ul><ul><ul><li>Full-day simulation-based course </li></ul></ul><ul><ul><li>Highly interactive, with high instructor-participant ratio </li></ul></ul><ul><ul><li>Detailed debriefings after each simulation </li></ul></ul>
  26. 26. ACRM Simulation Scenarios <ul><li>High-fidelity (x surgery), typically 4 per session @ 30-45 min, participants rotate roles </li></ul><ul><ul><li>Spectrum of challenging clinical situations </li></ul></ul><ul><ul><ul><li>Equipment & environment failures </li></ul></ul></ul><ul><ul><ul><li>Clinical crises </li></ul></ul></ul><ul><ul><ul><li>“ Stat” or “Crash” cases </li></ul></ul></ul><ul><ul><li>Spectrum of challenging interpersonal situations (surgeon, nurse, patient, family) </li></ul></ul>
  27. 27. Simulation Room -- VA Palo Alto
  28. 28. Scenarios are challenging medically, technically, and in terms of teamwork
  29. 29. A Picture of “Face Validity”
  30. 30. Debriefings with video allows discussion of alternatives and pros & cons of CRM behaviors & technical choices
  31. 31. Beyond ACRM: Expansion “Within” & “Without” <ul><li>ACRM derivatives for other specialties </li></ul><ul><li>Instructor training </li></ul><ul><li>Progressive curriculum </li></ul><ul><li>Clinical catastrophe </li></ul><ul><li>Combined team training </li></ul><ul><li>Multiple patient simulations </li></ul><ul><li>Simulation for executive level </li></ul>
  32. 32. Crew Resource Management (CRM) Training Applies to Many Medical Domains <ul><ul><li>OR - ICU </li></ul></ul><ul><ul><li>Emergency Dept. - Cardiac arrest teams </li></ul></ul><ul><ul><li>Delivery room - Cath lab / radiology </li></ul></ul><ul><ul><li>Field responders - Military medicine </li></ul></ul><ul><ul><li>Non-code patient emergencies (IMPES) </li></ul></ul><ul><ul><li>Interns - Medical students (intro) </li></ul></ul><ul><ul><li>Etc. </li></ul></ul>
  33. 33. Applications of Simulators RESEARCH <ul><li>A wide variety of research on human performance in health care requires simulation </li></ul><ul><li> * “Educational research” & performance assessment </li></ul><ul><ul><li>* Clinical techniques (e.g. pediatric sedation) </li></ul></ul><ul><ul><li>* Human machine interaction </li></ul></ul><ul><ul><li>* Decision making * AI in ICU </li></ul></ul><ul><ul><li>* Telementoring * Stress * Fatigue </li></ul></ul>
  34. 34. Applications of Simulators RESEARCH <ul><li>Simulation is a key research tool in human performance because it provides: </li></ul><ul><ul><ul><li>Reproducibility </li></ul></ul></ul><ul><ul><ul><li>Controllability </li></ul></ul></ul><ul><ul><ul><li>Criticality </li></ul></ul></ul><ul><ul><li>All in a confidential environment with no risk to patients </li></ul></ul>
  35. 35. Applications of Simulators RESEARCH <ul><li>Research extends well beyond anesthesiology and health care and well beyond medical investigators, e.g. </li></ul><ul><ul><li>Cognitive or social psychology </li></ul></ul><ul><ul><li>Biomedical engineering </li></ul></ul><ul><li>At several centers PhDs have been awarded based on experiments using a simulator </li></ul>
  36. 36. Applications of Simulators RISK MANAGEMENT <ul><li>Appropriate simulation training may REDUCE: </li></ul><ul><ul><li>The frequency of adverse clinical events </li></ul></ul><ul><ul><li>The impact of clinical events that do occur </li></ul></ul><ul><ul><li>The likelihood of litigation after an event </li></ul></ul><ul><ul><li>A jury’s perception that the institution did not take patient safety seriously </li></ul></ul>
  37. 37. Applications of Simulators PUBLIC RELATIONS <ul><li>Ongoing training & research activities attract considerable media attention </li></ul><ul><ul><li>Highly visual & dynamic </li></ul></ul><ul><li>Outreach programs are feasible, including </li></ul><ul><ul><li>Schools - Youth groups </li></ul></ul><ul><ul><li>Museums - Politicians </li></ul></ul>
  38. 38. Video-link with HM, Queen Elizabeth II The video-conferencing set-up Dr. Gaba addresses Her Majesty Dr. Donovan introduces Dr. Gaba to Her Majesty
  39. 39. Key Challenges Ahead for Simulation in Anesthesiology and Health Care <ul><li>Pedagogical Challenges </li></ul><ul><ul><li>Integrating different types of simulation-based education & training </li></ul></ul><ul><ul><ul><li>On-screen & mannequin; </li></ul></ul></ul><ul><ul><ul><li>Principles, technical skills, & behavioral skills </li></ul></ul></ul><ul><ul><li>Integrating simulation-based training with clinical training </li></ul></ul>
  40. 40. Key Challenges Ahead for Simulation in Anesthesiology and Health Care <ul><li>Challenges of the Clinical Environment </li></ul><ul><ul><li>Principles of patient safety taught in the simulator must be a part of the real clinical environment </li></ul></ul><ul><ul><li>They must be constantly reinforced or the training will be vitiated </li></ul></ul>
  41. 41. Unanswered Questions About Simulation Training and/or CRM <ul><li>Each can be the topic of a multi-day seminar </li></ul><ul><li>Does it work? </li></ul><ul><ul><li>How effective is it? Is it “cost-effective” </li></ul></ul><ul><ul><li>Who should get it and how often? </li></ul></ul><ul><li>Can you assess performance using the simulator, i.e. for certification & recertification </li></ul><ul><ul><li>Covered in later talk </li></ul></ul>
  42. 42. Does It Work? <ul><li>High face validity for this belief </li></ul><ul><li>We do not currently know for sure </li></ul><ul><li>We may well never know for sure </li></ul><ul><ul><li>Suggestive data from many sources </li></ul></ul><ul><ul><li>Definitive experiments may be impossible due to logistics and cost </li></ul></ul>
  43. 43. Obstacles to Investigating the Impact of Simulator Training on Performance <ul><li>No gold standard for measuring performance </li></ul><ul><ul><li>Need to use simulation to test simulation </li></ul></ul><ul><li>High inter- and intra- individual variability will require large cohorts of subjects </li></ul>
  44. 44. Prototypical Experimental Design Chopra, et al; others 3x
  45. 45. A Definitive “Impact on Performance Experiment” Will Be Very Expensive <ul><li>The number of simulations required is very high: </li></ul><ul><ul><ul><li>Familiarization sessions </li></ul></ul></ul><ul><ul><ul><li>Training sessions </li></ul></ul></ul><ul><ul><ul><li>Testing sessions </li></ul></ul></ul><ul><li>Expert evaluation of performance is expensive </li></ul>
  46. 46. at MDD/SD = 0.1, N=1944 Estimate of Required N (per cohort) for 80% power,  = 0.05 How Large Must the Cohorts Be? 0 50 100 150 200 250 300 350 400 450 500 Required N per Cohort 0 0.25 0.5 0.75 1 1.25 1.5 Minimum Detectable Difference / Std. Dev
  47. 47. Unanswered Questions Regarding Investigations of Impact on Performance <ul><li>After how many simulation sessions can or should the impact be measured? </li></ul><ul><ul><li>After 1 session only? </li></ul></ul><ul><ul><ul><li>Naive to think that a single course can have a profound impact </li></ul></ul></ul><ul><ul><ul><li>In commercial aviation simulation (and CRM) is a career-long endeavor </li></ul></ul></ul>
  48. 48. Should We Attempt to Perform Definitive Studies of Simulation Impact? <ul><li>Goal: To convince the skeptics </li></ul><ul><li>Answer: Maybe -- if the resources are there </li></ul><ul><li>BUT… Beware of being sucked into: </li></ul><ul><ul><li>Under-powered studies with high risk of Type II error </li></ul></ul><ul><ul><li>Studies of “one-off” simulation sessions rather than integrated long-term use of simulation </li></ul></ul>
  49. 49. Bottom Line <ul><li> industry in which human lives depend on the skilled performance of responsible operators has waited for unequivocal proof of the benefits of simulation before embracing it… Neither should anesthesiology . </li></ul><ul><li>(Gaba, Anesthesiology 76:491-494, 1992) </li></ul>
  50. 50. The End