MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY

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  • MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY

    1. 1. MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY Professor Harry Owen Director, Clinical Skills and Simulation Unit Flinders University Adelaide, South Australia [email_address]
    2. 2. MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY <ul><li>Background to simulation </li></ul><ul><li>Simulation technologies used in Medical Education in Australia, the US and Europe </li></ul><ul><li>Fundamentals of high-fidelity simulation </li></ul><ul><li>How simulation can improve patient safety </li></ul><ul><li>Emerging trends in simulation </li></ul>
    3. 3. Why simulation? <ul><li>Simulation is valuable when ‘on-the-job’ training is expensive or risky </li></ul><ul><li>Simulation has been adopted for training where consequences of error expose many people to risk or the cost of error is high, for example: </li></ul><ul><ul><li>Aerospace </li></ul></ul><ul><ul><li>Military </li></ul></ul><ul><ul><li>Nuclear power plants </li></ul></ul>
    4. 4. Medicine: A High-Risk Industry <ul><li>Harvard Medical Practice Study (1991) identified a ‘serious error’ rate of 3.7% </li></ul><ul><ul><li>(serious error leads to prolonged hospital stay or disability) </li></ul></ul><ul><li>Vincent (2001) NHS ~11% error rate with 50% preventable </li></ul><ul><ul><li>~50,000 patients pa die from medical error or accident. Litigation cost £44billion </li></ul></ul><ul><li>Australian data - adverse event rate of ~17% </li></ul>
    5. 5. How simulation can improve patient safety <ul><li>Fewer errors </li></ul><ul><li>Better error trapping </li></ul><ul><li>Improved recognition of error and/or consequences of error </li></ul><ul><li>Develop capacity to manage consequences of error </li></ul>
    6. 6. Advantages of Simulation <ul><li>Structured learning </li></ul><ul><li>Guaranteed and scheduled opportunities for teaching learning </li></ul><ul><ul><li>Uncommon situations can be presented </li></ul></ul><ul><ul><li>Teacher can model process, give feedback, repeat process, modify process </li></ul></ul><ul><li>Repetition as often as needed </li></ul>
    7. 7. Successful strategies for crisis management: <ul><li>Use of written checklists to help prevent crises </li></ul><ul><li>Use of established procedures in responding to crises </li></ul><ul><li>Training in decision making and resource co-ordination </li></ul><ul><li>Systematic practise in handling crises including part-task trainers and full-mission realistic simulation </li></ul>
    8. 8. Who’s who in medical education <ul><li>Basic medical education </li></ul><ul><ul><li>Medical students </li></ul></ul><ul><li>Pre-vocational medical education </li></ul><ul><ul><li>Interns, RMOs, PGY 1&2 </li></ul></ul><ul><li>Specialist training (discipline-based) </li></ul><ul><ul><li>Registrars/Senior registrars/Fellows </li></ul></ul><ul><li>Specialists and GPs (life-long learning) </li></ul><ul><ul><li>CME, MOPS, IRM, etc </li></ul></ul><ul><li>Teachers and trainers </li></ul>
    9. 9. Simulation technologies used in medical education <ul><li>Computer-based simulations (micro-worlds, micro-simulation) </li></ul><ul><li>Virtual environments +/- haptics </li></ul><ul><li>Part-task trainers </li></ul><ul><li>Low-fidelity simulators/manikins </li></ul><ul><li>Simulated or standardised patients </li></ul><ul><li>Hybrid simulations </li></ul><ul><li>High-fidelity (full mission) simulation </li></ul>
    10. 10. Cost and benefit in simulation Increasing level of fidelity and exclusivity $$$$$ Manikin training Part-task trainers Full mission simulation CBT
    11. 11. Medical Education includes Knowledge/Skills/Attitudes <ul><li>Individual psychomotor skills </li></ul><ul><li>Appropriate application of skills </li></ul><ul><li>Communication / Team performance / Leadership skills (CRM) </li></ul><ul><li>Supervision/teaching </li></ul><ul><li>Assessment </li></ul>
    12. 12. Knowledge/Skills/Attitudes <ul><li>Teaching best practice </li></ul><ul><ul><li>integrated </li></ul></ul><ul><ul><li>learner centred </li></ul></ul><ul><ul><li>appropriate use of technology </li></ul></ul><ul><li>Assessment best practice </li></ul><ul><ul><li>valid and reliable </li></ul></ul><ul><ul><li>reproducible </li></ul></ul>
    13. 13. The Flinders Clinical Skills and Simulation Unit <ul><li>Grew from a project to improve airway management teaching to medical students </li></ul><ul><li>Value to teaching other health professionals and other skills quickly recognised </li></ul><ul><li>Now involved in teaching across disciplines and outside the medical school </li></ul>
    14. 14. Endotracheal intubation <ul><li>Learnt on patients under anaesthesia </li></ul><ul><li>No special consent </li></ul><ul><li>but </li></ul><ul><li>Duty of care to protect patient from harm </li></ul><ul><li>Increased risk when performed by a student or trainee </li></ul>
    15. 15. Endotracheal intubation <ul><li>ETI needed by many health professionals, including anesthesiologists, paramedics/EMTs, rural GPs, emergency physicians, ICU staff, respiratory therapists, etc. </li></ul><ul><li>Competence requires practise </li></ul>
    16. 16. <ul><li>Animals </li></ul><ul><ul><li>Small, e.g. cats </li></ul></ul><ul><ul><li>Large, e.g. dogs or monkeys </li></ul></ul><ul><li>Unconscious patients </li></ul><ul><ul><li>In the OR </li></ul></ul><ul><ul><li>In ICU </li></ul></ul><ul><li>Newly dead/recently deceased </li></ul><ul><li>Cadavers </li></ul><ul><li>Simulators </li></ul>When and how should ETI be taught?
    17. 17. The learning environment <ul><li>Quiet, few distractors </li></ul><ul><li>Clinical equipment </li></ul><ul><li>Expert tutors </li></ul><ul><li>Realistic models </li></ul><ul><li>Many different models </li></ul><ul><ul><li>Easy  difficult  very difficult </li></ul></ul>
    18. 18. Outcomes of the ETI program <ul><li>Goal of reducing patient risk of trauma has been achieved </li></ul><ul><li>Improved confidence of students and trainees </li></ul><ul><li>Trainees receive more teaching </li></ul><ul><li>Improved trainer satisfaction </li></ul>
    19. 19. The Flinders Clinical Skills and Simulation Unit <ul><li>CBT </li></ul><ul><ul><li>ResusSim </li></ul></ul><ul><ul><li>CathSim </li></ul></ul><ul><ul><li>PA simulator </li></ul></ul><ul><ul><li>ECG </li></ul></ul><ul><ul><li>Local anaesthesia </li></ul></ul><ul><li>Part-task trainers </li></ul><ul><ul><li>BLS & ALS </li></ul></ul><ul><ul><li>IVI & CVC </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Adult </li></ul></ul><ul><ul><li>Gynae & Obstetric </li></ul></ul><ul><ul><li>Neonatal </li></ul></ul><ul><ul><li>Premature (28wks) </li></ul></ul><ul><ul><li>Paediatric (age range) </li></ul></ul>
    20. 20. 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)
    21. 21. The Flinders Clinical Skills and Simulation Unit <ul><li>Several whole body manikins including: </li></ul><ul><ul><li>ResusciBaby </li></ul></ul><ul><ul><li>ALS baby </li></ul></ul><ul><ul><li>ResusciAnne with SkillReporter </li></ul></ul><ul><ul><li>Mr Hurt </li></ul></ul><ul><ul><li>Nursing Anne </li></ul></ul><ul><ul><li>Megacode Kid </li></ul></ul><ul><ul><li>etc </li></ul></ul><ul><li>SimMan UPS </li></ul><ul><ul><li>Postoperative care modules </li></ul></ul><ul><ul><li>Trauma modules </li></ul></ul><ul><ul><li>Severe Trauma modules </li></ul></ul><ul><ul><li>Local produced dental trauma modules </li></ul></ul>
    22. 22. Anatomy of a simulation (1) <ul><li>Components </li></ul><ul><li>Student/trainee/ health professional </li></ul><ul><li>Procedure/task/skill/test/ treatment or equipment </li></ul><ul><li>Patient and/or disease process </li></ul><ul><li>Trainer/supervisor </li></ul>
    23. 23. Anatomy of a simulation (2) <ul><li>Function of components </li></ul><ul><li>Passive </li></ul><ul><ul><li>Enhance setting for realism </li></ul></ul><ul><li>Active </li></ul><ul><ul><li>Change in a programmed way </li></ul></ul><ul><li>Interactive </li></ul><ul><ul><li>Responds to action or event </li></ul></ul>
    24. 24. <ul><li>Trainees learning cricothyrotomy on a part-task trainer </li></ul><ul><li>(Note educational aids in background) </li></ul><ul><li>Trainee performing an emergency cricothyrotomy in a full-mission simulation. </li></ul><ul><li>(Note more realistic setting) </li></ul>
    25. 25. High fidelity simulation (1) <ul><li>Determine educational needs and choose most efficient and effective </li></ul><ul><li>Need to balance resource availability and student demand </li></ul><ul><li>May need to ‘promote’ low-tech solutions </li></ul>
    26. 26. High fidelity simulation (2) <ul><li>Confirm teaching goals can be achieved using simulation </li></ul><ul><li>Develop scenario, acquire equipment needed and prepare associated materials </li></ul><ul><li>Test and validate the simulation </li></ul>
    27. 27. Resources <ul><li>Equipment </li></ul><ul><ul><li>Simulators, monitors, defibrillator, trolleys, etc </li></ul></ul><ul><li>Disposables </li></ul><ul><ul><li>Appropriate for scenario, setting and participants, re-use w/o compromising fidelity </li></ul></ul><ul><li>Faculty </li></ul><ul><ul><li>Trained, available, practised </li></ul></ul><ul><li>Support staff </li></ul><ul><ul><li>Bio-medical technician essential! Also clerical. </li></ul></ul>
    28. 28. Before and after simulations... <ul><li>Set-up scenario </li></ul><ul><ul><li>eg. make blood, set up OR, X-rays, etc </li></ul></ul><ul><li>Load up simulation program </li></ul><ul><li>Check everything works </li></ul><ul><ul><li>Cameras, VCR, communicators </li></ul></ul><ul><li>Afterwards... </li></ul><ul><li>Check simulator </li></ul><ul><li>Clean everything used and put away </li></ul><ul><li>Replace/reorder all used items </li></ul>
    29. 29. High fidelity simulation (3) <ul><li>Allow time for familiarisation with the simulator & equipment </li></ul><ul><li>Brief participants on: </li></ul><ul><ul><li>The scenario </li></ul></ul><ul><ul><li>Educational objectives </li></ul></ul><ul><ul><li>How to get help </li></ul></ul>
    30. 30. High fidelity simulation (4) <ul><li>Always follow the script but... </li></ul>… have alternative outcomes planned and rehearsed Simulation control room
    31. 31. High fidelity simulation (5) <ul><li>Using simulation situations can be re-run to explore outcome with different treatments </li></ul>Mission critical tasks can be performed by learners without putting patients at risk
    32. 32. High fidelity simulation (6) <ul><li>Facilitated debriefing with an expert practitioner. Participants reflect on their own performance and discuss this with the group </li></ul>
    33. 33. How we use the SimMan UPS <ul><li>Anaesthesia </li></ul><ul><li>Emergency medicine </li></ul><ul><li>Family Medicine/GP </li></ul><ul><li>CCU/ICU </li></ul><ul><li>Trauma/retrievals </li></ul><ul><li>Paramedics/EMT </li></ul><ul><li>Specialist nurses </li></ul><ul><li>Medical Imaging </li></ul><ul><li>Paediatrics </li></ul><ul><li>Rural health workers </li></ul><ul><li>Sim Centre settings </li></ul><ul><ul><li>OR, PACU, ER, Imaging suite, post-op ward, clinic, aircraft, ambulance, home, roadside, terrorist incident, etc </li></ul></ul><ul><li>Outreach settings </li></ul><ul><ul><li>Regional hospitals, rural settings, etc </li></ul></ul>
    34. 34. Source: Jones A (BMSC)
    35. 35. Simulation centres 2 20 9 5 25 10 195 6 11 2 10 2 May 2003 Flinders Uni
    36. 36. Publications on ‘patient simulation’ in clinical care Year
    37. 37. Research needed on simulation in healthcare training <ul><li>Improved outcomes </li></ul><ul><ul><li>Fewer adverse events, fewer preventable incidents, fewer ‘near miss’ events </li></ul></ul><ul><li>Increased efficiency of training </li></ul><ul><ul><li>Improved outcomes in same or (preferably) less training time </li></ul></ul><ul><li>Improved use of resources </li></ul><ul><ul><li>Fewer failures, more efficient training, quicker performance </li></ul></ul>
    38. 38. Simulation technologies used in medical education <ul><li>Computer-based simulations (micro-worlds, micro-simulation) </li></ul><ul><li>Virtual environments +/- haptics </li></ul><ul><li>Part-task trainers </li></ul><ul><li>Low-fidelity simulators/manikins </li></ul><ul><li>Simulated or standardised patients </li></ul><ul><li>Hybrid simulations </li></ul><ul><li>High-fidelity (full mission) simulation </li></ul>
    39. 39. The future of simulation... <ul><li>Skills training tool for all disciplines </li></ul><ul><ul><li>Acute care </li></ul></ul><ul><ul><li>New techniques and/or equipment </li></ul></ul><ul><ul><li>Managing complications </li></ul></ul><ul><ul><li>Retraining </li></ul></ul><ul><li>Multi-disciplinary training </li></ul><ul><ul><li>inter-professional communication </li></ul></ul><ul><ul><li>team performance </li></ul></ul><ul><li>Training in decision-making/resource co-ordination </li></ul>

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