SIMULATION IN MEDICAL EDUCATION Professor Harry Owen

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SIMULATION IN MEDICAL EDUCATION Professor Harry Owen

  1. 1. SIMULATION IN MEDICAL EDUCATION Professor Harry Owen and Val Follows Flinders University School of Medicine [email_address]
  2. 2. Simulation in Medical Education <ul><li>Simulation technologies used in Medical Education in Australia, the US and Europe </li></ul><ul><li>Setting up the Flinders University Medical School Clinical Skills and Simulation Unit </li></ul><ul><li>Fundamentals of high-fidelity simulation </li></ul><ul><li>Where do we go from here? Some observations on the future of simulation </li></ul>
  3. 3. 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>
  4. 4. Adelaide South Australia 1 1 2 1 (1) (1)
  5. 5. Source: Jones A (BMSC)
  6. 6. Simulation centres 2 20 9 5 25 10 195 6 11 2 10 2
  7. 7. Publications on ‘patient simulation’ in clinical care Year
  8. 8. 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>
  9. 9. 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>
  10. 10. Knowledge/Skills/Attitudes <ul><li>Teaching best practice </li></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>
  11. 11. 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 recognised </li></ul><ul><li>Funding generated from teaching outside the medical school </li></ul>
  12. 12. Endotracheal intubation <ul><li>Learnt on patients under anaesthesia </li></ul><ul><li>No special consent </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>
  13. 13. 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>
  14. 14. <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?
  15. 15. 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>
  16. 16. 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)
  17. 17. The Flinders Clinical Skills and Simulation Unit <ul><li>Computer-based Teaching </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>
  18. 18. 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>
  19. 19. 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>
  20. 20. 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>
  21. 21. <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>
  22. 22. 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>
  23. 23. 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>
  24. 24. Options for running simulations <ul><li>Free-form </li></ul><ul><ul><li>Easy but poor learning </li></ul></ul><ul><li>‘On the fly’ </li></ul><ul><ul><li>Scripted but intensive for the ‘controller’ and some variables may appear discontinuous </li></ul></ul><ul><li>Programmed trends </li></ul><ul><ul><li>More sophisticated simulations possible </li></ul></ul><ul><li>Trends and event handlers </li></ul><ul><ul><li>Facilitates high-fidelity simulation with most realistic response to interventions </li></ul></ul>
  25. 25. Resources needed <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>Technician/bio-medical engineer essential! </li></ul></ul>
  26. 26. Before and after simulations... <ul><li>Set-up scenario </li></ul><ul><ul><li>eg. make blood, set up area, X-rays, notes, etc </li></ul></ul><ul><li>Load 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 (replace or repair parts) </li></ul><ul><li>Clean everything used and put away </li></ul><ul><li>Replace/reorder all used items </li></ul>
  27. 27. High fidelity simulation (3) <ul><li>Allow time for briefing and familiarisation with the patient simulator and equipment </li></ul><ul><li>Brief participants on: </li></ul><ul><ul><li>Broad objectives </li></ul></ul><ul><ul><li>The scenario </li></ul></ul><ul><ul><li>How to get help </li></ul></ul>
  28. 28. High fidelity simulation (4) <ul><li>Always follow the script but... </li></ul>… have alternative outcomes planned and rehearsed Simulation control room
  29. 29. 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
  30. 30. 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>
  31. 31. 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>
  32. 32. 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>
  33. 33. 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>
  34. 34. 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>Try new techniques and/or equipment </li></ul></ul><ul><ul><li>Patient safety initiatives </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>
  35. 35. 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>
  36. 36. Simulation research must address healthcare training needs <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>

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