Use of Simulation to Improve Patient Safety Health Forum Summit ...


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  • Recommendations from the IOM state very clearly that not only should simulation-based training be incorporated, but that it has to be developed with patient safety as the goal. It is safe, it provides an avenue for both individual and team training, and it is cost effective.
  • Studies have documented that simulation training provides retention of knowledge and skill that equals real life scenarios. Significant increased performance versus traditional teaching technologies.
  • First powered flight by man was recorded on December 17, 1903, officially creating the first “test pilot” and beginning the high risk field of aviation. What is interesting is in less than four years the first “flight simulators were developed. Test pilots wanted to minimize the risks associated with their first flight. This slide shows a French made simulator from 1907.
  • Aviation depends on flight simulation for training and re-certification. It is mandated by the FAA that pilots spend 36-40 hours yearly to maintain their license. Pilots advancing to newer aircraft are required up to 4 weeks of simulation training. In healthcare, anesthesia has taken the initial step in simulation training, followed by surgery.
  • Simulation training has become the standard in all other high risk fields, aviation, nuclear power, maritime and military, where a single error of the professional could result in death.
  • Simulation in anesthesia has been successful because it is realistic, reproducible, and engaging. Improved learning occurs during simulation training.
  • The SimSuite System is the first full vascular procedure simulator training system. This system incorporates real “hands on” catheter manipulation, with patient monitoring, imagery, drug intervention team training capabilities, SAEs, metrics, and more.
  • Use of Simulation to Improve Patient Safety Health Forum Summit ...

    1. 1. Use of Simulation to Improve Patient Safety Health Forum Summit--2005 John R. Combes, MD Senior Fellow, HRET John C. Messenger, MD, FACC Associate Professor of Medicine University of Colorado Health Sciences Center July 30 th , 2005
    2. 2. <ul><li>Current Training Paradigm in Perspective </li></ul><ul><li>Background of Simulation in Medicine </li></ul><ul><li>Improving Skills with Simulation </li></ul><ul><li>Outcome Studies of Medical Simulation </li></ul><ul><li>AHRQ Pilot Project for Skills Training </li></ul><ul><li>Challenges for Improving Medical Care using Simulation </li></ul>
    3. 3. Current Training in Healthcare– Our Approach in Perspective : <ul><li>Time-intensive “apprenticeship” model that is directed at individuals </li></ul><ul><li>Practice occurs on patients </li></ul><ul><li>Life-threatening events/complications are rare </li></ul><ul><li>Focus is primarily on technical skills —not the non-technical team skills </li></ul><ul><li>Little emphasis on interdisciplinary training </li></ul>
    4. 4. Recommendations from IOM <ul><li>Use simulators to ensure that clinical training is safe for patients </li></ul><ul><li>Develop simulators for use in skills assessment </li></ul><ul><li>Use simulation technology to improve individual and team performance through interdisciplinary team training </li></ul><ul><li>Use simulation for problem solving and recovery from problems — “crisis management” </li></ul>To Err is Human: Building a Safer Health System , Institute of Medicine, Committee on Quality, National Academy Press, 1999
    5. 5. Human Learning: Level of Interactivity Why Use Simulations? <ul><ul><ul><li>Interaction is associated with learning achievement and retention of knowledge </li></ul></ul></ul><ul><ul><ul><li>Participants learned faster and had better attitudes when they used an interactive instructional environment </li></ul></ul></ul>Retention Teach Others 90% Collaborative Simulations Learn By Doing 75% Simulations Discussion Groups 50% Web Seminars, IM, chat Demonstration 30% Animation Audio Visual 20% PowerPoint Slides Lecture 5% Streaming media Source: Andersen Consulting Najjar, L. J. (1998). Principles of educational multimedia user interface design. Human Factors , 40(2), 311-323.
    6. 6. <ul><li>Current Training Paradigm in Perspective </li></ul><ul><li>Background of Simulation in Medicine </li></ul><ul><li>Improving Skills with Simulation </li></ul><ul><li>Outcome Studies of Medical Simulation </li></ul><ul><li>AHRQ Pilot Project for Skills Training </li></ul><ul><li>Challenges for Improving Medical Care using Simulation </li></ul>
    7. 7. Birth of Aviation—And Simulation Training The Wright Flyer Dec 17 th , 1903 French Simulator circa 1907 Current Simulator
    8. 8. History of Simulation <ul><li>The Flight Industry established simulation as a basis for training that has become widely accepted </li></ul><ul><ul><li>Flight simulators improved pilot skills </li></ul></ul><ul><ul><li>Certification required on simulator prior to flying </li></ul></ul><ul><ul><li>Re-certification on a simulator is required yearly </li></ul></ul><ul><ul><li>Intensive simulation required to pilot different aircraft </li></ul></ul>Office of Naval Research, 1973 Visual Elements in Flight Simulation National Council of the National Academy of Science Dusterberry JC. Introduction to simulation systems. Soc Photo-Optical Eng 1975;59:141-142
    9. 9. Improving Safety & Outcomes in High Risk Industries Wachtel J. In: Walton DG ed. Simulation for Nuclear Reactor Technology, 1985;339-349 Ressler EK et al. Military Mission Rehearsal in:Tekian et al eds. Innovative Simulations for Assessing Professional Competence. 1999;157-174
    10. 10. Anesthesia Simulation <ul><li>Complex “realistic” simulations in OR-like setting </li></ul><ul><li>Standardized simulations can be controlled and “catastrophes” introduced to simulate rare events </li></ul><ul><li>Behavior and performance during crises can be studied--Based on Crew Resource Management </li></ul><ul><li>Simulation training has been shown to: </li></ul><ul><ul><li>improve acquisition and retention of knowledge </li></ul></ul><ul><ul><li>decrease unplanned errors </li></ul></ul><ul><ul><li>improve correction of problems </li></ul></ul>Chopra V et al. Br J Anaesth 1994;73:287-292 DeAnda A et al. Anesth Analg 1991;72:308-315
    11. 11. Simulation in the Field of Surgery <ul><li>Early use in laparoscopic surgery </li></ul><ul><ul><li>instrument use, hand-eye coordination and depth perception </li></ul></ul><ul><li>Level of training and frequency of skill repetition are predictors of skill proficiency </li></ul><ul><li>Residents trained with simulation had significantly greater improvement on the simulator vs. controls for several common tasks and for overall scores </li></ul>Derossis AM et al Am J Surg 1998;175:482-487 Derossis AM et al Surg Endosc 1998;12:1117-1120
    12. 12. Validation of Simulators <ul><li>Face Validity </li></ul><ul><li>Content Validity </li></ul><ul><li>Construct Validity </li></ul><ul><ul><li>Distinguish between subjects with different levels of experience </li></ul></ul><ul><li>Predictive Validity </li></ul><ul><ul><li>-- Performance measured correlates with measured technical ability in vivo </li></ul></ul>Datta V et al. J Am Coll Surg 2004;199:603-606
    13. 13. Validated Simulators Have Been Developed in Numerous Fields: <ul><li>Anesthesiology </li></ul><ul><li>ENT Surgery </li></ul><ul><li>Emergency Medicine </li></ul><ul><li>Trauma Surgery </li></ul><ul><li>Neonatal Medicine </li></ul><ul><li>Laparoscopic Surgery </li></ul><ul><li>Orthopedic Surgery </li></ul><ul><li>Colonoscopy/Flexible Sigmoidoscopy </li></ul><ul><li>Bronchoscopy </li></ul><ul><li>Colposcopy/Hysteroscopy </li></ul><ul><li>Cardiovascular Medicine </li></ul><ul><ul><li>“ Harvey” Patient Simulator </li></ul></ul><ul><li>Endovascular Medicine </li></ul><ul><ul><li>Coronary angiography </li></ul></ul><ul><ul><li>Cerebral angiography </li></ul></ul><ul><ul><li>Peripheral angiography </li></ul></ul><ul><ul><li>Coronary/Carotid/Peripheral Intervention </li></ul></ul><ul><ul><li>Pacer/defibrillator insertion </li></ul></ul><ul><ul><li>New device training </li></ul></ul>
    14. 14. <ul><li>Current Training Paradigm in Perspective </li></ul><ul><li>Background of Simulation in Medicine </li></ul><ul><li>Improving Skills with Simulation </li></ul><ul><li>Outcome Studies of Medical Simulation </li></ul><ul><li>AHRQ Pilot Project for Skills Training </li></ul><ul><li>Challenges for Improving Medical Care using Simulation </li></ul>
    15. 15. Simulation--Defined <ul><li>A device or exercise that enables a participant to reproduce or represent, under test conditions, phenomena that are likely to occur in actual performance </li></ul><ul><li>Lack of data comparing the impact of the type of simulation on the effectiveness of training </li></ul>Krummel TM. Ann Surg 1998;228:635-637.
    16. 16. What Skills Can We Train/Evaluate Using Simulation? <ul><li>Technical Skills </li></ul><ul><ul><li>Technical proficiency measured by: </li></ul></ul><ul><ul><ul><li>Procedural time </li></ul></ul></ul><ul><ul><ul><li>Number of errors </li></ul></ul></ul><ul><ul><ul><li>Need for Assistance </li></ul></ul></ul><ul><li>Non-Technical Skills </li></ul><ul><ul><li>Teamwork </li></ul></ul><ul><ul><li>Communication </li></ul></ul><ul><ul><li>Judgement </li></ul></ul><ul><ul><li>Leadership </li></ul></ul>
    17. 17. Goals of Simulation Training for Individuals <ul><li>Improve skills through interval practice </li></ul><ul><li>Improve consistency of performance </li></ul><ul><li>Decrease errors </li></ul><ul><li>Provide proximate and summative feedback </li></ul><ul><li>Allow for assessment of progress </li></ul><ul><li>Incorporate a standardized, comprehensive curriculum </li></ul><ul><li>Optimize patient safety by accelerating the learning curve prior to patient exposure </li></ul>Adapted from Gallagher AG et al. Ann Surg 2005;241:364-372
    18. 18. Proposed Goals for Team Training <ul><li>Focus on leadership </li></ul><ul><li>Improve team communication </li></ul><ul><li>Encourage cooperation </li></ul><ul><li>Understand roles in team performance </li></ul><ul><li>Improve learning and transfer </li></ul><ul><li>Enhance patient safety </li></ul>Ostergaard HT et al. Qual Saf Health Care 2004;13(supp):i91-i95
    19. 19. Why focus on the team?--Factors Involved in Adverse Medical Events Available at
    20. 20. Why is team training important? <ul><li>Many fields in medicine are complex </li></ul><ul><li>Dynamic situations </li></ul><ul><li>Providers are under time pressure </li></ul><ul><li>There is little time to synthesize data </li></ul><ul><li>Workload is often very high </li></ul><ul><li>Medicine is a high risk environment similar to field of aviation </li></ul>Ostergaard HT et al. Qual Saf Health Care 2004;13(supp):i91-i95
    21. 21. Training with Simulation--Impact on Team Performance <ul><li>Error reduction and improved team behavior have been demonstrated in the fields of: </li></ul><ul><ul><li>Anesthesia </li></ul></ul><ul><ul><li>Emergency Medicine </li></ul></ul><ul><ul><li>Trauma Surgery </li></ul></ul><ul><ul><li>Medical Crisis Teams </li></ul></ul>Morey et al. Health Serv Res 2002;37:1553-1581 Holcomb JB et al. J Trauma 2002;52:1078-1086 DeVita MA et al. Crit Care Med 2004;32:S61-S65
    22. 22. Team Training Applications <ul><li>Emergency Medicine Training </li></ul><ul><li>Use for ATLS/ACLS resuscitation </li></ul><ul><li>Training in Critical Care Medicine </li></ul><ul><ul><li>Doctoral, post-doctoral, CME and CPD </li></ul></ul><ul><li>Training for neonatal resuscitation </li></ul><ul><li>Operative Suite Training </li></ul><ul><li>Role in Endovascular Medicine </li></ul><ul><ul><li>AHRQ-funded demonstration project in cardiac catheterization lab </li></ul></ul>Grenvik A et al. Curr Opin Crit Care 2004;10:233-237 Lighthall GK et al. Crit Care Med 2003;31:2437-2443 Messenger JC et al. Top Health Inform Man 2002;23:82-93
    23. 23. Challenges Facing Team Training <ul><li>Medicine teams are often transitory involving multiple disciplines working together </li></ul><ul><ul><li>Nurses, physicians, technicians, respiratory therapists…. </li></ul></ul><ul><li>Difficult to measure an impact on specific patient outcomes/patient safety “hard endpoints” </li></ul><ul><ul><li>Decrease in deaths, complications etc </li></ul></ul><ul><li>Objective methods for detecting an effect on team performance have been limited </li></ul><ul><li>Who is going to broadly fund simulation-based training? </li></ul>
    24. 24. <ul><li>Current Training Paradigm in Perspective </li></ul><ul><li>Background of Simulation in Medicine </li></ul><ul><li>Improving Skills with Simulation </li></ul><ul><li>Outcome Studies of Medical Simulation </li></ul><ul><li>AHRQ Pilot Project for Skills Training </li></ul><ul><li>Challenges for Improving Medical Care using Simulation </li></ul>
    25. 25. Improved Clinical Outcomes from Technical Skills Training <ul><li>The field of surgery has used simulation training in laparoscopy to: </li></ul><ul><ul><li>Improve technical skills and retention of knowledge when tested in simulator </li></ul></ul><ul><ul><li>Transfer learned technical skills to the clinical setting </li></ul></ul><ul><ul><ul><li>↓ procedure time, ↓ errors significantly during cholecystectomy </li></ul></ul></ul>Seymour NE et al. Ann Surg 236(4):458, 2002 Grantcharov TP et al. Br J Surg 2004;91:146-150 Derossis AM et al Am J Surg 1998;175:482-487
    26. 26. VR Training Improves Operating Room Performance: A Randomized, Double-blinded Study. <ul><li>Objective: </li></ul><ul><li>To demonstrate that virtual reality (VR) training transfers technical skills to the operating room environment. </li></ul><ul><li>Background: </li></ul><ul><li>Use of VR surgical simulation to train skills and reduce error risk in the OR has never been demonstrated in a prospective, randomized, blinded study. </li></ul>Seymour NE et al. Ann Surg 236(4):458, 2002
    27. 27. <ul><li>Results: </li></ul><ul><li>No differences in baseline skills were found between groups. </li></ul><ul><li>All subjects successfully completed the procedure: </li></ul><ul><ul><li>Gallbladder dissection was 29% faster in VR-trained residents. </li></ul></ul><ul><ul><li>Non VR-trained residents were 9 times more likely to transiently fail to make progress (p<0.007) </li></ul></ul><ul><ul><li>5 times more likely to injure the gallbladder or burn non-target tissue (p<0.04) </li></ul></ul>Seymour NE et al. Ann Surg 236(4):458, 2002
    28. 28. Randomized Clinical Trial of Virtual Reality Simulation for Laparoscopic Skills Training <ul><li>Objective: </li></ul><ul><li>To demonstrate that virtual reality (VR) training transfers technical skills to the operating room </li></ul>Grantcharov TP et al. Br J Surg 2004;91:146-150
    29. 29. <ul><li>Results: </li></ul><ul><li>No differences in baseline skill assessments were found between groups. </li></ul><ul><li>Subjects in the VR-trained group: </li></ul><ul><ul><ul><li>Performed the procedure significantly faster (p=0.021) </li></ul></ul></ul><ul><ul><ul><li>Had greater improvement in error score (p=0.003) </li></ul></ul></ul><ul><ul><ul><li>Had greater improvement in economy of motion (p=0.003) </li></ul></ul></ul>Grantcharov TP et al. Br J Surg 2004;91:146-150
    30. 30. VR-OR: Error Scores Grantcharov TP et al. Br J Surg 2004;91:146-150
    31. 31. <ul><li>Current Training Paradigm in Perspective </li></ul><ul><li>Background of Simulation in Medicine </li></ul><ul><li>Improving Skills with Simulation </li></ul><ul><li>Outcome Studies of Medical Simulation </li></ul><ul><li>AHRQ Pilot Project for Skills Training </li></ul><ul><li>Challenges for Improving Medical Care using Simulation </li></ul>
    32. 32. AHRQ Pilot Project in Patient Safety— E nhancing Patient Safety During Cardiac Catheterization Using Simulation-Based Training <ul><li>J. Messenger, MD, J. Combes, MD (PI), J. Rumsfeld, MD PhD, </li></ul><ul><li>J. Carroll, MD, S.Y. Chen, PhD, P. Kletke, PhD, M. Pittman Dr. PH, S. MaWhinney, ScD, K. Kioussopoulos, RN, BSN. </li></ul><ul><li>Department of Medicine, Department of Preventive Medicine University of Colorado Health Sciences </li></ul><ul><li>Health Research and Educational Trust </li></ul><ul><li>Hospital Association of Pennsylvania </li></ul><ul><li>Medical Simulation Corporation </li></ul>Agency for Healthcare Research and Quality
    33. 33. Aims <ul><li>To compare simulator-based teaching paradigm vs. traditional patient-based teaching </li></ul><ul><li>To evaluate medical simulation to improve education to enhance patient safety </li></ul><ul><li>To improve clinical skills and promote patient safety directed behavior </li></ul><ul><li>To disseminate an educational and training program that employs simulation </li></ul><ul><li>To obtain feedback from health care providers on simulation </li></ul>
    34. 34. Three Phase Project <ul><li>Phase 1: Curriculum Development </li></ul><ul><li>Phase 2: Training </li></ul><ul><ul><li>Cardiology Fellows </li></ul></ul><ul><ul><li>Cath Lab Teams </li></ul></ul><ul><li>Phase 3: Dissemination </li></ul>
    35. 35. Vascular Simulation Training System—Medical Simulation Corporation <ul><li>SimSuite ™ Training System </li></ul>
    36. 37. Patient Safety Curriculum Content <ul><li>Pre-procedural risk assessment </li></ul><ul><li>Radiation safety </li></ul><ul><li>Informed consent and ethics </li></ul><ul><li>Recognition/management of adverse events </li></ul><ul><li>Medication errors and complications </li></ul><ul><li>Guideline adherence </li></ul><ul><li>Conscious Sedation </li></ul><ul><li>Procedural performance </li></ul>
    37. 38. Pilot Study Metrics <ul><li>The following primary metrics were recorded for each simulation: </li></ul><ul><ul><li>Successful completion of the simulation </li></ul></ul><ul><ul><li>Time to successfully complete the simulation </li></ul></ul><ul><ul><li>Total fluoroscopy time </li></ul></ul><ul><ul><li>Successful recognition/management of adverse events </li></ul></ul><ul><ul><li>Time to treat adverse events </li></ul></ul><ul><ul><li>Performance on case based MCQ’s </li></ul></ul><ul><ul><li>Performance on post-training MCQ’s </li></ul></ul>
    38. 39. Simulated Cases for AHRQ Pilot Project Hypoglycemic episode requiring treatment; Development of CHF during graft angiography Diabetic patient with LV dysfunction s/p CABG with 3 SVG’s. Case 6—Coronary Angiography with Saphenous Vein Graft Angiography Contrast reaction requiring treatment;Oversedation Multivessel disease in an elderly female Case 5—Coronary Angiography Need JL6 due to dilated aorta; Patient develops symptomatic rapid a. fib needing cardioversion Aortic stenosis with LAD/diag high grade stenosis Case 4—Coronary Angiography Pressure dampening; if >30 sec patient has VF. Spasm of right coronary artery upon cannulation Case 3—Coronary Angiography Vasovagal reaction with bradycardia and hypotension Patient with Severe Primary Pulmonary Hypertension Case 2—Right Heart Cath Complete heart block requiring temporary transvenous pacing Acute myocarditis with decompensated CHF and underling LBBB Case 1—Right Heart Cath Adverse Event Patient Scenario Case #/ Procedure
    39. 40. PATIENT SAFETY ELEMENTS USED IN ALL CLINICAL SIMULATION STAGES OF CORONARY ANGIOGRAPHY Implementation of pre-procedure aspects of Safety Plan Recognition and management of patient reactions Preparation of a patient-specific Safety Plan Debriefing session with team s/p near misses and adverse events Recognition and management of adverse events Informed consent Explanation of adverse events to patient, family, and friends Recognition and management of technical difficulties Assessment of patient-specific risks Documentation of adverse reactions, technical difficulties, near-misses, and recommendations for future procedures Performance of procedure Determination of relative contraindications On-going recognition and management of adverse events Implementation of procedural aspects of Safety Plan Determination of indications for procedure Implementation of post-procedural aspects of Safety Plan Review of procedure plan & risks by team Initial patient evaluation Post-Procedure Procedure Pre-Procedure
    40. 41. Enhancing Patient Safety During Cardiac Catheterization Using Simulation-Based Training Completion of Six Simulated Case Scenarios <ul><li>Study Design: </li></ul><ul><li> </li></ul><ul><li>28 First and Second Year Cardiology Fellows </li></ul><ul><ul><li>UCHSC </li></ul></ul><ul><ul><li>Geisinger Medical Center </li></ul></ul><ul><ul><li>Hershey Medical Center </li></ul></ul><ul><li>Randomized in stratified fashion to control group versus simulation-based training group </li></ul>Pre-test Assessment Simulation-based Didactic curriculum N=13 N=15 N=28 Control Group Post-Test MCQ Assessment Post-Test MCQ Assessment
    41. 42. Results <ul><li>Survey of Field Awareness of Simulation </li></ul><ul><ul><li>322 respondents (32% response rate) </li></ul></ul><ul><ul><li>60% Familiar with simulation based training </li></ul></ul><ul><ul><li>36% of respondents used some form of simulation </li></ul></ul><ul><ul><li>Mostly Low Fidelity Simulation </li></ul></ul><ul><ul><ul><li>Most were clinical scenarios and computer based simulation </li></ul></ul></ul><ul><ul><ul><li>Virtual reality training in 12% of centers </li></ul></ul></ul>
    42. 43. Results <ul><li>A total of 28 cardiology trainees have undergone simulation based training and assessment </li></ul><ul><li>Subjects were randomized to either control group or a simulation-based didactic curriculum focusing on patient safety </li></ul>
    43. 44. Results—Patient Safety Knowledge <ul><li>Control group and simulation group performed equally on pre-test assessment (20.1 vs 20.3) </li></ul><ul><li>Simulation group performed significantly better on post-test assessment (23.5 vs 28.4, p<0.003) </li></ul>
    44. 45. Simulation Results <ul><li>No differences were found between groups for procedural time, contrast or radiation </li></ul><ul><li>There were marked variations in practice </li></ul><ul><li>There were differences in the recognition and management of simulated adverse events (SAE’s) between the two groups </li></ul>
    45. 46. Treatment of Adverse Events
    46. 47. How Do We Know Simulation Will Impact Patient Safety? <ul><li>Simulators are validated in a number of fields </li></ul><ul><li>Simulation based training improves performance in a variety of simulator systems </li></ul><ul><li>Transfer of skills to clinical practice now shown </li></ul><ul><li>Learning curve shifted to a “safer” simulated environment </li></ul><ul><li>Incorporation into credentialing/certification </li></ul>
    47. 48. <ul><li>Current Training Paradigm in Perspective </li></ul><ul><li>Background of Simulation in Medicine </li></ul><ul><li>Improving Skills with Simulation </li></ul><ul><li>Outcome Studies of Medical Simulation </li></ul><ul><li>AHRQ Pilot Project for Skills Training </li></ul><ul><li>Challenges for Improving Medical Care using Simulation </li></ul>
    48. 49. Unanswered Questions <ul><li>Does this training have a lasting effect on skills and judgment? </li></ul><ul><li>Can this type of curriculum be incorporated into other simulations? </li></ul><ul><li>Will awareness of these projects translate into wider acceptance of simulation training in healthcare? </li></ul>
    49. 50. The Road Ahead <ul><li>Integrate team training curricula in a structured, comprehensive manner </li></ul><ul><li>Understand how and when it is most effective </li></ul><ul><li>Develop reliable, valid and reproducible measures of team performance </li></ul><ul><li>Expand the evidence base for the efficacy and cost effectiveness of team training using simulation </li></ul>
    50. 51. “ No industry in which human lives depend on the skilled performance of responsible operators has waited for unequivocal proof of the benefit of simulation before embracing it.” --David Gaba, MD Gaba DM Anesthesiology 1992;76:491-494