Introduction to the science and practice of medical and surgical simulation. Topics Covered: History, Taxonomy, Learning Processes, Standardized Patients, Patient Simulators, Team Training, Surgery Simulators, Best Practices.

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A Comprehensive Introduction to
Medical Simulation
Roger Smith, PhD, Florida Hospital
Danielle Julian, MS, Florida Hospital
Karen Kelly, MSN, RN, Florida Hospital
Sumi Michael, MSN, ARNP, Orlando Health

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Outline
➢ Introduction
➢ History
➢ Taxonomies
➢ Learning Processes
➢ Standardized Patients
➢ Patient Simulators
➢ Team Training
➢ Surgery Simulators
➢ Best Practices
➢ The Future

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History of Medical Simulation, Roger Smith

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Static Earth Materials Models
Circa 1900-1600BC
Clay Sheep Liver
Model. Diagnosis of
disease for health
and religious
reasons.
- British Museum

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Anatomy Textbooks
Circa 1538AD
“Outline of the
Skeleton” a study of
anatomy.
- Orfila Museum, Paris
Owen H. (2016) Simulation in Medical Science. In: Simulation in Healthcare Education. Springer, Cham

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Cadaver & Animal Models
The Anatomy Lesson of Dr. Nicolaes Tulp, by Rembrandt va Rijn, 1632 Vivisection performed on a dog, by Emile-Edouard Mouchy, 1832.

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Mechanical Simulators
Owen H. (2016) Simulation in Medical Science. In: Simulation in Healthcare Education. Springer, Cham
Circa 1740AD
“Breathing Venus”
Lung Simulator by
Benjamin Hoadly.
- Orfila Museum, Paris

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Hybrid Bio Models
Circa 1763AD
Macchina Anatomica
by Guiseppe Salerno
for teaching
circulation.
- Museo Cappela Sanservo

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Synthetic Anatomical Models
Circa 1798AD
Anatomical Venus by
Clemente Susini for
teaching anatomy.
- Natural History Museum
at the University of
Florence

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Multi-layered Textbooks
Circa 1876AD
Anatomie
Iconoclasticque
layered illustrations in
book form.

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Dolls as Training Devices
Circa 1911AD
Josephine Chase Doll
Hartford Hospital, CT
- Hartford Hospital
Archives

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Ventilator and Mannikin
Circa 1907AD
Resuscitation
ventilator on a doll
- Drager Co.
Ubeck, Germany

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Intubation Simulator
Circa 1929AD
Plaster head with
elastic tongue and
throat.
- Schlossarek Co.
Vienna, Austria

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Denson JS, Abrahamson S. A computer-controlled patient simulator. Journal of the American Medical Association 1969; 208:504–8.
Computerized Mechanical Simulators
Sim One (1967):
Computers, Mechanics,
& Manikins
Respiration
Heartbeat, Pulse, and BP
Eye Blink
Physiologic Response to Drugs

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Virtual Reality Simulators
Circa 1995
Minimally Invasive
Surgery Trainer –
Virtual Reality (MIST-
VR).
- Bob Stone, UK

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Reference Taxonomies, Roger Smith

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Military Simulation Taxonomy
Live Virtual
Constructive GamesHofer, 1995

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LVC+G is not the best structure for
Medical Simulation

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Progressive Complexity
Satava, 2001
Precision
Placement
Simple
Manipulation
Complex
Manipulation
Integrated
Procedure
Fits very specific types of treatment
Needle placement
for blood draw
Ultrasound wand
manipulation
Anastomosis suturing Multiple steps
of hysterectomy

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Sim Tools Taxonomy
Sulistio, 2004 Not helpful to users of simulators

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Sim Structure Taxonomy
Pott, 2009
Confusing, Difficult to understand

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Healthcare Simulation Modalities
Chiniara, 2012 Very Useful
Computer-
based
Simulation
Simulated
Patient
Simulated
Clinical
Immersion
Procedural
Simulation
Hybrid
Simulation

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Taxonomy of Mechanism and Application
Biological
Virtual
Mechanical

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Taxonomy of Mechanism and Application
Biological
Virtual
Mechanical
Cadaver Animal
Stdized
Patient
Live
Team
Mannikin
White
Box
VR Games
Part
Task
Useful, But many categories

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Learning Processes, Karen Kelly

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Simulation Based Healthcare Education
Didactic
Learning
Partial
Task
Trainer
Human
Patient
Simulator
Team
Training

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Bloom’s Taxonomy of Learning
Create
Evaluate
Analyze
Apply
Understand
Remember

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Clinical Competency
Based on work by Miller GE, The Assessment of Clinical Skills/Competence/Performance: Acad. Med. 1990:65(9): 63-67
Adapted by Drs. R. Mehay & R. Burns, UK (Jan 2009)

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Debrief Models
Advocacy
Inquiry
Reaction
Analysis Summary
GAS Gather Analyze Summarize
3 D Introduction Defuse Discover Deepen Summarize
PEARLS Reaction Description Analysis Summary
Healthcare
Sim AAR
Define rules
Explain
objectives
Benchmark
performance
Review
expected
actions
Identify what
happened
Examine why
they
happened
Formalize
Learning

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Simulation Assessment Tools

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Simulating Patient Behavior and
Response, Karen Kelly

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Standardized Patient Models

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Hybrid Simulations with Simulated Patients

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Simulating External Anatomy and
Physiology, Sumy Michael

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Task Trainers

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Ultrasound phantom task trainer

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Pediatric Task Trainers

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Task Trainers in Research
38

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Tissue Task Trainer
39
Used with author permission
Image Author: James M McKee
Retrieved from National Library of Medicine MedPix site

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High Fidelity Patient Simulators

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Moulage and Fidelity

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Hybrid Simulators and Innovations
42
Copyright © 2018 Society for Simulation in Healthcare

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Patient Safety and Healthcare
Simulation, Sumy Michael

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Team Training

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Simulation-Enhanced Interprofessional
Education
TeamSTEPPS
Strategies & Tools to Enhance Performance and Patient Safety

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Insitu Simulation

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Error Proofing

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System Probing
toughmudder@dyehardfansupply.com

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Simulating Internal Anatomy and
Physiology, Danielle Julian

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Surgical Modalities

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Open Surgical Simulation
Cadaver
Bench Models
VR
Animal

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Laparoscopic Surgery Simulators

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Robotic Surgery Simulators
Intuitive DVSS Mimic dV-Trainer Sim Surg RoSS Simbionix Robotix Mentor

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Robotic Surgery Simulators
Assessments

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Simulating Internal Anatomy

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Medical Simulation Best Practices,
Danielle Julian

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Simulation Program Standards and Processes

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Characteristics of a Simulation Program
Four main domains of a simulation program:
Curriculum/
Assessment
Instructor/
Personnel
Equipment/
Technology
Supporting
Infrastructure

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Summary of Characteristics
Organization
Scope
(Broad vs. Specialty Specific)
Physician Medical Students Nurses Other Health Care
Professionals
Society for Simulation
in Healthcare ✓ ✓ ✓ ✓
American College of
Surgeons ✓ ✓ ✓ ✓
American Society of
Anesthesiologist ✓
American Congress of
Obstetricians and
Gynecologists
✓

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Summary of Characteristics
Organization
Format Focus
Curricula and
Learners
Instructor/
Personnel
Requirements
Equipment and
Technology
Organization and
Infrastructure
Other
Society for Simulation in
Healthcare ✓ ✓ ✓ ✓ ✓
Research, system
integration
American College
of Surgeons ✓ ✓ ✓ ✓
American Society of
Anesthesiologist ✓ ✓ ✓ ✓
American Congress of
Obstetricians and
Gynecologists
✓ ✓ ✓ ✓
Shared curricula

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Future Directions, Roger Smith

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Modeling the Body
Geometry
•Complex
•Non-linear
•Non-uniform
Appearance
•Layered
•Translucent
•Dense
Dynamics
•Nerve movement
•Blood flow
•Elasticity
Center for Research in Education and Simulation Technologies, Rob Sweet, MD

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Synthetic & Virtual – Inside & Out
SynDaver Inc., Tampa Florida Envision Experience.com

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Summary
Computer-
based
Simulation
Simulated
Patient
Simulated
Clinical
Immersion
Procedural
Simulation
Hybrid
Simulation
History Taxonomies
Learning
Processes
Patient
Simulators
Team Training
Surgical
Simulators Best Practices
Standardized
Patients

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Thank You
We just touched the tip of the iceberg.
There is so much more.

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References
History
Denson JS, Abrahamson S. A computer-controlled patient simulator. Journal of the American
Medical Association 1969; 208:504–8.
Hofer, R & Loper M. (1995). Distributed interactive simulation today. Proceedings of the IEEE,
83(8).
Taxonomy
Chiniara, G, et al. (2013) Simulation in healthcare: A taxonomy and a conceptual framework for
instructional design and media selection, Medical Teacher, 35:8
Owen H. (2016) Simulation in Medical Science. In: Simulation in Healthcare Education.
Springer, Cham
Pott, L., Budde, A., Murray, W. (2009). A Proposed classification of simulators. Middle East
Journal of Anesthesiology, 20(2).
Satava, R. (2001). Surgical education and surgical simulation. World J. of Surgery, 25.
Smith, R. (2009). Simulation and Game Technology in Medical Education. Modelbenders
Press.
Sulistio, A, Yeo, C., & Buyya, R. (2004). A Taxonomy of computer-based simulations and its
mapping to parallel and distributed systems simulation tools. Software Practice and
Experience, 34
Padilla, J, Diallo, S, Armstrong, R. (2018). Toward live virtual constructive simulation in
healthcare learning. Simulation in Healthcare, 13(35), S35-S40.
Team Training
Jeffries, P. (2014). Clinical Simulations in Nursing Education Advanced Concepts, Trends, and
Opportunities. Wolters Kluwer/Lippincott, Williams & Wilkins
Palaganas, J., Maxworthy, J., Epps, C., & Mancini, M. (2014). Defining Excellence in
Simulation Programs. Lippincott, Williams & Wilkins
Sawyer, T., Eppich, W., Brett-Fleegler, M., Grant, V., & Cheng, A. (2016). More than one way
to debrief: A critical review of healthcare simulation debriefing methods. Simulation in
Healthcare, 11:3. 209-217.
Sewell, C., Morris, D., Blevins, N., Dutta, S., Agrawal, S., Barbagli, F., & Salisbury, K. (2008).
Providing metrics and performance feedback in a surgical simulator, Computer Aided Surgery,
13:2, 63-81. DOI:10.3109/10929080801957712

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References
Medical Simulation Best Practices
Fernandez, R., Sherman, M., Strother, C., Benedetti, T., & Andreatta, P. (2013). Program and
Center Accreditation. In A.I. Levine et al (Eds.), The Comprehensive Textbook of Healthcare
Simulation (pp. 641-648). New York, NY: Springer Science+Business.
Society for Simulation in Healthcare Accreditation Committee. SSH Accreditation Process.
http://www.ssih.org/Portals/48/AccreditationSSH%20Accreditation%20Informational%20Guide.
pdf?ver=2017-03-09-133118-517. Accessed 28 August 2018.
American College of Surgeons Division of Education. Accredited Education Institutes. 2013.
https://www.facs.org/~/media/files/education/aei/aei%20requirements.ashx. Accessed 26
August 2018.
American Society of Anesthesiologist. ASA simulation program endorsement application.
http://simapps.asahq.org/. Accessed 26 August 2018.
Simulating External Anatomy and Physiology
Jeffries, P. (2014). Clinical Simulations in Nursing Education Advanced Concepts, Trends, and
Opportunities. Wolters Kluwer/Lippincott, Williams & Wilkins
Cheng, A., Belanger, C., Wan, B., Davidson, J., & Lin, Y. (2017). Effect of Emergency
Department Mattress Compressibility on Chest Compression Depth Using a Standardized
Cardiopulmonary Resuscitation Board, a Slider Transfer Board, and a Flat Spine
Board. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare,1.
doi:10.1097/sih.0000000000000245
Pongpaibul, A., Chiravirakul, P., Leksrisakul, P., Silakorn, P., Chumtap, W.,
Chongpipatchaipron, S., . . . Jitvichai, E. (2017). Rectal Carcinoma Model. Simulation in
Healthcare: The Journal of the Society for Simulation in Healthcare,12(3), 189-195.
doi:10.1097/sih.0000000000000214