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

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Application of simulation in anesthesia Application of simulation in anesthesia

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