MEDICAL SIMULATION IN MEDICAL SIMULATION IN IMPROVING PATIENT SAFETYIMPROVING PATIENT SAFETY

Professor Harry OwenProfessor Harry Owen

Director, Clinical Skills and Simulation UnitDirector, Clinical Skills and Simulation Unit

Flinders UniversityFlinders University

Adelaide, South AustraliaAdelaide, South Australia

harry.owen@flinders.edu.auharry.owen@flinders.edu.au

MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY

• Background to simulation

• Simulation technologies used in Medical Education in Australia, the US and Europe

• Fundamentals of high-fidelity simulation

• How simulation can improve patient safety

• Emerging trends in simulation

Why simulation?

• Simulation is valuable when ‘on-the-job’ training is expensive or risky

• Simulation has been adopted for training where consequences of error expose many people to risk or the cost of error is high, for example:– Aerospace– Military– Nuclear power plants

Medicine: A High-Risk Industry• Harvard Medical Practice Study (1991)

identified a ‘serious error’ rate of 3.7%– (serious error leads to prolonged hospital

stay or disability)

• Vincent (2001) NHS ~11% error rate with 50% preventable– ~50,000 patients pa die from medical error

or accident. Litigation cost £44billion

• Australian data - adverse event rate of ~17%

How simulation can improve patient safety

• Fewer errors

• Better error trapping

• Improved recognition of error and/or consequences of error

• Develop capacity to manage consequences of error

Advantages of Simulation

• Structured learning

• Guaranteed and scheduled opportunities for teaching learning– Uncommon situations can be presented– Teacher can model process, give

feedback, repeat process, modify process

• Repetition as often as needed

Successful strategies for crisis management:

• Use of written checklists to help prevent crises

Use of established procedures in responding to crises

Training in decision making and resource co-ordination

• Systematic practise in handling crises including part-task trainers and full-mission realistic simulation

Who’s who in medical education

• Basic medical education– Medical students

• Pre-vocational medical education– Interns, RMOs, PGY 1&2

• Specialist training (discipline-based)– Registrars/Senior registrars/Fellows

• Specialists and GPs (life-long learning)– CME, MOPS, IRM, etc

• Teachers and trainers

Simulation technologies used in medical education

• Computer-based simulations (micro-worlds, micro-simulation)

• Virtual environments +/- haptics

• Part-task trainers

• Low-fidelity simulators/manikins

• Simulated or standardised patients

• Hybrid simulations

• High-fidelity (full mission) simulation

Cost and benefit in simulation

Increasing level of fidelity and exclusivity

$$$$$$$$$$

Manikin training

Part-task trainers

Full mission simulation

CBT

Medical Education includesKnowledge/Skills/Attitudes

• Individual psychomotor skills

• Appropriate application of skills

• Communication / Team performance / Leadership skills (CRM)

• Supervision/teaching

• Assessment

Knowledge/Skills/Attitudes

• Teaching best practice– integrated– learner centred– appropriate use of technology

• Assessment best practice– valid and reliable– reproducible

The Flinders Clinical Skills and Simulation Unit

• Grew from a project to improve airway management teaching to medical students

• Value to teaching other health professionals and other skills quickly recognised

• Now involved in teaching across disciplines and outside the medical school

Endotracheal intubation

• Learnt on patients under anaesthesia

• No special consent

but• Duty of care to protect

patient from harm• Increased risk when

performed by a student or trainee

Endotracheal intubation

• ETI needed by many health professionals, including anesthesiologists, paramedics/EMTs, rural GPs, emergency physicians, ICU staff, respiratory therapists, etc.

• Competence requires practise

• Animals– Small, e.g. cats– Large, e.g. dogs or

monkeys

• Unconscious patients– In the OR– In ICU

• Newly dead/recently deceased

• Cadavers• Simulators

When and how should ETI be taught?

The learning environmentThe learning environment

• Quiet, few Quiet, few distractorsdistractors

• Clinical equipmentClinical equipment• Expert tutorsExpert tutors• Realistic modelsRealistic models• Many different Many different

modelsmodels– Easy Easy difficult difficult

very difficult very difficult

Outcomes of the ETI program

• Goal of reducing patient risk of trauma has been achieved

• Improved confidence of students and trainees

• Trainees receive more teaching

• Improved trainer satisfaction

The Flinders Clinical Skills and Simulation Unit

• CBT – ResusSim– CathSim– PA simulator– ECG– Local anaesthesia

• Part-task trainers– BLS & ALS– IVI & CVC– Trauma– Adult– Gynae & Obstetric– Neonatal– Premature (28wks)– Paediatric (age

range)

CPR Prompt ®

(Compliant)Actar D-Fib® (Armstrong)

Little Anne™ (Laerdal)

CPR Pal® (Ambu)

Basic Buddy™ (Lifeform)

Economy Saniman ®

(Nasco)

Adult A-A Female ®

(Nasco)

Fat Old Fred ®

(Lifeform)David/Adam ®

(Nasco)

The Flinders Clinical Skills and Simulation Unit

• Several whole body manikins including:– ResusciBaby– ALS baby– ResusciAnne with

SkillReporter– Mr Hurt– Nursing Anne– Megacode Kid– etc

• SimMan UPS– Postoperative care

modules– Trauma modules– Severe Trauma

modules– Local produced

dental trauma modules

Anatomy of a simulation (1)

Components• Student/trainee/

health professional • Procedure/task/skill/test/

treatment or equipment• Patient and/or disease process• Trainer/supervisor

Anatomy of a simulation (2)

Function of components• Passive

– Enhance setting for realism

• Active– Change in a programmed way

• Interactive– Responds to action or event

Trainees learning cricothyrotomy on a part-task trainer

(Note educational aids in background)

Trainee performing an emergency cricothyrotomy in a full-mission simulation.

(Note more realistic setting)

High fidelity simulation (1)

• Determine educational needs and choose most efficient and effective

• Need to balance resource availability and student demand

• May need to ‘promote’ low-tech solutions

High fidelity simulation (2)

• Confirm teaching goals can be achieved using simulation

• Develop scenario, acquire equipment needed and prepare associated materials

• Test and validate the simulation

Resources

• Equipment– Simulators, monitors, defibrillator, trolleys, etc

• Disposables– Appropriate for scenario, setting and

participants, re-use w/o compromising fidelity

• Faculty– Trained, available, practised

• Support staff– Bio-medical technician essential! Also clerical.

Before and after simulations...• Set-up scenario

– eg. make blood, set up OR, X-rays, etc

• Load up simulation program

• Check everything works– Cameras, VCR, communicators

Afterwards...

• Check simulator

• Clean everything used and put away

• Replace/reorder all used items

High fidelity simulation (3)

• Allow time for familiarisation with the simulator & equipment

• Brief participants on:– The scenario– Educational objectives– How to get help

High fidelity simulation (4)

Always follow the script but...

…have alternative outcomes planned and rehearsedSimulation control room

High fidelity simulation (5)Using simulation situations

can be re-run to explore outcome with different treatments

Mission critical tasks can be performed by learners without putting patients at risk

High fidelity simulation (6)

Facilitated debriefing with an expert practitioner. Participants reflect on their own performance and discuss this with the group

How we use the SimMan UPS• Anaesthesia• Emergency medicine• Family Medicine/GP• CCU/ICU• Trauma/retrievals• Paramedics/EMT• Specialist nurses• Medical Imaging• Paediatrics• Rural health workers

• Sim Centre settings– OR, PACU, ER,

Imaging suite, post-op ward, clinic, aircraft, ambulance, home, roadside, terrorist incident, etc

• Outreach settings– Regional hospitals,

rural settings, etc

Source: Jones A (BMSC)

Simulation centres

2

209

5

25

10

195

6

11

2

10

2

May 2003

Flinders Uni

Publications on ‘patient simulation’ in clinical care

0

10

20

30

40

50

60

70

80

90

100

'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02

Papers

Year

Research needed on simulationin healthcare training

• Improved outcomes– Fewer adverse events, fewer preventable

incidents, fewer ‘near miss’ events

• Increased efficiency of training– Improved outcomes in same or (preferably)

less training time

• Improved use of resources– Fewer failures, more efficient training,

quicker performance

Simulation technologies used in medical education

• Computer-based simulations (micro-worlds, micro-simulation)

• Virtual environments +/- haptics

• Part-task trainers

• Low-fidelity simulators/manikins

• Simulated or standardised patients

• Hybrid simulations

• High-fidelity (full mission) simulation

The future of simulation...• Skills training tool for all disciplines

– Acute care– New techniques and/or equipment– Managing complications– Retraining

• Multi-disciplinary training– inter-professional communication– team performance

• Training in decision-making/resource co-ordination