simulation technology in critical care: 1000 deaths for medical education technology for teaching...
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Simulation technology Simulation technology in critical care: in critical care: 1000 deaths for 1000 deaths for
medical educationmedical education
Technology for teaching Technology for teaching and evaluating critical care and evaluating critical care
knowledge, skills and knowledge, skills and attitudesattitudes
Randy S. Wax, MD, FRCP(C)Technology Application Unit and Critical Care
Unit, Department of Medicine, Mount Sinai Hospital
Lecturer, Department of Medicine, University of Toronto
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Learning objectivesLearning objectives
Why simulation?Features of a simulatorApply simulation technologyLimitations and resource
requirements
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A traditional approach to learningA traditional approach to learning
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Problem #1Problem #1
Just because students learn a task in the classroom doesn’t mean they can demonstrate successful performance during a crisis.
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Problem #2Problem #2
Some clinical experiences are so life threatening that students are not going to be involved in the management.
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Problem #3Problem #3
Some are so rare that the student may not ever experience the situation until they are in the midst of caring for the patient.
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Different simulation Different simulation formatsformats
Patient management problems (paper/pen)
Computerized simulation– Internet-based
Role playing/standardized patientsMannequin-based (e.g., CPR BCLS
trainer)Virtual reality
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Why simulation?Why simulation?
Used in many “high reliability” fields– Aviation
– Nuclear power
– Military flight operations
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Why simulation?Why simulation?
No risk to patients Many scenarios can be presented,
including uncommon but critical situations in which a rapid response is needed – E.g. malignant hyperthermia 1:40,000 cases
Participants can see the results of their decisions and actions; errors can be allowed to occur and reach their conclusions
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Why simulation?Why simulation?
Identical scenarios can be presented to different clinicians or teams
The underlying causes of the situation are known
With mannequin based simulators clinicians can use actual medical equipment– examine limitations in the human-machine
interface
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Why simulation?Why simulation?
Re-create clinical environments– Assess interpersonal interactions with other
clinical staff
– Evaluate and improve teamwork, leadership, and communication skills
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Why simulation?Why simulation?
Intensive and intrusive recording of the simulation session is feasible– Audiotape
– Videotape
– Physiological monitoring of participants (EEG, ECG, etc.)
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Why simulation?Why simulation?
There are no issues of patient confidentiality
Recordings can be preserved for research, performance assessment, or accreditation
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How can we use How can we use simulation?simulation?
Skills trainingEvaluation
Epidemiology and modification of errors (and their consequences)
Crisis resource management
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What can you What can you teach/evaluate?teach/evaluate?
Specific skills– Intubation– Bronchoscopy– Defibrillation
Integration of knowledge, skills and decision making– Resuscitation– Refractory hypoxemia
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Level 1 Level 2 Level 3
Skill Integrate High-fidelity
Medical Student
Bag ventilation
Hypoxemic patient
Ward team
Resident Intubate Hypoxemic patient
ER/ICU RN, RT
Fellow/
Staff
LMA, surgical airway
Difficult airway management
Full ER/ICU team
CME
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Evaluation of the evaluation toolEvaluation of the evaluation tool
Type of simulator– Low to high fidelity
Type of simulation– Full theatre environment or real location– Training device for specific tasks
Efficacy of assessment– Valid– Reliable
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SIM MANSIM MAN
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Life-size Life-size mannequinmannequin
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Computer Computer ControlledControlled
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Teach airway Teach airway managementmanagement
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Use airway devicesUse airway devices
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Fibreoptic intubationFibreoptic intubation
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Difficult airway– Decreased cervical range of motion– Tongue edema– Pharyngeal edema– Laryngospasm– Trismus– Fiberoptic intubation/bronchoscopy– Surgical airway – Detectable carbon dioxide
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Breath soundsBreath sounds
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Check pulse & blood pressureCheck pulse & blood pressure
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Obtain peripheral IV Obtain peripheral IV accessaccess
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Mask ventilationMask ventilation
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Decompress tension Decompress tension pneumothoraxpneumothorax
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Monitor cardiac rhythmMonitor cardiac rhythm
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Shock unstable rhythmsShock unstable rhythms
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Additional featuresAdditional featuresChest tube insertionInvasive hemodynamicsVentilator management (including
HFOV)
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Control crisis situationsControl crisis situations
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Give feedbackGive feedback
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Assessment instrumentsAssessment instruments
Specific– Debriefing (oral or written…good for factual)– Observation and scoring system (checklist
or score sheet or palm pilot)– Time to performance of specific task
Global– Simulated mortality as end-point– Time to solve problem
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How can we use How can we use simulation?simulation?
Skills trainingEvaluation
Epidemiology and modification of errors (and their consequences)
Crisis resource management
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Epidemiology of Medical Epidemiology of Medical ErrorError
Types of errors made during anaesthesia simulation
37%
17%13%
10%
33%
Monitor usage
Airwaymanagement
Ventilatormanagement
Drugadministration
Other
Schwid and O’Donnell Anesthesiology 1992
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Crisis Resource Crisis Resource ManagementManagement
Using all available resources during a crisis to achieve safety and efficiency– Information– Equipment– People
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Crisis Resource Crisis Resource ManagementManagement
Error countermeasures– Reduce the frequency of errors– Correct errors– Limit the impact of errors
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ResourcesResources
Simulator PLUS operational budget Competency standards
– Who/what are you testing? Content experts
– Set objectives and clinical setting Simulation experts
– Translate objectives and clinical setting into functional simulation scenarios
AV equipment (debriefing)
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Limitations of simulationLimitations of simulation
Difficult to demonstrate improved outcome from use of simulation– Adverse events are unusual– Extreme number of potential
confoundersForced to use simulation
performance as surrogate outcome
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Initiatives at MSHInitiatives at MSH
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Initiatives at MSHInitiatives at MSH
Mock cardiac arrests– ACLS protocols– Use of equipment– Systems issues (elevators, cancel
arrest)– Crisis resource management– Feedback/debriefing
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Initiatives at MSHInitiatives at MSH
Life-saving delegated medical acts– ICU/CCU nurses– Use of epinephrine/atropine– Defibrillation
Pre-ACLS interventions– Bag-valve-mask ventilation– Understanding respiratory failure and
shock
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Initiatives at MSHInitiatives at MSH
Medical and Critical Care Residents Continuing education courses
– Difficult airway management– Advanced ARDS strategies
Technology evaluation– OCCIN Project
Multidisciplinary approachPortable
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Parting commentsParting comments
Simulation is fun for students and teachers
You can use simulation technology as an evaluation tool
Choose the most appropriate tool for achieving educational goals
Remember basics of education, otherwise simulator is an expensive toy