simulation what can smart people learn from...
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Simulation What can smart people learn
from dummies? Ambulatory Surgical Facilities
November, 2015
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• Inclusion of specific simulators does not imply endorsement
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Could this happen at your facility?
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• Who should respond? Who should stay away?
• Where will the fire department arrive?
• Where are the gas cut-off valves?
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What should they do next?
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To create a simulation
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Goal
Debriefing
Simulation Simulator
Repeat: to practice, or to modify
Goals of simulation
• To improve
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Individuals Knowledge, technical and non-technical skills
Teams Knowledge, technical and non-technical skills
Systems
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High technology manikins
• Breathe, chest wall motion, normal and abnormal breath sounds
• Palpable pulses
• Reactive pupils
• Can be defibrillated
• Vital signs displayed on monitor in real time
• Respond to interventions
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Image courtesy of Beth Rymeski, DO
Low technology simulators
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Low technology simulators
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Video courtesy of Glenn Stryjewski, MD
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Biologic tissue
• Pig larynges
– Cricothyrotomy
• Pig feet
– Simple suturing
– Local flaps
• Cadavers
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Virtual reality (screen-based) simulators
• Endoscopic
• Laparoscopic
• Otologic and Sinus
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Images courtesy of Gregory Wiet, MD and David Rodgers, EdD
Robotic simulators
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Humans!
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Debriefing: Essential component of learning from simulation
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Examples of simulation applications
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Individuals Knowledge Technical skills: procedures Non-technical skills: providing information, expressing concerns
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Individuals
• Example: intubation
• Repetition with varied models helps reinforce commonalities
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“Just-in-time; Just-in-place”
• Central line “Dress Rehearsal”
• “train to excellence”
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Examples of simulation applications
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Individuals Knowledge Technical skills: procedures Non-technical skills: providing information, expressing concerns
Teams Knowledge Technical skills: coordinating roles in resuscitation Non-technical skills: communication, collaboration
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Teams Communicate, coordinate, manage (or avert)
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• Example: trauma
• Manage the team as well as the patient
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Does simulation make a difference? • Growing body of evidence demonstrating effectiveness
– Wiet GJ et al. Laryngoscope. 2012;
– Fried MP et al. Otolaryng Head Neck. 2010;
– Draycott TJ et al. Obstet Gynecol. 2008;
– McGaghie WC et al. Acad Med. 2011;
– Cook DA. Med Educ. 2014;
– Wolfe H et al. Crit Care Med. 2014
• Simulation supports early acquisition of complex skills; improves procedural skills, surgeon confidence, patient care practices and outcomes, as well as providing collateral benefits such as transfer of skills and knowledge to other trainees, and reduced healthcare costs
– McLaughlin S et al. Acad Emerg Med. 2008;
– McGaghie WC et al. Med Educ. 2014;
– Cohen ER et al. Simul healthc. 2010;
– Scholtz AK et al. Simul healthc. 2013;
– Barsuk JH et al. Acad Med. 2011.
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Does simulation make a difference?
• Specific skills relevant to otolaryngology have been demonstrated to be transferrable from simulation to procedures on actual patients (“in vivo”) – Fried MP et al. Otolaryng Head Neck. 2010;
– Howells TH et al. Br J Anaesth. 1973.
• Residents trained on an endoscopic sinus surgery simulator, when compared to controls, showed decreased completion time, increased confidence and fewer technical errors on basic surgical tasks done on patients – Fried MP et al Otolaryng Head Neck. 2010
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Examples of simulation applications
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Individuals Knowledge Technical skills: procedures Non-technical skills: providing information, expressing concerns
Teams Knowledge Technical skills: coordinating roles in resuscitation Non-technical skills: communication, collaboration
Systems Processes, equipment, environment, information technology, staffing
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Employees must wash hands
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Transitions in Care
• Transport from the helipad to the Emergency Department
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Investigate serious events or incidents
• Re-enacted a medication error using actual equipment:
– Dose double-check protocol not well understood
– The infusion pump “stuttered” (duplicated a keystroke), delivering 22.3 mg, rather than 2.3 mg, of a medication
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Intentional probes during planning, before opening new/renovated units
• Simulate patient admissions
– Confusing room numbers were rearranged
– Location of certain equipment was optimized
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Intentional probes during planning, before opening new/renovated units
• Simulations included:
– Equipment failure
– Medical crisis
• Results
– Clarified transport processes
– Clarified medication management
– Standardized information given to, and announced by, dispatchers
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Simulation to improve systems
• To err is human – To err is human:
building a safer health system. Institute of Medicine 1999
• To err is human, don’t forget – Pat Croskerry, CMAJ March 2010
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The search for a human in the path of a failure is bound to succeed.
If not directly at the sharp end – as a ‘human error’ or unsafe act – one can usually be found a few steps back.
The assumption that humans have failed therefore always vindicates itself.
Hollnagel, E.; Woods, DD. Joint Cognitive Systems: Foundations of Cognitive Systems Engineering
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It's not bad people it's bad systems. Lucian Leape. NPSF conference April 30 2015
To better is human Terry Fairbanks. MedStar Health National Center for Human Factors in Healthcare medicalhumanfactors.net accessed Nov 2, 2014
To blame is human. The fix is to engineer
Holden RJ. People or systems? To blame is human. The fix is to engineer. Prof Saf 2009
Refine equipment and processes
• Computer placement in patient care rooms affected caregiver traffic patterns
– Changed computer locations
• Practiced replacing medication infusion pumps during active use
– Revised protocol to manage “dirty” pumps
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Healthcare is a complex adaptive system
• Constant evolution
– Fluid, dynamic
• Networks of agents who constantly act and react
• Control is dispersed and decentralized
• Environment is not in equilibrium
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Charles Vincent, Patient Safety, also referencing Holland, Mann, Plesk, Greenhalgh
Dekker, Drift into Failure, referencing Von Bertalanffy
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Safety is not inherent in systems
• The systems themselves are contradictions between multiple goals that people must pursue simultaneously. People have to create safety.
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Attributed to Dekker 2002 and Hollnagel & Woods 2005, by Holden RJ. People or systems? To blame is
human. The fix is to engineer. Prof Saf 2009
• Preventing errors and improving safety for patients require a system approach in order to modify the conditions that contribute to errors
• People working in health care are among the most educated and dedicated work force in any industry
• The problem is not bad people, the problem is that the system needs to be made safer
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IOM. To Err is Human. 2000
In situ simulation
In theory there’s no difference between theory and practice.
In practice there is.
Yogi Berra (1925-2015)
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Simulation to improve systems: real teams, real settings
• Example: manage post-partum hemorrhage
• Iterative improvement of protocols, processes; test and improve before implementing
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VALUE
RESILIENCE
RESPECT
STANDARDIZATION
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Resilience
• …refers to a property of organizations, as well as individuals, which have the “ability to recognize, and adapt to handle unanticipated perturbations …[which] demand a shift of processes, strategies, and coordination.
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Woods D. Essential Characteristics of Resilience in Hollnagel, Woods, Leveson eds. Resilience Engineering Concepts and Precepts. Ashgate Publishing. 2006. P22
4 Essential capabilities of Resilience
1. Monitor: know what to look for
2. Respond: know what to do, be capable of doing it
3. Learn: know what has happened
4. Anticipate: find out, know what to expect
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Monitor: know what to look for
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Respond: know what to do, be capable of doing it
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Learn: know what has happened
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Anticipate: find out; know what to expect
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Simpao et al, Anesthesiology 2014
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There’s rules to riding a horse
But the horse won’t necessarily know ‘em
-Texas Bix Bender
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Simulation can be used to support the emergence of resilience
• Direct learning, improved teamwork and environment result in decreased cognitive
load, improved adaptive capacity, and increased margin for maneuver
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Simulation is adaptable
• Simulation can be used to replicate almost any part of a process or system
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Develop
condition
Obtain
consult
Undergo
surgery Recover Thrive
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In situ simulation can help us improve Work as Done
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Work as Done
Work as simulated
Work as imagined
Work as abstracted
Questions?
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