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A case for Funding Large Scale Simulations in Australian Healthcare
Marcus Watson PhD
Senior Director Queensland Health Skills Development CentreSchool of Medicine, The University of Queensland
Does size matter?
Does size matter?
California Queensland
Area 163,696 sq mi 668,207 sq mi
Population 36,500,000+
(234.4/sq mi)
4,100,000+
(6.3 /sq mi)
Cairns Cairns
Townsville Townsville
Mackay Mackay
BundabergBundaberg
Hervey BayHervey Bay
RockhamptonRockhampton
Toowoomba Toowoomba (not an official centre)(not an official centre)
RomaRoma
QH SDCQH SDC
Skills Development Centre
Skills Development Centre
28. Fundamentals of Laparoscopic Surgery29. Minimally Invasive Surgical Techniques30. Introduction to Laparoscopic Surgery31. National Endoscopic Training Initiative32. Operative Laparoscopy Workshop for O&Gs33. Perioperative Advanced Laparoscopic Skills
Surgical and Psychomotor Skills
Intensive Care and Anaesthetics
7. Intensive Care Crisis Event Management8. Anaesthetic Crisis Resource Management9. Anaesthetic Crisis Resource Management for GPs10. Paediatric Anaesthetic Crisis Resource
Management11. Recovery Room Crisis Resource Management12. Basic Assessment & Support in Intensive Care13. Effective Management of Anaesthetic Crises14. Advanced Paediatric Intensive Care Critical Skills15. Physiotherapy and Critical Care Management16. Introduction to Physiotherapy Cardiorespiratory
Management
Emergency and Rural
19. Advanced Life Support – Interns20. Advanced Cardiac Life Support21. Clinical Rural Skills Enhancement22. Emergency Events Management23. Emergency Crisis Resource Management24. Emergency Technical Skills Course for
Doctors25. Acute and Critical Medical Emergencies26. Pre-Hospital Trauma Life Support27. Paediatric Emergency Crisis Resource
Management
Communication Skills5. Frontline Communications6. Friday Night in the ER
34. Emergo Train
Disaster Medicine
Courses Delivered by the SDC
Medical Radiations
35. Introduction to Vascular Ultrasound36. Basic Skills in O&G Ultrasound37. Practitioner Initiated X-ray
17. Maternity Crisis Resource Management
18. Newborn Crisis Recourse Management
Maternity and Newborn
Faculty Training
1. Simulation With Integrated Mannequins2. Crisis Resource Management Train the
Trainer3. Difficult Debriefing Training4. Grad Dip Health Simulations
Changing the face of healthcare
What healthcare needs is clinical training on an industrial scale with simulation efficiently integrated into clinical practice along with other educational methods.
Identifying the Critical Motivation
Training Systems
Technical skills
Non-Technical skills
Interdisciplinary learning
Specialty skills
Human Factors
Organisations design
Equipment design
Technology integration
Pre-employment skills Process design
Workload assessment
Performance assessment
Workplace orientation
Competency assessment
Safety
Quality
Quantity
Efficiency
Identifying the Critical Motivation
Training Systems
Technical skills
Non-Technical skills
Interdisciplinary learning
Specialty skills
Human Factors
Organisations design
Equipment design
Technology integration
Pre-employment skills Process design
Workload assessment
Performance assessment
Workplace orientation
Competency assessment
Safety
Quality
Quantity
Efficiency
Identifying the Critical Motivation
Training
Safety
Quality
Quantity
Efficiency
Quantity of Quality argument
• We have a clinical skills shortage • Increasing the number of students increase the burden
on already overs stretched clinical mentor• We can provide more simulation experience but we
cannot guarantee more experience on clinical placements
• We can control the quality of simulations experience
Quantity of Quality argument
• The opportunity for clinicians to develop clinical skills is often haphazard and there are examples of clinicians graduating without having been assessed or in some cases performing crucial clinical skills.
Wall, Bolshaw, & Carolan, 2006, Medical TeacherFox, Ingham Clark, Scotland, & Dacre, 2000, Medical Education
Remmen, et. al., 2001, Medical Education
• In the 1960s medical students received 75% of their teaching at the bedside, in the late 1970s this dropped to 16% and since then it has decreased further.
Ahmed, & El Bagir, 2002, Medical Education
• The acquisition of basic clinical skills suffered when there is limited supervised hands-on experience, skill levels in health are likely to drop unless alternate training methods are used.
Remmen, et. al., 2004, Medical EducationSeabrook, 2004, Medical Education
Learning methods
Learning Method
Non-Technical Skill
Situation Awareness Communications
Decision-making Teamwork
Leadership
Didactic learning
Poor Poor Poor Poor Poor
Video examples
Fair Fair Strong Fair Fair
Discussion forum
Poor Poor Fair Poor Poor
Decision games
Fair Fair Strong Strong Strong
Virtual reality
Fair Fair Strong Fair Poor
Immersive learning
Strong Strong Strong Strong Strong
Debrief learning
Strong Strong Strong Strong Strong
How we learn now
Strong = High quality, Broad scope and Readily available Moderate = Limited quality or Limited scope or Limited availability
Lim ited = Limited quality or Limited scope and Limited availability OR Limited quality and Limited scope or Limited availability
Evaluation & research
Immersive learning
Virtual reality
Decision games
Video examples
Didactic learning
Discussion forum
E-learning Lectures series
Simulations Clinical practice
Debrief learning
Workshops & seminars
State standards
National standards
International standards
How we should be learning in 2015
E-learning Lectures Simulations Clinical practice
Workshops & seminars
Immersive learning
Virtual reality
Decision games
Video examples
Didactic teaching
Discussion forum
Debriefing
Change of focus from Limited quality and Readily available to High quality and Limited availability by increasing preparing through e-learning and simulations and increasing debriefing
Evaluation & research
State standards
National standards
International standards
Reduced reliance on didactic learning due to the availability of stronger training methods
Strong = High quality, Broad scope and Readily available Moderate = Limited quality or Limited scope or Limited availability
Lim ited = Limited quality or Limited scope and Limited availability OR Limited quality and Limited scope or Limited availability
How we should be learning in 2025
E-learning Lectures Simulations Clinical practice
Workshops & seminars
Immersive learning
Virtual reality
Decision games
Video examples
Didactic teaching
Discussion forum
Debriefing
Limited scope and availability due to development of more engaging methods of learning Evaluation
& research
State standards
National standards
International standards
Strong = High quality, Broad scope and Readily available Moderate = Limited quality or Limited scope or Limited availability
Lim ited = Limited quality or Limited scope and Limited availability OR Limited quality and Limited scope or Limited availability
Safety and Efficiency argument
• Patient error is estimated to have a direct cost in Australia of $2 billion a year
• Patient are treated by ‘teams’ of clinicians not by a clinician
• Patient safety reports indicated that non-technical skills are involved in the majority of adverse events reported that cause harm
Wilson, Runiman, Gibberd, Harrison, Newby, & Hamilton, (1995) Medical Journal of Australia
• Other industries have become safer by a combination of standards, regulations and appropriate preventative
• Healthcare needs to provide the right training
Team training Crisis Resource Management
Tertiary Hospital 2007• Births ~ 4,800
• Annual mandatory fire drills• Fires = 0
• Annual mandatory basic life support• Cardiac emergencies = 0
• Maternity emergencies that occurred in 2007• Cord prolapse = 22
• Placental abruptions = 41
• Shoulder dystocia = 71
• Maternity Crisis Resource Management MaCRM• 2 day multidisciplinary workshop including
scenarios and structured debriefing
Training – when, where and how
• Multidisciplinary training in healthcare is starting to occur in hospital systems with varied levels of success. Most issues arrive when clinicians undergo concurrent training rather than training as a team.
El Ansari, Russell & Willsc (2003) Public Health
• Australia has simulation centres that provide excellent immersive learning for technical and non-technical skills. • The training capacity of most centres is not limited by the
number of simulators or rooms but rather by the number of instructors and the support staff available to deliver training
• An analogy is cottage industries that provide high quality products to a small proportion of the population.
Training – when, where and how
1. Tertiary Skills Development Centres– Inter-disciplinary training – Specialty training– Technical hub – Supports University training – Conducts major research– Staff 10-50 FTE, – 100-200 PT instructors
2. Affiliated Skills Development Centres– Inter-disciplinary training – Supports University training – Conducts major research– Staff 3-9 FTE, 10-50 PT
instructors
3. Portable Simulations– Inter-disciplinary training– Specialty training– Opportunistic training– Supports University training– Staff 2-3 FTE, 2-100 PT
instructors
4. Departmental ‘Pocket’ Simulations– Department training– Inter-disciplinary training– Opportunistic training– Rehearsals– Research– 1-2 FTE, 3-20 PT instructors
How quickly can we grow?
Based on 2007 Queensland Healthclinical population - Actual trainingDays required will increase
How many people will it take?
Per participants training day in Instructors
Simulation Coordinators
Administration and Logistics
Support2008- current ratio 0.27 0.42 0.142015- estimated economy of scale
0.27 0.36 0.13
Queensland Health
30,000 training days 37-43 58-67 19-20
120,000 training days 148-172 230-265 77-80
Six Critical Training Issues
1. The right blended learning environments,
2. Emphasis on the knowledge and skills likely to prevent harm,
3. Standardisation of curriculum and reliable assessment,
4. Training as teams not just as individuals,
5. The use of skilled instructors,
6. Dedicated support staff to provide efficient and accountable education.
What Australia has to do
Rank Priority Description
1Curriculum exchange program
Centrally funded core curriculum to meet graduate and new clinicians training requirements (PGY 1-3 for all disciplines) with a focus on non-technical skills
Validate and mandate one or more methods of assessing non-technical skills Curriculum that supports a continuity throughout a clinician’s career across
disciplines and facilities
2
The development of immersive learning capability
The rapid development of skilled simulation coordinators and instructors Formal training and recognition of their educational and technical skills Significant administration and logistic support to minimise clinicians’ time away
from clinical service
3
The development of administrative hubs for simulation
Dedicated management and governance to ensure quality and appropriate coverage of simulations training integrated into clinical placements
Dedicated staff to provide the coordination and logistic support for course delivery in each state to ensure a continuum of interdisciplinary training across facilities for all clinical staff
4
The development of equipment and infrastructure for simulations
A review of existing simulation equipment to increase use through better access, regular maintenance by skilled instructors and simulation coordinators
The development of affordable portable audio visual systems to improve learning through effective debriefing
The expansion of simulation equipment to meet the needs of the expanding training capacity
Questions1. We can do things in simulation we cannot or
should not do with ‘real’ patients
2. We can apply simulation systematically and opportunistically to develop a leaner and safer healthcare system
3. We can develop more simulation-based training but we cannot rely on more quality clinical training opportunities
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