WILLIAM J. YOST, MD FACP STEVEN R. CRAIG, MD … · STEVEN R. CRAIG, MD MACP UNITYPOINT HEALTH-DES...

W I L L I A M J . Y O S T , M D F A C PS T E V E N R . C R A I G , M D M A C P

U N I T Y P O I N T H E A L T H - D E S M O I N E S

A H M E M A Y 2 0 1 6

Simulation Training in a Community Hospital

Disclosures: None

First, a little about us…..

UnityPoint Health (Des Moines)

Primary Campuses

IMMC and Methodist West

Iowa Lutheran Hospital

Blank Children’s Hospital

Iowa Methodist 364 beds, 44 bed ICU

Level I Trauma Center

Designated Stroke Center

Iowa Lutheran 224 beds

Blank Children’s Hospital 96 beds

Level III NICU

Methodist West 95 beds

Principally orthopedics, growing maternal services

Regional Campus for the University of Iowa 24 UI and 20 DMU students complete entire 3rd year clinical rotations

on our campus

Additional 60-80 students complete one or more rotations on our campus

Advanced electives and subinternships available to 4th year students

GME 5 ACGME accredited programs and 1 CPME accredited residency

program FM, GS, IM, PD, TY and Podiatry

98 residents

Family Medicine is an unopposed residency program on campus at ILH

How we got to where we are……

A Tale of Three Residents

Resident A

Good performance on standardized testing, but mixed – and often poor – clinical evaluations

Described as “inefficient” and “slow” and received low scores in PC

Evaluation: Observed and recorded 5 different clinical scenarios of varying severity

Review revealed difficulty with prioritization and organization

Result: extension of training and successful remediation

Resident B

Satisfactory medical knowledge and patient care

Unsatisfactory communications skills with several early “sentinel events”

Evaluation: Observed and recorded 5 different communication skills exercises – satisfactory performance

Result: Continued intensive education and feedback, including reflection, with objective improvement in performance

Resident C

Placed a left IJ under indirect supervision at an affiliated institution

Therapeutic misadventure

Led to redesign of our curriculum using bedside US and placement CVL

Now, a literature review…….

Benefits of Simulation Training

Improved performance invasive procedures, including CVL 6,8

Improved performance in basic clinical skills when compared to cohort without sim training 3, 14, 17

Use of “Virtual Human Technology” has been shown to improve diagnostic accuracy in trainees 5

Simulation training in performance invasive procedures has been shown to be more cost-effective than traditional training 8

Simulation training may play a critical role in teaching and evaluating communication skills 1,9

What’s the down side?

Space

Expertise

Time…. new curriculum must be written, implemented

Money….. although costs may vary

Basic Facility Needs

Two RoomsOne large enough to stage two simulationsOne for small group discussion & de-briefing

Simulation RoomSinkHead Wall Units (oxygen, suction)Monitors (to display heart rhythm, vitals, O2 sat)Two hospital bedsWhite boards (portable or wall mounted)

Discussion Room for De-BriefingTable and chairsLarge video monitor for de-briefing sessions

Basic Supplies Needed

Camera system: ceiling mounted, iPad, hand-held

Crash Cart & Defibrillator

Mask + Bag-Mask Ventilation Equipment

Intubation Tray & Supplies (for NT and ET intubations)

IV Poles + IV containers and tubing

Drug demo dose vials* Caution if doing in-situ (hospital) simulations *

Blood draw equipment

Patient Care Mannequins: 3 Types

Task TrainersIV Arms, Intubation Heads, Pelvis Models, Upper Torso Models

Patient Care Mannequins (Low Fidelity)First Aid & ACLS Mannequins

Patient Simulators (High Fidelity)Adult, Child, Infant, Maternal-Fetal

High Fidelity Mannequins

Three Primary Companies to Choose From

CAE ~ Formerly METI (HPS® and PEDIASIMHPS®)

Gaumard (NOELLE® and Pedi HAL®)

Laerdal (SimMan® SimMom® SimJunior®SimBaby®)

3 Patient Care Mannequin Types: Costs

Task TrainersIV Arms $600, Intubation Heads $2150 (adult) / $600 (peds), Pelvis Models $2500, Upper Torso Models $1500

Patient Care Mannequins (Low Fidelity)First Aid & ACLS Mannequins $3000-4000

Patient Simulators (High Fidelity)Adult $60,000 – $80,000Pediatric/Infant $30,000 - $40,000Birthing Mom & Infant $60,000

Personnel Costs

Simulation Center StaffingNurse-Educator vs. Paramedic-EducatorEquipment Maintenance (IT support critical)

Physician Educator SupportDevelop ScenariosAssist at Simulations

Simulated Patients: Volunteers?

Sources of Funding Support

Hospital

Medical Staff

Nursing Schools

EMS Programs

Physician Groups

Foundations

Other Philanthropy

Program Charges: BLS, ACLS, ATLS, Nursing Orientation, Residency Program Use

UnityPoint Simulation Center

The Dorner-Villeneuve Simulation Center

Center Director = Wanda Goranson, MSN, RN-BC, CHSE, CHSOS

Thank you to Wanda for assistance with information about facilities, supplies, costs, center design

1st Floor: OR Simulation Center

2nd Floor: Clinic Room, ICU & ER Suites, 3 Hospital Rooms, Classroom/Debriefing Rooms

Current Simulation Center Space

OR Simulation (1st floor) 900 sf

Classrooms 890 sf

Simulation Rooms (2nd floor) 1200 sf

Control Rooms 520 sf

Offices 800 sf

Laundry/Storage 960 sf

Simulation Center Total Space 5270 sf

Hospital Hallway

Emergency Room Suite

ICU Room

Hospital Room

Control Rooms

How we have done it……

IM Curriculum

ACLS: Initial certification, recertification, and skills reinforcement

Procedures

Diagnostic Skills Exercises

Communication Skills/IPE Teams/Leadership Skills

ACLS

Initial certification incoming R1s

Recertification more senior residents

Reinforcement ACLS skills for R1s early fall and late spring

Reinforcement ACLS skills in winter, now including IPE

Procedures

Basic Procedures (MS and R1s) Phlebotomy, IV Lines, NGT Placement, Foley Catheter Placement Taught principally by nursing staff/educators

Advanced Procedures CVL, LP and advanced airway management Taught by physician faculty

Workshops CVL Placement IO Placement Joint Injections

Diagnostic Skills Exercises

On Call: Initial exposure to “best practice” at orientation

Series of individual exercises involving common problems encountered on call

Designed to evaluate professionalism, communication skills and clinical reasoning skills

Team Based Exercise: Group exercises using standardized “unknown” cases

Designed to evaluate professionalism, leadership and communication skills, and teamwork through collective reasoning

Communication Skills Exercises

Informed Consent

Advanced Directives

Disclosure of Medical Error

Disclosure of “Bad News”

Leading a Family Meeting

How do we do this?

I write the scripts

We arrange for simulated patients/family members….. mostly volunteers

Exercises limited to 20 minutes with few exceptions

Interaction is recorded…… followed by the “debrief”

Evaluations completed by experienced faculty

Other opportunities……

Diagnostic Tool – have used to evaluate resident performance and “diagnose the learner”

Teaching and evaluating IPE, including teamwork and leadership skills

In Summary…..

Simulation training is beneficial (critical?) in teaching and evaluating procedural skills and communication skills

May prove to be equally valuable in teaching teamwork and as component of IPE

May also be beneficial in recredentialing and remediation

Can be done effectively with limited facilities and resources, and build in step-wise fashion

References

1. Sukalich S, Elliott J, and Rufner G. Teaching Medical Error Disclosure to Residents Using Patient-Centered Simulation Training. Acad Med 2014;89:136-143.

2. Marr M, et al. Team Play in Surgical Education: A Simulation-Based Study. J Surg Ed 2012;69(1):63-69.

3. Cohen E, et al. Making July Safer: Simulation Based Mastery Learning During Intern Boot Camp. Acad Med 2013;88(2):233-239.

4. Yang J, and Howell M. Commentary: Is the Glass Half Empty? Code Blue Training in the Modern Era. Acad Med 2011;86(6):680-683.

5. Wendling A. Virtual Humans Versus Standardized Patients: Which Lead Residents to More Correct Diagnoses? Acad Med 2011;86(3):384-388.

6. Evans L, et al. Simulation Training in Central Venous Catheter Insertion: Improved Performance in Clinical Practice. Acad Med 2010;85(9):1462-1469.

7. Adler M, et al. Development and Evaluation of High-Fidelity Simulation Case Scenarios for Pediatric Resident Education. Amb Ped 2007;7(2):182-186.

References

8. Leshikar D, et al. Do more with less: a surgery directed institutional model for resident central line training. Am J Surg 2014;207(2):243-250.

9. Curtis J, et al. Effect of Communication Skills Training for Residents and Nurse Practitioners on Quality of Communication With Patients With Serious Illness: A Randomized Trial. JAMA 2013;310(21):2271-2281.

10. McSparron J, et al. Simulation for Skills-based Education in Pulmonary and Critical Care Medicine. Annals ATS 2015;12(4):579-586.

11. Terry R, Hiester E, and James G. The Use of Standardized Patients to Evaluate Family Medicine Resident Decision Making. Fam Med 2007;39(4):261-265.

12. Mills D, Williams D, and Dobson J. Simulation Training as a Mechanism for Procedural and Resuscitation Education for Pediatric Residents: A Systematic Review. Hosp Peds 2013;3(2):167-176.

13. Kogan J, Holmboe E, Hauer K. Tools for Direct Observation and Assessment of Clinical Skills of Medical Trainees. JAMA 2009;302(12):1316-1326.

References

14. Schroedl C, et al. Use of simulation-based education to improve resident learning and patient care in the medical intensive care unit: A randomized trial. J Crit Care (2012) 27, 219.e7-219.e13.

15. Skalski J, et al. Using Standardized Patients to Teach Point-of-Care Ultrasound-Guided Physical Examination Skills to Internal Medicine Residents. JGME 2015;95-97.

16. Kyrkjebo J, Brattebo G, and Smith-Strom H. Improving patient safety by using interprofessional simulation training in health professional education. J Interprof Care 2006;20(5):507-516.

17. Singh P, et al. An immersive “simulation week” enhances clinical performance of incoming surgical interns improved performance persists at 6 months follow-up. Surgery 2015;157(3):432-443.

18. Sharma J, Myers D, and Dinakar D. Simulation in Pediatrics. Missouri Med 2013;110(2):147-149.

19. Gohar A, Al-hihi E. Simulation in Internal Medicine Training. Missouri Med 2013;110(2):129-132.

References

20. Takayesu J, et al. Incorporating simulation into a residency curriculum. CJEM 2010;12(4):349-353.

21. Langhan T, et al. Simulation-based training in critical resuscitation procedures improves residents’ competence. CJEM 2009;11(6):535-539.

22. Antonoff M, et al. A Novel Critical Skills Curriculum for Surgical Interns Incorporating Simulation Training Improves Readiness for Acute Inpatient Care. J Surg Ed 2009;66(5):248-254.

23. Kneebone R, et al. Complexity, risk and simulation in learning procedural skills. Med Ed 2007;41:808-814.

24. Bath J, and Lawrence P. Twelve tips for developing and implementing an effective surgical simulation programme. Medical Teacher 2012;34:192-197.

25. Stamper D, et al. Simulation in Health Care Provider Education at Brooke Army Medical Center. Military Medicine 2008;173(6):583-587.

26. Beeson M, and Vozinelek J. Specialty Milestones and the Next Accreditation System: An Opportunity for the Simulation Community. Simulation in Healthcare 2014;9(3);184-191.

References

27. Pascucci R, et al. Integrating Actors Into a Simulation Program: A Primer. Simulation in Healthcare 2014:120-126.

28. Singer B, et al. First-Year Residents Outperform Third-Year Residents After Simulation-Based Education in Critical Care Medicine. Simulation in Healthcare 2013;8(2):67-71.

29. Smith C, et al. Simulation Training and Its Effect on Long-Term Resident Performance in Central Venous Catheterization. Simulation in Healthcare 2010;5(3):146-151.

30. Springer R, et al. Simulation training in critical care: Does practice make perfect? Surgery 2013;154 (2):345-350.

31. Wehbe-Janek H, et al. Residents’ perspective of the value of a simulation curriculum in a general surgery residency program: A multimethod study of stakeholder feedback. Surgery 2012;151(6):815-821.

32. Cox T, et al. Moving the Needle: Simulation’s Impact on Patient’s Outcomes. Surg Clin N Am 2015;95:827-838.

References

33. Willis R, et al. Current Status of Simulation-Based Training in Graduate Medical Education. Surg Clin N Am 2015;95:767-779.

34. Chauvin S. Applying Educational Theory to Simulation-Based Training and Assessment in Surgery. Surg Clin N Am 2015;95:695-715.

35. Magee S, et al. Low Cost, High Yield: Simulation of Obstetric Emergencies for Family Medicine Training. Teaching and Learning in Medicine 2013;25(3):207-210.

Any questions?