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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
[email protected]@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
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10
195
6
11
2
10
2
May 2003
Flinders Uni
Publications on ‘patient simulation’ in clinical care
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'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02
Papers
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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