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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.
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