A case for Funding Large Scale Simulations in Australian Healthcare

1. A case for Funding Large Scale Simulations in Australian Healthcare Marcus Watson PhD Senior Director Queensland Health Skills Development Centre School of Medicine, The University of Queensland

2. Does size matter?

3. Does size matter?

4. QH SDC Cairns Townsville Mackay Rockhampton Bundaberg Hervey Bay Roma Toowoomba (not an official centre)

5. Skills Development Centre

6. Skills Development Centre

7. Courses Delivered by the SDC Faculty Training Emergency and Rural • Advanced Life Support – Interns • Advanced Cardiac Life Support • Clinical Rural Skills Enhancement • Emergency Events Management • Emergency Crisis Resource Management • Emergency Technical Skills Course for Doctors • Acute and Critical Medical Emergencies • Pre-Hospital Trauma Life Support • Paediatric Emergency Crisis Resource Management Simulation With Integrated Mannequins Crisis Resource Management Train the Trainer Difficult Debriefing Training Grad Dip Health Simulations Communication Skills • Frontline Communications • Friday Night in the ER Intensive Care and Anaesthetics Surgical and Psychomotor Skills • Intensive Care Crisis Event Management • Anaesthetic Crisis Resource Management • Anaesthetic Crisis Resource Management for GPs • Paediatric Anaesthetic Crisis Resource Management • Recovery Room Crisis Resource Management • Basic Assessment & Support in Intensive Care • Effective Management of Anaesthetic Crises • Advanced Paediatric Intensive Care Critical Skills • Physiotherapy and Critical Care Management • Introduction to Physiotherapy CardiorespiratoryManagement • Fundamentals of Laparoscopic Surgery • Minimally Invasive Surgical Techniques • Introduction to Laparoscopic Surgery • National Endoscopic Training Initiative • Operative Laparoscopy Workshop for O&Gs • Perioperative Advanced Laparoscopic Skills Disaster Medicine • Emergo Train Medical Radiations Maternity and Newborn • Introduction to Vascular Ultrasound • Basic Skills in O&G Ultrasound • Practitioner Initiated X-ray • Maternity Crisis Resource Management • Newborn Crisis Recourse Management

8. 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.

9. Identifying the Critical Motivation Training Systems Interdisciplinary learning Technology integration Human Factors Non-Technical skills Safety Performance assessment Competency assessment Quality Workload assessment Specialty skills Quantity Organisations design Workplace orientation Technical skills Efficiency Equipment design Process design Pre-employment skills

10. Identifying the Critical Motivation Training Systems Interdisciplinary learning Technology integration Human Factors Non-Technical skills Safety Performance assessment Competency assessment Quality Workload assessment Specialty skills Quantity Organisations design Workplace orientation Technical skills Efficiency Equipment design Process design Pre-employment skills

11. Identifying the Critical Motivation Training Safety Quality Quantity Efficiency

12. 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

13. 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 Teacher Fox, 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 Education Seabrook, 2004, Medical Education

14. Learning methods

15. How we learn now

16. How we should be learning in 2015

17. How we should be learning in 2025

18. 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

19. 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

20. 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.

21. 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 Affiliated Skills Development Centres Inter-disciplinary training Supports University training Conducts major research Staff 3-9 FTE, 10-50 PT instructors Portable Simulations Inter-disciplinary training Specialty training Opportunistic training Supports University training Staff 2-3 FTE, 2-100 PT instructors Departmental ‘Pocket’ Simulations Department training Inter-disciplinary training Opportunistic training Rehearsals Research 1-2 FTE, 3-20 PT instructors Training – when, where and how

22. How quickly can we grow? Based on 2007 Queensland Health clinical population - Actual training Days required will increase

23. How many people will it take?

24. Six Critical Training Issues • The right blended learning environments, • Emphasis on the knowledge and skills likely to prevent harm, • Standardisation of curriculum and reliable assessment, • Training as teams not just as individuals, • The use of skilled instructors, • Dedicated support staff to provide efficient and accountable education.

25. What Australia has to do

26. Questions We can do things in simulation we cannot or should not do with ‘real’ patients We can apply simulation systematically and opportunistically to develop a leaner and safer healthcare system We can develop more simulation-based training but we cannot rely on more quality clinical training opportunities