MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY

1. MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY Professor Harry Owen Director, Clinical Skills and Simulation Unit Flinders University Adelaide, South Australia harry.owen@flinders.edu.au

2. 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

3. 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

4. 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%

5. 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

6. 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

7. 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

8. 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

9. 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

10. Cost and benefit in simulation Full mission simulation Manikin training $$$$$ Part-task trainers CBT Increasing level of fidelity and exclusivity

11. Medical Education includesKnowledge/Skills/Attitudes • Individual psychomotor skills • Appropriate application of skills • Communication / Team performance / Leadership skills (CRM) • Supervision/teaching • Assessment

12. Knowledge/Skills/Attitudes • Teaching best practice • integrated • learner centred • appropriate use of technology • Assessment best practice • valid and reliable • reproducible

13. 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

14. 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

15. ETI needed by many health professionals, including anesthesiologists, paramedics/EMTs, rural GPs, emergency physicians, ICU staff, respiratory therapists, etc. Competence requires practise Endotracheal intubation

16. When and how should ETI be taught? • Animals • Small, e.g. cats • Large, e.g. dogs or monkeys • Unconscious patients • In the OR • In ICU • Newly dead/recently deceased • Cadavers • Simulators

17. The learning environment • Quiet, few distractors • Clinical equipment • Expert tutors • Realistic models • Many different models • Easy  difficult very difficult

18. 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

19. 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) The Flinders Clinical Skills and Simulation Unit

20. Actar D-Fib® (Armstrong) Adult A-A Female ® (Nasco) CPR Prompt ® (Compliant) Fat Old Fred ® (Lifeform) David/Adam ® (Nasco) Little Anne™ (Laerdal) CPR Pal® (Ambu) Economy Saniman® (Nasco) Basic Buddy™ (Lifeform)

21. 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 The Flinders Clinical Skills and Simulation Unit

22. Components Student/trainee/health professional Procedure/task/skill/test/treatment or equipment Patient and/or disease process Trainer/supervisor Anatomy of a simulation (1)

23. Function of components Passive Enhance setting for realism Active Change in a programmed way Interactive Responds to action or event Anatomy of a simulation (2)

24. 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)

25. 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

26. 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

27. 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.

28. 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

29. High fidelity simulation (3) • Allow time for familiarisation with the simulator & equipment • Brief participants on: • The scenario • Educational objectives • How to get help

30. High fidelity simulation (4) Always follow the script but... …have alternative outcomes planned and rehearsed Simulation control room

31. 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

32. High fidelity simulation (6) Facilitated debriefing with an expert practitioner. Participants reflect on their own performance and discuss this with the group

33. 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 How we use the SimMan UPS

34. Source: Jones A (BMSC)

35. Simulation centres May 2003 11 9 10 20 195 25 2 10 6 5 2 2 Flinders Uni

36. Publications on ‘patient simulation’ in clinical care Year

37. 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

38. 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

39. 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