Dr Kirtida Mukherjee Dr Manisha Shah Medway NHS Foundation Trust, Kent, UK

1. From Screen based simulation to SimMan based simulation – does it improve systemic approach to critical incidents for new trainees in Anaesthesiology? Dr KirtidaMukherjee Dr Manisha Shah Medway NHS Foundation Trust, Kent, UK AMEE, Vienna, 31st August 2011

2. Background • Anaesthesia is a high risk specialty, where occurrence of critical incidents in the perioperative period can be life threatening. • Competency in managing Critical incidents is an essential training unit for basic level competency in Anaesthetic curriculum in UK.

3. To manage a critical incident, anaesthetists need to have a systemic approach with differential diagnosis and quick actions to prevent major morbidity/mortality • New trainees in Anaesthesia may come across a critical incident early in their career, which they may not be able to diagnose and treat appropriately in the very short time available.

4. Aims of the teaching sessions • Trainees will be able to diagnose a critical incident, develop situational awareness and manage the incident in real time • Learn management protocols, increase their knowledge base and learn the concept of team-working in a crisis situation

5. We had previously used lecture-based or one to one theoretical teaching to make them aware of critical incidents and their management in the perioperative setting. • With less time available for training due to EWTD, we felt it essential to teach and train the trainees to deal with critical incidents more formally.

6. Methodology • We developed a two stage teaching using simulations. • 1st stage – we used SimMan software to develop Screen based scenarios for teaching a group of trainees who had completed one month of supervised training in Anaesthesia

7. 1st stage • SimMan software used for preparing screen based scenarios for various critical incidents commonly encountered (e.g. hypoxia, laryngospasm, haemorrhage, raised CO2, altered heart rate etc). • The patient monitor output was screened in a lecture hall as a shared screen for all trainees • Background information was given at the beginning of each scenario. Then, the scenario was run in real time on the screen and a critical incident was introduced. • A faculty member moderated each unfolding scenario

9. The trainees were asked to come up with diagnosis and immediate management interventions including their input as to the type and dose of a drug to be administered and other manoeuvres • Each intervention was reflected in monitoring parameter changes in real time • Debriefing after completion of each scenario, based on of predefined management protocol

10. Feedback • Very positive feedback, with rating of the session as excellent or very good. • They felt more comfortable and more able to deal with critical incidents in future

11. 2nd Stage • After completion of 2 months of training, the same group of trainees participated in a day of simulated critical incidents in a simulation centre • Similar critical incidents were created for this session but with somewhat different clinical cases • Two trainees at a time were in the “hot seats” and other trainees in the observation room making notes

12. In the simulation suite

13. 2nd stage • We observed the following: • Knowledge and skills in handing a critical situation • Non-technical skills such as anticipation, planning and preparation, communication, delegation and use of resources • Calling for help early and appropriately

14. 2nd stage • Debriefing was done at the end of each scenario, with observing participants joining in the discussions that followed. • Management protocols were discussed and management priorities were emphasised

15. Results • The trainees as a whole demonstrated a much more systemic approach to interpreting, diagnosing and managing various critical incidents in a much more confident manner. • Specific areas of improvement were • knowledge retention, • calling for help, • use of resources and • management protocols

16. Feedback • Trainees felt more confident in dealing with a crisis situation. • They were more aware of management protocols and their application to a critical incident. • They felt that they would like more experience in the Sim centre to get more exposure to non-technical skills which would make them better prepared in handling of a crisis situation

17. Summary • All critical incidents may not be encountered in clinical practice. • A systemic approach is needed to deal with the incidents effectively and appropriately. • Screen-based simulation was used in a non-threatening environment with peer support. • This was reinforced with Sim based simulation and to complement their knowledge and skills. • Screen-based simulation can be an effective approach before Sim based simulation.