Transcript Surgical Skills - Stanford University

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
Does size matter?
Does size matter?
California
Area
Queensland
163,696 sq mi 668,207 sq mi
Population 36,500,000+
4,100,000+
(234.4/sq mi)
(6.3 /sq mi)
QH SDC
Cairns
Townsville
Mackay
Rockhampton
Bundaberg
Hervey Bay
Roma
Toowoomba (not an official centre)
Skills Development Centre
Skills Development Centre
Courses Delivered by the SDC
Faculty Training
1.
2.
3.
4.
Simulation With Integrated Mannequins
Crisis Resource Management Train the Trainer
Difficult Debriefing Training
Grad Dip Health Simulations
5.
6.
Communication Skills
Frontline Communications
Friday Night in the ER
Emergency and Rural
19.
20.
21.
22.
23.
24.
25.
26.
27.
Intensive Care and Anaesthetics
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
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 Cardiorespiratory
Management
Maternity and Newborn
17. Maternity Crisis Resource Management
18. Newborn Crisis Recourse Management
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
Surgical and Psychomotor Skills
28.
29.
30.
31.
32.
33.
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
34.
Emergo Train
Medical Radiations
35. Introduction to Vascular Ultrasound
36. Basic Skills in O&G Ultrasound
37. Practitioner Initiated X-ray
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.
Identifying the Critical Motivation
Training
Systems
Interdisciplinary learning
Technology integration
Human Factors
Non-Technical skills
Safety Performance assessment
Competency assessment Quality
Specialty skills
Quantity
Workload assessment
Organisations design
Workplace orientation
Technical skills Efficiency Equipment design
Pre-employment skills
Process design
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
Pre-employment skills
Process design
Identifying the Critical Motivation
Training
Safety
Quality
Quantity
Efficiency
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
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
Learning methods
Learning
Method
Non-Technical Skill
Situation
Awareness
Communications
Decisionmaking
Teamwork
Leadership
Didactic
learning
Poor
Poor
Poor
Poor
Poor
Video
examples
Fair
Fair
Strong
Fair
Fair
Discussion
forum
Poor
Poor
Fair
Poor
Poor
Decision
games
Fair
Fair
Strong
Strong
Strong
Virtual
reality
Fair
Fair
Strong
Fair
Poor
Immersive
learning
Strong
Strong
Strong
Strong
Strong
Debrief
learning
Strong
Strong
Strong
Strong
Strong
How we learn now
State
standards
National
standards
International
standards
Evaluation
& research
Workshops &
seminars
Didactic
learning
Strong
Moderate
=
=
Lim ited
=
Lectures
series
Video
examples
Discussion
forum
E-learning
Decision
games
Simulations
Virtual
reality
Immersive
learning
High quality, Broad scope and Readily available
Limited quality or Limited scope or Limited availability
Limited quality or Limited scope and Limited availability OR
Limited quality and Limited scope or Limited availability
Clinical
practice
Debrief
learning
How we should be learning in 2015
State
standards
National
standards
Reduced reliance on didactic
learning due to the availability
of stronger training methods
Workshops &
seminars
Didactic
teaching
Evaluation
& research
Lectures
Video
examples
International
standards
Discussion
forum
E-learning
Decision
games
Simulations
Virtual
reality
Immersive
learning
Clinical
practice
Debriefing
Change of focus from Limited quality and Readily available to High
quality and Limited availability by increasing preparing through elearning and simulations and increasing debriefing
Strong
Moderate
=
=
Lim ited
=
High quality, Broad scope and Readily available
Limited quality or Limited scope or Limited availability
Limited quality or Limited scope and Limited availability OR
Limited quality and Limited scope or Limited availability
How we should be learning in 2025
National
standards
State
standards
Limited scope and availability
due to development of more
engaging methods of learning
Didactic
teaching
Strong
Moderate
=
=
Lim ited
=
Evaluation
& research
Lectures
Workshops &
seminars
Video
examples
International
standards
Discussion
forum
E-learning
Decision
games
Simulations
Virtual
reality
Immersive
learning
High quality, Broad scope and Readily available
Limited quality or Limited scope or Limited availability
Limited quality or Limited scope and Limited availability OR
Limited quality and Limited scope or Limited availability
Clinical
practice
Debriefing
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
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
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.
Training – when, where and how
1. 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
2. Affiliated Skills Development
Centres
–
–
–
–
Inter-disciplinary training
Supports University training
Conducts major research
Staff 3-9 FTE, 10-50 PT
instructors
3. Portable Simulations
–
–
–
–
–
Inter-disciplinary training
Specialty training
Opportunistic training
Supports University training
Staff 2-3 FTE, 2-100 PT
instructors
4. Departmental ‘Pocket’
Simulations
–
–
–
–
–
–
Department training
Inter-disciplinary training
Opportunistic training
Rehearsals
Research
1-2 FTE, 3-20 PT instructors
How quickly can we grow?
Based on 2007
Queensland Health
clinical population
- Actual training
Days required will
increase
How many people will it take?
Instructors
0.27
Simulation
Coordinators
0.42
Administration
and Logistics
Support
0.14
0.27
0.36
0.13
30,000 training days
37-43
58-67
19-20
120,000 training days
148-172
230-265
77-80
Per participants
training day in
2008- current ratio
2015- estimated
economy of scale
Queensland Health
Six Critical Training Issues
1. The right blended learning environments,
2. Emphasis on the knowledge and skills likely to prevent
harm,
3. Standardisation of curriculum and reliable assessment,
4. Training as teams not just as individuals,
5. The use of skilled instructors,
6. Dedicated support staff to provide efficient and
accountable education.
What Australia has to do
Rank
Priority
Description

1
Curriculum
exchange
program
2
The development
of immersive
learning
capability
3
The development
of administrative
hubs for
simulation
4
The development
of equipment and
infrastructure for
simulations


Centrally funded core curriculum to meet graduate and new clinicians training
requirements (PGY 1-3 for all disciplines) with a focus on non-technical skills
Validate and mandate one or more methods of assessing non-technical skills
Curriculum that supports a continuity throughout a clinician’s career across
disciplines and facilities



The rapid development of skilled simulation coordinators and instructors
Formal training and recognition of their educational and technical skills
Significant administration and logistic support to minimise clinicians’ time away
from clinical service

Dedicated management and governance to ensure quality and appropriate
coverage of simulations training integrated into clinical placements
Dedicated staff to provide the coordination and logistic support for course
delivery in each state to ensure a continuum of interdisciplinary training across
facilities for all clinical staff




A review of existing simulation equipment to increase use through better
access, regular maintenance by skilled instructors and simulation coordinators
The development of affordable portable audio visual systems to improve
learning through effective debriefing
The expansion of simulation equipment to meet the needs of the expanding
training capacity
Questions
1. We can do things in simulation we cannot or
should not do with ‘real’ patients
2. We can apply simulation systematically and
opportunistically to develop a leaner and safer
healthcare system
3. We can develop more simulation-based training
but we cannot rely on more quality clinical training
opportunities