MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY Professor Harry Owen Director, Clinical Skills and Simulation Unit Flinders University Adelaide, South Australia [email protected].
Download ReportTranscript MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY Professor Harry Owen Director, Clinical Skills and Simulation Unit Flinders University Adelaide, South Australia [email protected].
MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY Professor Harry Owen Director, Clinical Skills and Simulation Unit Flinders University Adelaide, South Australia [email protected] 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 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 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% 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 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 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 coordination • Systematic practise in handling crises including part-task trainers and full-mission realistic simulation 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 Simulation technologies used in medical education • Computer-based simulations (microworlds, micro-simulation) • Virtual environments +/- haptics • Part-task trainers • Low-fidelity simulators/manikins • Simulated or standardised patients • Hybrid simulations • High-fidelity (full mission) simulation Cost and benefit in simulation Full mission simulation Manikin training Part-task trainers CBT Increasing level of fidelity and exclusivity $ $ $ $ $ Medical Education includes Knowledge/Skills/Attitudes • Individual psychomotor skills • Appropriate application of skills • Communication / Team performance / Leadership skills (CRM) • Supervision/teaching • Assessment Knowledge/Skills/Attitudes • Teaching best practice – integrated – learner centred – appropriate use of technology • Assessment best practice – valid and reliable – reproducible 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 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 Endotracheal intubation • ETI needed by many health professionals, including anesthesiologists, paramedics/EMTs, rural GPs, emergency physicians, ICU staff, respiratory therapists, etc. • Competence requires practise • 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 The learning environment • Quiet, few distractors • Clinical equipment • Expert tutors • Realistic models • Many different models – Easy difficult very difficult 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 The Flinders Clinical Skills and Simulation Unit • 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) CPR Prompt (Compliant) ® David/Adam ® (Nasco) CPR Pal® (Ambu) Adult A-A Female ® (Nasco) Actar D-Fib® (Armstrong) Little Anne™ (Laerdal) Fat Old Fred ® (Lifeform) Economy Saniman ® (Nasco) Basic Buddy™ (Lifeform) The Flinders Clinical Skills and Simulation Unit • 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 Anatomy of a simulation (1) Components • Student/trainee/ health professional • Procedure/task/skill/test/ treatment or equipment • Patient and/or disease process • Trainer/supervisor Anatomy of a simulation (2) Function of components • Passive – Enhance setting for realism • Active – Change in a programmed way • Interactive – Responds to action or event 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) 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 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 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. 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 High fidelity simulation (3) • Allow time for familiarisation with the simulator & equipment • Brief participants on: – The scenario – Educational objectives – How to get help High fidelity simulation (4) Always follow the script but... Simulation control room …have alternative outcomes planned and rehearsed 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 High fidelity simulation (6) Facilitated debriefing with an expert practitioner. Participants reflect on their own performance and discuss this with the group How we use the SimMan UPS • • • • • • • • • • 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, postop ward, clinic, aircraft, ambulance, home, roadside, terrorist incident, etc • Outreach settings – Regional hospitals, rural settings, etc Source: Jones A (BMSC) Simulation centres May 2003 11 10 9 20 195 25 2 10 6 2 5 2 Flinders Uni Publications on ‘patient simulation’ in clinical care 100 90 80 70 60 Papers 50 40 30 20 10 0 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 Year Research needed on simulation in 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 Simulation technologies used in medical education • Computer-based simulations (microworlds, micro-simulation) • Virtual environments +/- haptics • Part-task trainers • Low-fidelity simulators/manikins • Simulated or standardised patients • Hybrid simulations • High-fidelity (full mission) simulation 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 coordination