Transcript SIMULATION IN MEDICAL EDUCATION Professor Harry Owen and Val Follows Flinders University School of Medicine [email protected].

SIMULATION IN MEDICAL
EDUCATION
Professor Harry Owen
and
Val Follows
Flinders University School of Medicine
[email protected]
Simulation in Medical Education
• Simulation technologies used in Medical
Education in Australia, the US and
Europe
• Setting up the Flinders University
Medical School Clinical Skills and
Simulation Unit
• Fundamentals of high-fidelity simulation
• Where do we go from here? Some
observations on the future of 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
(1)
(1)
1
1
1
2
Adelaide
South Australia
Source: Jones A (BMSC)
Simulation centres
11
10
9
20
195
25
2
10
6
2
5
2
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
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
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
– 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 recognised
• Funding generated from teaching outside
the medical school
Endotracheal intubation
• Learnt on patients
under anaesthesia
• No special consent
• 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
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
• Computer-based
Teaching
–
–
–
–
–
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
• 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
Options for running simulations
• Free-form
– Easy but poor learning
• ‘On the fly’
– Scripted but intensive for the ‘controller’ and
some variables may appear discontinuous
• Programmed trends
– More sophisticated simulations possible
• Trends and event handlers
– Facilitates high-fidelity simulation with most
realistic response to interventions
Resources needed
• 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:
– Technician/bio-medical engineer essential!
Before and after simulations...
• Set-up scenario
– eg. make blood, set up area, X-rays, notes, etc
• Load simulation program
• Check everything works
– Cameras, VCR, communicators
Afterwards...
• Check simulator (replace or repair parts)
• Clean everything used and put away
• Replace/reorder all used items
High fidelity simulation (3)
• Allow time for briefing
and familiarisation
with the patient
simulator and
equipment
• Brief participants on:
– Broad objectives
– The scenario
– 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
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%
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
The future of simulation...
• Skills training tool for all disciplines
– Acute care
– Try new techniques and/or equipment
– Patient safety initiatives
– Retraining
• Multi-disciplinary training
– inter-professional communication
– team performance
• Training in decision-making/resource coordination
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
Simulation research must address
healthcare training needs
• 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