MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY

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MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY

• Professor Harry Owen
• Director, Clinical Skills and Simulation Unit
• Flinders University
• Adelaide, South Australia
• harry.owen_at_flinders.edu.au

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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

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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

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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

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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

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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

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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

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Whos who in medical education

• Basic medical education
• Medical students
• Pre-vocational medical education
• Interns, RMOs, PGY 12
• Specialist training (discipline-based)
• Registrars/Senior registrars/Fellows
• Specialists and GPs (life-long learning)
• CME, MOPS, IRM, etc
• Teachers and trainers

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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

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Cost and benefit in simulation
Full mission simulation
Manikin training

Part-task trainers
CBT
Increasing level of fidelity and exclusivity
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Medical Education includesKnowledge/Skills/Attitu
des

• Individual psychomotor skills
• Appropriate application of skills
• Communication / Team performance / Leadership
  skills (CRM)
• Supervision/teaching
• Assessment

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Knowledge/Skills/Attitudes

• Teaching best practice
• integrated
• learner centred
• appropriate use of technology
• Assessment best practice
• valid and reliable
• reproducible

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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

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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

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Endotracheal intubation

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

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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

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The learning environment

• Quiet, few distractors
• Clinical equipment
• Expert tutors
• Realistic models
• Many different models
• Easy ? difficult? very difficult

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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

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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)

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Adult A-A Female (Nasco)
CPR Prompt (Compliant)
Fat Old Fred (Lifeform)
Little Anne (Laerdal)
David/Adam (Nasco)
CPR Pal (Ambu)
Basic Buddy (Lifeform)
Economy Saniman (Nasco)
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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

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Anatomy of a simulation (1)

• Components
• Student/trainee/health professional
• Procedure/task/skill/test/treatment or equipment
• Patient and/or disease process
• Trainer/supervisor

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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

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• 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)

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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

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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

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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.

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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

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High fidelity simulation (3)

• Allow time for familiarisation with the simulator
  equipment
• Brief participants on
• The scenario
• Educational objectives
• How to get help

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High fidelity simulation (4)

• Always follow the script but...

have alternative outcomes planned and rehearsed
Simulation control room
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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
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High fidelity simulation (6)

• Facilitated debriefing with an expert
  practitioner. Participants reflect on their own
  performance and discuss this with the group

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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, post-op ward,
  clinic, aircraft, ambulance, home, roadside,
  terrorist incident, etc
• Outreach settings
• Regional hospitals, rural settings, etc

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Source Jones A (BMSC)
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Simulation centres
May 2003
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Flinders Uni
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Publications on patient simulation in clinical
care
Year
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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

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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

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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