best practices in simulation plann
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Best Practices in Simulation Plann
At the recent International Conference on Residency Education, several
speakers emphasized the importance of planning when using expensive
simulation labs. Residents who train exclusively on high fidelity
simulators frequently complain about the complexity and confusion of learningin this manner. I decided to write an article about the best way to plan the use of4-step progressive simulations.
Preplanning
a. Begin by analyzing what competencies should be taught in this manner.
Dangerous, painful, rare and embarrassing procedures make the best candidates.
Determine what level of competency is required depending on the level of the
resident. Setobjectivesfor each stage.
b. Create learning activities including written instructions for each level of the
progressive process described in the following document. Train preceptors to
provide the necessary role modeling.
c. Create assessment tools appropriate for each level.
d. Train raters to use the assessment tools.
http://medicaleducation.wetpaint.com/page/Objectiveshttp://medicaleducation.wetpaint.com/page/Objectiveshttp://medicaleducation.wetpaint.com/page/Objectiveshttp://medicaleducation.wetpaint.com/page/Objectives -
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1. Intentional Role Modeling
An experienced preceptor demonstrates (without comment to the trainee) the
complete procedure including interactions with patients/families and team
members. This provides the student with an understanding of the goal of
training including completion time, explanations given to the patient, safetymeasures etc.
This step may involve watching a video if an experienced preceptor is notavailable for observation.
2. Low Fidelity Simulation
Low fidelity simulations use learning resources such
as videos, animations and virtual reality with written procedural guides. Ideally
this will involve a self-directed process whereby the learner learns the basic step
by step mechanics and can repeatedly use the required resources until they
believe they have reached an understanding of the objective.
Assessment at this stage uses multiple choice and listing questions; either paper
based or online with a pass mark of >80%. Learners must have the option toretest at this stage.
3. Mid Fidelity Simulations
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Mid fidelity simulators are the body parts task trainers that expose students to
the tools used to complete procedures in a portable, minimally complex manner.
Again students practice with minimal supervision or peer support until they feelconfident to undergo formal testing. Direct observation by raters or a lab
supervisor followed by a feedback session is the usual test at this stage. Students
should be allowed to retest after returning to the simulation if they dont
demonstrate proficiency.
The student now has the basic knowledge and tool proficiency to move to theinteractive level.
4A. Interactive Hybrid Patient Simulation
Hybrid simulations are used for simple procedures which might be painful or
embarrassing for patients to have beginners practice. Simulated body parts areattached to standardized patients who act out pre-arranged scenarios and
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Interactive models
More recently, interactive models have been developed that respond to
actions taken by a student or physician.]Until recently, these simulations
were two dimensional computer programs that acted more like a textbook
than a patient. Computer simulations have the advantage of allowing a
student to make judgements, and also to make errors. The process of
iterative learning through assessment, evaluation, decision making, and
error correction creates a much stronger learning environment than
passive instruction.
Computer simulators
3DiTeams learner is percussing the patient's chest in virtual field
hospital
Simulators have been proposed as an ideal tool for assessment of students
for clinical skills. For patients, "cybertherapy" can be used for sessions
simulating traumatic expericences, from fear of heights to social anxiety.
Programmed patients and simulated clinical situations, including mock
disaster drills, have been used extensively for education and evaluation.
These lifelike simulations are expensive, and lack reproducibility. A
fully functional "3Di" simulator would be the most specific tool available
for teaching and measurement of clinical skills. Gaming platforms have
been applied to create these virtual medical environments to create an
interactive method for learning and application of information in a
clinical context.
Immersive disease state simulations allow a doctor or HCP to experience
what a disease actually feels like. Using sensors and transducers
symptomatic effects can be delivered to a participant allowing them to
experience the patients disease state.
http://en.wikipedia.org/wiki/Simulation#cite_note-pmid19103813-22http://en.wikipedia.org/wiki/Simulation#cite_note-pmid19103813-22http://en.wikipedia.org/wiki/Simulation#cite_note-pmid19103813-22http://en.wikipedia.org/wiki/File:3DiTeams_percuss_chest.JPGhttp://en.wikipedia.org/wiki/File:3DiTeams_percuss_chest.JPGhttp://en.wikipedia.org/wiki/File:3DiTeams_percuss_chest.JPGhttp://en.wikipedia.org/wiki/File:3DiTeams_percuss_chest.JPGhttp://en.wikipedia.org/wiki/Simulation#cite_note-pmid19103813-22 -
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Such a simulator meets the goals of an objective and standardized
examination for clinical competence This system is superior to
examinations that use "standard patients" because it permits the
quantitative measurement of competence, as well as reproducing the same
objective findings.
Modern medical simulation
The American Board of Emergency Medicine employs the use of medical
simulation technology in order to accurately judge students by using "patient
scenarios" during oral board examinations.[1]
However, these forms of
simulation are a far cry from high fidelity models that have surfaced since the
1990s
Due to the fact that computer simulation technology is still relatively newrelative to flight and military simulators, there is still much research to be done
about the best way to approach medical training through simulation. That said,
successful strides are being made in terms of medical education and training. A
thorough amount of studies has have shown that students engaged in medical
simulation training have overall higher scores and retention rates than thosetrained through traditional means.
The Council of Residency Directors (CORD) has established the followingrecommendations for simulation
1.Simulation is a useful tool for training residents and in ascertainingcompetency. The core competencies most conducive to simulation-basedtraining are patient care, interpersonal skills, and systems based practice.
2.It is appropriate for performance assessment but there is a scarcity ofevidence that supports the validity of simulation in the use for promotion
or certification.
3.There is a need for standardization and definition in using simulation toevaluate performance.
4.Scenarios and tools should also be formatted and standardized such thatEM educators can use the data and count on it for reproducibility,
reliability and validity.
Training
The main purpose of medical simulation is to properly educate students invarious fields through the use of high technology simulators. According to the
Institute of Medicine, 44,000 to 98,000 deaths annually are recorded due
primarily to medical mistakes during treatment.[3]
Other statistics include:
http://en.wikipedia.org/wiki/Medical_simulation#cite_note-academicResident-0http://en.wikipedia.org/wiki/Medical_simulation#cite_note-academicResident-0http://en.wikipedia.org/wiki/Medical_simulation#cite_note-academicResident-0http://en.wikipedia.org/wiki/Medical_simulation#cite_note-medicalMistakes-2http://en.wikipedia.org/wiki/Medical_simulation#cite_note-medicalMistakes-2http://en.wikipedia.org/wiki/Medical_simulation#cite_note-medicalMistakes-2http://en.wikipedia.org/wiki/Medical_simulation#cite_note-medicalMistakes-2http://en.wikipedia.org/wiki/Medical_simulation#cite_note-academicResident-0 -
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225,000 deaths annually from medical error including 106,000 deaths due to"nonerror adverse events of medications"
7,391 deaths resulted from medication errors
If 44,000 to 98,000 deaths are the direct result of medical mistakes, and the
CDC reported in 1999 that roughly 2.4 million people died in the United States,
the medical mistakes estimate represents 1.8% to 4.0% of all deaths,
respectively.
A near 5% representation of deaths primarily related to medical mistakes is
simply unacceptable in the world of medicine. Anything that can assist in
bringing this number down is highly recommended and medical simulation has
proven to be the key assistant.
Examples
The following is a list of examples of common medical simulators used for
training.
Advanced Cardiac Life Support simulators Partial Human Patient Simulator (Low tech) Human Patient Simulator (High tech) Hands-on Suture Simulator (Low tech) IV Trainer to Augment Human Patient Simulator (Low tech) Pure Software Simulation (High tech) Anaesthesiology Simulator (High tech) Minimally Invasive Surgery Trainer (High tech) Bronchoscopy Simulator Battlefield Trauma to Augment Human Patient Simulator Team Training Suite Harvey mannequin (Low tech)Advantages
Studies have shown that students perform better and have higher retention rates
than colleagues under strict traditional methods of medical training. The table
below shows the results of tests given to 20 students using highly advanced
medical simulation training materials and others given traditional paper based
tests. It was found that high technology learning students outperformedtraditional students significantly.
E-Learning vs. Textbook Learning
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Mode of LearningMean Test Score on Multiple
Choice Test
Time to Complete
Module
E-Learning (N=20) 4.03 / 5 (80.6%) "B" 2830 minutes
Traditional Paper
Based3.05 / 5 (61%) "D" 2830 minutes
Significant
DifferenceYes (p < .001) N/A
In addition to overall better scores for medical students, several other distinct
advantages exist not specifically related to training.
Less costly Time efficient Less personnel required Many automated processes Ability to store performance history Track global statistics for many linked medical simulators Less medical related accidents
Medical Simulation
There is a lot of discussion at the University of Saskatchewan about the use of
medical simulation in health science education. To understand the decisions
being made in this area, you need to understand that there are four distinct
categories of simulation:1. Physical Simulators
2. Human Manipulated Physical Simulators
3. Virtual Simulators4. Virtual Environment Simulators
Physical Simulators
Physical simulators are reusable mannequins that students practise skills on
such as physical examinations, injections and other invasive treatments. Using
this type of simulator provides initial practice when willing patients are in short
supply or when practise could be invasive, unpleasant or painful to patients.Once the student has developed an acceptable level of skill, they complete their
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learning with human patients. Below you can see some examples of physical
simulators manufactured by Kyoto Kagaku Co. Ltd., which were recentlydisplayed at the university.
Human Manipulated Physical Simulators
A more sophisticated level of simulator is a full body mannequin that can be
manipulated by a human operator located behind a two-way mirror. This type ofsimulator can answer questions, raise limbs as well as be
examined/draped/treated. This provides students with a more holistic simulation
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in which they role-play interactions with the patient. The draw back here is ahigh initial cost as well as an ongoing expense of an operator.
Virtual Simulators
Virtual Simulators use 3D animation to teach parts of the body (Guide to aHealthy Heart) or to teach steps in a procedure (Sim Praxis video)
Costs to create these simulations can be very high, therefore, they are oftenpurchased as CDs with a textbook or accessed through sponsored online sites.
See also The Visible Human
Virtual Environment Simulators
The Virtual Environment Simulators are computer-based medical scenarios that
usually include a 3D model of a location, equipment, personnel and patients that
students enter with an Avatar. They work well for What if? case studies suchas disaster training, pandemic planning, problem solving and modeling of
unusual diagnosis that students might not encounter in their clinical experience.
Costs of initial production can be lowered by using already existing virtualworlds such as Second Life, a virtual world with a higher population than theprairies. Cost per student is frequently minimal.
USES OF SIMULATION IN MEDICAL EDUCATION
Studies in cognitive psychology inform us that the recall of information and itsapplication are best when it is taught and rehearsed in environments similar to
workplace. The healthcare professions are heavily task- and performance-based
where non-technical skills, decision making and clinical reasoning are important
alongside integrity, empathy and compassion. Most of these attributes are
difficult to teach and assess in the traditional classrooms. Enhanced patient
safety on one hand has to be the ultimate outcome of any medical curriculumwhile on the other hand, it itself can be potentially compromised in an
apprenticeship-based model of medical education. A range of simulation
techniques are very well placed to be used alongside clinical placements. Thesecan be employed to enhance learning of healthcare professionals in safe
environments, without compromising the patient safety, while maintaining ahigh degree of realism..
It enhances the students understanding
Simulation-based learning is used to promote medical students' mastery of
communication skills, medical interviewing, physical examination and basic
clinical procedures. Students and tutors both recognize the effectiveness of
simulation-based learning in medical education.
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Virtual patient education will help to prevent the medical errors
There are very few medical schools that would not routinely use such
simulation as a standard part of their curriculum. This is not because they are
cost effective (although they are) but rather because they have been shown to
reduce human error in performing these clinical skills and provide a safe
environment for doctors to learn such procedures without endangering real
patients. Simulation has taken many forms in Medicine including: (1)
Computer-based simulations; (2) Standardised patients widely used in OSCE
training and examination; (3) Virtual environments; (4) mannequins such as
Resuscitation Annie, and (5) so-called "high fidelity" simulations resembling as
much as possible the actual clinical situations. These forms of simulation have
been used to teach the important skill of clinical decision-making as well as
technical procedures.
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