Simulation 101ACOEP Faculty Development

November 4, 2016

Charles D. Bortle, Ed.D.

Director Clinical Simulation

Einstein Medical Center, Philadelphia

Disclaimer SlideDr. Bortle has no pertinent financial entanglements to disclose.

He is not trying to sell you anything.

Information in this program is given to illustrate a variety of available simulation devices. Inclusion should not be construed

as endorsement of any particular vendor or device.

Objectives……

• After enjoying this session, the participant will be able to:

• Describe the four basic categories of simulation• Describe a variety of debriefing approaches• Discuss how simulation can be used as an evaluation

tool in Milestones• Review a variety of simulation resources, including

simulation organizations, vendors, and products.• Discuss cost-efficient options for simulation

Types of Simulation Centers

• Medical Schools• Heavy on Standardized Patients/OSCEs

• Nursing Schools• Heavy on Nursing Process/Assessment• 2015 NCSBN Study

• Other• Consolidate existing infrastructure• Continuing education, competency, patient safety

My Simulation Center

• 6,500 Sq Feet• 2 ICU beds

• With control room

• 1 OR• 1 2-bed Ward• 2 task trainer rooms• 2 Multipurpose Rooms• 1 Large classroom

Accreditation Options

• SSH• Society for Simulation in Healthcare

• ACS• American College of Surgeons

• ASA• American Anesthesia Association

Certification Options

• CHSE• Certified Healthcare Simulation Educator

• CHSE-A• Certified Healthcare Simulation Educator-Advanced

• CHSOS• Certified Healthcare Simulation Operations

Specialist

Simulation Organizations

• SSH• Society for Simulation in Healthcare• Annual Conference known as IMSH

• INACSL• International Nursing Association for Clinical Simulation and Learning

• IPSS• International Pediatric Simulation Society

• INFORMS Simulation Society• SCS

• The Society for Modeling and Simulation International

• Sim Ghosts• www.SimGhosts.org

NCSBN National Simulation StudyNational Council of State Boards of Nursing

• Phase 1 (2010)• Survey 1060 Nursing programs representing 50

States• Phase 2(2011 – 2013)

• Group 1 – Traditional Clinical Experience (up to 10% simulation)

• Group 2 – 25% simulation in place of clinical hours

• Group 3 – 50% simulation in place of clinical hours

• Phase 3 (2014)• Follow students (N=666) for 6 months post graduation

Results

• No statistically significant difference between the 3 groups in:

• Clinical competency• As assessed by clinical preceptors

• Comprehensive clinical knowledge• Pass rate on NCLEX

• Manager ratings of overall competency• At 3, 6, and 9 months as practicing nurses

• Conclusion: • substantial evidence that up to 50% of traditional clinical time

can be replaced by simulation

Simulation & Milestone Project

1. Emergency Stabilization

2. Focused History and Physical

3. Diagnostic Studies

4. Differential Diagnosis

5. Pharmacotherapy

6. Observation and Reassessment

7. Disposition

8. Multitasking

9. Procedures

10. Airway management

11. Anesthesia and Pain Mgt

12. Focused Ultrasound

13. Wound management

14. Vascular Access

15. Medical Knowledge

16. Performance Improvement

17. Healthcare Flow

18. Documentation

19. Practice-based P.I.

20. Professional Values

21. Accountability

22. Pt. Centered Communications

23. Team Management

4 Basic kinds of Simulation

• Virtual Reality

• Standardized Patients

• High Fidelity Simulation

• Task Trainers

Task HiF

VRSP

What do we currently do

45%

45%

5%5%

Simulation by Type - Last 6 Months

Task

HF

SP

VR

Task Trainers

Task Trainers

• Allow repetitive practice of psychomotor skills prior to practice on patients

• Build muscle memory• Allow for proper sequencing and equipment

selection• Provide a backdrop for other skills

• Communication, problem solving, interdisciplinary

• Not always realistic• Beware ongoing upkeep and disposable supply

costs.

Task Trainers

• Thoracentesis ($2K)• LP ($2K)• Airway Management ($2K)• Knee Aspiration• FAST Exam ($6K)• Blue Phantoms ($1K)• Rectal Exams ($1K)• Vaginal Exams ($3K)• Post Partum Hemorrhage

($+1K)• OB Manikins ($11K/set)• Breast Milk Expression ($1.2)• Central Lines ($5K)

• IV Hands ($250)• IV Arms ($500)• Pediatric

• IO, Scalp, Peripheral ($300-$700)• Old Fat Fred ($365)• CPR

• Adult, Infant, Child ($250 - $2K)• CPR Skill Reporters ($2K)

Rentals

• Trauma Man (Simulab)• Cricothyrotomy• Tracheostomy• Needle Decompression• Chest Tube Insertion• Pericardiocentesis• DPL

• $150.00/student• (in groups of 8)

Ultrasound

• Ultrasound machine available

• Most newer task trainers are ultrasound compatable

• Difficult to demonstrate pathologies

• “Fake” ultrasound• Able to show

pathologies• Lose “knobology”

component

$5K+

$5.8K

CPR with immediate feedback

High Fidelity

• Overused/nonspecific term• Total immersion?

• Immersive Patient Care Management Scnario (IPCM)• Video Games?

• The Flight Simulator Analogy• Critical Thinking, Teamwork, Leadrship,• Multidisciplinary teams• These are not usually about the medicine

Multiple Options Available

• Laerdal• Medical-X• Meti (CAE)• Simulaids Smart STAT

SimMan3G ($96K)

SimBaby ($58K)

Sim NewB ($38K)

The History of “High Fidelity”

• 1960 Austrian Peter Safar developing CPR

• Asmund Laerdal, Norwegian Toy maker

• Uses death mask of L’inconnue de la Seine

• Annie is born

Not sure where SimMan’s face came from

Early High Fidelity

• Annie +• Fred the Head +• IV Arm +• Cardiac Monitor +• “Electronic Heart”

Simulation should be a “safe place”

• But not without its issues• Accidental Cranial Defibrillation – A case study

-JACEP 8:1 (January), 1979

• Video taping scenarios• Why?• Who sees them?• How Secure?• When deleted?

Virtual Reality

• 2D and 3D• Haptic devices• Not a lot of EM applications yet• Still an expensive proposition

Haptics

Military Virtual Reality

Standardized Patients (SPs)

• Most learners are used to this from OSCEs

• Can be an inexpensive and effective approach

• As always, what are your objectives?

Less Expensive Options

• Use Residents as SPs• Bonus – Residents get to feel like patients• Most are used to OSCEs

• Use other local resources as SPs• Kids• Acting Classes• EMS Agencies• Allied Health Programs

Games

Friday Night in the E.R.

Medical Games/Technology

• Septris – sepsis case studies• SICKO – surgical case studies• ATLS application• Numerous medical “Apps”

Turning Point

How to float the boat

Less expensive Options

• Simply NRP• Mama Natalie• SimMan Essential

$157.00$867.00

$36K

Less expensive options

Simulaids Smart-Stat manikin with

iPad

$12.5K

Simulab Lumbar Puncture

$1,850

Obese and geriatric Modules

$895.00

Limbs & ThingsComplete Set $2,000

But be careful…….

• Storage• Maintenance• Set-up/Tear-down• Disposable supplies• Ancillary supplies

• Airway supplies, bandages, dressings, kits

Disposable Supplies

• Glucose Test Strips ($17.45/bx) ($800 this year)

• Central Line Dressings ($7.90) ($12,000 this year)

• IV Start Kits ($3.52)• Surgical Airway Kit ($140.00)• Gloves ($9.06/bx)• IV Catheters ($1.50)• Cric Kits ($150)• Laryngoscope batteries ($1-$5 apiece)

Biologicals?

• Chicken Bones – Intraosseous• Pigs feet - Suturing• Beef Ribs – Chest Decompression• Deer/Cow trachea – Cric• Beef Hearts- Anatomy/Pacing• Live biologicals ????

Share Equipment?

• Merit Badge Courses• Local EMS Agencies or Training programs• Local Nursing programs• Cooperative/Mobile Models

Build your own

• Lots of formulas for fake skin/tissue• 3D printing opens a whole new set of options• Creative individuals have been doing this for

years

Home made task trainers

• Limited only by your imagination and time• Task residents with making creative task trainers

• Transvenous Pacemaker Training

Pericardiocentesis

Zerth, H., Harwood, R.,Tommaso, L., Girzadas, D.The Journal of Emergency Medicine, Vol. 43, No. 6, pp. 1066–1069, 2012doi:10.1016/j.jemermed.2011.05.066

• Annie Body• ET Tube Ribs• Jello filled

balloons• Shelf Liner Skin

Very Low End

• Do you draw pictures for patients?

Repurpose other “dolls”

Keep Technology in context

Technology should only be seen as a means to an end. The technology should not drive the

simulation center/lab, but rather instructional, training, assessment, and/or

curricular objectives should drive what technology is chosen, and how it is used.

Young, H.M., (2012) Tarleton State University.

Simulation Center Activities

Sim Center Mission

• Education• And re-education (remediation)

• Research• Institution-wide initiatives• Patient Safety• Collaboration and Consolidation

• Particularly between• Nursing Education and Physician Education• The various residencies and fellowships

• Interdisciplinary education remains an elusive but priority goal.

Standing Courses

• CPR (4000/year)• ACLS (1000/year)• PALS (250/year)• ATLS (75/year)• NRP (125/year)• CTC Activity (outside instructors and agencies)

• Approximately 9,000 cards/year

How much might you save the institution

if they currently send people out?

Lets MAKE a bunch of Money!

• Probably not• 7 Sim Centers in Philadelphia

• No one made more than $50K last year.

• Look out for other entanglements

• Stark Legislation• Are you a non-profit?

Educational TheoryWithout it, you’re just playing with dolls

Clear Learning Objectives

• What are our goals for this simulation?• Just signing an attendance roster isn’t enough!

• Don’t try to do too much• You can always cover more in the debriefing• Best Practices = 3-5 objectives

• Objectives should be measureable• How do you grade a back flip?

Objectives should match the learner

Nursing Orientation• Identify arrest• Call 6-911• Start CPR• Get the crash

cart into the room and position it properly

• Give report to the code team when they arrive

EM Interns • Start CPR• Ventilate

Appropriately• Defibrillate• Achieve

Vascular Access

• Give proper first round medications

EM Seniors • Advanced

Airway Placement

• Central Line• Rule out PEA

causes• Terminate

Resuscitation

Bloom’s Taxonomy

• Evaluation - creates new answers• Synthesis - understands other complex systems

and relates shock to them• Analysis - discuss the pathophysiology of shock• Application - recognize a pt in shock• Comprehension - restate in own words• Knowledge - definition of shock

Scaffolding

• Build upon existing structures

• 71 - 79 - 40489 - 4• Red light / Green Light• Prior Experience

• O2 Cylinders• Radio Dial

• Provide a Prior Experience• WAR STORIES

• Start with HOW TO USE THE SIMULATOR

Ken Murray

• Subconscious Incompetence• Don’t know what they don’t know

• Conscious Incompetence• Know what they don’t know

• Conscious Competence• Know what they know

• Subconscious Competence• Know without “thinking about it”

• Conscious Competence of Subconscious Incompetence• Know that they don’t know everything

Kirkpatrick’s 4 levels of evaluation

• Reaction, or student satisfaction• Smiley sheets

• Learning, or the ability to express knowledge• Pass tests

• Behavior, or a demonstrated change in job performance

• Improved work performance• Identified and filled an educational gap

• Results; demonstrates an effect on achieving important organizational goals

• Improved patient survival, Better HCAPPS scores

Expert Demonstration

• Particularly for task trainer work• Provides some orientation to the manikin and

equipment• Allows the learner to see the expectations• Answers many of the soft questions that the

learner has• Hones and clarifies the simulation during its

development• Could be a video (provides great consistency)

• But its not always as easy to shoot a video as it looks!

Erikson

• Rapid Cycle Deliberate Practice• Repeat the same scenario 3 times in

30 minutes

• Pick up all those small procedural issues

• How to put the head of the bed down• Inflating the bag on non-rebreather

Safe Environment

• Confidentiality Agreements• All video erased at the end of each day• Collegial Environment• Its OK to make mistakes

• Better here than at the bedside

• Flight Simulation Analogy

No observers in Control RoomNo pictures

How many students?

• You can put 24 people in a Sim rooom, but……• Optimal = 4 or less

• Rotate responsibilities?• Multidisciplinary teams

• Observers/Scorekeepers• Watch video feed in another room

• Avoid unrelated observers in the control room• Participants deserve to know who is watching them

Different Sims for different goals

New equipment/bundle/procedure/competency• Routine scenarios allow learner to demonstrate competency

Communication/Teamwork skills• Repeat the same scenario over and over with team members

switching roles (aka: Rapid Cycle Deliberate Practice (RCDP))Critical Thinking Skills

• Same set-up (chest pain) with multiple scenario outcomesTeam Leadership Skills

• Stresses the individual’s ability to lead• Frequently high stress/low volume scenarios

Push it until they fail?

• For Advanced learners or teams• “Let them flail to identify the deficit” (Hunt (2009),Resusciation)

• Really smart people prefer to troubleshoot rather than be given the answer

• For systems evaluation or troubleshooting• Will our new protocol work?

• The Kobayashi Maru scenario• A test of character• “The best figure skaters in the world fall more in practice”

Einstein Center for Clinical Competency

Simulation allows you to fail safely!

Facilitation Methods

• Facilitator Prompting Simulation▫ Facilitator in room during session

• Partial Facilitator Prompting▫ Facilitator adds prompts that help

steer the simulation▫ Prompts vs. Injects

• Media Facilitator Prompting▫ No person in the room

• No Facilitator Prompting

IMMERSION

PARTICIPANT

EXPERIENCE

FORMATIVE

TO

SUMMATIVE

Facilitator Prompting

• Intentionally used complex scenarios not typical with 1st year as wanted to focus on nursing process. Required facilitator prompting as scenario was beyond the scope of the students.

• Burns, H., O’Donnell, J., & Artman, J. (2010). High-fidelity simulation in teaching problem solving to 1st year nursing students: A novel use of the nursing process. Clinical Simulation in Nursing, 6:e87-e95.

Media Facilitator Prompting

• Both injects and prompts can be delivered to a video monitor in the simulation room without an in-room facilitator breaking the suspended reality of the simulation.

• -Bortle, C. (2013)

Debriefing

• Formal Debrief with Video• Adjourn to another room• Review the case

• Open-ended questions• “What went right?”

• Debrief in the room• Same basic rules – no video playback• Less opportunity for reflection• Varies from fairly formal, to “on the fly”

• Debrief yourself• Essentially no formal debrief• Possible to allow participants to review video on their own

Kolb Experiential Learning Theory

• Concrete experience (feeling): • Learning from specific experiences and relating to people.

Sensitive to other's feelings.

• Reflective observation (watching):• Observing before making a judgment by viewing the

environment from different perspectives. Looks for the meaning of things.

• Abstract conceptualization (thinking): • Logical analysis of ideas and acting on intellectual understanding

of a situation.

• Active experimentation (doing): • Ability to get things done by influencing people and events

through action. Includes risk-taking.

Cognitive Load Theory

• Short Term Memory = Desktop (ROM)• Long Term Memory = Hard Drive• Miller – 7 plus/minus 2• Avoid extraneous input that increases the cognitive load

• Like having to remember how the manikin works

• Have distinct objectives in mind for each scenario• Additional objectives may vicariously occur during debriefing

The Classic Sim Model

• Psychological Safety• Perform Scenario

• Experiential Learning• Build toward goals with Simulation curriculum

• Scaffolding – watch the Cognitive Load

• Debrief• Reflective Learning

• Repeat

Psychological Safety

• A Slice of Vegas: “What happens here stays here”

• Setting ground rules (see http://ahc.buffalo.edu/simulation/resources.php)

• Video provides objective review if questions arise

• Video saved or destroyed?

Scenario

• Grounded in curriculum and educational objectives • Main Focus / Foci are goals of the scenario linked to

curriculum • Performance Measures are discrete and measurable

indicators of expected behavior • Not achieving performance measure indicates

performance gap that needs to be closed during debriefing

• Debriefing based on and linked to these performance measures

Location and Timing

• Location• Ideally room separate from simulation room. • Unlinks emotional attachments• Separate room continues neutrality and safety

• Timing• Immediately after scenario concludes (NO BREAKS!) • Capture emotions and events while memory is fresh

Reflective Learning

• Processing events and situation • Get at the “why’s” of the scenario • Consider alternate diagnoses/treatments/management

strategy • Debriefer elicits information from the group • Inquiry-Advocacy

• Asking open-ended questions to determine how learners feel about the situation

• Identifies thought processes

• Socratic Method • Socrates used directed questioning to identify deficiencies in logic • “playing dumb” about facts and ideas asking opponent to explain

their thoughts

Does it work empirically?

• The simulation community seems quite honest and willing to evaluate the effectiveness of the medium.

• Is it effective• Is it COST effective• Is it better than other approaches

• That being said, educational research is quite difficult to validate

• Recent questions bout learning styles being relevant

Take Home Messages

• There’s a lot you can do without spending $100K

• Don’t forget the expense of supplies and disposables

• Who is going to do the scut work?• Have an overall plan (curriculum)• Have a plan for ach Sim (objectives)• Document everything so it counts!

Hands on

• Lets see what some manikins can do.

Pick a Milestone

1. Emergency Stabilization

2. Focused History and Physical

3. Diagnostic Studies

4. Differential Diagnosis

5. Pharmacotherapy

6. Observation and Reassessment

7. Disposition

8. Multitasking

9. Procedures

10. Airway management

11. Anesthesia and Pain Mgt

12. Focused Ultrasound

13. Wound management

14. Vascular Access

15. Medical Knowledge

16. Performance Improvement

17. Healthcare Flow

18. Documentation

19. Practice-based P.I.

20. Professional Values

21. Accountability

22. Pt. Centered Communications

23. Team Management

Write some Sim objectives

• Where does this fit into a larger curriculum?• How do we measure and document success?• What approach are you going to use?

• Classic scenario + debrief• Rapid cycle• Rotate roles• Modified debriefing?

Some Simulation Vendors

• High Fidelity• CAE Healthcare

• Meti Man• Blue Phantom

• Gaumard• Laerdal medical• Simulaids• Medical-X

• Task trainers• AirwayCam Technologies• IngMar Medical• Limbs & Things• Simulab• Smooth-On• Syndaver

• General Supplies• Channing & Bette• Nasco• Pocket Nurse