Session T212Development & Implementationof Simulated Interactive Medicine

Michael Rota, MS, PA-C Nora Lowy, PhD, MPA, PA-C

Development & Implementation of

Simulated Interactive Medicine

Development & Implementation of Simulated Interactive Medicine

I. Introduction II. Development of “PA SIM” Project III. Curriculum Development IV. Insights Gained V. Simulation as an Educational Tool VI. Wrap-up and Q&A

I. Introduction

Wagner College

• The Wagner Plan – “… personalized

education” – “… field-based learning

opportunities of NYC” – “… theory and practice”

• Mission – “… comprehensive

educational program” – “… experiential and co-

curricular learning” – “… interculturalism” – “… service to society”

Wagner College

• Vision Statement – “… engaged student

learning […] reflective and integrated, theoretical, and practical.”

– “… provide a transformative college experience”

• Strategic Plan – Enhancing and expanding

on… • Classroom experiences • Civic engagement • Experiential learning • Global education

Cunard Hall

• Built around 1852 by Edward Cunard, son and heir of Canadian shipping magnate Samuel Cunard

• Administrative building since the move to Grymes Hill in 1918

• PA program occupies the 3rd floor

Cunard Hall

Key Members of our “PA SIM” Project

• Nora Lowy, PhD, MPA, PA-C • Natalya Kusheleva, MS, PA-C • Shaun Beaulieu, MS, PA-C • Michael Rota, MS, PA-C • Robert Marchese, MS, PA-C • Austin Epstein, PA-C • Krystal Cromeyer, MBA

Goals

1. Share roadmap for development of our “PA SIM” lab

2. Provide guidelines for development of simulation curriculum

3. Discuss insights gained during the implementation of simulation into our curriculum

4. Facilitate discussions regarding use of simulation as an educational tool

II. Development of our “PA SIM” Project

Discovering Simulation• Numerous faculty meetings • Reflections on teaching

modalities • Discussions on advantages of

simulation • Inclusion of innovations in

teaching • Literature searches • Site visits

– Laerdal conference – NS-LIJ SIUH – NY SIM (NYU) – Wagner College School of

Nursing

Planning and Development• Meetings with consultant

–Natalya Kusheleva, MS, PA-C Director of Patient Safety Institute & Clinical Educational Programs at NS-LIJ SIUH

• Meetings with on-campus administration – Vice President for Finance and Business – Director of Operations – Chief Information Officer (CIO) – Media Director

Project Needs• Experiences we wanted to offer students…

– High-fidelity manikin-based experiences – Skill stations – Standardized patients – Virtual standardized patients – Debriefing sessions

• Equipment we needed to house… – Manikins – Task trainers – Portable exam tables and medical equipment – Computer stations – AV equipment for recording/viewing sessions

Project Needs

High-fidelity manikin-based experiences

Skill stations Standardized Patients (SPs)

Virtual Standarized

Patients

Debriefing Sessions

Experiences we wanted to offer students…

Project Needs

Manikins Task TrainersPortable Exam

Tables & Medical Equipment

Computer Stations

AV Equipment for Recording & Viewing Sessions

Equipment we needed to house…

Project Limitations

• Limited square footage • Building code

restrictions • Electrical system

limitations • Budgetary constraints • Groups of varying

sizes

Project DesignLimited Space • 4 Rooms

Equipment • Manikins • Task Trainers • Medical Supplies • AV Equipment

Project Design

• Floor plan – 3rd floor of Cunard Hall – 4 rooms, each

designated for a spectrum of learning experiences

• Equipment –Manikins – Task trainers –Medical supplies – AV equipment – Storage containers

Floor Plan

Simulation Laboratory

Simulation Lab• 2 stations divided by a mobile hospital screen • 2 LCD screens for vital signs • 2 faculty viewing areas behind by

one-way mirrors • Digital video recording equipment including

microphones • 4 full sized manikins

– 2 male manikins – 1 female birthing manikin – 1 neonate manikin

• Dry-erase walls for student note taking

Simulation Lab

Simulation Lab

Floor Plan

Clinical Skills Lab & Large Debriefing Room

Clinical Skills Lab & Large Debriefing Room• Utilized as both a clinical skills lab and

a large debriefing room • Equipped with…

– Foldable exam tables – Movable desks – 80” flat screen television – Lectern with laptop

• Creative configurations – Physical exam practice – Skills training – Viewing live/recorded sessions – Debriefing – Lectures

Clinical Skills Lab & Large Debriefing Room

Activity Equipment CapacityPhysical exam practice Foldable exam tables 8Skills training Movable desks, task trainers 8Viewing live orrecorded sessions

Flatscreen TV, movable desks, chairs

16

Debriefing Movable desks 16Lectures Flatscreen TV, movable desks,

lecturn laptop, chairs32

Large Clinical Skills Lab & Debriefing Room

Floor Plan

Research & Debriefing Room

Research & Debriefing Room• Utilized for virtual simulation experiences, evidence-based

research, thesis research meetings, debriefing, and group skills practice

• Equipped with… – Large conference table – 4 computer workstations – 70” flat screen television – Lectern with laptop

• Creative configurations – Virtual simulation experiences – PBL sessions – Research/statistics meetings – Skills training (e.g., suturing) – Viewing live/recorded sessions – Debriefing

Research & Debriefing RoomActivity Equipment Capacity

Virtual simulation experience Computer workstations 4Research and statistics meetings

Conference table, computer workstations

8

PBL sessions Conference table 16Skills training Conference table 16Viewing live/recorded sessions Flatscreen TV, conference

table16

Debriefing Conference table 16

Research & Debriefing Room

Floor Plan

Faculty & Administrative Viewing Room

Faculty & Administrative Viewing Room

• Utilized for simulation lab viewing and faculty conferences • Equipped with…

– 8-person conference table –Computer workstation – 60” flatscreen television –Breakout box to allows faculty/students to connect

their computers to the screen for utilization during conferences, workshops, and presentations

Faculty & Administrative Viewing Room

Activity Equipment CapacityAdvisement meeting Conference table 4Small group debriefing Conference table, viewing screen 8Research meeting Conference table, computer

workstation8

Faculty meeting Conference table, viewing screen 12

Faculty & Administrative Viewing Room

Faculty & Administrative Viewing Room

AV Capabilities• Wall-mounted HD PTZ cameras (2) and ceiling-

mounted directional microphones (2) • Recording equipment utilizing flash drives for

storage • Small flat-screen TVs (2) in the simulation lab for

viewing vital signs and diagnostic imaging • Large flat-screen TVs (3) for viewing live simulation

sessions in HD with audio, observing recorded simulation sessions during debriefing, and broadcasting presentations

Directional Microphones

HD PTZ Cameras

Equipment: Manikins

• High-fidelity male manikin with tablet • High-fidelity female

birthing manikin with tablet and laptop • Additional male manikin • Neonate manikin

Equipment: Models

• Abdominal cavity model • Adult skull • Arterial wall layer model • Brain model • Breast model • Cardiac/pulmonary circulatory system • Complete hanging skeleton • Complete set of disarticulated bones • Complete spinal column • Complete upper and lower extremity

bone • Cross section model of ear

• Cross section stomach model • Female genitalia model • Heart model • Inflatable lung kit – includes smokers

lungs for comparison • Male genitalia model • Pregnancy hemi-pelvis model • Pregnancy stages model • Prostate model • Rectal model • Skin layer model • Stand-up human muscle model • Thoracic cavity model

Equipment: Procedure Trays• Arterial line tray • Bone marrow aspiration tray • Central mine tray • Cricothyrotomy tray • Dressing change kit • Foley insertion tray • Incision and drainage tray • Laceration tray • Lumbar puncture tray • Nosebleed tray • Paracentesis tray • Pericardiocentesis tray • Pneumothorax tray

Equipment: Task Trainers

• Arterial blood gas trainer • Breast exam trainer • Contraceptive methods trainer • CPR trainers • Female urinary catheter trainers • Intra-osseous injectable trainer • Intradermal injection trainer • Intramuscular injection trainer • Intravenous trainer • Intubation trainer

• Male urinary catheter trainers • Nasogastric tube trainer • Pap smear trainer • Pelvic exam trainer • Prostate exam trainer • Rectal exam trainer • Subcutaneous injection trainer • Tracheostomy site replacement

trainer • Venipuncture trainer

Equipment: Task Trainers

Equipment: Task Trainers

Timeline

III. Curriculum Development

Defining Mission & GoalsMission:

Goals: 1. 2. 3.

Objectives: 1. 2. 3. 4. 5.

Abstract

Concrete

Curriculum Development:What Direction Do We Take?

PA SIM Curriculum

Teaching? Assessment?

Curriculum Development: Assessment

Assessment

Students?

Diagnostic (Pre-test)

Formative

Summative

Curriculum?

Didactic Knowledge

Clinical Skills

Professionalism

Curriculum Development: Teaching

Teaching

Theory to Practice?

Application of knowledge

Clinical Skills?

Interview Skills

Physical Exam Skills

Procedural Skills

Laboratory / Diagnostic Interpretation Skills

Decision-Making Skills

Safety Skills

Professionalism?

Respect

Cultural Sensitivity

Adaptability

Communication / Counseling

Interaction in Multi-Disciplinary Teams

‘PA SIM’ Mission

To improve student learning outcomes through individual and team utilization of advanced technology.

‘PA SIM’ Mission & Goals

Mission: • To improve student learning outcomes through

individual and team utilization of advanced technology.

Goals:1. Strengthen Clinical Knowledge 2. Enhance Clinical Skills 3. Promote Culture of Safety

‘PA SIM’ Goals & Objectives1. Strengthen Clinical Knowledge

2. Enhance Clinical Skills3. Promote Culture of Safety

a) Supplement classroom learning with interactive experiences

b) Recognize strengths and address gaps in knowledge in debriefing process

‘PA SIM’ Goals & Objectives1. Strengthen Clinical Knowledge2. Enhance Clinical Skills

3. Promote Culture of Safety

a) Develop and reinforce procedural skills b) Practice clinical skills in a controlled environment c) Provide on-demand access to patient scenarios

‘PA SIM’ Goals & Objectives1. Strengthen Clinical Knowledge2. Enhance Clinical Skills3. Promote Culture of Safety

a) Improve patient safety b) Maintain compliance with hospital and professional

requirements

Teaching Skills

Skill Professional Year 1

Professional Year 2

Professional Year 3

Interview SkillsPhysical Exam SkillsProcedural SkillsLab/Diagnostic SkillsDecision-making SkillsSafety Skills

ModalitiesModalities

Low Fidelity Simulations

Manikins

Task Trainers

High Fidelity Simulations

Manikins

Task Trainers

Computer-based

Standardized Patients

Volunteers

Actors

Real Patients

Hybrid

Standardized Patients (SPs)

• Used in clinic-like settings where no interventions or treatments are provided

• Evoke many aspects of the real clinical world

• Respond with consistent and pre-defined accounts of their conditions

• Effective for early learners and advanced learners

Task Trainers

• Allow for practice of specific tasks • Reinforce key

elements of procedure or skill • Allow learners to

acquire basic procedural skills

Manikin-based Simulators

• Computerized manikin that stands in for patient

• Can replicate various functions of the human body

• Compatible with various medical equipment (e.g., ECG machine)

• Simulate life-threatening situations that require prompt recognition and treatment

• Effective for early learners and advanced learners

Manikin-based Simulators

Computer-based Simulators

• Enables a full patient encounter as a ‘gaming experience’ • Patients are depicted as

3D animations or drawings • Allow learners to interact

by asking questions, viewing data, and selecting diagnostic or therapeutic actions

Computer-based Simulators

Computer-based Simulators

IV. Insights Gained

Insights Gained

Recognize Limitations

Cultivate Creativity

Develop Relevant Cases

Utilize Different Modalities

Create a Progressive Curricula

Recognize Limitations

• Accept the limitations of your facility • High tech equipment is

not a requirement • Start small and build

up • Additions can be

made as the need arises

Cultivate Creativity

• Use your imagination • Make your own task

trainers (e.g. using balloons and toothpaste to simulate incision & drainage of an abscess)

• Dress manikins with old clothing

• Print overlays for common medical conditions (e.g. rashes)

• Use food coloring to simulate body fluids

Creating a Simulated Abscess

Creating a Simulated Abscess

Creating a Simulated Abscess

Develop Relevant Cases

• Standardize the learning process

• Create cases that meet objectives

• For each case, have no more than 3 or 4 objectives

• Tailor the degree of difficulty to the professional year

• Avoid complex or convoluted cases

• Focus on ‘teachable moments’

• Make your cases ‘fun’

Utilize Different Modalities

• Determine which cases are best run in the sim lab • Recognize the

limitations of the various modalities • Utilize the correct

modality for each case

Create Progressive Curricula

• Crawl, walk, run! • Develop a plan that

takes into account all phases of your program • Focus the objectives

to the phase of the program

Breakdown of SIM Activities by Phase

CrawlDidactic

• Skills training • Introduction to PBL

WalkClinical

• OSCE practice sessions

Run Graduate

• Advanced simulation cases • Advanced procedures

Development → Outcomes

Development

Implementat

ion

Assessment

of Outcomes

Development → Outcomes Analysis of Outcomes

Faculty Training

Practice Runs

Implementation

Research

Design

Blueprint

Products

Staging

Development

Implementation

Assessment

Example of Outcome Measurement

Example of Outcome Measurement

V. Simulation as an Educational Tool

‘PA SIM’Goals & Objectives1. Strengthen Clinical Knowledge

a) Supplement classroom learning with interactive experiences

b) Recognize strengths and address gaps in knowledge in debriefing process

2. Enhance Clinical Skills a) Develop and reinforce procedural skills b) Practice clinical skills in a controlled environment c) Provide on-demand access to patient scenarios

3. Promote Culture of Safety a) Improve patient safety b) Maintain compliance with hospital and professional

requirements

1. Strengthen Clinical Knowledge

a) Supplement classroom learning with interactive experiences

1) Reinforce didactic knowledge through case scenarios

2) Participate in simulated cases utilizing a variety of modalities

3) Practice screening, education, and advocacy for common medical conditions

1. Strengthen Clinical Knowledge

b) Recognize strengths and address gaps in knowledge in debriefing process

1) Guide students through critical thinking and problem-solving processes

2) Reinforce unique characteristics of disease processes

3) Correct misunderstandings in assessment and managment of case scenarios

2. Enhance Clinical Skills

a) Develop and reinforce clinical skills

1) Observe clinical skills demonstrations 2) Perform skills in focused domains 3) Receive feedback and assessment of

performance 4) Develop proficiency through repeated practice

2. Enhance Clinical Skills

b) Practice in a controlled environment

1) Take advantage of teachable moments 2) Receive constructive feedback in a safe, non-

judgmental environment 3) Develop confidence needed for practice in a

clinical environment

2. Enhance Clinical Skills

c) Provide on-demand access to patient scenarios

1) Participate in standardized learning experiences

2) Encounter less common disease scenarios 3) Reinforce specific learning objectives on an as-

needed basis

3. Promote Culture of Safety

a) Improve patient safety

1) Develop procedural proficiency prior to performance on patients

2) Identify and correct patient care errors without adverse consequences

3) Recognize personal limitations and importance of inter-professional cooperation

3. Promote Culture of Safety

b) Maintain compliance with hospital and professional requirements

1) Obtain BCLS and ACLS certifications 2) Gain exposure to advanced procedures 3) Supplement program requirements for patient

encounters and performance of procedures

VI. Wrap-up

Pitch your ideas to institutional administration and get their backing

Before you build a sim lab, do your research, design your layout, prepare your blueprints, and determine the products you will need

Do not break the bank, be creative with props and task trainers!

Take advantage of institutional resources to further develop your plans

Acknowledge the limitations of your project and keep your expectations realistic

Target a few definitive goals

Create a curricula that is progressively more difficult as students advance through the phases of your program

Utilize simulation to help your students develop confidence in treating future patients

Practice in a safe environment promotes the safety of future patients

Encourage team building and collaborative efforts

Small steps can lead to big strides

Q&A