1. Use of Simulation to ImprovePatient Safety Health Forum Summit--2005 John R. Combes, MD Senior Fellow, HRETJohn C. Messenger, MD, FACC Associate Professor of Medicine University of Colorado Health Sciences Center July 30 th , 2005

2.

Current Training Paradigm in Perspective

Background of Simulation in Medicine

Improving Skills with Simulation

Outcome Studies of Medical Simulation

AHRQ Pilot Project for Skills Training

Challenges for Improving Medical Care using Simulation

3. Current Training in Healthcare Our Approach in Perspective :

Time-intensive apprenticeship model that is directed at individuals

Practice occurs on patients

Life-threatening events/complications are rare

Focus is primarily on technical skills not the non-technical team skills

Little emphasis on interdisciplinary training

4. Recommendations from IOM

Use simulators to ensure that clinical training issafefor patients

Develop simulators for use in skills assessment

Use simulation technology to improveindividualandteam performancethrough interdisciplinary team training

Use simulation for problem solving and recovery from problems crisis management

To Err is Human: Building a Safer Health System , Institute of Medicine, Committee on Quality, National Academy Press, 1999 5. Human Learning: Level of Interactivity Why Use Simulations?

• • Interactionis associated with learning achievement and retention of knowledge

• • Participantslearned fasterand hadbetter attitudeswhen they used an interactive instructional environment

Retention Teach Others 90% Collaborative Simulations Learn By Doing 75% Simulations Discussion Groups 50% Web Seminars, IM, chat Demonstration 30% Animation Audio Visual 20% PowerPoint Slides Lecture 5% Streaming media Source: Andersen Consulting Najjar, L. J. (1998). Principles of educational multimedia user interface design.Human Factors , 40(2), 311-323. 6.

Current Training Paradigm in Perspective

Background of Simulation in Medicine

Improving Skills with Simulation

Outcome Studies of Medical Simulation

AHRQ Pilot Project for Skills Training

Challenges for Improving Medical Care using Simulation

7. Birth of AviationAnd Simulation Training The Wright Flyer Dec 17 th , 1903 French Simulator circa 1907 Current Simulator 8. History of Simulation

The Flight Industry established simulation as a basis for training that has become widely accepted

• Flight simulators improved pilot skills

• Certification required on simulator prior to flying

• Re-certification on a simulator is required yearly

• Intensive simulation required to pilot different aircraft

Office of Naval Research, 1973Visual Elements in Flight Simulation National Council of the National Academy of Science Dusterberry JC. Introduction to simulation systems.Soc Photo-Optical Eng1975;59:141-142 9. Improving Safety & Outcomes in High Risk Industries Wachtel J. In: Walton DG ed.Simulation for Nuclear Reactor Technology,1985;339-349 Ressler EK et al. Military Mission Rehearsal in:Tekian et al eds.Innovative Simulations for AssessingProfessional Competence.1999;157-174 10. Anesthesia Simulation

Complex realistic simulations in OR-like setting

Standardized simulations can be controlled and catastrophes introduced to simulate rare events

Behavior and performance during crises can be studied--Based on Crew Resource Management

Simulation training has been shown to:

• improve acquisition and retention of knowledge

• decrease unplanned errors

• improve correction of problems

Chopra V et al.Br J Anaesth1994;73:287-292 DeAnda A et al.Anesth Analg1991;72:308-315 11. Simulation in the Field of Surgery

Early use in laparoscopic surgery

• instrument use, hand-eye coordination and depth perception

Level of training and frequency of skill repetition are predictors of skill proficiency

Residents trained with simulation had significantly greater improvement on the simulator vs. controls for several common tasks and for overall scores

Derossis AM et alAm J Surg1998;175:482-487 Derossis AM et alSurg Endosc1998;12:1117-1120 12. Validation of Simulators

Face Validity

Content Validity

Construct Validity

• Distinguish between subjects with different levels of experience

Predictive Validity

• -- Performance measured correlates with measured technical ability in vivo

Datta V et al.J Am Coll Surg2004;199:603-606 13. Validated Simulators Have Been Developed in Numerous Fields:

Anesthesiology

ENT Surgery

Emergency Medicine

Trauma Surgery

Neonatal Medicine

Laparoscopic Surgery

Orthopedic Surgery

Colonoscopy/Flexible Sigmoidoscopy

Bronchoscopy

Colposcopy/Hysteroscopy

Cardiovascular Medicine

• Harvey Patient Simulator

Endovascular Medicine

• Coronary angiography

• Cerebral angiography

• Peripheral angiography

• Coronary/Carotid/Peripheral Intervention

• Pacer/defibrillator insertion

• New device training

14.

Current Training Paradigm in Perspective

Background of Simulation in Medicine

Improving Skills with Simulation

Outcome Studies of Medical Simulation

AHRQ Pilot Project for Skills Training

Challenges for Improving Medical Care using Simulation

15. Simulation--Defined

A device or exercise that enables a participant to reproduce or represent, under test conditions, phenomena that are likely to occur in actual performance

Lack of data comparing the impact of the type of simulation on the effectiveness of training

Krummel TM.Ann Surg1998;228:635-637. 16. What Skills Can We Train/Evaluate Using Simulation?

Technical Skills

• Technical proficiency measured by:

• • Procedural time

• • Number of errors

• • Need for Assistance

Non-Technical Skills

• Teamwork

• Communication

• Judgement

• Leadership

17. Goals of Simulation Training for Individuals

Improve skills through interval practice

Improve consistency of performance

Decrease errors

Provide proximate and summative feedback

Allow for assessment of progress

Incorporate a standardized, comprehensive curriculum

Optimize patient safety by accelerating the learning curve prior to patient exposure

Adapted from Gallagher AG et al.Ann Surg2005;241:364-372 18. Proposed Goals for Team Training

Focus on leadership

Improve team communication

Encourage cooperation

Understand roles in team performance

Improve learning and transfer

Enhance patient safety

Ostergaard HT et al.Qual Saf Health Care2004;13(supp):i91-i95 19. Why focus on the team?--Factors Involved in Adverse Medical Events Available at www.jcaho.org 20. Why is team training important?

Many fields in medicine are complex

Dynamic situations

Providers are under time pressure

There is little time to synthesize data

Workload is often very high

Medicine is a high risk environment similar to field of aviation

Ostergaard HT et al.Qual Saf Health Care2004;13(supp):i91-i95 21. Training with Simulation--Impact on Team Performance

Error reduction and improved team behavior have been demonstrated in the fields of:

• Anesthesia

• Emergency Medicine

• Trauma Surgery

• Medical Crisis Teams

Morey et al.Health Serv Res2002;37:1553-1581 Holcomb JB et al.J Trauma2002;52:1078-1086 DeVita MA et al. Crit Care Med2004;32:S61-S65 22. Team Training Applications

Emergency Medicine Training

Use for ATLS/ACLS resuscitation

Training in Critical Care Medicine

• Doctoral, post-doctoral, CME and CPD

Training for neonatal resuscitation

Operative Suite Training

Role in Endovascular Medicine

• AHRQ-funded demonstration project in cardiac catheterization lab

Grenvik A et al.Curr Opin Crit Care2004;10:233-237 Lighthall GK et al.Crit Care Med2003;31:2437-2443 Messenger JC et al.Top Health Inform Man2002;23:82-93 23. Challenges Facing Team Training

Medicine teams are often transitory involving multiple disciplines working together

• Nurses, physicians, technicians, respiratory therapists.

Difficult to measure an impact on specific patient outcomes/patient safety hard endpoints

• Decrease in deaths, complications etc

Objective methods for detecting an effect on team performance have been limited

Who is going to broadly fund simulation-based training?

24.

Current Training Paradigm in Perspective

Background of Simulation in Medicine

Improving Skills with Simulation

Outcome Studies of Medical Simulation

AHRQ Pilot Project for Skills Training

Challenges for Improving Medical Care using Simulation

25. Improved Clinical Outcomes from Technical Skills Training

The field of surgery has used simulation training in laparoscopy to:

• Improve technical skills and retention of knowledge when tested in simulator

• Transfer learned technical skills to the clinical setting

• • procedure time, errors significantly during cholecystectomy

Seymour NE et al.Ann Surg236(4):458, 2002 Grantcharov TP et al.Br J Surg 2004;91:146-150 Derossis AM et alAm J Surg1998;175:482-487 26. VR Training Improves Operating Room Performance: A Randomized, Double-blinded Study.

Objective:

To demonstrate that virtual reality (VR) training transfers technical skills to the operating room environment.

Background:

Use of VR surgical simulation to train skills and reduce error risk in the OR has never been demonstrated in a prospective, randomized, blinded study.

Seymour NE et al.Ann Surg236(4):458, 2002 27.

Results:

No differences in baseline skills were found between groups.

All subjects successfully completed the procedure:

• Gallbladder dissection was 29% faster in VR-trained residents.

• Non VR-trained residents were 9 times more likely to transiently fail to make progress (p