MEdSim Magazine - Issue 2/2013

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Issue 2.2013

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Training TECHNOLOGY

Standing Up for Simulation Simulation Programs

Robot-Assisted Surgery: Why There Should Now Be a Push For This Technology International Programs

Russia Accelerates Healthcare Simulation Plans; Overhauls Medical Training

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ISSUE 2.2013

Editorial comment

Editor's Comment Medical education and training prepares physicians and other healthcare providers for a lifetime of professional work.

However, the learning environment which shapes and reinforces the professional attitudes and behavior of physicians throughout their continuum of learning is quite diverse. That environment begins in medical school and extends through residency training and hopefully to lifelong learning.

The formal curriculum requires that students meet certain objectives and requirements that are defined by accreditation agencies. Each of these educational activities has learning objectives and address the core competencies required to meet the requirements of the accrediting agencies, of which there are many.

American medical education has evolved from pure apprenticeships to proprietary medical schools, to a reformed and formal educational system that stresses both science and professionalism.

The latter half of the last century saw the growth of requirements by state licensing boards and specialty certification boards for demonstrated participation in accredited continuing education activities.

There are presently 141 accredited MD-granting institutions and 29 accredited DO-granting institutions (AACOM) who have begun to share programs in some areas. There are approximately 400 major teaching hospitals, with thousands of faculty members and medical students.

There are more than 8,000 accredited residency programs for all specialties and subspecialties. Additionally, there are more than 16,000 active full-time and part-time residents, more than 740 national providers of accredited continuing medical education and 1,600 accredited state providers and, last but not least, the Liaison Commission on Medical Education (LCME). LCME is the oversight agency that is responsible for the accreditation of the nation’s medical schools. Its members are appointed by the AAMC and the American Medical Association (AMA). The Accreditation Council for Graduate Medical Education (ACGME) accredits residency training programs in the United States. The sponsoring institution for a residency program may be a hospital, medical school, university, or group of hospitals. Accreditation bodies define the core competencies for students, residents, and fellows and ensure that the formal

curriculum covers all essential aspects of medical education. ACGME board members are appointed by AAMC, AMA, the American Board of Medical Specialties, the American Hospital Association (AHA), and the Council of Medical Specialty Societies (CMSS). Accredited continuing medical education providers are accredited by the Accreditation Council for Continuing Medical Education (ACCME). Its member organizations are AHA, AMA, AAMC, CMSS, the Association for Hospital Medical Education, and the Federation of State Medical Boards. You can begin to understand what a complicated process we have, and I am not sure my understanding is correct! However, many medical educators are frustrated by the lack of cooperation among boards, associations and institutions.

Therefore, a cultural change must take place so that a top down bottom up system of medicine can be established.

In a recent editorial, Chris Lehman, Editor of Civil Aviation Training Magazine, discussed cultural leadership. An extract is provided below. This is part of a great cultural shift needed in the medical community to meet the demands of 21st century medicine, including the Affordable Care Act. Cultural Leadership “One of my favorite truisms is ‘Organizational culture is set at the top and measured at the bottom.” Yet another is “Unless you can measure it, you can’t improve it.’ A lengthier one that resonated for me recently is “Look, each air operator within a specific route structure and flying the same equipment has essentially the same cost paradigms: fuel, aircraft maintenance, catering, airport fees, and salaries. The only competitive advantage one operator may have over another is their corporate culture – and that culture drives everything from safety operations to customer care.”

And while economic realities are exacerbating aviation recruitment at the moment, an even more important issue is the degree that they may be contributing to employeemanagement strain and internal communications within aviation operations. Is there an impact to safety as a result?

Since the greatest threats to safety have their roots in organizational issues, making the system even safer will always require specific action by the organization.

We are all familiar with Safety Management Systems (SMS), and know that it’s a system

that integrates certain tools, including senior management commitment, identification of hazards, risk management, safety reporting, investigation, education and remedial activity. A good SMS can be seen to generate a Safety Culture and provide the positive management environment necessary to identify and resolve safety issues. A Safety Culture is often viewed as an enduring or pervasive characteristic of an organization, created over time, which gives rise to a consistent way of dealing with safety issues.

A central tenet of a Safety Culture is excellence in communications from the bottom up, but particularly from the top down. Senior management encourages and rewards employee initiative in providing safety information, and analysis and action quickly occurs. Feedback is continuous with all employees clear on what is acceptable and unacceptable, and they are motivated to apply their own skills and knowledge to enhance organizational safety.

Senior management must have the knowledge, vision and commitment to ensure that a true Safety Culture is created and nurtured. In the current environment of cost-pressures, strained labor relations, extreme competition and little customer loyalty, this is more than a challenge. If these internal and external pressures are mitigating an organization’s Safety Culture, can the deterioration be measured? No doubt we all have our views, but when we see a decline in internal communications, a fall-off in morale, or a noticeable disconnect between senior management and employees, there is cause for concern.

In my view, one can always obtain a hint of an organization’s culture – safety or otherwise – by that first contact. That first subjective assessment often remains consistent right through the entire experience with an organization.

Ultimately a positive organizational culture is the responsibility of senior management and if it can provide a competitive advantage in the marketplace, I can’t think of anything more important to the executive suite.”

Can the same aviation tenets be applied to medicine? This editor certainly believes they can.

Judith Riess Editor in Chief, MEdSim Magazine

e judith@halldale.com MEDSIM MAGAZINE 2.2013

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Contents

ISSUE 2.2013

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03 Editor's Comment. Editor in Chief Judith Riess, declares that a cultural change must take place so that a top down bottom up system of medicine can be established.

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On the cover: Members of WakeMed’s Mobile Critical Care Services simulate Standing Up for Simulation. William K. Atkinson, PhD, MPH, shares valuable transporting a insights on how to enlist and maintain the support of senior organizational leaders critically ill neonate and other important stakeholders for medical simulation programs. from the ambulance to the unit.

Image credit: Interview.

WakeMed. Interview with Dr. Jonathan Woodson, the Assistant Secretary of Defense for Health

Affairs and Director, TRICARE Management Activity.

14 CAPE (The Center for Advanced Pediatric and Perinatal Education). In the first of two articles, Barbara Beebe describes the innovative work in simulation being conducted at CAPE. 18 Simulation Centers - Connecting the Dots. Marty Kauchak describes how the medical simulation center technician community is on the cusp of embracing standards, enhanced formal education programs and other initiatives to bolster its professionalism.

24 Decisions, Decisions – Surgical Cognitive Training with Touch Surgery.

Andre Chow BSc, MRCS and Jean Nehme BSc, MSc, MRCS address how the Touch Surgery platform was designed to meet community needs in surgical cognitive surgery.

28 Robot-Assisted Surgery: Why There Should Now Be a Revolution to Push For This Technology. Jeff Berkley, PhD, presents his compelling case for using robot-assisted surgery and simulation training to revolutionize healthcare.

30 Russia Accelerates Healthcare Simulation Plans; Overhauls Medical Training. The Russian healthcare community is rapidly embracing learning technology in its curricula reports Lesya Hoover.

32 Seen & Heard. Updates from the medical community. Compiled and edited by the Halldale editorial staff.

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Editorial

Editor in Chief Judith Riess, Ph.D. e. judith@halldale.com

Group Editor Marty Kauchak

e. marty@halldale.com US & Overseas Affairs Chuck Weirauch e. chuck@halldale.com US News Editor Lori Ponoroff e. lori@halldale.com RoW News Editor Fiona Greenyer e. fiona@halldale.com Advertising Director of Sales Jeremy Humphreys

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www.blinemedical.com ©2013 B-Line Medical, LLC, an Atellis® company. All rights reserved. Patented technology.

Training Technology

Standing Up for Simulation William K. Atkinson, PhD, provides insights on how to gain and maintain support from organizational leaders for medical simulation programs.

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f you were a member of the Navy Seal team engaged in the now infamous 2011 raid in Pakistan on Osama Bin Laden’s hide-inplain-sight compound, you know it took years of preparation, specialized training, and intense simulation to culminate in the successful 40-minute on-site operation.

Likewise, if you were one of the passengers on US Airways Flight 1549 piloted by Captain Chesley “Sully” Sullenberger on January 15, 2009, you would have been thanking your lucky stars for the simulation training that helped prepared Captain Sully to bring the plane down safely on the Hudson River. Three and a half minutes to determine the best 06

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course of action to save 155 passengers and crew – not to mention the lives on the ground. Sullenberger, a former US Air Force fighter pilot and 30-year veteran as a commercial pilot, specialized in accident investigations and instructed flight crews on how to respond to crises in the air. He had spent hundreds of hours in flight simulators and thousands more in the cockpit.

These are extreme examples demonstrating the value of simulation, but simulation in healthcare has untold impact each and every day in both routine and complex procedures. If you are reading this article, you may already be a believer in the value of simulation in healthcare looking to share this knowledge with oth-

ers to increase awareness, support, utilization, and funding. The reality is simulation can mean the difference between life and death for patients. But how do you convince non-believer senior leaders that simulation is worth the investment?

Recently, while at an international simulation conference, a presenter made the comment that hospital CEOs in general are not engaged in simulation and do not understand the impact it can have in the healthcare arena. As a president and CEO of a large multi-hospital system serving North Carolina’s capital city, I was compelled to dispel this myth, but how can you too get your hospital’s CEO to stand up in support of simulation?

Value of Personal Experience When it comes to understanding the value of simulation, I have the benefit of personal experience. Military boarding school and an early career in emergency medical services (EMS) have given me opportunities to participate in simulation and experience the value first hand.

When I was initially training for a career in EMS, training was limited to classroom-based presentations and discussions.

EMS providers would walk and talk through the process, often using themselves as mock patients. Teachers would ask questions and students would respond with the textbook answer.

But what if things on-scene don’t go according to plan? A textbook cannot teach the response, and in the moment during a scene response, providers may not be mentally or physically prepared for what can and often does happen.

It quickly became evident to me that education, practice and reeducation were critical for healthcare providers to become comfortable and adept at caring for the sick and critically ill.

The ability to orchestrate realistic simulations has significantly improved since my first experiences, and it is changing how providers are taught and the way healthcare is delivered in almost every healthcare setting.

Today, scenario-based programs more and more frequently involve computer games and human patient simulators, enabling providers to have the opportunity to practice a response or a skill repeatedly in a safe, realistic environment. This repetitive, realistic practice helps engrain second-nature responses to early morning car crashes, baby deliveries in rural communities, cardiac arrests and so much more. Simulation-enabled training also offers the opportunity to practice skills complete with snafus and what ifs, and simulation training helps instill competence and confidence, improve and enhance communication, impart experience with uncommon situations and procedures, and identify areas of opportunity.

Speak the Language of the Leader

A team of critical care nurses resuscitating SIM Man after a significant cardiac event.

Image credit: WakeMed.

As great as simulation is, leaders are challenged to balance the needs and desires of patients, board members, physicians, employees, volunteers, funders, politicians, students and more.

Leaders are pulled in many different directions. There is pressure to provide quality services and expand access to meet the needs of constituents all while meeting or beating budget.

Every decision a leader makes must be tied back to the end goal – in healthcare this means providing access to a quality service at a reasonable cost. When you are speaking to a leader trying to convince them of the need for or value of simulation, it is important to speak their language. Tell them, or better yet show them, the value simulation can provide to the organization, student or patient. This is best communicated via a wellthought out business plan proving value and showing a return on investment (ROI) either in dollars, system-wide improvements, or lives saved. Nothing speaks stronger to a CEO (or funder) than a professional who is organized, motivated and can provide strong examples of the positive impact their program is having on the organization.

The initial start-up costs for simulation are high, but believe it or not, finding funding for equipment and simulators is

(although still challenging) actually the easy part. Endowments, grants and personal donations are a great place to find the money to start a program. The difficult funding conundrum for simulation facilities is securing long-term support and funding sources for staffing, space, equipment and expansion. This longterm funding problem is exacerbated by the fact education is typically one of the first discussion points when leaders are faced with a budget crunch.

To combat these funding issues, simulation professionals within an organization must all be singing from the same song sheet and must be able to easily show their value at every opportunity.

The business plan must clearly demonstrate the impact of simulation - whether that be training more students, attracting more students into the college, providing a place for healthcare professionals to do clinical rotations to maintain competencies, or retaining additional employees.

Whatever it is, define the value you bring and translate that value into measurable results.

Evaluate how your business plan can support your organization’s mission, vision and values. At WakeMed, our mission is to provide outstanding and compassionate care to all who seek our services. We are the safety net healthcare provider in Wake County, North Carolina, providing nearly $200 million in charity care and unreimbursed Medicare and Medicaid per year.

Maintaining the ability to meet our mission in the face of healthcare reform is challenging. We are already beginning to see major changes in the way healthcare is being reimbursed, and everyone in the industry is bracing for significant declines in reimbursement.

With reform, there will be an increased demand for efficiency, measurable quality, and a more highly skilled workforce.

These are areas where simulation training can be made relevant for even the most skeptical leader because simulation enables the workforce to learn, not solely by reading (although reading is very important), but by doing and practicing.

Simulation presents a new interface tool that is real time and allows providers to repeat activities, hone skills, improve teamwork, and alleviate risk and stress that comes with inexperience.

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Training Technology At WakeMed, simulation training occurs in our Center for Innovative Learning, a facility featuring a nurses’ station, intensive care/trauma suite, and a flexible patient care room that can be used for general medical or birthing. The center is a key to helping our system achieve and succeed under healthcare reform by being an important component to the safety program and serving as a testing ground and solution incubator.

Its impact spans from information services to infection control to error prevention to physician education and beyond.

Specific examples of the center’s impact include but are by no means limited to: • Infection Prevention: Staff from the Center for Innovative Learning coordinated simulated IV starts and studied videos of the procedures. They then broke down the 61 processes to start an IV and identified that the biggest chance for infection occurs between steps 15 and 16 during site cleaning and IV insertion. By identifying when the biggest risk occurs, the staff can then educate providers and significantly reduce the chance for infection during such a routine procedure.

• Patient Safety: In the course of running simulation classes, many of the participants expressed concern with the layout of the crash carts throughout the system. In response to the voiced concern, Center for Innovative Learning staff evaluated the concerns and observed how crash carts were used during real codes in our hospitals. Through a comprehensive feedback and review process involving nursing administration, pharmacy, and the “code blue” teams, every crash cart across the system was modified, standardized, and uniquely identified as pediatric or adult. If it were not for students practicing responding to codes in a simulated environment, the need for modification would not have been identified.

• Information Technology: We, as an organization, will soon be transitioning from a best of breed information system to investing nearly $100 million into Epic, a comprehensive electronic health record. This is a massive investment and getting the implementation right is criti-

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cal. Having the opportunity to work out the bugs in the Center for Innovative Learning is going to be a key component where we test the solution and identify issues before rolling it out to our providers.

In addition to a well-developed business plan, it is also important to create and distribute an annual report showing progress toward goals and explaining, where appropriate, why you didn’t meet certain measures. Show in this annual report how many students you impacted, hours of simulation completed, downtime, total number of visitors, total number of sessions, student and teacher evaluations, and if possible, hard evidence of simulation working within the system. This annual report is also nice to have as a “sales piece”, but it means more than that because data rules when requesting funding or justifying the need for extra personnel, equipment or space. These hard facts are messages that will be well received by any leader.

Selling Your Program Having a business plan, an annual report, and being able to communicate your value are not the only keys to success. You must also be able to get an audience with your leaders. This can happen formally and informally, but regardless, communicating value has to be an ongoing focus. It is also important to realize everyone who has experience with your program has the potential to be a strong and powerful advocate from the freshman allied health student to the most experienced physician to your CEO, so do not self-limit the individuals who can have a positive influence on your program. If you are asked to give a tour, accept the request whenever possible. You never know if a member of the random chamber group, pharmaceutical company employee, or nurse may have strong influence in the overall decision process.

It is always excellent to be able to bend the ear of the high-level decision makers, but it is more reasonable and equally as important to build local and regional collaborations and relationships.

Members of WakeMed’s Mobile Critical Care Services simulate transporting a critically ill neonate from the ambulance to the unit.

Image credit: WakeMed.

THESE CLASSES REALLY EMPOWERED ME... IN THE BACK OF MY MIND I ALWAYS FIND MYSELF THINKING SIMULATION! –Lourdes Cody R.N., M.S.N. West Georgia School of Nursing, Carrollton, Georgia

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To learn more, contact Valerie M. Howard, Ed.D., M.S.N, R.N., director of RMU’s R.I.S.E. Center (howardv@rmu.edu, 412-397-6807) or Sherri Aufman, graduate enrollment manager (aufman@rmu.edu, 412-397-5229.)

4540-28_MedSim 178MMX254MM.indd 1

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Training Technology This means meeting administrators at all of your local hospitals, building relationships with your state’s medical society, seeking out key academic leaders outside of simulation, and connecting with other educational institutions in your field even if they are not in your immediate area.

Invite decision makers and key stake holders to be a part of your program by creating a volunteer board or steering committee. Meet your organization’s grant writers as these folks can be exceptionally helpful in getting you to the table and helping you secure additional resources. The health planning council or similar organization in your state also has a great deal of influence.

Additionally, know your elected officials. Continuously work to educate the parade of officials who can have influence at the legislative or administrative level in health care. Often this can be done through a trade organization or, in some organizations, your institution’s government affairs department.

Through simulation, providers have the opportunity to train and improve until they have skills down perfectly, honing individual performance, teamwork and quality to produce exceptional outcomes. Through simulation, students are able to experience an error and identify where and how the error occurred and then make changes so the error disappears. Through simulation, students are able to prepare for the unexpected. Simulation-inspired changes in behavior and increases in preparation

for the unexpected prove the value of simulation.

The value of simulation to your organization will not be as dramatic as a plane landing on the Hudson or an early morning raid on Bin Laden’s compound, but the real results will be evident when employees or others are using their new, advanced skills on the job. That’s when you’ll see the real return on investments, so be sure to share those opportunities and successes frequently with decision makers including but not limited to the CEO or other designated senior leaders in your work place.

About the Author William K. (Bill) Atkinson, PhD, MPH, MPA, EMT-P, is President & CEO of WakeMed Health & Hospitals. Atkinson, a Greensboro, NC, native, became involved in health care as a member of North Carolina’s initial paramedic

Amar Patel, director of the WakeMed Center for Innovative Learning, runs a simulation experience with a team of nurses from the ICU control room.

Image credit: WakeMed.

«Towards ExcEllEncE in HEalTHcarE»

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chief executive officer in rural and urban settings in several states. He is only the third CEO in the 50-year history of WakeMed Health & Hospitals, a private, not-for-profit multi-hospital system and one of the top health care providers in the state. With more than 7,000 employees WakeMed is one of Wake County’s largest private employers. WakeMed’s heart program is North Carolina’s largest. medsim

class and remains passionately involved in a wide-range of emergency services, public health and public policy issues to this day.

Dr. Atkinson has more than 25 years of experience as a hospital president and

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Interview

Interview with The Honorable Jonathan Woodson, MD Dr. Jonathan Woodson, Assistant Secretary of Defense for Health Affairs and Director, TRICARE Management Activity.

Image credit: US DoD.

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r. Jonathan Woodson is the Assistant Secretary of Defense for Health Affairs and Director, TRICARE Management Activity. In this role, he administers the more than $50 billion Military Health System budget and serves as principal advisor to the Secretary of Defense for health issues.

In response to questions from Group Editor Marty Kauchak, Dr. Woodson addresses a number of policy-level insights on simulation and other learning technologies in his expansive portfolio.

MEdSim: Please share with us your perspectives, as a health care provider and a senior defense official, on the benefits of simulation and other learning technologies for US DoD health care providers and, as important, their patients.

Dr. Jonathan Woodson: The Military Health System is working to develop and sustain healthcare teams that provide compassionate patient-centered care at the highest level of clinical proficiency. To achieve this goal we employ a broad range of learning technologies. One of these technologies, and one that has garnered a great deal of interest, is medical simulation. We are engaged across the Military Health System (MHS) in the development and use of this promising training adjunct and believe that the use of medical simulation in the MHS has the potential to serve as a model for the nation.

MEdSim: As one follow up, what are some of the returns on investment the Pentagon expects from its procurement of medical simulation and other learning technologies?

Dr. JW: We invest in training our people, and the return we hope to see from that investment is better health, and a force that is fit and ready to respond when called upon to do its duty in the

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defense of our nation. The training tools that we develop and provide to our medical personnel are used to bolster their clinical proficiency, enhance their abilities to work together as members of a skilled and effective healthcare team, and bring proper focus to their efforts to provide patient-centered care.

MEdSim: Tell us about some of the DoD healthcare community's collaborative efforts with its public and private sector counterparts in using medical simulation centers and other technology resources.

Dr. JW: Collaboration is the lifeblood of innovation, and we strive to leverage the expertise of our public and private sector counterparts as we work to advance the state of the art in medical simulation. Our Federal Medical Simulation and Training Consortium represents a broad range of training interests, with membership that includes our military services, the Veterans Health Administration, the Uniformed Services University of the Health Sciences, the Department of Defense Patient Safety Program, our Military Education and Training Campus, and other specialty interests. This group routinely engages with academic learning centers and private sector agencies to share knowledge.

MEdSim: Looking five years downstream, how might the Pentagon's healthcare community's use of simulation expand, in terms of using technology to rehearse for procedures and achieve other outcomes?

Dr. JW: One of the many advantages related to the use of medical simulation is the ability to break a task down into its component parts, then start, stop, rewind, and re-do those component parts, building an effective and capable team. It allows us to practice high-risk interventions and approach infrequently encountered clinical scenarios without putting patients at risk. The opportunity to rehearse and practice to perfection is greatly enhanced by the availability of highly effective medical simulation tools and we anticipate ongoing development in both technology and curriculum related to the use of these tools. We aim to remain at the forefront of that development, utilizing the most up-to-date technology paired with the most effective teaching strategies to improve health outcomes for our service members, retirees, and their families.

MEdSim: Your help wanted list: what are some learning technology and DoD healthcare training gaps you need the simulation and training industry's support to help close?

Dr. JW: The realism of our training models must improve if we hope to leverage medical simulation’s full potential. The more closely a training model can approximate the look, feel, anatomy, and responsiveness of a human patient, the more effective it will be as a training tool. In addition to improving fidelity, we prize durability and utility in austere training environments. We provide medical care to patients anywhere, anytime, and our training models must be capable of enduring the rigors of the environments in which they are used.

MEdSim: What is the approximate investment the department will make in simulation and other learning technologies for its health care communities through the budget out-years?

Dr. JW: We are dedicated to being good stewards of the resources entrusted to us, balancing current needs with investments in our future. Those future-looking investments include research into the utility of simulation-based training, development of next-generation training tools, and development of a training curriculum that uses those next-generation tools to their best advantage. We must remain flexible and responsive in the face of an unpredictable economic climate, while returning the greatest possible yield to those counting on us to provide highquality patient-centered care. More than just a static fiscal commitment, our investment will include the human capital dedicated to creating an out-years reality that will integrate highly

realistic simulation into a comprehensive education and training strategy. That strategy will provide highly competent, compassionate, and patient-centered teams dedicated to improving the health of those we serve.

MEdSim: As a follow up, what message do you have for any simulation and technology company that wants to do business with the DoD healthcare community under the department's Better Buying Power 2.0 initiative?

Dr. JW: BBP 2.0 initiatives are organized into seven focus areas: 1. Achieve Affordable Programs 2. Control Costs Throughout the Product Lifecycle 3. Incentivize Productivity and Innovation in Industry and Government 4. Eliminate Unproductive Processes and Bureaucracy 5. Promote Effective Competition 6. Improve Tradecraft in Acquisition of Services 7. Improve the Professionalism of the Total Acquisition Workforce These focus areas align perfectly with our efforts to use and develop cutting-edge simulation technology to improve the quality of our medical education and training. I would encourage simulation and technology companies to embrace these focus areas as they pursue business opportunities with the DoD, or with any other entity. medsim

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PATIENT SAFETY

CAPE (The Center for Advanced Pediatric and Perinatal Education) Barbara Beebe’s first of two articles highlights the innovative work in simulation at CAPE.

S

imulation is being used with increasing frequency in healthcare. At CAPE, the Center for Advanced Pediatric and Perinatal Education at Packard Children’s Hospital at Stanford, we use simulation to address human, system and process performance objectives that directly improve the safety, efficacy and efficiency of patient care. As the world’s first simulation program dedicated to the fetal, neonatal, pediatric and obstetric sciences, CAPE seeks to provide healthcare professionals with the cognitive, technical and behavioral skills necessary to deliver competent and compassionate care to children and pregnant women. CAPE is the nexus of simulation expertise and activities at the Lucile Salter Packard Children’s Hospital and its mission is closely aligned with that of the hospital. The CAPE team works closely with the professionals in patient safety, quality assurance and risk management at Packard in order to use simulation as a methodology to directly improve patient care and outcomes. The numerous faculty in the School of Medicine at Stanford University who consider CAPE their academic home, conduct clinically relevant research that uses simulation as the research methodology. Creation of new knowledge enhances not only the field of healthcare simulation but also has a direct impact on patient care by investigating issues that are difficult or impossible to study in the real world.

Extensive and Worldwide Outreach Now celebrating 10 years in service, CAPE’s training and research programs are recognized internationally for their innovative approach to skill acquisition and performance assessment. CAPE faculty and fellows have published more than 50 manuscripts, presented in excess of 100 abstracts, and delivered 14

MEDSIM MAGAZINE 2.2013

well over 200 formal presentations describing our simulation-based training and research work in obstetric, fetal, neonatal and pediatric medicine to audiences on five continents. To date, thousands of trainees from nearly every state in the U.S. and more than 45 countries have participated in our programs.

One of CAPE’s most popular offerings is our Simulation Instructor Program. Often viewed as a national benchmark for those striving to establish simulation-based training at their home institutions, our Instructor Program has attracted professionals from more than 70 global and domestic institutions. The program includes three full days of immersion into the knowledge and skills needed to create and deliver successful simulation-based training experiences focused on pertinent cognitive, technical and behavioral skills, for all members of the multidisciplinary healthcare team. Participants are given the opportunity to design, execute and debrief highly realistic simulated clinical scenarios that serve to improve human performance and patient care.

Our Instructor Program is designed to benefit multidisciplinary teams consisting of physicians, nurses, respiratory therapists and other allied healthcare professionals. We also encourage hospital administrators and experts from patient safety, quality assurance

Behavioral skills, commonly known as teamwork, are an integral part of all programs at CAPE and include such things as clear communication, leadership and delegation of workload.

Image credit: CAPE.

and risk management departments to observe the program. This allows them to understand the value of simulation and offer their support to simulation champions who work within their hospitals to recruit and train staff, secure necessary resources, and manage space, scheduling and reimbursement issues.

Indeed, this model of support from hospital administration is a fundamental part of CAPE’s past and future success.

CAPE’s newest program offerings are single, full-day experiences concentrated on two vital aspects of simulation-based learning: scenario design and debriefing. During CAPE’s Intensive Scenario Design Program, trainees learn the intricacies of crafting scalable, highly realistic simulated clinical scenarios that are tailored to meet the needs of healthcare professionals with varying levels of experience using the same core content.

Participants leave this program with two fully drafted scenarios tailored to meet the needs of trainees at their home institution.

During CAPE’s Intensive Debriefing Program, participants immerse themselves in a progression of debriefing roles, first as the trainee being debriefed, next as the facilitator or lead debriefer, and finally as the expert, critically evaluating the lead debriefer using objective, real-time assessment tools designed at CAPE. Based on a standard approach used in the fields of aviation and space flight, our objective approach to debriefing is a notable benefit to healthcare trainees and one of several features that makes CAPE unique. While the Intensive Scenario Design and Intensive Debriefing Programs are open to all healthcare professionals, development of these offerings was driven by demands from alumni of CAPE’s Simulation Instructor Program who desired to return to CAPE in order to refresh and deepen these particular skill sets.

Advancing Neonatal Care CAPE’s work in the field of simulationbased training and research in neonatal resuscitation has contributed significantly to advancements in the care delivered to the neonatal patient population. CAPE’s Founder and Director, Louis P. Halamek, MD, is a practicing neonatologist who works in the level IV neonatal intensive care unit at Packard Children’s Hospital at Stanford. He has been a member of the Steering Committee of the Neonatal Resuscitation Program (NRP) of the American Academy of

Pediatrics (AAP) since 2001. In his role as Steering Committee Co-chair from 20072011, Dr. Halamek directed the transition of the NRP from a textbook and skills station-based program into a simulationbased immersive learning experience based on CAPE’s NeoSim Program, its intensive neonatal resuscitation training course. In collaboration with the AAP, CAPE co-developed a number of novel training resources including the 2011 NRP Instructor DVD filmed on-site at CAPE, the 2011 NRP Instructor Manual containing program development aids and other original content from CAPE, and a Key Behavioral Skills Wall Chart for display in delivery rooms across the US. The NRP sets the national standard for the care of newborns in the delivery room in the US and also serves as an international model for healthcare professionals caring for newborns in more than 100 countries. It has over 27,000 instructors distributed throughout the US and has been delivered to more than 3 million trainees during its 25-year history. We are especially proud that the work conducted at CAPE in collaboration with the AAP is influencing the care of mothers and their newborns all around the world. CAPE’s NeoSim Program continues to attract healthcare professionals who wish to experience a rich, fullday experience responding to neonatal emergencies.

Clinical Care at Packard Children’s CAPE’s simulation services are delivered to Packard Children’s professionals through a model of unit-based simulation task forces. The Center for Nursing Excellence (CNE) at Packard Children’s highlights and supports the important professional role that nurses play in the delivery of care to patients and families. CAPE and CNE have collaborated closely over the last 10 years to provide simulation-based training to each and every nurse across all units of the hospital. Clinical nurse specialists trained in CAPE’s Simulation Instructor Program combine annual goals formed at the executive level of the hospital with unitspecific goals to form the learning objectives for their unit’s simulation curriculum. This model of unit-based simulation is a national example for building a successful large-scale simulation program.

In order to ensure a direct link to clinical care, CAPE originated the Packard Circle of Safety, the process that defines how simulation is integrated into the MEDSIM MAGAZINE 2.2013

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healthcare professional training programs come to CAPE seeking to conduct research in the domains of pediatric and obstetric medicine, human performance and simulation. With the support of preceptors at Packard Children’s, CAPE hosts local graduate nursing students who strive to fulfill their education and experience requirements in their profession. Last, but certainly not least, we welcome tours and partner with summer programs on the Stanford University campus to provide high school students with an experience that provides great insight into careers in pediatric and obstetric medicine, adult learning, human performance and simulation.

Future Directions in Research

daily activities of the hospital. In the circle, the care of real patients is assessed by the hospital’s risk management, quality assurance and patient safety groups to inform and define training conducted at CAPE. Upon completion of simulation training at CAPE, in-hospital drills further identify and refine issues of human and system performance, improvements from which feed directly into the care of real patients. This mechanism that triggers tight collaboration with key hospital leaders in the areas of risk, quality and safety makes CAPE unique in its ability to provide extremely relevant simulation training.

Collaboration with Industry An expert in the field, CAPE has worked with a number of industry players to develop and field test new technologies for use in simulation-based learning. These include an interface to control bedside monitor data streams (Patient Monitor Driver™, Advanced Medical Simulation, Inc.), a fetal monitor simulator (FetalSim™, Advanced Medical Simulation, Inc.) and a number of neonatal, infant, pediatric and obstetric patient simulators (Laerdal Medical, Inc.). We have also actively collaborated in the development and implementation of a novel high definition audiovisual system tailored to meet the needs of simulation centers (Apple, Inc., VMI, Inc. and Spark Alley, Inc.).

Community Outreach CAPE’s outreach to the community at large contributes to the buzz of daily activity that takes place within its walls. Our international reputation brings professionals from academic institutions far and wide to serve as visiting faculty, enabling partnerships and dissemination of simulation as a methodology to promote better care for children and pregnant women worldwide. Similarly students from national and international

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Building on our strong research tradition, CAPE is investigating human performance during emergency patient care scenarios.

Central to the ongoing discovery of optimal functioning is the inquiry regarding the psychophysiology of peak performance.

This is a specialty of Dr. Gary Hamill, Senior Research Scholar at CAPE, for which more detail will be presented in a subsequent on-line issue of MEdSim magazine, www.halldale.com

Teamwork CAPE’s core team consist of the following professionals: • Louis P. Halamek, MD, CAPE’s Founder and Director, is a Professor in the Division of Neonatal and Developmental Medicine, Department of Pediatrics, and the Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics (by courtesy) at Stanford University. Dr. Halamek is an internationally recognized pioneer in the field of simulation-based training and assessment in healthcare. Through his work as Senior Fellow and Adjunct Faculty in the Center for Aviation Safety Research in the Department of Aviation at the Parks College of Engineering, Aviation and Technology at St. Louis University, he has had the opportunity to interact with and learn from professionals working in multiple high-risk industries • Gary Hamill, EdD, a Senior Research Scholar and Program Manager at CAPE, specializes in human performance optimization. Through applications of simulation, team science, selfregulation, and psycho-neuromuscular theory, Dr. Hamill works with healthcare professionals to further develop their adaptive expertise, situational awareness, and medical decision-making skills to drive their overall engagement and effectiveness in the delivery of patient care.

• Kim Yaeger, RN, M.Ed., is a Senior Simulation Specialist at CAPE with over 10 years of team-based simulation expertise. She possesses a Masters in Medical Education, focusing on curriculum design and instruction using the methodology of simulation.

• Julie Arafeh, RN, M.S.N., a Senior Simulation Specialist at CAPE, has extensive experience in both simulation-based training and as an obstetrical nurse in outpatient and inpatient settings. . Her focus is on using simulation to identify and improve human, process and system interactions.

• Alice Oliver, B.S.N., a Simulation Specialist at CAPE, has fifteen years of neonatal and pediatric critical care experience.

Oliver, Arafeh and Yaeger form the core team that develops, plans and delivers CAPE’s team-based simulation training programs.

About the Author Barbara M. Beebe is the Business Manager at the Center for Advanced Pediatric and Perinatal Education, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine. medsim

HPSN World 2013 in San Francisco June 30-July 2, 2013

Immerse Yourself in Simulation Our largest and most comprehensive event, HPSN World brings together over 1,000 healthcare simulation experts and practitioners from around the globe to share best practices and new simulation technologies. For the first time ever, HPSN World 2013 will convene in San Francisco, and it’s a must for everyone who wants to optimize their simulation learning environment and see the latest in healthcare simulation technology.

CONFERENCE HIGHLIGHTS More than 100 workshops and interactive sessions

A special rate of $199 per night at the San Francisco Marriott Marquis

Round-table discussions of dynamic topics in simulation

Exhibit floor with new product showcase

The CAE Cup Critical Care Skills Competition for nursing students

Opportunity to earn CEUs Best of all, HPSN is FREE!

An exciting location in the heart of San Francisco

Free registration at hpsn.com

Training

Connecting the Dots In the third in a series of articles on medical simulation centers, Group Editor Marty Kauchak provides insights on the rapidly evolving role of these facilities’ technicians.

M

EdSim has had the privilege of visiting medical simulation centers on both sides of the Atlantic. While the mission of each center varies to address learning for individual and teams of health care providers, the one unifying element among the facilities is the technicians.

Paul Phrampus, MD, the Director of the Peter M. Winter Institute for Simulation, Education and Research (WISER), noted this occupational group is the one common, uniting, bonding element that “connects the dots” among the many community facilities. So, “they are at every point, the substrate layer of connectivity that is starting to emerge in a group that may often coalesce at an industry forum. These are the people who ‘keep the magic going’,” he emphasized.

Similarly, Paul Pribaz, the Executive Director at the Center for Education in Medicine, Feinberg School of Medicine, Northwestern University, pointed out the technician is the one common feature in simulation, across medical specialties, professions, learner levels, and geography. “They truly are the source of ‘cross-pollination’ in simulation-based medical education, sharing what works best and helping faculty take maximum advantage of the learning opportunities in simulation,” he said.

Varying Job Descriptions and Responsibilities The responsibilities of medical simulation center technicians vary greatly throughout the community. In some instances, smaller centers with one or several training devices may have a part-time staff member to provide technical support. At the 18

M E D S I M M AGA Z IN E 2 . 2 0 1 3

other end of the spectrum are the larger facilities with full time staff members immersed in simulation-like responsibilities throughout their workday.

H. Michael Young, a Simulation Technology Specialist at Tarleton State University’s Center for Instructional Innovation, told MEdSim that he supports the university’s nursing department in its simulation activities, and has other wide-ranging responsibilities including his consultations with partner and extension campuses in their simulation programs.

Similarly, James Cypert, the Technical Director for the School of Nursing at California Baptist University, modestly indicated his expansive job portfolio includes “anything that touches electronics and electrical, and data, the day-to-day IT [information technology] issues, exclusively for the School of Nursing – with a special concentration on simulation.”

The Riverside, California-based community member recalled his simulationspecific activities include in-depth collaboration with faculty and learning

While the mission of medical simulation centers around the globe may vary to address learning throughout the continua of individual or team programs for different health care providers, there is one unifying element among the facilities – the technicians.

Source: Paul Phrampus, MD/ WISER.

content educators to establish scenarios and finalize hands-on time with learners and mannequins. “I also work with the mannequins to make sure they are prepared to help create the appropriate learning environment, whether it be a staged presentation so they know what is happening or even a ‘surprise’,” he added.

Cypert also draws upon his previous 15 years of experience as a technical educator to go beyond being a “button pusher”, to develop innovative ways to integrate simulation into the curriculum. “I can definitely communicate with the nurse educators here at a different level,” he remarked.

Brian Florek, an Audio Visual (AV) Systems Engineer for Simulation Technology and Immersive Learning at Northwestern’s Feinberg School of Medicine shared insights from a larger community facility’s perspective. Florek noted his colleagues have several main areas of function. “The primary responsibility includes day-to-day operation of the center, which ranges from setting up and taking down events to running high fidelity simulations. Each tech is responsible for learning the features and operation of each simulator, as well as all AV equipment used within the center. The techs are also responsible for maintaining the center's infrastructure of IT, AV and simulator equipment,” he said. Repairs and upgrades are kept as much in house as possible to ensure minimal costs and maximum up time of equipment. The Feinberg School of Medicine’s technicians are also encouraged to play an active role in assisting faculty with the development of future simulations. Florek continued, “Techs have a unique perspective on ensuring the proper amount of fidelity goes into each simulation. Techs are asked to play ‘confederate roles’ such as nurse, attending, resident, medical student, and family members during simulations. They also help faculty pick simulators appropriate to their needs, which might include modifications to those simulators if needed.”

Certification and Standards While these individuals often have impressive resumes, skill sets and experience, they collectively lack the rigor of certification, qualification and standards found in the technical workforces in other high risk industries.

Indeed, when this author visited the Delta Airline TechOps center in Atlanta to write an article for MEdSim’s sister publication CAT (www.halldale.com/cat), that organization’s leadership emphasized how its airline maintenance academic program, instructors and graduating students have agency and airline certifications, and other credentials. (“A Firm Maintenance Foundation in Atlanta,” CAT issue 6, 2012, pp. 8-10).

Of initial interest for the medical simulation technician community is the lack of commonality among institutions on their requirements for prospective workforce members. An undated University of Miami School of Nursing and Health Studies “Positions Available” announcement distributed at this January’s 2013 International Meeting on Simulation in Healthcare (IMSH) conference listed requirements, in part, for a Simulation Technician: “high school diploma or equivalent and a minimum of 1 year work experience, Associate Degree and/or working toward a BS in computer science, engineering, or other related field preferred; experience in a medically related field or certificate program preferred. EMT [Emergency Medical Technician] training preferred.”

Conversely several other positions available announcements randomly viewed online for community technicians specified IT and medically related experiences as required for consideration by the human resources offices.

This and other gaps may soon be closing. What emerges from discussions with healthcare community members is a compelling need to elevate the position of center technicians through

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M E D S I M M AGA Z IN E 2 . 2 0 1 3

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Training the types of certification, standards and formal education found in other sectors.

In one instance, the Society for Simulation in Healthcare (SSH) is helping to establish a certification process for medical simulation center technicians.

WISER’s Phrampus, who is also the society’s president and holds faculty assignments at the University of Pittsburgh School of Medicine, said his organization’s Technology Specialists Special Interest Group, to which center technicians may join, has been growing by “leaps and bounds” through the recent past. Indeed, when he spoke with MEdSim this January that group’s increase in membership, activities and other criteria warranted consideration of its elevation to a Section within the society.

Another natural progression of the medical simulation center technician community’s growth is the interest in establishing certification and standards for the group. Phrampus pointed out that his society’s “certification committee this year is embarking on the development of the technician certification and associated standards and we are eagerly anticipating a launch of the program at our 2014 IMSH meeting.”

The concept of workforce standards resonates clearly with one front line professional, Northwestern’s Florek.

“If a governing body did exist, it would certainly make things easier for institutions seeking to hire qualified techs for their labs. The time it takes for on-thejob training to proficiency in our lab is 6 to 9 months. If we were able to hire in certified techs, that time should be significantly reduced,” he explained.

Similarly, Northwestern’s Pribaz is a front office advocate for these professional enhancements, noting, in part, his institution has been very involved in the SSH efforts to help define technician competencies and develop a credentialing process. “The simulation technician is truly the one common feature between sim centers. As the research and validation around the use of simulation for high stakes exams progresses (e.g. MOCA), it is clear to me that clinicians must have the same learning experience wherever they choose to go to take a certifying exam,” he said and added, “The competency of the tech is absolutely critical if simulation is going to achieve acceptance for this purpose.

My personal opinion is that a governing body should define standard/s and 20

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any institution can implement training programs that could be accredited to teach and assess that a standard has been achieved. At our institution, we would love to be a center for providing these kinds of training programs.”

A Boost for Education Tarleton State University’s Young also holds positions of responsibility at SSH, including membership on its board of directors.

With no actual formal education in simulation he mirrors many of his contemporaries who often come from a variety of different professional backgrounds.

In another dramatic development for this community, Young and others have a new-found professional interest to advance the state of formal education for this community – through the awarding of an associate degree, undergraduate degree or a certificate.

The proponents of formal education for this community conceptually want to provide the technicians with a common academic background to better understand the basics of human physiology and anatomy, support increasingly complex simulation center technologies through their life cycles, contribute to instructional course design, and obtain other skill sets.

A common academic framework would also level the playing field among different accessions into the community. So nurses or EMTs and others with a medical background who become center technicians would increase their knowledge in IT and related technologies. Likewise those proficient in technology would learn about instructional design, basic medical topics and other “new” professional subjects.

California Baptist University’s Cypert noted that while a wellrounded certification plan and education strategy would help the community, he cautioned that technical skills should be only one part of a learning curriculum. “The component that is missed a lot is intercommunication, along the line of interdisciplinary education. We need to be able to deliver that in a manner so the faculty members who are content experts have to communicate with individuals who are very technically capable – there frequently is no ‘bridging experience’. The techs are not educators.

It would be good to supplement those IT skills to allow them to communicate with healthcare educators who ‘don’t speak technology’ and similarly, help the tech who doesn’t understand many healthcare topics. This is the key,” he emphasized.

Young also provided several compelling reasons to develop professional education programs for the community. “We need to

Northwestern’s Florek said "There truly is a science to being a simulation technician.

It would be nearly impossible for anyone with an education in any one of the areas we cover to step in and be a proficient technician.

Sim techs need formal education in such a wide variety of topics that it is necessary to develop a formal curriculum and degree path."

Credit: Center for Education in Medicine, Feinberg School of Medicine, Northwestern University.

A non-profit global movement to equalize surgical skills across borders and boards.

Leading world experts created the content of this unique meeting where 45 excellent lecturers from different surgical specialties gather at the same spot for 3 days:

2nd World Congress on

Surgical Training

CME Accreditation EACCME 8923 G

SurgiCON June 17-19, 2013, Gothenburg, Sweden

Opening: Dr Marie Wedin, Chairman of the Swedish Medical Association Honorary Guest Lecture: Pr. Carlos A. Pellegrini, University of Washington, USA

Main topics Keynote speakers 1. Quality and Safety in Surgical Training

Ajit K. Sachdeva, FACS, ILL, USA

2. The Imperative of Metric-based Surgical Assessment and Training

Anthony G. Gallagher, M.Sc., IRE

3. The Value of Scientific Research Activities in Surgical Training

Richard Hanney FRACS, Sydney, AUS

4. Surgical Training in Evolving Countries

Leon Snyman, MBChB, Pretoria, South Africa

5. The Governance Required to Provide Effective and Consistent Surgical Training Programs

Spencer Beasley FRACS, Christchurch, NZ

6. Social Media and E-learning in Surgical Training

Sean Tierney FRCSI, IRE

7. The Resident’s Dream Scenarios

Richard Reznick, FRCSC, Ontario, Canada

8. ‘Rules & Roles’ - Collaboration between Surgeons and the Industry

Kai Olms, GFFC, GE

9. Update on Simulation

Richard M. Satava, FACS, WA, USA

10. Teaching New Surgical Techniques to Mature Surgeons

Barbara L Bass, FACS, TX, USA

www.surgicon.org

stop trying to niche the sim tech (simulator technician) role. The reality is there is not one sim tech role. The word ‘technician’ means different things to different communities. A technician in the medical community means an entry level, low level clinician tasked with very specific skills, an X-ray technician for example.”

He further pointed out that at the same time the very complex learning technology domains are “always butting heads and crossing boundaries.” For instance, “a sophisticated technology crosses boundaries among audiovisual, pneumatics, microcomputers, networking, servers and in other ways these systems are all constructed.”

One embryonic academic program is the Associate of Applied Science (AAS) degree program in simulation technology under development between The University of Akron and the Austen BioInnovation Institute in Akron (ABIA).

Scott Atkinson, a simulation specialist at ABIA’s Center for Simulation and Integrated Healthcare Education (CSIHE), told MEdSim that he is collaborating with Martha Conrad, ABIA’s Director of Interprofessional Education, and faculty from The University of Akron to develop the program.

Atkinson said the program has two proposed options, an AAS degree or a certificate award.

The certificate options will support the study of healthcare simulation technology. Conceptually, a nurse or paramedic without an IT background would learn basic skill sets in simulation technology. An IT or computer specialist with a strong technical background would learn about the basic concepts of simulation in healthcare. “We’re trying to help people with healthcare or technology backgrounds explore new ways to use their current skills and experience in simulation technology,” Atkinson said.

The second track, leading to the award of an AAS degree in simulation technology will offer courses in computer technology, healthcare simulation and leadership skills.

An important feature of both the certificate and the AAS degree options is Akron’s unique geographical location of multiple simulation centers. The program will support students’ engagement in simulation centers for nursing education, medical student education, acute care adult, children and inter-professional education. The ABIA CSIHE supports all levels of simulation education from novice to expert.

The outcomes of the AAS degree program will allow the aspiring techni-

cian to operate a simulator, work with inter-professional teams to embed simulation into curriculum, and manage daily operations of a simulation center.

The new AAS degree and Certificate Program at The University of Akron will launch in the fall semester 2013.

While the initial classes will be completed in residence, Atkinson envisions some of the courses migrating to an online format.

Northwestern’s Florek provided a compelling reason to continue the dialogue and progress in bolstering formal education programs for this workforce. “I believe at a minimum certificates should be issued. There truly is a science to being a simulation technician. It would be nearly impossible for anyone with an education in any one of the areas we cover to step in and be a proficient technician,” he pointed out and added, “Sim techs need formal education in such a wide variety of topics that it is necessary to develop a formal curriculum and degree path. Creating this educational pathway will also lead the way to full career paths for the tech, something that does not currently exist. I believe having this career path: from tech, to master to educator, will encourage more qualified applicants to enter into the field, and reduce turnover for institutions.”

Vendor-Supplied Training As formal education programs evolve and expand for this community, the original equipment manufacturers of the centers’ products and systems also provide specialized instruction to support their materiel’s life cycle.

KbPort delivers high fidelity multimedia solutions to medical simulation centers – supporting after action reviews and other components of the training cycle for individuals and teams.

Only when center technicians are integrated into the life cycles of stateof-the-art multimedia and other systems’ are they able to effectively and efficiently operate the technologies on demand. KbPort has set one standard for the vendor community with its logistics model, which provides for hands-on training, supplemented by online and telephone help desk resources for all new customers.

Scott Giroir, a company sales manager, said that upon installation of a system, his technicians will typically spend one or two days with their simulation center counterparts to conduct familiarization training. “We sit down in front of the system and learn, for example, how to operate a mannequin from a laptop.

We tailor our training depending on the type of equipment they get.”

A month later, the customer’s technicians will often complete online training. “At that point they are ‘getting their feet wet’ – moving into the system, understanding it better and retaining more. So they need to address some questions at that point,” Giroir emphasized. KbPort additionally provides a telephone help desk as another layer of customer support.

Wendy Jo Wilkinson, CAE Healthcare’s Director of Clinical Support Solutions, similarly said her company invites “simulation center technicians to participate in our Simulation in Practice and our Core Education courses alongside educators and clinicians where they can interact and share their expertise."

CAE Healthcare further integrates community technicians in its products’ life cycle support strategy by offering advanced training and certification for simulation technicians or operators who would like to learn how to troubleshoot, perform preventative maintenance and repair the company’s patient simulators. Wilkinson continued, “Our four-day Simulation Technologies course leads to certification in operating and maintaining our simulators. Since each customer site is unique, our educators, and our customer service and technical staff can provide a customized training course specific to the customer needs as well as ongoing support."

Other Resources There are other resources, in addition to MEdSim and its supporting website www.halldale.com/medsim, to educate and inform this community and help it evolve.

One website which caught our attention was the simtech http://thesimtech.com/ The online resource notes that based “on continuing contributions from the simulation community, the simtech's goal is to become an 'online hub' for sharing ideas and information.”

And this August 6 through 9, the Gathering of Healthcare Simulation Technology Specialists (SimGhosts) http://www.simghosts.org/ will hold its annual meeting in San Antonio, Texas.

This organization was created to provide technology specialists within the healthcare simulation field with a community dedicated to developing and sharing resources, knowledge, training and standards for fostering excellence in the operation of healthcare simulation. medsim M E D S I M M AGA Z IN E 2 . 2 0 1 3

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SIMULATION

Decisions, Decisions Surgical Cognitive Training with Touch Surgery Andre Chow BSc, MRCS and Jean Nehme BSc, MSc, MRCS describe developments in Touch Surgery – a mobile surgical simulation platform that was created specifically to address the needs of surgical cognitive training

“

T

he decision comes before the incision” is a com-

Challenges of Surgical Practice

mon saying in surgical practice, explaining how

Like traditional craft specialties, much of surgical training and experience is based upon an apprenticeship model. The process of gaining surgical experience extends beyond core resident programs as even senior surgeons are required to attend educational courses and conferences to keep up with the latest evidence based practice.

Learning by repetition and observation of experts, expecting to attain all the subtleties and intricacies of the surrounding surgical process is an inherently variable and inefficient process -- and potentially dangerous to patient care. A novice surgeon must progress through the stages of unconscious incompetence as a novice, conscious incompetence, conscious competence and finally unconscious competence when an expert. Expert surgeons have automated many of their procedural skills, which makes it difficult to articulate decisions in both

it is a surgeon’s mind and not just his hands that

are critical to performing an effective and safe operation.

This distinction of cognitive abilities separate from technical abilities has been the subject of increasing attention in recent years, with writer and surgical safety guru Atul Gawande explaining in a 2011 New Yorker piece that “…doing surgery is no more physically difficult than writing in cursive. Surgical mastery is about familiarity and judgment. You learn the problems that can occur during a particular procedure or with a particular condition, and you learn how to either prevent or respond to those problems”.

This split between the mind and body has even been formally investigated, with esteemed surgeon Lord Ara Darzi explaining in the British Medical Journal that “a skillfully performed operation is 75% decision making and 25% dexterity.”1 Studies deliberately investigating the relationships between cognitive and technical skill have also shown that conscious rule and knowledge-based behaviors precede any motor response.2 However, despite under-

standing the importance of cognitive surgical skill, decision making within surgery is not formally taught or assessed within surgical training programs, and remains a vital but hidden part of the curriculum.

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simple and complex decisions.3 Transfer of these skills to a novice is often incomplete, with studies demonstrating that experts

Touch Surgery is a mobile surgical simulation platform created to address surgical cognitive training using Cognitive Task Analysis.

Screenshot: Touch Surgery.

omit up to 70% of the required information to trainees when explaining complex tasks.4 The success of this type of training relies heavily on the relationship between the expert and training surgeon, and the amount of time spent in the operating theatre being able to observe and practice. However, this training model is becoming increasingly strained by changes to working hour practices and increasing demands from service delivery and patient safety. In addition, it does not address continued surgical training and revalidation of experts. A significant gap in the process exists here. It is clear to all within the surgical education field that surgical training needs to change, and become more efficient with the necessary objective measurable outcomes of proficiency.

Advances in Surgical Training: Simulation A comparison is commonly made between training in surgery and the aviation industry. Both surgeons and pilots need to operate under potentially stressful conditions, with time-sensitive decision-making and lives at risk. The aviation industry has an enviable safety record, aided in a large part by a robust simulation-based training program, with regular 6 month assessments for pilots.

Within medicine, the issue of safety is paramount. There are 98,000 deaths in the US alone resulting every year from medical error,5 and the majority of adverse events have been shown to occur in the operating room.6 Recognizing the potential gains from surgical simulation, there are now many simulation solutions ranging from simple suturing rigs, to life-size mannequins, to expensive computer laparoscopic simulation rigs with tactile feedback, and even entire simulated operating suites. It has been repeatedly demonstrated that simulation can work, with a Cochrane review 7 finding reduced operative time and error rates associated with virtual reality training. Simulation training can also affect clinical outcomes with a significant fall in infection rates associated with central line insertion.8 However, healthcare systems have been slow to incorporate simulation into training curricula. Part of this is due to consid-

erations of economy and scale. The airline industry is currently struggling with estimates that the annual need for pilots will grow to approximately 25,000 per year, with current training capacity being around 15,000. Compare this with the almost 1 million surgeons in the western world alone, and it becomes clear that attention to economy and scalability of training programs is a key to success.

A good example of a systems-based approach to surgical simulation training is the Fundamentals of Laparoscopic Surgery curriculum for US-based residents.

This is a low-cost, low-fidelity box trainer that allows practice of generic laparoscopic technical skills. It allows objective assessment of these skills, and therefore standardization across the country. However, key surgical cognitive skills are not taken into account with this or the majority of surgical simulation solutions.

Touch Surgery and Cognitive Task Simulation Touch Surgery is a mobile surgical simulation platform that was created specifically to address the needs of surgical cognitive training. It builds on a process called Cognitive Task Analysis (CTA), a method for obtaining sophisticated performance expertise for areas where many covert decisions are linked with complex overt actions. CTA has been used in highly technical fields as well as in the military to hasten the acquisition of expert skill, and can improve learning and retention of technical skills as well as decision-making in surgical procedures.

Touch Surgery utilizes CTA to create an operative framework, and then combines this with a proprietary software engine to create a Cognitive Task Simulation, which teaches operative steps and decision-making using interactive computer generated images to depict the surgical process. The integration of interactivity into the platform is a key point for education as knowledge retention can be significantly increased when using an interactive learning method compared with traditional learning method such as lectures, reading or video.

Touch Surgery will host modules ranging from basic procedures to more complex tasks aimed at attending surgeons. Touch Surgery captures data on surgical cognitive performance as well

as mistakes and will have modules aimed at specific complications experienced by the most senior surgeons. In this way Touch Surgery will be able to facilitate the transfer of knowledge between experts on a global basis.

Touch Surgery and Assessment of Surgical Cognitive Skill The Touch Surgery engine is built upon a base of powerful analytics. Touch Surgery not only teaches intra-operative decision making, but also has a test function, allowing surgeons to actually practice and simulate the decision making process. This allows a quantitative analysis of decision-making pathways and skill, building of individual learning curves, and identification of weakness and areas that require development. The platform therefore has the potential to allow objective assessment and standardization of surgical decision-making training in curricula. Furthermore, being a software solution that is based upon readily available and accessible devices makes the Touch Surgery platform extremely scalable, and accessible to surgical trainees worldwide at minimal cost.

Touch Surgery Validation In the field of healthcare and surgical training, validation of novel technologies is paramount to prove effect prior to widespread adoption. Within the realms of simulation, studies of face, content and construct validity are the “gold standard� measures used for validation. These studies involving Touch Surgery are currently underway at leading institutions in the US and UK with interim reports demonstrating strong face and content validity for the platform (unpublished data), and studies on construct validity upcoming. Currently further academic collaborations are currently being agreed to allow continued development of this platform to the standards needed by surgical training curricula.

Touch Surgery, Clinical Outcomes, and Patient Safety Although surgeons work their whole careers to provide the best care for their patients, inevitably mistakes will be made that will ultimately lead to patient harm. This is because, despite all our advances in technology, surgery is still a very human profession.

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SIMULATION Although system-based measures are undoubtedly important to improving care and reducing error, ultimately outcomes will come down to the interaction and mistakes that occur between a surgeon and their patient. This is a fact that was described in the report from the Institute of Medicine “To Err is Human”.

Atul Gawande addressed this issue of surgeon error by saying that “…the real problem isn’t how to stop bad doctors from harming… It’s how to prevent good doctors from doing so”. Errors of judgment and decision-making are central to this theme. It has been shown that errors of cognition account for two-thirds of all malpractice claims in surgery. This is a huge proportion, and indicative of how important high quality cognitive training and assessment is for surgeons, no matter at what stage of their careers. Using systems like Touch Surgery could help to make a vital difference.

The Concept of Surgical Rehearsal One area that is often overlooked in the field of medical simulation is the concept of rehearsal. If you turn up to a concert early, you will see the orchestra busy practicing and warming up for the main event. Go to watch a tennis match, and you will see the players warming up and practicing their strokes. Observe how Tiger Woods thinks about his shot and practices his swing prior to stepping up to the tee. Highly skilled individuals in every profession routinely rehearse and practice prior to performance. In this way their performance is honed, refined, and optimized. However, compare this with surgery where the concept of rehearsal prior to an operation is almost foreign.

Time is spent between cases rushing

to the ward to see other patients, or absorbed in the other issues surrounding patient care. As we have already established that surgery is even more of a cognitive specialty than a technical one, surely time spent considering your decision-making could make a difference to surgical performance. This was exactly the effect shown in studies that demonstrated how mental rehearsal prior to a task translated into superior physical performance in surgery. In this way Touch Surgery can also be used for surgical rehearsal, and therefore directly affect performance.

Touch Surgery Development Touch Surgery was founded by four surgeons, who are dedicated to improving the surgical training process. The ultimate aims of Touch Surgery are to raise the standards of surgical care globally, utilizing cutting edge, affordable, and accessible technology.

The team is currently involved with building an academically validated curriculum of surgery and interventional medicine that will be able to be used worldwide, so that physicians from around the globe will have access to the expertise and training from leaders within their fields. To this end, Touch Surgery is reaching out to academic institutions and hospital groups to collaborate in developing content for an open surgical education platform.

The medical device industry will also be involved heavily with this process, as surgical education now is incomplete without learning about current tools and devices which are used in operating rooms every single day. Furthermore, Touch Surgery provides a cost effective means of safe introduction of devices

and real time evaluation of surgeon education.

Surgeons will be able to use validated Touch Surgery assessment tools to receive real-time feedback, identify areas for attention, and develop their own personalized surgical training pathway to shorten their learning curve to expertise.

Surgical training systems will be able to have an overview of a surgeon’s development, and ensure that proficiency is reached and maintained in a quantifiable and standardized manner. Hospitals will be able to use this system to understand surgical performance, and mitigate risk with early identification of problem areas and actionable data, which will become even more critical as systems move towards pay-by-performance reimbursement strategies.

Although there is a lot of work to be done before such a situation exists, the marriage of new technologies and attention to cognitive performance in surgery will allow the rapid development of new surgical training solutions that can transform surgical training and care as we know it.

About the Authors Andre Chow is a General Surgical Resident with an academic background in Surgical Care quality, Data Analysis and Tissue Engineering. Jean Nehme is a Plastic Surgical Resident with an honors degree in Surgical Simulation and Training. Together with the team at Touch Surgery they share a desire to improve the practice of surgery worldwide using cutting edge and affordable technology.

You can contact the team at andre@ touch-surgery.com and jean@touch-surgery.com. medsim

REFERENCES 1

Darzi A, Smith S, Taffinder N. Assessing operative skill. Needs to become more objective. BMJ 1999;318(7188):887-8.

2

Pugh CM, Santacaterina S, DaRosa DA, Clark RE. Intra-operative decision making: more than meets the eye. J Biomed Inform 2011;44(3):486-96.

3

Smink DS, Peyre SE, Soybel DI, Tavakkolizadeh A, Vernon AH, Anastakis DJ. Utilization of a cognitive task analysis for laparoscopic appendectomy to identify differentiated intraoperative teaching objectives. Am J Surg 2012;203(4):540-5.

4 Clark RE, Pugh CM, Yates KA, Inaba K, Green DJ, Sullivan ME. The use of cognitive task analysis to improve instructional descriptions of procedures. J Surg Res 2012;173(1):e37-42.

5

To Err is Human: Building a Safer Health System. In: Kohn L, Corrigan J, Donaldson M, editors. Washington DC, 2000.

6

Dankelman J, Grimbergen CA. Systems approach to reduce errors in surgery. Surg Endosc 2005;19(8):1017-21.

7

Gurusamy KS, Aggarwal R, Palanivelu L, Davidson BR. Virtual reality training for surgical trainees in laparoscopic surgery. Cochrane Database Syst Rev 2009(1):CD006575.

8

Barsuk JH, Cohen ER, Feinglass J, McGaghie WC, Wayne DB. Use of simulation-based education to reduce catheter-related bloodstream infections. Arch Intern Med 2009;169(15):1420-3.

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MEDSIM MAGAZINE 2.2013

International Nursing Association for Clinical Simulation and Learning

12th Annual International Nursing Simulation/ Learning Resource Centers Conference June 13-15, 2013 Pre-conference Workshops June 12, 2013

Hit the Jackpot with Evidence Based Simulation Paris Hotel Las Vegas 3655 Las Vegas Blvd. South, Las Vegas, NV 89109

This conference, a leading forum for nurse educators, researchers, nurse managers, and staff development professionals, provides the ideal environment to disseminate and gain current knowledge in the area of simulation /skills lab management and simulation enhanced education. Nurses and other healthcare professionals will have the opportunity to network with colleagues and exhibitors and discuss best practice, research, safety-related outcomes, competencies, and challenges.

The conference has five concurrent tracks with novice and advanced sessions in Education, Practice, Lab Coordination and Management, Research, STAR (Simulation, Technology and Resources).

For more information about the conference or to join INACSL visit: https://inacsl.org/ Sponsored By: The International Nursing Association for Clinical Simulation and Learning (INACSL)

Local Hosts: University of Nevada Las Vegas School of Nursing Nevada State College

SIMULATION PROGRAMS

Robot-Assisted Surgery: Why There Should Now Be a Revolution to Push For This Technology.

Mimic’s dV-Trainer allows surgeons to train with a virtual robot rather than an actual robot, which can result in significant savings on training costs.

Credit: Mimic Technologies.

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Jeff Berkley, PhD, examines why robot-assisted surgery and simulation training has the very real potential to revolutionize healthcare, by boosting quality while cutting overall costs.

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s recently reported in The Wall Street Journal, The New York Times, and Bloomberg, there is a controversy brewing over robotic surgery and whether it is superior to alternative surgical approaches.

Robotic training practices have also been questioned and it has been debated whether surgeons are receiving enough supervised cases before flying solo.

What is surprising is that few people are picking up on a larger issue that most supervised training still takes place on patients. This is not unique to robotics, but is commonplace for surgery overall. However, with the technological advances that come with robotics we certainly might expect training alternatives that would minimize our reliance on animals and patients for surgical education. After all, military and commercial pilots undergo hundreds of simulation training hours before they fly actual planes. Shouldn’t our robot-assisted surgeons take advantage of similar technologies?

MEDSIM MAGAZINE 2.2013

In full disclosure, I founded Mimic Technologies, a surgery simulation company, to address this very problem back in 2001. So it should be noted that I have a vested interest in the adoption of surgery simulation. I have been building medical simulators since 1990, when I began my journey towards a PhD, and I have been focused on robotic surgery simulation since 2003. I freely profess that I am a very strong proponent of robotic surgery and its benefits when coupled with simulation. My hope is that my background allows me to offer a unique perspective.

See one, do one, teach one - that’s the classic model of surgical training practiced in medical schools, teaching hospitals, and clinics worldwide.

Problem is, not every MD has the finely honed motor skills and 3-D spatial reasoning needed for many delicate operations. And, while the human hand is sensitive and subtle beyond comprehension, the hand's sheer size makes it little better than a blunt instrument when considered in the context of the precise surgical procedures that increasingly require microsurgical precision.

Few will argue against the benefits of minimally invasive surgery (MIS) over “open” surgery, where large incisions are used to access internal organs. With MIS,

“key-hole” incisions are used with specialized instruments to reach biological structures. As a result, recovery time is far shorter and much less painful. And when the patient’s reduced hospital stay is taken into account, MIS is a very costeffective option.

The real challenge is learning to perform minimally invasive procedures. The steep learning curve partially explains why in recent years nearly 90% of all surgical procedures were done in an open fashion.

For example, it can take a new surgeon numerous surgeries, sometimes hundreds, to master typical MIS gallbladder removal, or laparoscopic cholecystectomy, which is now the standard for this relatively straightforward surgery.

The difficulty of MIS increases significantly in the case of more-complex procedures, such as prostate removal.

Prostatectomy is challenging, as it involves intricate cutting to remove cancerous tissues without severing difficultto-see nerves that control bladder and erectile function. In fact, a laparoscopic approach to prostatectomy is so challenging that only a handful of surgeons around the world have mastered it. Yet nearly 90% of all prostatectomies are now done with the assistance of the robot.

With robot-assisted surgery, the surgeon guides miniature motorized “wristed” instruments from a remote console, rather than manipulating “straight wristed” laparoscopic tools directly by hand as with conventional MIS. Robotics

therefore allows surgeons to approach tissue from angles that aren't possible with laparoscopic surgery. Robotics also allows the surgeon's motion to be scaled so that large hand movements correspond to small instrument motion. In addition, hand tremor can be filtered out to allow for increased precision. A highresolution 3-D view of the surgery is also standard in robotics, compared with the flat 2-D view that is typically found in MIS. A less obvious but potentially even more significant advantage is that the robotic computer-mediated interface lends itself to virtual reality (VR) training.

In a manner similar to flight simulation, a simulated environment is ideal for learning to control the robot. VR training also has the potential to introduce surgeons to a wide variety of surgical scenarios before they ever cut into a patient.

In other words, surgeons can climb the learning curve on simulated patients without risking injury to flesh-and-blood humans. Although the instrument costs are higher, the comparative ease of learning robotics does allow surgeons to reach expert levels of performance faster than with traditional MIS. A recent study has shown that a rigorous simulation curriculum can enable surgeons to perform a hysterectomy, or removal of the uterus, at expert levels on their very first case.

This study, among others, emphasizes the real potential for training and testing of surgeons through simulation prior to live surgery.

The challenge of creating surgery

Mimic’s simulation platform enables surgeons to practice running suture applications related to myomectomy, which is fibroid (non-cancerous tumors) removal from the wall of the uterus. Credit: Mimic Technologies

simulators is greater than it is for flight simulation and the industry is still in its infancy. Robot-assisted surgery and simulation training is already helping address the challenge of increasing the adoption of minimally invasive procedures. This technology has just begun to change the way surgery is developed, taught, and performed. It has the very real potential to revolutionize healthcare, by boosting quality while cutting overall costs.

About the Author Jeff Berkley has a PhD in mechanical engineering with a bachelor’s of science and master’s degree in biomedical engineering. Jeff also served as a medical corpsman in the Naval Reserves. Jeff is the founder and CEO of Mimic Technologies, which began selling da Vinci robotic simulators in January of 2007. Intuitive Surgical licensed Mimic’s software and began selling Mimic’s surgery simulation software in December of 2010. medsim

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Russia Accelerates Healthcare Simulation Plans; Overhauls Medical Training.

MEdSim correspondent Lesya Hoover describes Russia’s high-level efforts to integrate learning technology throughout that nation’s healthcare training programs.

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n 2006, the Russian government initiated a Priority National Program in its Public Health Service, to improve the nation’s healthcare standards. The program specified changes to the accreditation system for doctors that are to be in place by 2015. Amongst these, in the Ministry of Health’s in-depth review and modernization of curriculum for various disciplines, is mandated simulation-based training in both Internship and Residency training.

Indeed, 72 hours of Internship and 108 hours of Residency training must be provided using simulation.

As in most countries many of Russia’s medical schools and hospitals have already upgraded their facilities and developed centers for practical simulation using the full range of equipment and techniques. The Russian Society of Simulation (ROSOMED) has also recognized the lack of common training standards at a national level, to ensure that best practices in training are operated at all centers.

The main tasks identified by ROSOMED to correct the community’s training shortfalls include: • Development of educational programs incorporating simulation training; • Development of standards of objective assessment of acquired skills; • Introduction of procedure for admission to carrying out manipulations on the patient; 30

• Training of teachers and trainers; • Certification of simulation centers (on a voluntary basis); • Adaptation of international standards of certification for simulation training centers to Russian certification standards; • Organization of a unified system of simulation training, testing and certification; and • Linking of simulation centers into a national network.

The goal is the creation of an allRussian system of simulation training, testing and certification in health care and a centralized, interactive simulation training center complex, interconnected on organizational, functional, and information levels and working to the same standards and technology of training, testing and certification.

The System of Medical Simulation Training in Russia The national system is designed to mirror the administrative construction of the Russian healthcare system divided into Federal, Regional (Oblast) and Municipal (Rayon) levels. Accordingly, it consists of a main service center, regional branches (virtual clinics) and existing simulation centers, connected on a voluntary basis.

The main service center is the administrative, managerial, organizational, methodological, and informational hub of the system. On its server it hosts shared

Image credit: I.M. Sechenov First MSMU.

International Programs educational software used by regional branches and a national database of trainees. The main center monitors and analyses the performance of all branches and maintains an archive of training recordings. The Regional branch is modeled as a "virtual clinic", which imitates the structure (therapeutic, diagnostic and ancillary departments), to reproduce the functions and processes of the medical institution with simulation technology.

“Train the trainers” Program at the Newly Established Center for Medicine of the Future.

The National Center of Innovation Educational Programs Medicine of the Future, which opened at I.M. Sechenov First Moscow State Medical University (MSMU), one of the oldest and most prestigious medical universities in Russia, has been tasked with creating a training course and cadre of professional experts in simulation based medical training.

One of the center’s goals is to investigate the standards and process of regulation and accreditation of simulation centers by international agencies. This will harmonize Russia’s new national network with the efforts of its global counterparts.

The first of the “new” generation of medical simulation centers in Russia was opened on October 18, 2011 at the Central Clinical Hospital in Moscow, Krylatskoe, and is officially known as Attestation Simulation Medical Clinic at the Educational and Research Center of the Presidential Administration (www.unmc. su/masc.htm). The facility is a unique multidisciplinary educational center fully equipped with the latest medical technologies including robotics.

The national plan includes the development of at least one high level medsim center in every federal region - totaling about 83 such centers.

Also of interest, the Russian medical equipment and devices market is already in the global top 20 rankings. This industrials development will give a large boost to the country’s emerging medical simulation sector.

MEdSim will be featuring more on global healthcare education and training developments, including those in Russia, in future issues. medsim

ME D S I M MAGA Z I NE 2 . 2 0 1 3

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World News & Analysis

MedicalNews Updates from the medical community. Compiled and edited by the Halldale editorial staff. For the latest breaking news and in-depth reports go to www.halldale.com.

Simulation Provides Medical Device Manufacturers With Valuable Tool - Simulation has long been an aspect of the healthcare industry, but how it is used - and how often - has changed dramatically over the course of the last decade. According to an article published by the Association for the Advancement of Medical Instrumentation, since 2000 the number of clinical simulation centers in the United States has increased more than tenfold from the mere 100 that originally dotted the landscape.

Medical device manufacturers are now using simulation technology for human factors testing. Simulation testing is usually comprised of several different studies: formative and summative. Aspects of early feasibility testing includes recording the experiences of patients and professionals interacting with the device in order to further study how its interface and overall functionality can be refined.

Complex computer modeling has its place in the development of medical devices, but hands-on simulation provides an additional depth of testing and product evaluation that can be invaluable for gauging how well a product will function in a clinical setting. Careful analyses of recorded medical device interactions are increasingly becoming crucial to medical device design.

AMA Funds Faculty Consortium to Develop Online Simulations - The American Medical Association is sponsoring a consortium of faculty from eight medical schools to develop simulated, interactive patient encounters for the i-Human PatientsÂŽ online platform.

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Mayo Clinic’s New Simulation Center Opens in Florida. Credit: Mayo Clinic.

A $100,000 AMA grant will support the authoring of internal medicine cases, in an effort initiated and overseen by Vinay Kumar, Senior Editor and Author of Robbins Pathology; and Chair, Department of Pathology at the University of Chicago Pritzker School of Medicine. Faculty members from eight prominent medical schools will help support the development effort. i-Human Patients is a web-based service for medical students that simulates a patient visit. Students use i-Human Patients to interview and examine animated patients, order/ review diagnostic tests, develop diagnostic hypotheses, and develop treatment plans – and they receive online guidance and comprehensive feedback

at every step of the learning process.

Robotic Surgery Training First Simulation-Based Robotic Surgery Training Curriculum Study - Researchers from Roswell Park Cancer Institute (RPCI) in Buffalo, New York, and four collaborating institutions evaluated the effectiveness of a novel curriculum to safely train surgeons on the da Vinci Surgical System that is used to perform robot-assisted surgeries. Results, published in Urology, showed participants trained in the curriculum executed key skills with greater precision than those who did not receive training.

The Fundamental Skills of Robotic Surgery training curriculum, jointly

developed by the study’s authors, uses the Robotic Surgical Simulator (RoSS) to train surgeons in four basic areas required in robot-assisted surgeries: orientation, motor skills, basic surgical skills and intermediate surgical skills.

RoSS is one of the first robotic surgical simulators to accurately simulate the da Vinci system. It was developed by Khurshid Guru, MD, director of robotic surgery at RPCI; and Thenkurussi Kesavadas, PhD, director of the Virtual Reality Lab and a professor of mechanical and aerospace engineering at the University at Buffalo.

Legacy Research to measure surgeon performance with Mimic Trainer - Legacy Research Institute (LRI) in Portland, Oregon, is purchasing the Mimic dV-Trainer as a tool to measure surgeon performance with robotic surgery and to improve performance via specific training exercises.

The dV-Trainer allows the potential for 24/7 surgeon access without taking a robot out of clinical use and provides a robust series of training and assessment tools. “We believe that this technology will not only broaden the education opportunities in a variety of our LISEI courses, but will also provide a systemwide and regional resource for measuring and improving robotic surgical skills,” said P. Ashley Wackym, MD, LRI’s Clinical Vice President of Research in an article he wrote about the facility.

Academic Simulation & Training Center News USM Sanderson Clinical Simulation Lab Gifted, Named - The University of Southern Mississippi Foundation's College of Nursing Building Campaign received $1 million gift commitment from Joe and Kathy Sanderson, helping the school to exceeded the $5 million mark on its way to reaching its $8 million goal. The contribution by the Sanderson’s will name the school's Clinical Simulation Lab for the family.

The Sanderson Clinical Simulation Lab will cover more than 8,000 square feet in the proposed building and will feature specialized patient care areas with patient simulators, task trainers, simulated health care records and equipment needed to provide care that

will enhance patient safety.

Joliet Junior College Opens Health Professions Center - Joliet Junior College in Joliet, Illinois, opened its new 124,000 square-foot Health Professions Center that houses a simulation area for the Nursing, Fire science/EMS, Radiologic Technology, CPR, EKG and Phlebotomy programs. These programs, previously scattered throughout the college and with limited space and resources, are now consolidated in the new building with the cutting-edge technology needed for real, hands-on experience for their students.

University of Charleston Opens New Simulation Lab - The University of Charleston in West Virginia opened a new simulation lab for its Health Science Programs, thanks in part to a $1.5 million donation to the school from the Estate of former Kanawha County Circuit Judge Robert K. Smith. The new Health Science Simulation Lab will help benefit the University’s nursing and physician assistant students and features simulation mannequins.

Kettering University Students Developing Haptics for Surgical Tools - Students in Kettering University’s Research in Engineering and Collaborative Haptics Lab in Flint, Michigan, are working with Genesys Regional Medical Center on a haptic-enabled device that simulates the laparoscopic adrenalectomy, or removal of the adrenal gland, procedure. The surgery is minimally invasive with laparoscopic instruments, but officials at Genesys have shown an interest in adding a haptic element to their surgical tools.

UNC Med School Opens Surgical Skills Lab - The University of North Carolina School of Medicine opened its new multidisciplinary surgical skills lab, thanks to a $1 million gift from the North Carolina Eye Bank .The gift to the Department of Ophthalmology will be shared among three neurosciences departments – and the newly created laboratory, the only of its kind in the region, will provide state-of-theart surgical training opportunities in Ophthalmology, Neurosurgery, and Otolaryngology/Head and Neck Surgery to medical students, residents, fellows and physicians across the state.

Ozarks Technical College Opens

Health Clinical Simulation Center - The Ozarks Technical Community College (OTC) in Springfield, Missouri has opened it s new 2,000-square-foot Allied Health Clinical Simulation Center. The center is designed as a simulated hospital environment and has a multi-disciplinary high-fidelity simulation lab that will allow OTC to educate more than 600 students across 12 programs, including all of the college's Allied Health programs. The center will also provide training for a variety of healthcare professionals already in the workforce.

NorthWest Arkansas CC Opens Health Center, Nursing Sim Lab - NorthWest Arkansas Community College has opened its new 83,000-squarefoot Center for Health Professions, that features state-of-the-art simulation labs and the latest in green building technologies. Classes began in January in the new building that houses nursing, respiratory therapy, physical therapist assistant, paramedic, emergency medical technician, fire science, certified nurse assistant and patient care assistant programs.

The Nursing Simulation Lab, made possible by a gift from Washington Regional Medical Center, features high-fidelity mannequins that can be programmed to engage NWACC nursing students in more than 100 scenarios, allowing students to be exposed to many of the real-world situations they may encounter in their work.

Pueblo Community College Opens Simulation Lab - Pueblo Community College in Colorado opened a simulation lab at St. Mary-Corwin Medical Center that will be used for training both students and medical center personnel. The two institutions announced their partnership last March, and since then have equipped the lab with using a $340,000 Carl Perkins grant that provided six simulators and related control equipment such as TV monitors and cameras, an infant warmer, and other equipment.

Hospital Simulation & Training News Mayo Clinic's New Simulation Center Opens in Florida - The Mayo Clinic opened its J. Wayne and Delores Barr Weaver Simulation Center M EDSI M M A G A Z I N E 2 . 2 0 1 3

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World News & Analysis in Jacksonville, Florida, where medical teams and community organizations can practice everything from basic skills to the most complicated scenarios with stunning realism.

The center is part of a two-story addition to the Vincent A. Stabile Building and was made possible by a $7 million gift from J. Wayne and Delores Barr Weaver, along with gifts from other benefactors. The 9,600-square-foot center replaces a 2,600-square-foot simulation center that opened in April 2011.The center can be used by all staff to practice safe, effective and efficient care, and the center's rooms replicate actual spaces at Mayo Clinic in Florida.

STAR Center Receives Grant for Surgical & EMS Simulation - The West Penn Allegheny Health System Simulation Teaching and Academic Research (STAR) Center received a $350,000 grant from the Richard King Mellon Foundation to expand its educational programs. STAR is a virtual hospital that reflects the patient and family experience from admission to discharge. STAR students use simulated patients and individual task trainers to learn and practice clinical skills in a riskfree environment prior to performance on real patients.

Mass. Eye and Ear Otolaryngology to Open Surgical Training Lab Massachusetts Eye and Ear is opening a new Otolaryngology Surgical Training Laboratory that was built by Wise Construction. The state-of-the-art surgical skills training laboratory will advance instruction capabilities in nearly every subspecialty of otolaryngology, including: skull-base surgery, head and neck surgery, laser surgery, otology and neurotology, facial plastic and reconstructive surgery, sinus surgery, laryngology and pediatric otolaryngology. The laboratory will serve as a resource for Harvard Otolaryngology residents and fellows, as well as experienced surgeons in the department preparing for complex cases.

Nursing Education and Training Kentucky Medical Center 's New Facility to House Nursing Program - The Medical Center in Bowling Green, Kentucky – part of Commonwealth 34

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Health Corporation - plans to construct a 73,471 square-foot, three-story facility on the hospital’s campus at a cost of $18.4 million. The new facility will house Western Kentucky University’s (WKU) nursing and physical therapy programs and provide educational space for the hospital. The Medical Center-WKU Health Sciences Complex will help address the national nursing shortage by providing space for the university to expand its nursing program and double the number of students who can enroll in it.

Colleges Collaborate on New Nursing Education Center in Missouri - Lindenwood University and St. Charles Community College (SCC) in St. Charles, Missouri reached an agreement to launch a new LU/SCC Center for Nursing and Allied Health Sciences. Lindenwood will offer post-associate degree coursework in nursing for students who already have a two-year nursing degree.

SCC will move its entire associate degree nursing programs to the site, as well as its Licensed Practical Nursing, Occupational Therapy Assistant, Health Information Technology and Health Occupational programs.

SCC will lease approximately 26,000 square feet of the building’s space under terms of the agreement. As part of the collaboration, SCC will move its stateof-the-art simulation lab to the new location and expand the space to create a “virtual hospital” that will provide the ability to offer concurrent simulations.

Kaplan University-Augusta Offers New Nursing Degree Program Kaplan University’s Augusta, Maine campus is now offering they school’s new Prelicensure Bachelor of Science in Nursing degree program designed to help fill Maine’s need for qualified nurses and assist in closing a persistent skills gap prevalent throughout the state. The program will operate out of Kaplan University’s new 19,500 square-foot campus in Augusta that opened in October and features a state-of-the-art nursing simulation laboratory.

Grand Canyon University Opens New Nursing Facility - Grand Canyon University - Albuquerque in New Mexico expanded its nursing program with additional classrooms and hands-on teaching tools. The renovated

16,249-square-foot facility is modeled after the university's campus in Phoenix, Arizona, and features a skills and simulation lab, including a mock, home health-care setting. There also are conference rooms, faculty offices, and a student lounge.

UT Gains Approval for New Nursing BSN Degree - The University Texas of the Permian Basin received approval for a 4-year Bachelor of Science in Nursing degree from the Texas Higher Education Coordinating Board and will now seek approval of this degree from the Texas Board of Nursing .“We are very optimistic,” said Dorothy Jackson, director of program development in nursing. “We are planning for a start day immediately after the program is approved by the Texas Board Pitt Titusville Nursing Integrates Simulation into Curriculum - The University of Pittsburgh at Titusville nursing program took on three different types of simulation mannequins that allow students to practice nursing care and procedures on life-like patient. The Gaumard Susie S 2000 is a specially designed unisex mannequin for nursing programs operated with a tablet computer. A second mannequin, the VitalSim, is a simulated 6-month-old baby that can be operated with a SimPad tablet.

A third mannequin, an adult unisex VitalSim mannequin, gives students the opportunity to re-enact a variety of reallife patient medical case scenarios.

Ashland University College of Nursing Gets Donation - Sutton Bank gave Ashland University $75,000 to help pay for the College of Nursing’s new 46,000-square-foot facility that opened last fall in Ohio. So far, the Dwight Schar College of Nursing facility includes a number of clinical laboratories housed within the Simulation Center, including a Health Foundations lab, Family Health lab, Adult Health lab, Complex Health lab, ICU/CCU/NICU, Advanced Care lab, Community Health Home Care lab, and four patient examination labs.

Delta Health ClinicalVirtuoso Licenses for Penn State Nursing Ed - Delta Health Technologies gave Penn State Altoona 200 licenses for the medical software package entitled ClinicalVirtuoso. The in-kind gift, worth nearly $300,000 will allow the campus’s

nursing students to use electronic medical records software designed to document clinical services in a home health environment. ClinicalVirtuoso’s features let students record daily tasks, document an initial patient assessment, establish and conduct a care plan, manage ongoing services, chart discharges and transfers, and other administrative functions. The software is intended for educational purposes in simulated clinical environments only.

International Simulation, Training and Education News Simulation Australia to Get State Funding - According to Australian Manufacturing, Innovation and Trade Minister Tom Kenyon, the State Government would provide $160,000 to Simulation Australia to grow South Australia's modeling and simulation sector and retain its head office in Adelaide until June 2015. One of the organization's key initiatives will be to host the 2014 SimTecT and SimHealth conferences in Adelaide, expected to attract more than 1,000 national and international delegates. iSimCentre Opens in Coffs Harbour, Australia - Coffs Harbour Hospital in Australia is the home of a new, $1.5 million regional Interprofessional Simulation Centre (iSimCentre). The virtual hospital integrates training for nursing, medicine midwifery and allied health students and allows graduates and existing health professionals to experience medical emergencies well before they are faced with the real-life situation. The centre will also help experienced health professionals make a smooth transition into regional hospitals.

New Simulation Centre Opens in Newcastle - John Hunter Hospital in Newcastle, Australia, has opened a new medical simulation training facility where health professionals and students will have access to advanced medical training at the replica emergency department ward, operating theatre and intensive care unit. The nearly $3 million facility is the only such training centre outside of Sydney in NSW and has one of the only mannequins of its type in Australia. Inside, trainee doctors, nurses and other health professionals can prac-

tice their skills on computer-controlled mannequins that replicate routine procedures and human reactions.

Clinical Anatomy Skills Centre Opens in Glasgow - The Clinical Anatomy Skills Centre, a joint initiative of the University of Glasgow and the Royal College of Physicians and Surgeons, has opened in Glasgow.

The centre offers hands-on training for surgeons, with most of the surgical training being done using computer and video simulation or animal tissue.

I-tech surgical instruments will be used to train surgeons in traditional open and keyhole surgery and students will also be able to practice on cadavers that have been bequeathed to the University of Glasgow's body donation program.

Tatarstan to Build Russia’s Largest Medical Science Center - Private Russian companies Eidos and IPG, along with some other businesses and organizations, have entered a publicprivate partnership backed by the Russian Ministry of Health and the Govt. of the Republic or Tatarstan to develop a center for innovative medical products and technologies. It will include a new medical simulation training center that will allow physicians to advance their skills and rehearse complex procedures

on the latest simulation devices and will also serve as incubator for innovative projects.

Russia recently mandated simulation-based training for its physicians providing a base for the further growth and development of the Russian simulation industry. By 2015, the accreditation system for doctors will require that they undergo simulator-based training in order to gain accreditation in a number of disciplines. The new 1.2 bn Rubles ($40m US) center is in the final stages of development. When completed, it will include a technology incubator, labs, pilot plants and a simulation center.

British Columbia Simulation Network Expands - Implementation of a new training resource for health care practitioners in British Columbia is complete thanks to a partnership between Northern Health, the University of Northern B.C. School of Nursing, and the University of B.C. Northern Medical Program. The partnership opened the Northern Clinical Simulation Centre at Fort St. John Hospital and completed the final step in the implementation of a network of simulators that includes hospitals in Terrace, Prince George and Quesnel.

Ozarks Technical College Opens Health Clinical Simulation Center.

Credit: Ozarks Technical College.

M EDSI M M A G A Z I N E 2 . 2 0 1 3

35

World News & Analysis Education News Wales first Reader in Rural Health and Community Wellbeing appointed - Aberystwyth University, Hywel Dda Health Board and the University of Wales Trinity Saint David announced the appointment of Manoj Kulshrestha, MD, as Wales’ first Reader in Rural Health and Community Wellbeing. The position recognizes the unique opportunity available to the NHS and local universities in West Wales to work strategically in partnership and redefine how policies and services can improve the health and wellbeing of those living in rural communities.

Kulshrestha, a prominent Consultant Ophthalmologist based at Bronglais Hospital and North Road Surgery in Aberystwyth, will take up the role on 1May 2013 for an initial 12 month period.

Appointed jointly by Aberystwyth University and University of Wales Trinity Saint David, Kulshrestha will also work in close partnership with the Health Board to provide policy and service advice and through securing research grants and funding, to create a self-sustaining, supporting research infrastructure for the post.

Accreditations U of Tenn Sim Center Gets Top ACS Accreditation - The University of Tennessee Center for Advanced Medical Simulation just became the only facility in Tennessee and one of just 67 in the world to earn accreditation as a Level I Comprehensive Accredited Education Institute (AEI) from the American College of Surgeons (ACS) – the top accreditation available. The co-directors of the center believe the accreditation reflects the availability of advanced education and training through simulation in the Knoxville region.

Low Cost Medical Simulation Baby Bottle Simulates Mitral and Tricuspid Valve Surgeries - A paper published in the latest issue of Oxford Journal’s Interactive Cardiovascular and Thoracic Surgery reports that two of the medical educators from the Netherlands 36

M EDSI M M A G A Z I N E 2 . 2 0 1 3

developed a low-cost, low-fidelity simulator for both mitral valve and tricuspid valve surgery with a baby bottle and a piece of dental dam. The simulation model is very similar in size to the actual anatomical dimensions of the mitral valve and can be used to simulate various pathological conditions and can be use to for training in several mitral valve surgical techniques and tricuspid valve surgery techniques. The simulator cost about €5 ($6 US) to build, and can be used for about 45 suture placements.

Military Medical Simulation Naval Hospital Bremerton Expands Simulation Lab - Naval Hospital Bremerton (NHB) has expanded its Simulation Center (Sim Lab) with the addition of three medical mannequins, including Laerdal's SimMan, bringing its mannequin population to eight.

NHB's Simulation Center in Bremerton, Washington, gives healthcare providers with a chance to accurately replicate the experience of giving patient care. "The mission (of the Sim Lab) is to develop and maintain the skills of our healthcare staff and become the go-to source of skills development for regionally based military personnel," said NHB's Sim Lab Program Manager Hospital Corpsman 2nd Class Blake Hite.

New Products and Developments SonaCare Debuts Ablation System and High Frequency Simulator at EAU Congress - SonaCare Medical, a provider of minimally invasive high intensity focused ultrasound (HIFU) technology, launched two new products at the recent European Association of Urology (EAU) Congress in Milan, Italy. SonaCare Medical showcased the updated Sonablate® 500 with a redesigned software interface that features new treatment planning and enhanced simulation capabilities along with the Sonatherm® HIFU Surgical Ablation System, a new FDA 510(k)-cleared laparoscopic soft tissue ablation device.

SonaCare Medical's vision is to develop HIFU surgical ablation systems for a wide range of urological indications, in addition to prostate cancer, that allows for tissue targeting techniques.

Vitacon Portable Bladder Scanners Coming to U.S. Education Market Vitacon US entered a strategic alliance and national distribution agreement with Pocket Nurse® Enterprises to market its new VitaScan LT Bladder Scanner to US Healthcare Educators and Medical Simulation Labs. VitaScan LT allows real-time bladder volume measurement in hospitals, clinics, and long-term care with a new price point. The device operates via USB providing nearly limitless storage and data connectivity. VitaScan software uses intelligent targeting algorithms that allow personnel with limited training to obtain accurate measurements in seconds.

AAOS and Touch of Life Technologies develop Shoulder SimulatorThe American Academy of Orthopaedic Surgeons (AAOS) partnered with Touch of Life Technologies (ToLTech) to develop a virtual reality-based shoulder simulator to train and evaluate orthopaedic residents in surgical proficiency in shoulder arthroscopy. The shoulder simulator provides a precise and accurate handson experience using models from an actual human body – and is ToLTech's newest product release from the company's expanding ArthroSim™ platform.

The device combines 3-D graphics with robotic capabilities that simulate the "touch and feel" of a surgical procedure and human tissue without the risk of operating on a real patient or the limits of practicing on a cadaver, which only can be used once for surgical education.

Simbionix Signs Surgical Videos License Agreement with Duke Simbionix USA Corporation, a provider of medical simulators and education solutions, signed an agreement with Duke University to license surgical videos and other instructional materials.

The resources were developed by Duke physicians and cover the advanced skills and procedures addressed in Phase 2 of the ACS/APDS (American College of Surgeons and the Association of Program Directors in Surgery) Surgical Skills Curriculum for Residents Simbionix will make these materials available at no cost to users of its MentorLearn system as part of the implementation of the ACS/ APDS Surgical Skills Curriculum for Residents.

SIMULATION

Virtual Reali Surgery Pe

Thomas S. Lendvay, M rehearsal improves pe experienced surgeons

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fforts to reduce th annually from medi use of simulation cur ticing clinicians basic and a simulation for residents ha Board of Surgery among oth cal rehearsal or warm-up h performance and reduce op ity simulators have been cr to explore whether virtual r

would improve performanc trainees and experienced s Athletes and musician Surgery is a high stakes, te intense profession. In addi particularly important for information presented to th Surgeons need to process applied because of the lack

Methods

Surgical residents and fa ogy, General Surgery, a Washington Medical Cen ical Center (MAMC) we 22

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Sub Specialty Urology General Surgery OBGYN Recent Video Game Use None

on how virtual reality, robotic pre-surgical Thomas S. Lendvay, MD, FACS reports and reduces errors in both surgical trainees rehearsal improves performance and experienced surgeons.

E

98,000 US lives lost fforts to reduce the more than have included the annually from medical complications novice and pracuse of simulation curricula for teaching skills.1,2 Access to surgical ticing clinicians basic and advanced mandated by the American been has residents for simulation societies.3,4 PresurgiBoard of Surgery among other professional shown to enhance surgical cal rehearsal or warm-up has been times. Now that high fidelperformance and reduce operative for robotic surgery, we sought ity simulators have been created (VR) robotic surgical warm-up to explore whether virtual reality reduce errors in both surgical would improve performance and trainees and experienced surgeons. so why don’t surgeons?

Athletes and musicians warm-up, challenging, and cognitively Surgery is a high stakes, technically benefits of warm-up may be intense profession. In addition, the surgery due to the increased particularly important for robotic the visual monitor. through information presented to the surgeon visual cues into forces Surgeons need to process and transform feedback from the platform. applied because of the lack of haptic the Departments of UrolSurgical residents and faculty from at the University of ogy, General Surgery, and Gynecology and Madigan Army MedWashington Medical Center (UWMC) for our study. [Table 1.] ical Center (MAMC) were recruited

PGY-1 and 2 residents were excluded perforas we felt that robotic surgery was not level appropriate for mancetrAining technoLosubgy junior residents. We enrolled 51 jects and after a proficiency curriculum of to bring every subject to a baseline Inc., VR and da Vinci (Intuitive Surgical Sunnyvale, California) robotic surgical simuLAtion progrAms to a skills level, we randomized them exposseries of trial sessions either VR ing or not exposing them to a brief robotic simulator (dV-Trainer simulator, MIMIC Technologies, Inc., Seattle,

<2 x Week 2+ x Week

Laparoscopic Cases (primary surgeon) 1 (4.0%) None 3 (12.0%) 10 or less 3 (12.0%) 01/11/25 18 (72.0%) 25+

Demonstration of our set-up in the ISIS simulation center with the da Vinci.

Tasks are affixed to acrylic plates so that the orientation of the robot remains constant between modules. (Resident: Daniel Avery, Urology

Learning Enablers

Robotic Cases (primary surgeon) None 10 or less 11-25 25+ Table 1. Subject demographics between between the cohorts.

pAtient

warm-up.

Washington.)sAfety The proficiency curriculum included modfour VR and four da Vinci dry lab manipules that exercised basic robotic camulations such as instrument and era clutching, suturing, object transfer relaspatial and instruments, between 2.] To tions capabilities. [Figures 1. and had achieve proficiency, each subject criteria to pass performance benchmark the to advance to rates error with zero next degree of task difficulty.

0 (0.0%) 3 (11.5%) 1 (3.8%) 22 (84.6%) 8 (30.8%)

9 (36.0%) 6 (24.0%) 3 (12.0%) 7 (28.0%)

p-value 0.396 0.691

0.611

0.216

0.299

spent complete and the control subjects imme10 minutes reading a leisure book Vinci diately prior to performing the da time, criterion task. We tracked total task handed left and right path length for errors, tools, technical errors, cognitive of the and economy of motion for each the da sessions on the simulator and on Vinci.

Results

with The warm-up group performed decreased task time (-29.29 seconds, mm, p=0.001) and path length (-79.87 was p=0.014) for the similar tasks. There for a >6-fold reduction favoring warm-up rings sessions with errors of placing the In errors). (sequence pegs on incorrect Tables 2 and 3, performance metrics are for the first three similar sessions detailed. disthe whether When we tested similar VR task can warm-up subjects 4-fold for robotic suturing, we observed a reduction in the proportion of sessions suturwith global technical errors for the and air ing (needle entrance, exit errors [Table knot errors, collectively, p=0.020).

4.]

When we divided the groups by level and of MIS experience (> 10 laparoscopic vs. > 10 robotic cases as primary surgeon < 10 cases in each modality experience), effect we observed that the warm-up experience. with was more pronounced time Economy of motion (p=0.007), task (p=0.001), and path length (p=0.093) subfavored the warm-up ‘experienced’ group. [Table 5.]

We designed a da Vinci tool tracking tools method - SurgTrak™ - to locate the data in space so we could get path length [Figure to calculate economy of motion. already 3.] Using this technology, we had of the demonstrated construct validation 1 proficiency curriculum .

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10 (38.5%) 1 (3.8%) 7 (26.9%)

denote similarities control and warm-up groups. P-values

Initial Foundational Questions To Help Build Your Simulation Program PGY-4) Image credit: Author.

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Four trial sessions per subject were a simiperformed. The first three tested peg lar 1VR to dry lab task – the rocking tested board. And the fourth session peg a dissimilar task from the rocking [Figboard warm-up – da Vinci suturing. to ure2.] The warm-up took 3-5 minutes

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before Warming-up on a VR platform moddoing similar and dissimilar skills ules on the da Vinci improved surgeon some performance. It is intuitive that a task form of priming before doing that would be beneficial, but the finding persurgeon elevate dissimilar tasks can into formance is compelling to bring this

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World News & Analysis SLS Releases Laparoendoscopic Textbook for iPad - The Society of Laparoendoscopic Surgeons (SLS) released Prevention and Management of Laparoendoscopic Surgical Complications 4.0 (PM4.0), one of the first interactive medical textbooks on the new Apple iBook interactive format for the iPad. This complete medical text is now in a form that provides multi-touch text, images and videos. The immersive, interactive and engaging textbook lets medical students and educators use a textbook in a whole new way. For a limited time, SLS is offering this interactive, 75-chapter, 130-author Medical Textbook ($450 value) in interactive iBook for iPad format for a special introductory price of $14.99 on the iTunes store.

CAE Healthcare Sells Patient Simulators to Two Quebec Colleges CAE Healthcare sold advanced human patient simulators for nurse training to two of colleges in Quebec's colleges: Dawson College and Cégep de SeptÎles. Both schools will use CAE Health-

care's wireless METIman and iStan patient simulators to train students in their nursing programs.

Surgical Theater Receives FDA Approval of Surgery Simulator Surgical Theater received FDA approval of its Selman Surgery Rehearsal Platform (SRP), making it the only patented and approved platform for cerebral and spine pre-surgery simulation. Using standard scanned images of the patient, the SRP generates 3-D patient-specific and accurate models that show the interaction between life-like tissue and surgical instruments. The animated tissue “responds” to actions taken by the surgeon, allowing accurate presurgery planning and rehearsal. The software uses flight simulator technology to permit the remote connection of multiple SRPs. Participants anywhere in the world can simultaneously work together, practice the same case with real-time feedback, and collaborate on surgery planning. medsim

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