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Volume 3

T r a i n i n g

Issue 2.2014

Team Training

Growing a Culture of Safety


The California Simulation Alliance


Virtual Patient Simulation Supports Clinical Reasoning Skill Building

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ISSUE 2.2014

Editorial comment

Editor's Comment

"Thought needs to be given to the standardization of licensure and credentialing across states and international borders"

Do we have a system of healthcare or do we have many systems with many players all trying to play the game, with few playing by the same set of rules? In fact, many players don’t understand that each of the disparate players in the game have a set of rules that they must use regardless of the rules the other players are using. Each player has a set of standards that he or she must use and may or may not be aware that the other players are using different standards. There are few international healthcare rules or standards that are recognized by all players. That is why a doctor from Africa may observe a surgical procedure done in the United States or Europe but can only perform the procedure in a few locations other than Africa. For that matter, a doctor in Oregon may perform a procedure in Oregon and not be allowed to perform the same procedure in Ohio. How do you tackle the problem of developing a level playing field so all can participate, all are playing by the same set of rules and standards and that each of the players is equally qualified to play in his or her field? More thought needs to be given to standardizing education of healthcare providers worldwide to combat the shortage we are now facing. In the United States the Department of Labor has re-opened admission of qualified nurses to the US due to our shortage. Thought needs to be given to the standardization of licensure and credentialing across states and international borders, not just for nurses but for all healthcare providers. If other medical schools are like those in the US, when you have seen one medical school you have seen one medical school. This is not to say that the AAMC has not set criteria that all medical schools must meet, or the ACGME does not have rules and regulations that must be met, or that residency boards don’t have criteria that must be followed. It is to say that an effort must be made to communicate the same guiding principles across the community. It is to say that something other than written tests needs to be used to ensure that all participants are competent to perform the task required. When you look up the World Health Organization site and look at the A to Z list of studies, groups and projects, there is nothing on standards and the follow-

ing on education, “Course of study required to educate a legally qualified and licensed practitioner of medicine, concerned with maintaining or restoring human health through the study, diagnosis and treatment of disease and injury, through the science of medicine and the applied practice of that science.” What safeguards are in place to insure that the practitioner is competent? Medical schools are requiring students to learn more and more information. Jon Coleman, a medical student, in an article on February 23rd in Education wrote the following: “How do you ask a person to be the last person to go through an education system that is failing them?” Yet we’re doing just that. This is not to say that we are not producing good doctors. On the contrary, our doctors are likely the most well-educated and knowledgeable in history; but this is part of the problem. Every year the amount of information medical students are required to know increases. We do not replace information with better, more relevant information, we simply add more... For decades we defined physicians by the amount of knowledge they accumulated, knowledge that separated the physician from lay persons. The mentality of the status quo will not suffice for the next generation of physicians. After all, patients are already doing their part, coming to see their physicians with Internet printouts, 23andMe results, etc. Now it’s time for physicians and medical students to do ours." Very sage advice from a digital native medical student. When we make these changes to the curricula, the rules and regulations, should we not also be looking at how they would work globally? After all, there will be a worldwide shortage of qualified healthcare personnel very shortly if it does not already exist.

Judith Riess Editor in Chief, MEdSim Magazine




ISSUE 2.2014












Editorial Editor in Chief Judith Riess, Ph.D. e. Group Editor Marty Kauchak e. US & Overseas Affairs Chuck Weirauch e. US News Editor Lori Ponoroff e. RoW News Editor Fiona Greenyer e. Advertising Director of Sales Jeremy Humphreys & Marketing t. +44 (0)1252 532009 e. Sales Representative Justin Grooms USA & Canada t. 407 322 5605 e. Sales Representative Chris Richman Europe, Middle East t. +44 (0)1252 532007 & Africa e. Sales & Marketing Karen Kettle Co-ordinator t. +44 (0)1252 532002 e. Marketing Manager Ian Macholl t. +44 (0)1252 532008 e.


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Editor's Comment. Editor Judith Riess inquires do we have a system of healthcare or do we have many systems with many players all trying to play the game, with few playing by the same set of rules?


The California Simulation Alliance. KT Waxman, DNP, MBA, RN, CNL, CENP provides an overview of the alliance and its near-term plans and activities.


Virtual Patient Simulation Supports Clinical Reasoning Skill Building at the University of Pittsburgh. James B. McGee, MD shares his institution’s progress in advancing virtual patient simulation-based education and assessment.


Interprofessional Crisis Resource Team Training in an Ambulatory Surgical Setting: Growing a Culture of Safety. Suzanne M. Wright, PhD and Michael D. Fallacaro, DNS discuss their program to enhance patient safety – through crisis resource team training.


Game Changer. Group Editor Marty Kauchak describes the roadmap for the new BioGears™ open-source physiology engine.


2014 IMSH. The International Meeting on Simulation in Healthcare provided insights on the state-of-the-art in learning technologies for healthcare professionals. Editor in Chief Judith Riess and Group Editor Marty Kauchak attended the conference with Halldale Media Group Publisher and CEO Andy Smith and provide this report.


MEdSim CAMLS FORUM. Healthcare providers and industry leaders came together to address educational and training challenges.


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



On the cover: Lake Superior State University nursing students, Sam Balzer, Emily Schaub and Elizabeth Schlaud examine a baby mannequin used to learn and rehearse individual and team skills. Image credit: LSSU Education Dept.

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SIMULATION ALLIANCES tion, the aims of the alliance include providing a home within the CINHC for best practice identification, information sharing, faculty development, equipment/ vendor pricing agreements, space planning, scenario development, sharing and partnership models, and inter organizational research via a statewide research committee.

Regional Collaboratives

The California Simulation Alliance KT Waxman, DNP, MBA, RN, CNL, CENP educates and informs the community about the alliance.


he California Simulation Alliance (CSA), established in 2008, led by the California Institute for Nursing & Health Care (CINHC) in Oakland, California, is a virtual alliance to benefit all simulation users in the state of California. The mission of the CSA is to coordinate and expand the use of all forms of simulation in academic and service settings across the state to advance healthcare education, ultimately resulting in enhanced patient safety for Californians. The CSA is governed by an inter-professional advisory committee and a steering committee comprised of representatives from all seven regions comprised of schools of nursing, allied health, medicine and hospitals. The CSA evolved from initial work in the San Francisco Bay Area with the Bay Area Simulation Collaborative (BASC) in 2006. The CINHC, the state’s nursing workforce center, received a grant from the Gordon and Betty Moore Foundation



for the CINHC to create the first formal, urban simulation collaborative in the US. The BASC comprised more than 100 schools of nursing and hospitals, totaling more than 600 faculty and hospital educators from 10 counties around the San Francisco Bay. This 3-year funded project was designed to train and educate healthcare faculty in the concepts of simulation (Waxman, et al, 2011).1 The three objectives for the project included a faculty development plan, scenario development and a research agenda. The BASC is still operating as a regional collaborative under local leadership and is one of the seven regional simulation collaboratives in California. Leveraging the initial investment for BASC, the CSA was formed. The purpose of this alliance is to become a cohesive voice for simulation in nursing education across the state, to disseminate information to stakeholders, and to establish a universal entity for simulation. In addi-

Seven regional collaboratives have emerged within California over the past six years: the Rural Northern Area Simulation Collaborative (RNASC) serving the North, housed in Chico; the Capital Area Simulation Collaborative in the Sacramento region; the BASC serving the San Francisco Bay Area; the Central Valley Simulation Collaborative (CVSC), serving the Central Valley from Bakersfield to Modesto; the SCSC, serving the Los Angeles/Orange County region; the Inland Empire Simulation Collaborative (IESC), and the San Diego Simulation Collaborative (SDSC). Over the next few years, it is anticipated that several more collaboratives may emerge, especially in the Southern California area. Of the seven collaboratives, a few were funded, while others were grassroots groups. The SDSC in San Diego received start-up grant funds from the Education Department at the state capital, the RNASC received a rural grant and the SCSC is mentioned below. Through the initial investment and with the success of the BASC, another funder, Southern California Kaiser Permanente Community Benefits Program, funded the CINHC to lead a project in the Los Angeles region to replicate the work of the BASC. The 3-year grant called for the development of a Southern California Simulation Collaborative (SCSC), an academic/service operating committee, training for faculty, a site assessment of potential regional centers, and scenario development. After completing this 3-year project, more than 200 educators have been trained, a train-the-trainer program was implemented, the operating committee has met every other month, the site assessment is complete, and scenarios have been written. The SCSC is now one of the seven regional collaboratives in the state.

Other collaboratives around the state have been growing from grassroots efforts. The Central Valley Simulation collaborative (CVSC) is an example of one of the regions that, even though they have no funding, have managed to meet regularly, hold classes for constituents and work together to integrate simulation into both schools and hospitals in the central valley of California.

CSA Regional Collaboratives Rural Northern Area Simulation Collaborative (RNASC)

Capital Area Simulation Collaborative (CASC)

Bay Area Simulation Collaborative (BASC)

Central Valley Simulation Collaborative (CVSC)

Committees Four committees are in place within the CSA: • Research: This committee is comprised of multiple simulation stakeholders in the state. They track research activities in the state in schools and hospitals and were instrumental in conducting our statewide simulation survey over the past five years; • Scenario writing: This committee was instrumental in standardizing the CSA scenario template, which was modeled after the BASC template. They continue to hold scenario writing groups to contribute to the 75 scenarios on the CSA website; • Technology: This committee is comprised of simulation technicians and simulation faculty that assist with our website development, simulation technician training and overall simulation needs on the technical side. They also remind us that simulation isn’t all mannequin based; and • Scholarly writing: This committee led the effort to create a bibliography of current simulation articles for our subscribers. Additionally, they completed an inventory of CSA member writers and track this data.

Faculty Development Leveraging the successful BASC faculty development program, the CSA adopted the program to roll out statewide. In 2006, a comprehensive faculty development plan was designed by the BASC operating committee and program director. The goal was to train a large number of expert clinicians and nursing faculty in the Bay Area, and the plan was built on the novice-to-expert model. In this plan, the faculty member (learner) in Level 1 training (basic technical skills) is in the novice stage, Level 2 (simulation

Southern California Simulation Collaborative (SCSC)

Inland Empire Simulation Collaborative (IESC)

San Diego Simulation Collaborative (SDSC)

methodology) is the advanced beginner stage, Level 3 (apprenticeship) is the competence stage, and Level 4 (train-the-trainer) is the proficient and expert stage. Ultimately, a train-the-trainer model allowed the BASC to have its own qualified instructors to teach others.2 The CSA added an apprentice program in 2010 as it was successful in the Bay Area. This apprentice program is a 72 hour comprehensive training program where faculty can hone their skills with experts in the field. (This curriculum was purchased from SimHealth Consultants in Oregon). Four CSA sanctioned apprentice sites have been named: Samuel Merritt University in Oakland; the Center for Advanced Pediatric and Peri-natal Education (CAPE) at Stanford; and Little Company of Mary Medical Center in Torrance. Once faculty complete the apprentice program, many go on to become CSA faculty. The train-the-trainer program was implemented statewide and currently there are qualified CSA faculty in each of the seven regions to perform training in their specific area. Over 2,000 faculty from nursing schools, pharmacy schools, paramedics, medicine and technicians have been trained since 2008 through the BASC/CSA educational programs.

Governance The governance of the CSA includes representation on the steering committee from both schools and hospitals across the entire state. The CSA has been developed through the facilitated efforts of a group representing nursing education, nursing practice, professional organizations, allied healthcare disciplines, and the state licensing board for registered nurses, so that the best thinking can be tapped from leaders of key constituencies to build consensus. The future for CSA is to become the voice for simulation in Sacramento and facilitate state funding for simulation use and expansion.1

Above The California Simulation Alliance, established in 2008, led by the California Institute for Nursing & Health Care in Oakland, California, is a virtual alliance to benefit all simulation users in the state of California. Opposite The purpose of the CSA is to become a cohesive voice for simulation in nursing education across the state, to disseminate information to stakeholders, and to establish a universal entity for simulation. All Images: KT Waxman, DNP



SIMULATION ALLIANCES Sustainability Since no grant funding is currently available for the CSA, the organization has been sustainable due to their four revenue sources: subscription fees, course revenue, apprentice fees and industry partners/sponsors. Subscription fees were implemented in 2011 for individuals and institutions. The CSA has 75 scenarios available on their website ( and are available for download for all subscribers. These scenarios were written, validated and tested by CSA and BASC members and many of them have been updated to include QSEN competencies. With our partnership with the Victorian Simulation Alliance (VSA) in Melbourne Australia, plans to sell the CSA/ VSA programmed scenarios are on the agenda for the end of this year. Courses are discounted for subscribers and any excess of revenues goes back to the CSA for sustainability. The apprentice program also provides revenues and lastly, sponsorships and pricing agreements from industry partners help as well.

Partnerships The VSA was modeled after the CSA. This alliance has been in place for three years and is growing in their state. They have become a model in Australia for other states to develop their own regional or statewide alliance. Plans for the VSA and CSA to participate in joint educational sessions and scenario development are occurring this year. Together the VSA and CSA have launched the Trans-Pacific Simulation Alliance and will develop strategy around this alliance in 2014.

Clinical placements The current California Board of Registered Nursing regulation allows schools of nursing to utilize 25% of clinical hours per course in simulation. The CSA performed a statewide simulation survey recently that revealed many schools are only using 15% and there is still opportunity to increase by 10%. With clinical placements being more difficult to secure, simulation labs are being used as clinical sites where students can be 08


guaranteed a clinical experience. For this reason, the CSA hopes to standardize the way we teach in simulation, clearly define what simulation is (not an expensive skills lab) and monitor the use in California’s schools.

Conclusion The CSA has created an infrastructure for integrating all types of simulation into the curricula of California schools of nursing, allied health and hospitals and has made possible a consistent, standardized methodology for the use of simulation. Consistency in the education of faculty, students, and healthcare professionals through simulation will help improve patient safety and healthcare delivery in California. Integration into both school and hospital curricula is critical to the success of a simulation program. The alliance shares best practice models for successful curriculum integration, holds workshops on this process and, additionally, helps hospitals with integrating simulation into their patient safety programs to meet the national patient safety goals. Through collaborative relationships with hospitals, health systems, and schools of nursing committed to incorporating simulation into their education and training programs, the CINHC successfully supports the CSA and its sustainability. Moving forward, the CSA goals for 2014 include establishing more industry partnerships, hosting a 1-day simulation conference, and continuing to refine and offer simulation courses to subscribers and non-subscribers. These courses will include creating a business plan for simulation lab sustainability, preparing for certification and accreditation, specialty courses such as OB crisis and more. We hope to increase our number of subscribers, and creating videos for subscribers to view simulations as an educational tool. medsim About the Author KT Waxman, DNP, MBA, RN, CNL, CENP, is a nurse leader with over 30 years of experience in health care and corporate settings. She is a tenure-earning Assistant Professor at the University of San Francisco School of Nursing and Health

Professions and Chair of the Doctor of Nursing Practice (DNP) Department. She is co-director of USF’s Masters of Healthcare Simulation program, launching in Summer, 2014. As the Director of the Department of Defense grant funded simulation research study, she completed the study on medication error recognition and simulation modalities. The research paper is in press. Dr. Waxman is also Director of the California Simulation Alliance (CSA) at the California Institute for Nursing & Health Care. An internationally known speaker and author, She is past president of the Association of California Nurse Leaders and currently serves as Treasurer of the American Organization of Nurse Executives, a 9,000-member association. She served as Co-chair of the International Meeting on Simulation in Healthcare for the Society for Simulation in Healthcare in 2012. Dr. Waxman’s work has been published extensively and can be found in journals such as; Simulation in Healthcare, Clinical Simulation for Nursing, Journal of Nursing Education, Nurse Leader and Creative Nursing, and is a chapter author for three simulation textbooks. She also authored the book “A Practical Guide to Finance and Budgeting: Skills for Nurse Managers”, now in its second edition. Her second book “Financial and Business Management for the Doctor of Nursing Practice” was released in November 2012. Waxman received her DNP from the University of San Francisco, with an emphasis on health systems leadership and a concentration in clinical simulation. She holds national certification as a Clinical Nurse Leader and as a Nurse Executive. REFERENCES 1 Waxman, KT, Nichols, A., O’Leary- Kelley, C., & Miller, M. (2011). The Evolution of a Statewide Alliance: The Bay Area Simulation Collabora- tive. Journal for the Society for Simu- lation in Healthcare. 2 Waxman, KT, & Telles, C. (2009, November). The use of Benner’s framework in high-fidelity simulation faculty development: The Bay Area Simulation Collaborative model. Clini- cal Simulation in Nursing, vol (5).

Trauma is the leading cause of death in people under the age of 45 . *

Control the Bleed Exposure to trauma simulation can help facilitate team training exercises, especially those including a need to perform rapid assessments and hemorrhage control interventions. Does your training program include simulation?

Visit us to learn more about how simulation-based education can support emergency medical training. * Centers for Disease Control and Prevention. (Aug. 29, 2012) Web-based injury statistics query and reporting system (WISQARS). In U.S. Department of Health and Human Services, CDC, National Center for Injury Prevention and Control. Retrieved from on September 23, 2013.

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Virtual Patient Simulation Supports Clinical Reasoning Skill Building at the University of Pittsburgh James B. McGee, MD provides insights on how the community is developing a new generation of educators skilled at using virtual patient simulation.

A prototypical virtual patient screen containing textual clinical and narrative data, multimedia, scores and status indicators, and learner decision options. All Images: James B. McGee, MD.



magine that you are a medical student on your first day of your first clinical rotation. After an overloaded 10 hours in the pediatric intensive care unit (PICU) you return home to find three virtual patient simulations assigned to you. They have medical conditions similar to your three new patients in the ICU. With your tablet device propped up on your lap, a virtual chief resident reviews the key clinical features with you and challenges you to continue the history taking and examination and even order the initial laboratory tests. She gives you some feedback and guidance, and suggests a couple of video tutorials along with additional short practice cases. Fast forward 10 years‌ As a successful pediatric intensive care physician you now possess both experience and expert clinical reasoning skills. The pediatrics professional society just sent you an invitation to three virtual patient cases that will help you meet your maintenance of certification requirements. You quickly solve the diagnostic and therapeutic challenges with apparently good patient outcomes. However, new guidelines that streamline the diagnostic evaluation were not followed and resulted in a higher cost of care. After a brief review and a few more practice cases you demonstrate competency and maintain your board certification.


Virtual Patient Simulation The preceding examples demonstrate the range of application of virtual patient (VP) simulation-based education and assessment. Simulation in general is now a well-accepted and essential component of healthcare education, from basic skill building to clinical decision-making and assessment.1 Mannequins and part task trainers are commonly used for psychomotor and team skills and standardized patient (actors) are used to improve communication and physical exam skills. Less common but just as valuable, virtual patient simulators, ones that take place primarily on a computer screen or mobile device, are used to build cognitive skills like clinical reasoning and decision-making.2 Virtual patients take many forms and styles but tend to have in common a

clinical scenario that requires the learner to interact with the on-screen patient or patients to collect clinical data like history, physical exam, laboratory and imaging studies; establish a diagnosis; and select proper therapy and manage complications over time – all based on the learning objectives determined by the educator who created the case.3 They simulate a patient encounter using physiologic models or by branching down different clinical paths based on learner input. The on-screen VP responds clinically while the student receives contextual expert feedback at the key decision points. The University of Pittsburgh School of Medicine, (UPSOM) has a long history of employing computer-based clinical scenarios to train medical students and physicians and more recently, pharmacists, dental students and allied healthcare students. Beginning in the 1990s the school employed programmers to develop custom software for dedicated networked student workstations. In 2010 advances in hardware, software, and cloud computing enabled UPSOM’s Laboratory

for Educational Technology to create “vpSim.” This completely web-based virtual patient simulation and authoring environment is easy enough for teaching faculty to use, without the need for programmers or other technical support staff. Institutions worldwide now use this program (DecisionSim, Chadds Ford, Pennsylvania) to develop and deploy hundreds of simulations for all types of healthcare providers.

Virtual patients and clinical reasoning Research and experience with VPs suggest that this approach is ideal for teaching the essential skills of clinical decision-making and reasoning.2 This type of simulation, when properly designed, requires high-level cognitive processing skills like application, analysis, synthesis and evaluation. The learner must make decisions to progress through a case, often processing and prioritizing multiple and sometimes conflicting pieces of clinical data. Importantly, the learner receives contextual and immediate feedback as

the simulated patient either improves or worsens, often supplemented by a virtual tutor’s critique. The clinical reasoning research of both Eva and Croskerry highlights how novices and experts approach decisionmaking using either analytical or deductive reasoning.4 Novices tend to proceed step-by-step, with careful analysis of all possibilities,5 while obtaining a large data set of diagnostic tests. Experts, however, rely most often on inductive problem solving through pattern-recognition based on years of experience and comparison with similar cases or “illness scripts” stored in their brain. When challenged with the unfamiliar, an expert will flip back and forth between analytical and deductive reasoning. Virtual patient simulations, when carefully constructed, can provide challenges to novices and experts while adding to the learner’s library of illness scripts. They provide a structured environment to practice clinical reasoning along with personalized feedback adapted to the learner’s level and performance in the simulation.



VIRTUAL PATIENT Practical and pedagogical features of virtual patient simulation Because VPs, once written, do not require personnel, space or physical equipment beyond an Internet-connected computer, they are the least costly means of providing practice through simulation. If needed, they can be blended with other simulation modalities like task trainers and mannequins. When serving large numbers of learners over a wide geographic area the scaling costs of VP simulation make it an attractive option for improving clinical decision-making skills. The Veterans Health Administration, the largest healthcare system in the world, is doing just that with their nation-wide virtual patient educational programs. Simulation can mimic both common diseases that a healthcare provider should become proficient in and the uncommon conditions that a provider needs to recognize and manage expertly despite limited exposure. The breadth of conditions and decision-making scenarios possible with VPs is wider than any other type of medical simulation but obviously lacks the psychomotor and communication training capabilities that physical simulators and standardized patients possess. Pedagogically, VP simulation tends to be more flexible than other simulation tools based on the educational design employed by the case author. An author who understands his or her students can build decision-making challenges for both novices and experts by varying the complexity of the clinical decisions and the amount of distractors and confounding elements. For example, introducing contradictory data may not be appropriate for novices but can force the expert to carefully weigh clinical decisions and obtain more sophisticated testing. Adding in features such as cost tracking and limiting the time allowed to make decisions assesses and trains even high-level experts. Feedback provided during a virtual patient simulation can vary in style and depth. It may be scripted to the learner’s level of training or change dynamically based on his or her performance during the simulation. Learning research tells us that when feedback is immediate, personal and contextual it is more effective.4 Alternatively, VP cases can be used in a small group setting with no imbedded tutor. Students must use their own self-directed learning skills to seek answers to the patient’s clinical problems with a facilitator providing in-person guidance. Since all activity occurs on a computer, a virtual patient system can easily track the learner’s clinical decisions and report performance metrics back to the educator, curriculum directors and the students themselves. Aggregate data can provide valuable insight into practice patterns and reveal areas for improvement.

Examples of virtual patient simulation at the University of Pittsburgh To illustrate some of the above concepts here are a few examples of how virtual patient simulation is used at the University of Pittsburgh health sciences schools. Supplement basic science courses with clinical cases Supplemental and core curricular cases are a part of the medical school’s basic science curriculum and intended for selfstudy outside the classroom. The case is usually a stereotypi12


cal clinical scenario in order to begin to build a novices early illness scripts with common signs, symptoms and diagnostic evaluations. These situate the acquisition of knowledge and basic science with real patient stories to enhance learning, retention and recall. Fill gaps in the curriculum In order to ensure a balanced exposure to common diseases and conditions every medical school in North America is expected to track, quantify and report the type of patients encountered by its students. Janet Tworek and her colleagues outlined how virtual patients can help meet these expectations, especially when employing adaptive feedback and giving cases an authentic setting and clinical responses.6 For example, some childhood infections, such as measles, diphtheria and chickenpox, vary in incidence throughout the year. An individual student may

Above A screenshot from a formative evaluation case used by pharmacology students that requires them to manage a critically ill patient in the intensive care unit. Performance metrics and expert feedback is provided as the student makes complex medical decisions. Top The "node map" displays a complex branching structure from a case with multiple clinical outcomes. Each endpoint at the bottom of the map represents a different clinical outcome, score and expert feedback to the learner.

not encounter these conditions on his or her clinical rotations so virtual patients are used to fill these gaps. Also, some institutions do not have enough of a particular specialist to train all students directly so we and others supplement live experiences with online simulations created by the local experts. Practice before and after live clinical encounters The deliberate practice model for developing expertise requires many exposures and repetitive practice but with variation and level-appropriate complexity. Unfortunately the clinical wards where health science students are exposed to real patients are not as controlled and predictable as the simulated world. Clerkship directors and clinical curriculum designers are now directing students to structured sets of simulated cases such as the CLIPP collection for pediatric training (MedU, Lebanon, New Hampshire) or adding their own virtual patient cases to daily rounds.









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Prepare for clinical rotations and board exams At our institution all medical students take a capstone course (Integrated Case Studies) to reinforce basic science concepts, prepare for board exams and transition to clinical bedside training. It consists of a series of cases written by local faculty and solved in groups of twelve students and a facilitator. These virtual patients connect the basic sciences to the clinical sciences and introduce students to clinical decision-making. Board exams are, by design, filled with clinically oriented challenges that require reasoning and higher cognitive skills to solve. Step 3 of the USMLE even includes 12 virtual patient simulations. Our use of structured VP simulations throughout the medical curriculum is intended to provide the practice necessary to develop these clinical reasoning skills. Formative self-evaluation and practice Neal Benedict at the School of Pharmacology uses virtual patients that he and his colleague Kristine Schonder wrote as a self-directed formative exercise to complement classroom instruction. Each case has many potential outcomes that reflect varying levels of expertise in management. Learners practice these cases over and over, trying to achieve the optimal outcome while receiving on-screen feedback and critique.7 Blending virtual patient simulation with other simulation experiences Dr. Fiona Craig teaches pathology to the medical students using virtual microscopy software where

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VIRTUAL PATIENT students zoom and pan an on-screen pathology slide. She wrote a series of virtual patient simulations that add clinical data like symptoms, physical findings and radiographs to the virtual slide experience. Students are challenged to make clinical decisions based not only on what they can see on the slide but by synthesizing and analyzing all available information. Continuing education of medical professionals The latest effort in continuing education at UPSOM is lead by Dr. Gary Tabas who directs a team of faculty who write complex VP simulations to supplement a leading medical journal. These cases parallel clinical topics in the journal and go further by assessing the clinician’s ability to apply his or her new knowledge and skills to patient management challenges.

Conclusions, challenges and future directions In this author’s analysis and observation, virtual patient simulation has become a critical component of the health science curricula at the University of Pittsburgh. It supports a wide variety of learners from first year medical students through advanced specialist training and continuing education. It is applied when developing clinical reasoning skills and exposing learners to clinical scenarios is needed. Online access, reproducibility and the tirelessness of this technology provide practical advantages especially when the learners are geographically distributed and access learning at different times. When properly designed, a

virtual patient experience can adapt to the learner based on his or her performance and self-directed needs. We blend VPs with traditional and other simulation modalities to take advantage of the teaching strengths of each technique while simultaneously building a combination of clinical skills that reflect real life encounters. While the simulation authoring software no longer requires technicians and programmers, creating high quality teaching experiences always takes time regardless of the delivery platform. Cognitive science research tells us that exposure to numerous cases with epidemiologically accurate variation and of increasing complexity accelerates the progression from novice to expert. However, demand for expert clinicians’ time makes case writing and editing challenging. In addition, the instructional design skills and experience required to effectively use adaptive learning models, physiology models and branched clinical narratives is an emerging skill set in educators. Furthermore, cases need to be periodically updated, creating even more demand for clinical experts. These challenges accompany any new educational tool but the effectiveness and logistic advantages of virtual patient simulation are compelling. Other than bedside teaching by an expert clinical educator, there are few other ways to teach clinical reasoning. Now that we have the means to create and widely distribute simulation-based learning it is imperative that we use them. At the University of Pittsburgh and at institutions worldwide we are developing a new generation of educators skilled at using virtual patient simulation for a cohort of

learners who require and seek out effective learning experiences. medsim About the Author James B. McGee, MD is the Assistant Dean for Medical Education Technology at the University of Pittsburgh School of Medicine and an Associate Professor of Medicine in the Division of Gastroenterology, Hepatology and Nutrition. He directs the Laboratory for Educational Technology, which has discovered and developed a wide variety of novel e-learning applications. The most significant innovation from his lab is “vpSim,” a web-based virtual patient authoring system that is now used throughout the world by health professional schools, professional societies, and major healthcare networks. In addition to his academic appointments, Dr. McGee is the Co-Chair of the Virtual Patient Working Group at MedBiquitous (a medical education standards developing organization) and Chair of the Scientific Advisory Board at Decision Simulation. Dr. McGee received his undergraduate and medical degrees from Louisiana State University. He was an intern, resident, chief resident and faculty member at the University of Florida Health Science Center in Jacksonville Florida before pursuing advanced endoscopy training at Beth Israel in Boston and then joined the Harvard faculty. In 1996 he led Harvard’s Institute for Education and Research that created one of the first virtual patient applications. He can be reached at the Laboratory for Educational Technology (+1 412-6488993) or by email at Disclosure: Dr. McGee is an equity holder in Decision Simulation LLC, a commercial provider of virtual patient software.

REFERENCES Motola I, Devine LA, Chung HS, Sullivan JE, Issenberg SB. Simulation in healthcare education: A best evidence practical guide. AMEE Guide No. 82. Med Teach. 2013;35:e1511-e1530. 2 Cook, D.A. and M.M. Triola, Virtual patients: a critical literature review and proposed next steps. Med Educ. 2009;43(4):303-11. 3 Huang, G., R. Reynolds, and C. Candler. Virtual patient simulation at US and Canadian medical schools. Acad Med.. 2007;82(5):446-51. 4 Eva KW. What every teacher needs to know about clinical reasoning. Med Educ. 2004;39:98–106. 5 Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ Theory Pract. 2009;14(Suppl 1):27–35. 6 Tworek, Janet MSc; Coderre, Sylvain MD, MSc; Wright, Bruce MD; McLaughlin, Kevin MB, PhD. Virtual patients: ED-2 band- aid or valuable asset in the learning portfolio? Acad Med. 2010;85:155-158. 7 Benedict N, Schonder K, McGee J. Promotion of self-directed learning using virtual patient cases. Am J Pharm Educ. 2013;77(7):151. 1



Improving Education and Training to Enhance Safety, Efficiency, Capacity and Performance A multidisciplinary conference and tradeshow for the healthcare sector. August 22-24 2014 Rosen Shingle Creek Resort, Orlando, Florida, USA

Call for Papers Announced We welcome proposed presentations for the HEATT 2014 conference program. Your proposal may cover any of a wide range of topics such as training needs analysis, funding sources, curriculum design, Evidence Based Training or cost/benefit analysis A full list of suggested topic areas is shown at Please provide a synopsis of your proposed presentation up to 150 words to with a short biography by April 15. If your proposal is accepted you will be notified in May. Please send questions about the Call for Papers to

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Team Training

Interprofessional Crisis Resource Team Training in an Ambulatory Surgical Setting: Growing a Culture of Safety Suzanne M. Wright, PhD and Michael D. Fallacaro, DNS describe one effort to prepare surgical teams for managing an unexpected crisis and enhance patient safety. Above AOC team members responding to a simulated crisis within their own operating room. Opposite Project Director Suzanne M. Wright, PhD, in the simulation control room. All Images: Virginia Commonwealth University.


ith the advent of new technology, therapeutics and management techniques, anesthesia and surgery are safer today than perhaps at any point in history. Most patients enjoy favorable post-operative outcomes and are able to resume their personal and professional lives shortly after surgery. Evidence exists however, that despite the multitude of success stories, patients can still experience unexpected and unintentional harm when they come to the hospital for surgery.1 A low incidence of unfavorable outcomes can lead providers into a sense of false security and complacency. While anesthetic and surgical complications rarely occur, they can prove catastrophic. The challenge of preparing surgical teams for managing an unexpected crisis can be a daunting one. The rare occurrence of such untoward events offers limited opportunities to learn to manage these situations effectively. Crisis resource team training employing state-of-the-art high fidelity simulation technology has been shown effective in improving human performance in times of crisis.2

Background Beginning in 2013, faculty from the Center for Research in Human Simulation in the Department of Nurse Anesthesia at Virginia Commonwealth University (VCU) established a partnership with three distinct but related organizations to conduct a first of its kind crisis resource team training program in the central 16

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Virginia region. The “Growing a Culture of Safety” project was conducted over a 12 month period and comprised two half-day, hands-on workshops. The partnering groups consisted of Advanced Orthopaedics, Total Anesthesia, and The Doctors Company. The priority of the Department of Nurse Anesthesia at VCU is the education and training of Certified Registered Nurse Anesthetists (CRNAs) offering both masters and doctoral degrees in this specialty. The department’s research mission is to improve patient safety through clinical inquiry, innovations in education, the study of adverse events, and performance improvement. Advanced Orthopaedics is a physician-owned, orthopaedic surgery practice located in Richmond, Virginia. Their practice includes “Centers of Excellence” for hand surgery, foot and ankle, joint replacement, sports medicine, spine surgery, pain management, shoulder and cartilage restoration, and physical ther-

apy. The Advanced Orthopaedics Center (AOC) is home to three operating suites along with a dedicated special procedures room and served as the setting for this community project. Total Anesthesia is an anesthesiologist owned group of 21 physicians and over 40 CRNAs providing anesthesia services in the anesthesia care team model to three Richmond area hospitals and several surgery centers including the AOC. Total Anesthesia administers anesthesia services to over 25,000 patients each year. The Doctors Company is a medical malpractice insurance company headquartered in Napa, California and is among the largest physician-owned medical malpractice insurers in the United States with over 74,000 insured nationwide. This company provides malpractice coverage for practitioners at the AOC.

Purpose The purpose of this program was to explore the feasibility of a communitybased, team training program designed


to promote effective and reliable performance among surgical and anesthesia team members under high levels of workload and stress. The project incorporated lecture, observation, hands-on high-fidelity simulation training, and debriefing aimed at conveying knowledge of the impact of a stressful environment, emphasizing teamwork development, and building confidence in the ability to perform under high stress and critical circumstances.

The project was designed to explore the feasibility of bringing a simulation-based program out into a community-based operating room environment, where otherwise, VCU faculty engage in training in their state of the art Center for Research in Human Simulation. One proposed advantage of taking the program out into the community included improved access to training; often trainees are reluctant to travel into the city given issues related to parking, traffic, highway travel, and the complexity of the landscape. Another advantage of taking the program out into the community included enhanced fidelity of the operating room environment. While the Center for Research in Human Simulation is well-equipped with current operating room equipment and supplies, it could not possibly reach the level of fidelity of the true operating room environment in which trainees work every day. Anticipated challenges of bringing a simulation-based team training session out into the community included scenario design issues. For example, at the

Introducing the first robotic surgery simulator designed to help the first assistant and console side surgeon develop better teamwork.

Mimic Technologies Inc. / (800) 918-1670 /

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Team Training

Another scenario design issue included the absence of high fidelity simulated surgical experiences for the surgeons. To address this shortcoming, faculty were careful to design scenarios where the crisis occurred either after induction of anesthesia but before surgical incision or after the surgical incision had been closed but before emergence from anesthesia. The plant played an important role here. In case of a delay in the recognition of the critical event, the plant could distract the surgeon to keep him from making an incision or from leaving the room, respectively.

The Environment

Group photo of the interprofessional team of learners at the AOC, Richmond, Virginia.

Center for Research in Human Simulation, faculty usually train anesthesia providers rather than whole teams. When training anesthesia providers, faculty use simulated surgeons and circulating nurses as plants to keep the scenarios running along and to direct the learner down a predetermined path. New challenges arise when training entire teams where real surgeons and real circulating nurses are among the trainees. In essence, the scenario can unfold in unexpected ways which could be detrimental to training objectives. To overcome this obstacle and to retain control over the educational experience, we used an orthopaedic supply salesperson as the plant. The plant wore the earpiece of a two-way radio system and could follow the instructions of the scenario driver to keep the educational objectives within reach.

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The physical space for training at the AOC included two standard operating rooms which sandwiched a small (100-sq ft) control room. Training occurred in one fully functional operating room and the other operating room was set up for observation with 40 chairs, a projection screen and projector, a duplicate patient monitor, and a podium with a laptop. The lectures were delivered in the observation room and during the training session observing participants could see and hear the training session in real time while viewing the duplicate patient monitor which may otherwise be difficult to see on the projection screen. The audio-visual equipment also allowed for video playback of the training session during debriefing.


Visit Visit learnmore. more. OrOremail emailaccreditation

Recognizes Recognizessimulation simulationprograms programswith witha aminimum minimum ofoftwo twoyears yearsexperience experiencethat thathave havedemonstrated demonstrated adherence adherencetotoseven sevencore corestandards standardsand and compliance complianceininone oneorormore morefocused focusedareas. areas.

The Curriculum The curriculum was designed to incorporate Salas’s eight essential guidelines of simulation-based team training.3 Guideline 1, Understand the Training Needs: Prior to conducting the project, four meetings with all stakeholders were held to assess individual and group needs. A summary document was produced capturing these needs. Based on this work, the VCU team set out to design the program to highlight the essential characteristics of well-coordinated teams to include: - the ability to adapt to a changing environment; - open and flexible communication and - awareness and understanding of other team members’ work- load and performance. Guideline 2, Instructional Features, such as Performance Measures and Feedback: The VCU team established four simulation-based training scenarios each containing “trigger” events to elicit specific behaviors from learners to best meet the defined training needs. These were: - Malignant Hyperthermia Crisis; - Fire in the Operating Suite; - Intraoperative MI and - Anaphylaxis Employing a Laerdal™ SimMan full body human patient simulator and high definition Tandberg™ video recording technology, learner performances were captured for systematic observation. In total, over 40 participants including surgeons, anesthesiologists, CRNAs, registered nurses, scrub and surgical technicians as well as AOC administrators and Doctors Company representatives took part in this training. Surgical teams were assigned to cases per normal AOC operating procedures and were unaware of the critical events ahead of time. Guideline 3, Craft Scenarios Based on Guidance from Learning Outcomes: Learner outcomes were first established and scenarios were designed to illicit and systematically capture these embedded targeted behaviors. Upon completion of the program,

it was anticipated that learners would be able to: 1) identify when a situation becomes critical; 2) understand the negative impact of stress on performance; 3) communicate more effectively under high stress conditions; and 4) work more effectively as part of a team managing a critical event. The simulation scenarios were developed keeping content-validity in mind and as such were built around surgical procedures commonly performed at the AOC. Guideline 4, Create Opportunities for Assessing and Diagnosing Individual and/or Team Performance Within the Simulation: The Growing a Culture of Safety project was designed to focus on assessing team performance and efforts were made by faculty to minimize, if not completely eliminate, diagnosing individual performance. This was done purposely to encourage participation and to avoid public scrutiny of any individual(s). Immediately following these intense scenarios, sensitive debriefings were conducted by faculty employing time stamped audiovideo playback features designed within the Laerdal simulator software package. Observers not participating in actual handson portion of the training were asked to complete an observer worksheet (while watching the live training session) which highlighted characteristics of effective teamwork, and engaged by faculty during the debriefing to share their thoughts and real world experiences related to the simulated events. Guideline 5, Guide the Learning: Educational objectives laid the foundation for scenario development and three highly experienced nurse anesthesia educators were involved to guide learning in an effort to encourage positive team performance. Otherwise, simulation has the potential to destroy confidence and divide teams into dysfunctional units. Prior to engaging learners in scenarios, faculty presented lecture content on effective teamwork and communication, the impact of stress on performance and current threats to patient safety. This content was later reinforced again during the postscenario debriefings. Guideline 6, Focus on Cognitive / Psychological Simulation

SSH PROVISIONAL ACCREDITATION Provisional Accreditation allows programs that are new or do not yet have 2 years of outcome data to apply for an initial level of accreditation.

Team Training Fidelity: Research has suggested that if psychological fidelity is high, even if environmental fidelity is less than perfect, effective learning will still take place.4 While the VCU team made significant efforts to have the highest physical fidelity of the environment represented in their simulations, current limits in technology prevent an exact replication of the real world. That said, the team worked diligently to sustain a high level of cognitive validity by drawing on real world examples and soliciting actual learner like experiences when designing and debriefing the training scenarios. Guideline 7, Form a Mutual Partnership Between Subject Matter Experts and Learning Experts: The interprofessional team engaged in this project consisted of physicians, nurses, allied health professionals, educators, administrators and policy makers. This community of colleagues established this program with one prime purpose; to promote a culture of patient safety through thoughtful and effective collaboration. Guideline 8, Ensure that the Training Program Worked: Program objectives were measured by participant self-assessment on an 8-question program evaluation tool scored using a 5 point Likert scale. Questions included whether the program met the stated objectives: improved participant understanding of teamwork, effective communications, and resource management and improved understanding of the negative impact of stress on performance. Project faculty are pleased to report, taken in aggregate, 97% (n=68) of participants answered all questions with a 5, “Strongly Agree,” response. Only 3% (n=2) of respondents rated questions below a 5 and none rated any question

below a score of 4, “Agree.” In addition to scoring the evaluation, many positive comments were received giving faculty insight to planning future CRM training programs for the AOC.

Conclusion Simulation provides an opportunity to teach material that cannot be taught as effectively in any other conventional manner. Individual task performance can be enhanced through simulation training. But does team training translate into improved “real world” individual or team performance in crises? While it may be possible to improve teamwork in a simulated environment, the gold standard for proving the benefit of team training is through an assessment of whether projects such as the one described in this article improve actual patient outcomes. To make such an assessment is extremely difficult if not impossible because of the large number of confounding variables (e.g., surgical techniques, individual patient and provider characteristics, surgical complications) and the fact that such serious crisis events as those presented in this program are extremely rare. Some of those investigating simulatorbased training do not believe that such a study of patient outcome is logistically feasible .5 However, determining the impact of crisis resource team training on the intermediate variables of performance and ability is feasible in principle and worth the time and energy to pursue them just the same. Developing such complex behaviors such as those required to work effectively in teams requires more than a one or two time simulation training exercise. These behaviors grow over time by continued practice and reinforcement. Additionally, individuals must be immersed in

a workplace whose organizational leadership embraces a true teamwork mentality for any positive effect on outcomes to be realized. As a result of this project, the AOC has now established a daily Emergency Response Team whereby individual staff members are assigned each day to specific roles and responsibilities should a crisis occur. Also, the AOC has revised its policies with regards to the management of malignant hyperthermia and fire in the operating room. Similarly, staff at the AOC are in the process of designing a separate Anaphylaxis Response Kit containing the necessary medications to treat this rare condition. Faculty at VCU believe that the true value of crisis resource team training as it translates to clinical performance lies in the learner’s lived experience. The “Growing a Culture of Safety” project model provides an opportunity for interprofessional team training with high physical and psychological fidelity that promotes and supports a positive culture of patient safety. medsim About the Authors Suzanne M. Wright, CRNA, PhD., is Associate Professor and Vice Chair for Academic Affairs, Department of Nurse Anesthesia at Virginia Commonwealth University. She serves as Director of the Department’s Center for Research in Human Simulation; she focuses research on human factors influence on performance in clinical settings. Michael D. Fallacaro, CRNA, DNS, is Professor and Chair of the Department of Nurse Anesthesia, School of Allied Health Professions at Virginia Commonwealth University. Dr. Fallacaro founded the Department’s “Center for Research in Human Simulation”.

REFERENCES Research Council. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press, 2001. 2 Salas, E., & Cannon-Bowers, J. Decision-making under stress: Implications for individual and team training. American Psycho- logical Association, 2000. 3 Salas, E., Wilson, KA, Burke, CS, and Priest HA.: Using simulation-based training to improve patient safety: what does it take? Joint Commission Journal on Quality and Patient Safety, 31(7):363-71, July 2005. 4 Bowers, CA., Jentsh, F.: Use of commercial, off the shelf simulations for team research. In: Salas E. (ed.): Advances in Human Performance, Vol. 1. Amsterdam: Elsevier Science, 2001, pp. 293-317. 5 Gaba, DM., Howard, SK., Fish, KJ., Smith, BE., Sowb, YA.: Simulation-based training in anesthesia crisis resource management (ACRM): A decade of experience. Simulation and Gaming, 32(2):175-93, June 2001. 1 National


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Technology The main goal of BioGears is to lower the barrier to create medical training content. Image Credit: ARA.

The BioGears engine will be “lightweight” from a computational perspective as BioGears will not require an inordinate amount of central processing unit cycles to operate. The engine and the Common Data Model will be open source and will permit the end user to improve on individual systems or features. “Our software design promotes interoperability, ease of use and the Common Data Model standardizes inputs and outputs of the physiology engine,” Heneghan stated.


Game Changer Group Editor Marty Kauchak provides insights on the development of the BioGears open-source physiology engine


n January Applied Research Associates, Inc. (ARA) announced they were awarded a multiyear, $7 million assistance agreement by the US Army Medical Research and Materiel Command (USAMRMC) in Fort Detrick, Maryland under Contract Number: W81XWH-13-2-0068. A biomedical research team at ARA is developing BioGears™, an opensource physiology engine to support a USAMRMC technology thrust. The physiology engine will allow for distributed collaboration and consistent simulation across and beyond the medical training community. The US Army’s Telemedicine & Advanced Technology Research Center (TATRC) is administering the BioGears program. Jerry Heneghan, the director of HumanSim Product Development and the BioGears principal investigator at ARA, told MEdSim during the 2014 IMSH conference, BioGears is not being developed exclusively for biomedical engineers, but rather for “any folks who want to create content.” Indeed, BioGears is being developed to permit easy integration with immersive medical education software built on popular game engines such as

the award winning Unreal® Engine technology and Unity® game engine. The community leader continued, “A main goal of BioGears is to lower the barrier to create medical training content. Our team is doing just that by providing an open source, accurate physiology engine and source code for all types of users to benefit from this project.” BioGears will push the edge of the technology envelope by providing a model human response to trauma and treatment. BioGears will include physiologically accurate models for multiple systems, including cardiovascular, respiratory, renal and endocrine Conceptually, the BioGears end user could include multiple types of users from a content developer interested in integrating BioGears into a serious game, to a human physiology researcher who is running simulations to understand human response to trauma and treatment. “I had a guy come up to me today saying he was from a medical device company and said he wanted a physiology engine to do testing…So this is really a game changer as there has never been an open source physiology engine where something like this would be feasible,” Heneghan pointed out.

In September 2014 prime contractor ARA will release a limited functionality “minibuild” of the software. “We are going to put the build out there for the community to begin exploring how to use BioGears for medical training and education. We hope that by the Beta Build Release conference in 2015, users will come and talk about their experiences integrating BioGears and we can take these experiences and use them to improve the following releases,” Heneghan said. Concurrent with the BioGears Engine Beta Build Release in the Fall of 2015, the BioGears team will host a Users’ Group Conference in the Raleigh/Durham, North Carolina area. The conference’s focus will address: how to use BioGears in your application; how the community can contribute to the ongoing body of knowledge and and demonstrate how BioGears is working in a medical training tool ARA is developing for the US Army. Prospective conference delegates wanting to participate, speak and exhibit may sign up for email updates at You will receive news when the team reaches important project milestones and when conference registration becomes available. Following the Fall 2015 Beta Build Release conference, the BioGears team will migrate to the maintenance phase. “So here we’ll do ‘bug fixing’, updates and make tweaks. And we’ll continue to engage and involve the community for about two and one-half years after that. That’s the project,” Heneghan concluded. Editor’s note Jerry Heneghan may be contacted at M E D S I M M A G A Z I NE 2 . 2 0 1 4



2014 IMSH The International Meeting on Simulation in Healthcare provided insights on the state-of-the-art in learning technologies for healthcare professionals. Editor in Chief Judith Riess and Group Editor Marty Kauchak attended the conference with Halldale Group Publisher and CEO Andy Smith and provide this report.


not too subtle sign that the healthcare simulation market may be poised for additional growth was our recognition of a number of colleagues from companies in the defense simulation and training (S&T) sector “walking the conference floor” and attending IMSH sessions. Their attendance at IMSH was an indicator that companies are increasing their assessment of this market for possible entry in the coming months. Publisher and CEO Andy Smith observed this is “A sure sign of the potential growth of the healthcare market, and above all its need for new and better training methods is resonating with suppliers.” We also took notice of an increase in overseas companies exhibiting at this edition of IMSH. A partial list of non-US-based companies includes Model-med International Pty Ltd. (Australia), Medaphor Ltd (UK) and iSimulate (Australia). During our discussion with other exhibitors on the conference floor we again noted the S&T industry’s response to the community’s requirement for more robust team training products. Mimic allowed the delegates to put the new Xperience™ Team Trainer through its paces in several scenarios. The robotic surgery simulator was designed to permit the first assistant to bolster his or her communications and other robotic OR skills, with the console-side surgeon outside the actual operating environment. Thad Taylor, the company’s director of Marketing and Communications, told MEdSim the new trainer is designed to



complement the company’s flagship dV-Trainer® simulator. “This is like a plug-and-play component – users connect the Xperience Team Trainer to the dV-Trainer and they’re ready to begin team training exercises. It’s that simple,” he explained. Mimic expects to field the Xperience Team Trainer this summer with 10 to 12 training scenarios. Basic skills exercises on the dV-Trainer have been modified to accommodate the first assistant, and will facilitate skill development for common procedural tasks such as tissue retraction and needle passing. The 2014 IMSH was the venue for Simbionix to debut its ANGIO Mentor Suite in the US market. The device is designed to provide endovascular team training for learners across all disciplines. Rob Kurtzner, a regional sales executive for the company, pointed out this new product permits the learning audience to practice with 18 different full procedure modules and rehearse cases in select simulations.

A matchboard exercise on Mimic's Xperience Team Trainer brings simulation training to the first assistant. Image Credit: Mimic Simulation.

Simbionix also unveiled its LAP Mentor III platform. The product offers a new ergonomic design and will be offered to the community in second quarter of this year. Industry is also looking to other opportunities to enhance their current generation of products. David Micklewright, the director of The Chamberlain Group, noted that in a broad sense, his colleagues are looking at the collection of data for simulation. The Great Barrington, Massachusettsbased executive explained this effort may include establishing timed metrics in an operation and other processes to allow the end user to “manage a consistent experience in improvement.” And while supporting individual learning and team training will remain a focus of the Chamberlain Group’s evolving product portfolio, Micklewright noted that at the end of the day, it is important to support the total simulated experience. “We offer many procedure-related products that advance this strategy.” Another new product release which caught our attention was CAE Healthcare’s CAE Fidelis™ Maternal Fetal Simulator. Based on widely accepted and validated models of maternal-fetal physiology, the childbirth simulator offers human-like vital signs and responses for practice of obstetrical emergencies and labor and delivery scenarios.

Leadership Insights Jeff Berkley, PhD, CEO, chairman and founder at Mimic, told MEdSim that one of his company’s areas of interest is establishing standards. RTN (Robotic Training Network) and FRS (Fundamentals of Robotic Surgery) are two evolving community standards that Mimic plans to work on. “We expect to start testing these protocols at the end of February, beginning at the 2014 CREOG and APGO Annual Meeting,” he said. Asked about MEdSim’s perception of the medical community lagging behind other high risk industries in embracing standards for simulation, Berkley responded that is “primarily due to a lack of understanding of how simulation works well in other sectors.” He continued, “A lot of surgeons believe they can

sit down and put in one hour on a simulator and they will have those skills needed to do the surgery. That’s not true and it’s not how even flight simulation works, where you put in 100s of hours to get qualified.” While providing an upbeat assessment that it will be “difficult to find anybody in the medical simulation community that does not believe there is a role for simulation in education,” Berkley also opined “I don’t believe people are ready for the commitment to really utilize it” given competing demands of 80-hour work weeks and other challenges. “But it is getting there,” he concluded. The community leader revealed that one technology thrust on his company’s horizon through the remainder of 2014 is developing augmented reality of advanced procedures. At the show we had the opportunity to talk with new companies in the simulation arena as well as those mentioned above. There is an uptick in the number of “Simulation Education” programs such as the one at the University of San Francisco. These groups offer Healthcare educators the opportunity to get a masters or higher in Simulation Ed or something closely related.

Program Insights The theme for this year’s conference was Making Connections, with the focus being to connect people, institutions and simulation enthusiasts from around the world to share ideas and experiences. The program was divided into 10 different tracks ranging from basic to advanced themes, making it easier to select topics based on interest. The tracks were: Faculty Development, Assessment, Research, IPE/Team Training, Patient Safety/Quality, Course & Curriculum Design & Implementation, Program Evaluation/Outcome Measures, Debriefing, Administration and Simulation Operations (Sim Ops). Dr. Ian Curran was the keynote speaker and he discussed looking at simulation through history and the legacy left by healthcare leaders of the past. He talked about striving to be experts and being competent and that competency

certainly did not mean expertise, not only in healthcare but all fields. Dr. Curran is Clinical Advisor to the national Director of Education & Quality at Health Education England. His role covers national policy and strategy development particularly in relation to human factors, innovation and educational reform. The Lou Oberndorf Lecture on Innovation in Healthcare Simulation was given by Gary Klein, PhD, who discussed Connecting Medical Simulations to Cognition. Dr. Klein is a Senior Scientist at MacroCognition LLC, He has developed several models of cognitive processes. The best known is the RecognitionPrimed Decision (RPD) model to describe how people actually make decisions in natural settings. In his presentation he discussed using simulation to enhance cognitive skills and knowledge. One of the presentations by Dr. Annette Rebel and others from the University of Kentucky described how they had developed an anesthesia Olympics, starting with basic skills and progressing to more difficult to give students a crash course in necessary skills. The students rotate through six stations, each station staffed by a faculty mentor. They give prizes, everyone is challenged and they have had great success. (Editor's note: a feature article in MEdSim 3, 2014) Another interesting session that we attended was a panel on planning, developing and staffing a simulation center. The speakers were from different medical schools and they discussed fee plans, center models, scheduling, optimum space utilization and faculty involvement. Paul Pribaz discussed the importance of bringing together the different factions that play a role in designing and implementing the center. The speakers from the University of Pittsburgh, University of Washington and University of Illinois discussed the importance of integrating groups and programs. At the University of Washington everyone is cross trained. It was a lively and interesting discussion and Q and A. The usual problem that we encounter with IMSH is there are always so many meetings that you want to attend and not enough time! medsim MEDSIM MAGAZINE 2.2014


Conference Report

MEdSim CAMLS FORUM Healthcare providers and industry leaders came together to address educational and training challenges.


EdSim Magazine and the University of South Florida’s Center for Advanced Medical Simulation and Learning (CAMLS) sponsored a two-day conference in February that focused on five critical challenges facing medical education and training: • Faculty development and retention; • Hospital organization; • Competency based training and practice; • Breaking down silos, and • Valid assessment tools for technical and non-technical skills. Program speakers and working groups addressed these challenges that participants identified through a survey prior to attending the conference. In welcoming the group to CAMLS, CEO Deborah Sutherland, PhD, described the design, purpose and structure of the simulation center and explained that it follows an Academic Entrepreneurial Model – meaning that while it receives funds to help run the center, it is set up like a sustainable business to help cover the remainder of its expenses. So in addition to serving all of the University of South Florida’s needs, CAMLS is prepared to make its facility and services available to specialty societies, hospitals and healthcare systems, medical device companies, insurance companies and many others. Andy Smith, Publisher and CEO of Halldale Group, which publishes MEdSim, talked about Halldale’s 20-year history and involvement in training through simulation, first with publications for the 24

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defense and aviation industries, and most recently for medicine with the launch of MEdSim three years ago. He explained how Halldale has been instrumental in identifying and addressing education and training challenges in the other industries, and established the MEdSim/ CAMLS meeting to help do the same for the medical industry. To help get the groups started in addressing the challenges, a series of speakers talked about their centers and thoughts on the future of healthcare education and training. John Schaefer, III, MD, (pictured) Director of HealthCare Simulation of South Carolina (HCSSC) described the process the group’s founders took in establishing this state-wide collaborative – and how and why it works. Stuart Hart, MD, the Director of CAMLS Technology and Innovation Center, talked about projects and initiatives the center is involved in – such as medical device validation studies. Jan Cannon-Bowers, PhD, Director of Research at CAMLS, explained how the facility uses an Evidence-Based Best Practice approach to its educational planning process and how and why it is a good model for CAMLS. Rajesh Aggarwal, MD, PhD, currently a gastrointestinal surgeon and instructor, University of Pennsylvania and soon-to-be the simulation director for McGill University’s medical school, talked about surgical education in resident programs, a Value-Based Model for surgical education and a new course design he is developing with colleagues. Howard Champion, MD, founder and CEO of SIMQUEST, discussed where

surgical education and training currently stands and where it needs to go. Roger, Smith, PhD, and Chief Technology Officer for Florida Hospital’s Nicholson Center, gave an overview of the goals of the Fundamentals of Robotic Surgery curriculum development, steps taken, including the development of a skills trainer for psychomotor testing and the inclusion of all surgical societies that wished to participate in the development of the basic curriculum, the skills trainer and the validation study to be conducted this year. In the afternoon of day one, attendees participated in self-selected working groups to address the five challenges. All of the groups had assigned leaders and were tasked with establishing goals and developing steps to accomplish those goals. The groups met again on day two, and each group gave a report on their accomplishments and next steps to the conference participants before the conference adjourned. All of the groups – and their members – committed to meet on an ongoing basis to help make strides in addressing the critical challenges. Each group will be able to add new members who provide a special capability that the group needs and they all will reconvene and make progress reports at the HEATT Conference in August in Orlando. On the second day, three more speakers discussed their thoughts and experiences in the issues facing simulation in healthcare education and medical training. John Armstrong, MD, Florida’s Surgeon General, talked about the economic and healthcare capabilities Florida offers and said that simulation is the bridge between undergraduate, graduate and continuing education. Richard Satava, MD, Professor Emeritus of Surgery at the University of Washington, reviewed the five challenges and paths to overcoming them, and gave a brief look at the future of medical education and training. Jeff Berkley, CEO of MIMIC Technologies, Inc., talked about the challenges and opportunities of simulation in robotic surgery and how to achieve proficiency in surgical training. medsim Editor’s note The CAMLS conference took place right before this issue of MEdSim went to print. MEdSim Issue 3, 2014 will include an in-depth conference report.

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


New Products and Developments

Alberta Children’s Hospital Opens Pediatric Simulation Lab

Laerdal Medical & Wolters Kluwer Health Introduce vSim for Nursing

Alberta Children’s Hospital opened its KidSIM Centre, a facility the hospital says is Canada’s largest pediatric patient simulation lab. The centre provides simulated clinical pediatric experiences using computerized manikins that mimic clinical features such as breathing, pulses, blood pressure, speech and sounds. The lab’s facilities mimic real areas of the hospital such as the Emergency Department, the Intensive Care Units, operating rooms and out-patient clinics. The KidSIM Program is one of the broadest and busiest pediatric simulation programs in the world, according to its Medical Director, Dr. Vincent Grant, with more than 70 specially trained simula-

tion facilitators, 10 computer-generated manikins of varying ages and size, and five simulation labs. Traci Robinson, Program Coordinator for KidSIM, says there are very few areas of the hospital where simulation training is not used to enhance, supplement, or in some cases, replace traditional learning.

New Products and Developments


SIMETRI Developing Anatomical Arms Prototype for Training

UAE Gulf Medical University Officially Opens Learning Centres

SIMETRI, Inc., a manufacturer of medical training products, won a Phase I Small Business Innovation Research award to support the US Army Research Lab Simulation Training & Technology Center in developing the Humeral Head Intraosseous Part Task Training System. Intraosseous devices are used in the humeral head, also known as the shoulder socket, to administer fluid to patients at the point of injury. SIMETRI will develop a proof-of-concept training system that represents a realistic arm to teach students the correct anatomical landmarks for needle insertion, how to verify proper insertion, and how to insert the catheter to introduce fluids for an intraosseous insertion at the humeral head.

Gulf Medical University in Ajman in the United Arab Emirates (UAE) opened its new Centre for Advanced Simulation in Healthcare (CASH) and Centre for Advanced Biomedical Research and Innovation (CABRI). The two new facilities will help the university transition from a purely academic institution to that of a researchand innovation-based school, according to Professor Gita Ashok Raj, Provost of Gulf Medical University. CASH is a multidisciplinary educational facility that provides high-tech simulated and virtually created hospital set-up for teaching and training clinical and communication skills for all health care professionals.

Wolters Kluwer Health, a provider of information and point-of-care solutions for the healthcare industry, and Laerdal Medical, a provider of simulation solutions for healthcare, introduced vSim for Nursing™, an online learning solution they co-developed that simulates curriculum-driven patient scenarios. The product integrates Laerdal's virtual simulation technology with Wolters Kluwer Health's curriculum expertise and Lippincott course materials used by nursing educators. The product was unveiled at the International Meeting on Simulation in Healthcare 2014 conference. vSim for Nursing is accessed online and simulates a patient encounter using computer-animated avatars that let nursing students access and practice patient care anytime and anywhere. In the virtual simulation scenarios students are responsible for making a variety of clinical reasoning decisions; the simulator reacts to each patient-care decision and tracks and stores the actions so they can be reviewed and measured with personalized feedback. vSim for Nursing/Medical-Surgical is available for individual or institutional sales to nursing schools and additional vSim for Nursing products are in development for all core undergraduate nursing courses. It is sold as part of Lippincott CoursePoint, which includes integrated course content and adaptive quizzing, or as a standalone product. M EDSI M M A G A Z I N E 2 . 2 0 1 4


World News & Analysis Research and training


New Training Approach Saving Kids from Cardiac Arrest

Dubai Healthcare City Hosted First UAE Clinical Simulation Conference

Researchers at the Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford found a way to boost the survival of pediatric patients whose hearts stop while they are hospitalized. The researchers developed a broader approach to resuscitation training to include everyone who responds to a pediatric "code" event, the emergency call broadcast through the hospital when a patient's heart stops. Before the new training was implemented, about 40 percent of the hospital's code patients survived their cardiac arrest, a figure comparable to the national average for children's hospitals. After training, survival jumped to 60 percent. "The study used in-situ simulation to train our staff — we recreated scenarios from actual cases," said Deborah Franzon, MD, medical director of the hospital's pediatric intensive care unit, a clinical associate professor of pediatrics at Stanford and the senior author of a paper about the findings that appear online in Critical Care Medicine. "Kids did better because our team was better prepared and better trained." Past research studied only nurses' and resident physicians' participation in training to respond to codes, according to Lynda Knight, RN, MSN, the hospital's pediatric resuscitation program educator, and lead author of the paper – so she decided to broaden the training and assess any resulting differences. The new study involved the entire code team, from attending physicians to security guards, to give everyone the practice they needed to be expert in their roles. The research team staged mock codes in all areas of the hospital where the code team works. Staffers were paged as if there was a real code and did not know until they arrived that they were participating in a simulation. They resuscitated a medical mannequin whose condition could be programmed to improve or worsen depending on the effectiveness of their responses. The simulations occurred both in locations where real codes are more common – such as intensive care units – and those with few real codes, like the radiology 26

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department; and they were videotaped so all team members could review and discuss their responses afterwards. One key goal of the training package was for one person to quickly assume the role of the code team leader and for others to take on specific, pre-defined roles in the team's response. The roles were based on American Heart Association guidelines about best practices for resuscitation. For instance, one physician or nurse stood at the code cart, distributing equipment; a social worker comforted the patient's parents; security guards directed unnecessary foot traffic away from the area; and a nursing supervisor made sure all essential roles were filled quickly. The hospital's capacity expanded during the study, in part because of the opening of a new cardiovascular intensive care unit and a new cancer treatment center – but the hospital's survival rate for code events improved during the study – even with the influx of sicker patients using the new facilities. Not only did more patients survive, survivors had similar neurologic scores before and after the new training was implemented. The simulations provided risk-free opportunities to identify problems in hospital operations – for instance, during one simulation the code team leaders found their security badges did not give them access to the portion of the hospital where the simulation was staged. As a result of the new findings, Lucile Packard Children's Hospital Stanford made the new training program a permanent part of its resuscitation education – and the study's authors hope other hospitals will make similar changes based on the success of their technique.

Dubai Healthcare City hosted the first Clinical Simulation Conference in the United Arab Emirates February 26 27, 2014 to demonstrate simulation in patient safety. The conference delivered the message that no doctor or nurse should perform a clinical procedure for the first time on a real patient; instead, clinical training should be in a simulated environment, allowing healthcare professionals to learn in a setting where they can make mistakes on a machine – instead of on a real patient. The conference connected industry experts, academic institutions and healthcare professionals with the goal of advancing simulation in clinical training. Endorsed by SESAM – the Society in Europe for Simulation Applied to Medicine, healthcare professionals were able to try out simulation training first-hand during the conference. For more information visit Academic

Howard University Opens New Simulation Center Howard University opened a new $5 million virtual medical training facility equipped for computer-based simulation, task training simulation, virtual reality simulation, manikin-based simulation and improvised technology. The 6,000-square-foot simulated hospital environment is designed to help improve communication skills between healthcare workers and their patients. It will serve as an integral part of training for the university’s more than 800 health science students in more than 20 academic programs. The Health Sciences Simulation Center houses five high-tech human patient simulators, an operating room, an intensive care/emergency room and a task training/surgical skills suite. The Simulation Center complements the Clinical Skills Center, which lets medical, nursing, pharmacy and allied health students, residents train at Howard University Hospital and lets medical fellows practice treating patients in a controlled environment.

The Gathering Of Healthcare Simulation Technology Specialists Now an Officially Recognized Non-Profit 501(c)3 Educational Group

Since 2011, the SimGHOSTS organization has been specifically dedicated to empowering the growing international community of healthcare simulation technology specialists through: hands-on training events, online resources and professional development support. Join us in-person to receive affordable hands-on training from your technical peers & leading vendors in: • Manikin programming & hardware repair • A/V system design, integration and consolidation • IT networking & debugging • Trauma moulage makeup • Video production & editing • Team communication & leadership • Basic medical courses for technical staff • Career development & staff management • Much much more!

2014 Events Australia University of the Sunshine Coast Sippy Downs, Queensland Pre-Con: June 25th Con: June 26th-27th

USA American College of Chest Physicians Greater Chicago, Illinois Pre-Con: August 5th Con: August 6th-8th

Register Early for Discounted Rates!

Subscribe online today for downloadable courses and private global discussion groups 34

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World News & Analysis INTERNATIONAL

Covidien Opens Medical Training and Education Center in India Covidien, a healthcare products company, opened its first training and education center in India. The Covidien Center of Innovation India (CCI India) in Mumbai lets clinicians train on advanced procedures and techniques using leading equipment and technology. The center has the capacity to train more than 5,000 healthcare professionals annually from within India and from the surrounding region. CCI India will focus on raising awareness of various disease states and providing opportunities for clinicians to see how Covidien’s devices can help healthcare professionals treat these diseases. The top three priorities will be procedures to

address vascular disease, metabolic disorders (obesity and Type II diabetes) and cancer. Chronic diseases contribute to more than half of Indian deaths, according to Mark Rooney, Covidien’s India Subcontinent Managing Director. “Cardiovascular disease, dyslipidemia and many types of cancers are highly prevalent in urban and rural areas,” he said. “Many of these diseases, although common, are inadequately diagnosed and treated. At CCI India, we will focus on innovative procedures and disease management that address many of India’s most challenging disease states.”

CCI India has a surgical lab with seven fully-equipped operating stations, a simulation lab for clinical scenario training with a human patient simulator, a library stocked with the latest medical journals and four workstations and an auditorium with an optimized multimedia system to provide an immersive training environment. The CCI India is Covidien’s third training center in an emerging market, with other centers located in Shanghai, China, and Osong, South Korea. The company plans to open additional centers this year in Istanbul, Turkey and São Paulo, Brazil.


New Products and Developments

University of Toronto Getting 66 OtoSim Otoscopy Trainers

ECS and SIMETRI to Build Medical Training Simulation for US Army

The University of Toronto is creating a Student Training Fund in Otoscopy in partnership with OtoSim Inc., thanks to a $200,000 donation led by Ralph Chiodo, founder of Active Green + Ross. The donation allows OtoSim to provide 66 of its OtoSim™ otoscopy training units to the university. The devices will give undergraduate medical students access to better otoscopy training and can be networked to facilitate mass training exercises. Otoscopy is the diagnostic examination of the ear, and according to OtoSim, is one of the most poorly acquired medical skills in students, general practitioners and pediatricians, achieving only a 50 percent accuracy rate. “A clinical study demonstrated that with only a couple hours of group training, the accuracy of third-year medical students increased from 54 percent to 78 percent,” said Dr. Andrew Sinclair, OtoSim CEO and former senior director at MaRS Innovation.

Engineering & Computer Simulations (ECS) was selected to build the HapMed Needle Chest Decompression (NCD) training system for the US Army Research Laboratory, Human Research and Engineering Directorate, Simulation and Training Technology Center. ECS is teaming with SIMETRI, Inc. for this project. The HapMed NCD training system teaches the correct procedures to help prevent tension pneumothorax, which is the second leading cause of preventable death in a combat theater. Tension pneumothorax results from a chest wound where air is trapped inside the chest cavity and pressure builds on both the heart and lung. The system trains users to insert the needle into the cavity to allow trapped air to escape and relieve the pressure. The ECS team will deliver a realistic HapMed NCD training system that not only supports hands-on training, but enhances the decision-making skills to determine when the system will be most effective. The part-task trainer will provide cost-effect training to a geographically disperse group of combat medics.

New Products and Developments

SonoSim LiveScan Transforms Volunteers into Training Cases SonoSim, Inc., the developer of the SonoSim® Ultrasound Training Solution, says it has established a new standard in medical simulation with the release of SonoSim LiveScan™, which instantly transforms live volunteers and mannequins into ultrasound training cases with real pathologic conditions. Whereas ultrasound simulation has traditionally relied on inanimate mannequins that use computer animation, SonoSim's LiveScan lets users transform live volunteers and training mannequins into a wide range of ultrasound training cases with real pathologic conditions. When it’s combined with the SonoSim Ultrasound Training Solution, which integrates didactic content and knowledge assessment, SonoSim LiveScan makes anytimeanywhere bedside ultrasound simulation possible. 28

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New Products and Developments

Laerdal Introduces SimMan 3G Trauma Laerdal introduced SimMan® 3G. Trauma model adult simulator designed to train military and civilian emergency medical personnel in trauma situations. The company says the new trainer is well suited for any group focusing on trauma situations, especially the need to perform rapid assessment, interventions such as hemorrhage control, and airway management. With SimMan 3G Trauma, teams can train in the actual environment in which they work – such as in a hospital or ambulance or even in a military combat environment. The wireless, self-contained trainer comes with a rugged PC, giving users the flexibility to hold training when and where it is needed.


Mimic Previews Partial Nephrectomy Robotic Surgery Simulation Mimic Technologies released a preview of its new, augmented video simulation technology that will be available in May. The new procedure-specific simulation training module for partial nephrectomy was developed in collaboration with Inderbir S. Gill, MD (University of Southern California (USC)) Chairman and Professor of the Catherine and Joseph Aresty Department of Urology; Founding Executive Director of the Institute of Urology and Associate Dean for Clinical Innovation, Keck School of Medicine of USC); and Andrew J. Hung, MD (Clinical Fellow, Advanced Robotics and Laparoscopy, Keck School of Medicine of USC). The new training technique will help users advance their clinical decisionmaking skills while using virtual robotic instruments to interact with anatomical

regions within augmented 3-D surgical video footage of a case performed by Dr. Gill. Trainees will learn to identify anatomy, anticipate tissue retractions, predict regions for dissection and refine surgical skills such as suturing. The interactive module includes audio narration from Dr. Gill to bring the user through the steps of the procedure.

The partial nephrectomy procedure module is available from Mimic on the dV-Trainer, and is available for purchase for May 2014 delivery. To see the preview, go to http://pages.mimicsimulation. com/AR.html. The dV-Trainer MSim platform update marks the release of a full suite of simulation exercises developed in collaboration with the Robotic Training Network (RTN). The RTN simulation suite has five new skill drills and is available through an exclusive license to RTN members, only on the dV-Trainer. The RTN exercises are modeled after physical dry lab exercises used by RTN in an assessment program for its robotic surgical training curriculum. More information about simulation for RTN is available at

New Products and Developments



ECS to Build Orlando VA Medical Center’s Simulation Training Program

Hinds Community College Opens Nursing Sim Center

Dubai Healthcare City and Cambridge University Hospitals Partner on Peds Training Courses

Engineering & Computer Simulations (ECS) was selected by the US Department of Veterans Affairs, Orlando VA Medical Center (OVAMC) to build its Patient-Centered Care Hospital Simulation and Training Program. The Virtual OVAMC is conceived as a 3-D virtual hospital environment that can augment existing methods of interacting by allowing veterans, their families, and VA healthcare providers to meet online for a variety of activities – including guided tours; orientation to procedures; and informative content such as lectures, discussions and case studies. It will also offer new ways to collaboratively view, discuss and experiment with operational processes that will be used in the new facility.

Hinds Community College in Jackson, Mississippi opened its new Dr. George Ball Nursing Simulation Center. A $2.5 million federal grant helped renovate and equip the center’s building that was donated to the college by brothers and physicians Dr. Christopher Ball and Dr. Kyle Ball and named for their father who served on the HCC Foundation board and specialized in obstetrics and gynecology before his 1998 retirement. The new facility has four simulation labs that are equipped with manikins that simulate real patients. Three of the labs mimic hospital rooms and the other is set up like a real-life operating room. The center also has control rooms that allow for videotaping students performing clinical skills.

New Products and Developments

Mint Medical Introduces Knobology Training for Mindray M7 Mint Medical Education introduced ultrasound user knobology training for the Mindray M7 ultrasound system. The online training resource is designed for physicians, sonographers and other allied health professionals

that are getting started with the Mindray M7. The online training covers all the basics – from opening the box and setting up the machine, to measurements and reporting, to frequently asked questions.

Dubai Healthcare City (DHCC) and Cambridge University Hospitals (CUH) signed a Memorandum of Understanding (MoU) to provide pediatric emergency training courses to medical professionals in the United Arab Emirates. The pediatric emergency training courses are the first of a series of courses with Cambridge University Hospitals planned for 2014. As per the MoU, CUH academics will conduct two different pediatric courses at DHCC’s Khalaf Ahmad Al Habtoor Medical Simulation Center, located within the Mohammed Bin Rashid Academic Medical Center. The first course, Managing Emergencies in Pediatric Anesthesia, aims to give all anesthetic trainees the opportunity to develop management strategies for emergencies in pediatric anesthesia. The second course, MAnaGing Ill Children, covers more common pediatric and neonatal emergencies through the use of high-fidelity simulation. M EDSI M M A G A Z I N E 2 . 2 0 1 4


World News & Analysis New Products and Developments

Simbionix Releases New Arthroscopy and Coronary Modules Simbionix released two new training modules: the Shoulder Labral Module for its ARTHRO Mentor and the Transradial Coronary Intervention Module for the ANGIO Mentor. The Shoulder Labral Module is the company’s first complete procedure training module for arthroscopic shoulder surgery on the ARTHRO Mentor. It includes training for three complete shoulder arthroscopic procedures: SLAP (Superior Labral Tear from Anterior to Posterior), Bankart and posterior Bankart repairs. The module is geared toward advanced trainees who need a powerful didactic tool to practice shoulder instability procedures. In the module, students can practice the steps involved in various instability repair procedures including: • Diagnostic Arthroscopy. • Labral debridement. • Conservative debridement – Contour edges of torn Labrum.

• Debride Glenoid. • Decorticate Glenoid boney. • Drilling into bone. • Placement of suture anchors. • Suture-thread manipulation. • Passing suture thread through the Labrum. The Transradial Coronary Intervention Module for the ANGIO Mentor provides hands-on training for physicians learning how to perform diagnostic coronary angiography and coronary intervention using the transradial approach. It offers basic anatomy and anatomical variants that present difficulty during transradial coronary catheterization, such as tortuous subclavian, CABG and brachial loop. During the procedure, trainees may experience complications such as spasm and perforation and will be able to treat them using medications and common techniques.

New Products and Developments

CAE Healthcare Unveils CAE Fidelis Maternal Fetal Simulator CAE Healthcare introduced the CAE Fidelis™ Maternal Fetal Simulator at the International Meeting on Simulation in Healthcare 2014. The childbirth simulator offers human-like vital signs and responses for practice of obstetrical emergencies and labor and delivery scenarios based on widely accepted and validated models of maternal-fetal physiology. The CAE Fidelis Maternal Fetal Simulator is a medical robot with pupils that dilate or constrict, measurable vital signs, a blood reservoir to simulate postpartum hemorrhage and a birthing process that delivers a fetus through the birthing canal. The mother has palpable soft skin that simulates uterine contrac-

tions as well as leg and hip articulation to practice childbirth positioning and maneuvers. The fetal vital signs, which are integrated with the mother's, respond to labor and delivery treatments and maneuvers, and produce AGPAR scores at one minute and five minutes after birth. The simulator detects and

records birth positioning and treatments for post-simulation review. The simulator was developed by CAE Healthcare in partnership with leading maternal-fetal clinical educators in the United States and biomedical engineers at Instituto de Engenharia Biomédica (INEB) at the University of Porto in Portugal.

New Products and Developments

PETA, Simulab & Surgeons Partner to Bring $1Million in Simulators to Nine Countries People for the Ethical Treatment of Animals (PETA), medical simulation manufacturer Simulab and trauma surgeons in nine countries are collaborating to modernize medical training and save animals in Latin America, the Middle East and Asia. Limited budgets have prevented many international programs that teach the American College of Surgeons–sponsored Advanced Trauma Life Support (ATLS) course from establishing modern simulation laboratories, so ATLS trainees were training on animals. An agreement between PETA; Simulab; and surgeons in Bolivia, Costa Rica, 30

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Egypt, Iran, Jordan, Mexico, Mongolia, Panama, and Trinidad and Tobago is bringing 64 TraumaMan surgical simulators to these nations to train doctors, instead of using animals. TraumaMan replicates a breathing, bleeding human torso and has realistic layers of skin and tissue, ribs and internal organs. Through the formal agreement, PETA is donating the 64 TraumaMan systems and Simulab has extended ATLS programs in the nine nations a special discount on the replacement "skins," so training facilities will now spend less to use TraumaMan than they did to use animals. Also, because TraumaMan is

portable, these countries can now offer the courses more frequently and expand their ATLS programs into remote regions. Studies show doctors who learn lifesaving surgical skills on TraumaMan are more proficient than those who cut into animals, largely because TraumaMan actually mimics human anatomy and allows trainees to repeat procedures until they're confident and adept. PETA's donation of TraumaMan systems, also supported by PETA Germany and the McGrath Family Foundation of San Diego, is the group's single-largest contribution to promote the use of nonanimal scientific methods.

13th Annual Conference

PLENARY SPEAKERS Plan to attend this Conference and enjoy a blend of festivities and opportunities to network, share expertise; take part in workshops and courses. PRE-CONFERENCE & ANNUAL CONFERENCE: Immersion Courses: Saturday – all day (extra fee applies) Half Day Workshops: Sunday morning (extra fee applies) ASPE 13th Annual Conference: Sunday afternoon – Wednesday Watch the ASPE website ( for detailed information on the Conference to be posted soon. Register early and Save! Registration opens April 1, 2014. HOTEL RESERVATIONS: The Marriott Indianapolis Downtown is now taking reservations for the ASPE 13th Annual Conference. The ASPE discounted room rate is: $179/single/ double. Reservations can be made by calling Marriott Group Reservations at 877-3030104. Information about booking your room online can be found on the ASPE website. MEMBERSHIP: Not a member of ASPE? Join now and SAVE! Visit to complete an online membership application. You may then return to the conference site and register (when registration opens) at the discounted member rate – an immediate savings of $100!

REFLECTIONS ON SIMULATED (STANDARDIZED) PATIENT METHODOLOGY: A PILLAR OF THE HEALTHCARE SIMULATION COMMUNITY DEBRA NESTEL, PhD, CHSE, is Professor of Simulation Education in Healthcare, School of Rural Health, and HealthPEER, Faculty of Medicine, Nursing & Health Sciences, Monash University, Australia.

DEBRIEFING: CULTURE AND CONVERSATION WALTER EPPICH, MD, MEd, is a pediatric emergency medicine physician at the Ann & Robert H. Lurie Childrenʼs Hospital of Chicago and the Northwestern University Feinberg School of Medicine, Chicago, IL, where he is Director of Faculty Development for the Center for Education in Medicine and Assistant Professor of Pediatrics and Medical Education.

We look forward to seeing you in Indianapolis!

Visit to register!

World News & Analysis Academic


Keene State College Opens High-Tech Nursing Lab

Bermuda Gets First Simulation Lab Bermuda College’s Nursing Department opened a new simulation lab, a first for the College and Bermuda. The lab has a viewing classroom and clinical test bed that features patient manikins for clinical simulation. The manikins can be programmed to speak, exhibit symptoms, give birth and respond to healthcare interventions to provide ‘real life’ training for those in the College’s Nursing Education Programme and those in general health care on the island. The new simulation lab was developed in conjunction with the Bermuda

Hospitals Board, the Department of Corrections, the Ministry of Health and the Fire and Rescue Service to address the challenge of clinical space for healthcare education.

New Products and Developments

Cloud-Based Solution for Storing, Accessing and Sharing Medical Imaging The World Health Organization (WHO) says millions of medical images are wasted every year – which means higher costs and longer wait times for patients for diagnosis. WHO estimates more than 30% of medical images are lost every year and says for doctors, it saps vital resources and is a source of significant frustration. To stem this waste, a group of physicians actively involved in telemedicine and some technologists came up with the idea of myMedImage ( – and to make access to this DICOM (Digital Imaging and Communications in Medicine)-compliant PACS (Picture Archiving and Communication Systems) system free to patients and participating physicians. myMedImage is looking to raise over $200,000 via a crowdfunding campaign on IndieGogo They say myMedImage is a “game changer” – it directly links supported patients (no matter where they are in the world) to primary care and specialty physicians through its unique medical imaging sharing and consultative network. The model ensures the highest-quality, timely care for patients by maintaining the patient-physician contract. The myMedImage system allows diagnostic images to be seen in a full-featured, online, cloud-based medical image viewer using internally developed vendor-neutral uploading software and storage, accessible through virtually any internet-enabled device. It offers its service to individuals, physicians, caregivers, hospitals and governments – globally streamlining the entire medical imaging viewing process and preventing unnecessary, wasted and duplicate medical imaging.

Keene State College in New Hampshire opened a new nursing lab that has a realistic hospital and clinic setting and features high-fidelity manikins, intensive care rooms, medical-surgical areas, an exam area, a nurses’ station and audio visual equipment to record student simulations for review and evaluation. The lab has the potential for interdisciplinary education and to be able to offer an enhanced learning environment for any other health science programs that need the latest physical assessment equipment. The school expects to make the lab available to the community to help augment the knowledge and skills of providers, such as first responders, to medical emergencies. It is also exploring the potential to offer continuing education opportunities for other licensed health care practitioners. International

Equiniti 360 Clinical Appoints Dr. Virginia Clough Equiniti 360° Clinical in the UK appointed Dr. Virginia Clough as associate medical director. Clough will be responsible for supporting organizations and individuals with their revalidation. Clough was medical director and responsible officer at the Countess of Chester Foundation Trust until 2012, and is a Revalidation Support Team (RST) Level 2 appraisal trainer.


University of Cincinnati Opens Critical Care Simulation Center University of Cincinnati (UC) Health and the UC Department of Emergency Medicine opened its new 4,000-square-foot UC Health Simulation Center. The center houses 12 high-fidelity patient simulators that will be used to train both United States Air Force teams and UC Health physicians. UC Health will also use the facility to train physicians, residents, medical students, nurses and medical staff in critical care and transport medicine. The simulators can mimic the actions and conditions of critically injured patients and respond to treatment given by the training teams – and the 24 cameras in the facility’s control room let trainers view, record and evaluate live simulations and use the recordings for later training. The Simulation Center is an extension of the C-STARS sim32

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ulation center in the University of Cincinnati Medical Center. C-STARS (Center for Sustainment of Trauma and Readiness Skills) is a joint program between UC Medical Center and the US Air Force that offers trauma and critical care training for military medical personnel. The UC Health Simulation Center was made possible by a cooperative research and development agreement between the U.S. Air Force School of Aerospace Medicine and Air Force Expeditionary Medical Skills Institute and UC Health and the UC College of Medicine’s Department of Emergency Medicine. Future plans call for supervised training opportunities to be open to regional fire/EMS departments, UC Health employees and UC students enrolled in healthcare degree programs.


Siemens Signs Medical Education Agreement in Dubai Siemens signed an agreement with Dubai Healthcare City (DHCC) in the United Arab Emirates to collaborate on medical education and training. DHCC is a health and wellness company that offers healthcare

services, medical education and medical research. As part of the collaboration, Siemens will supply a mock-up of its Somatom Emotion CT scanner to DHCC’s Khalaf Ahmad

Al Habtoor Medical Simulation Center. The new Siemens equipment will be used to help familiarize healthcare teams with some of the latest imaging innovations being used in the region’s hospitals.


New Products and Developments

University of Hawaii at Manoa Simulates Drama in Nursing

Surgical Quality Alliance Recommendations for Public Reports on Surgical Care

The University of Hawaii at Manoa has a new program that’s bringing a new kind of education to nursing and theatre students. With HealthCAST, a partnership between the University’s Department of Nursing and Department of Theatre and Dance, theatre students play the roles of patients in simulations that let nursing students practice giving care in emotionally charged situations. The simulations take place in the nursing department’s Translational Health Science Simulation Center – where the theatre students add a critical dimension of realism, according to the nursing faculty. “There are certain simulations where you really need that human factor, the psych social, the death and dying or anxiety or stress,” explains Lorrie Wong, director of the simulation center. It’s helpful to the theatre students, too, because it gives them a chance to really work in depth on characters, says Paul Mitri, the theatre and dance department chair. Nursing students never know what kind of situation they will encounter, what kind of people they will deal with or how those people will respond to their care. To make the simulations as realistic as possible, each theatre student works with an expert from the nursing department to master every detail of the illness they are portraying. Academic

NorthShore University HealthSystem Adds Advanced Practice Provider Program NorthShore University HealthSystem’s Center for Simulation and Innovation (NCSI) received a large donation from the Jane R. Perlman Trust that is being used to establish an Advanced Practice Provider (APP) residency program to teach nurse practitioners and physician assistants how to further improve patient care and clinical outcomes, while reducing healthcare costs, through innovative medical scenario simulation. The 13,000-square-foot facility, NCSI, at NorthShore Evanston Hospital is multispecialty, multidisciplinary center that helps healthcare practitioners improve their clinical performance, reduce human errors, and refine their teamwork and communication skills using a variety of simulation modalities including human patient simulators, virtual reality and patient actors. In the APP residency program, simulation will be used extensively in training candidates to accelerate their learning curve, according to Ernest E. Wang, MD, Medical Director of NCSI, and the Alvin H. Baum Family Fund Chair of Simulation and Innovation. “Our hope is that the establishment of this program at NorthShore will lead to a paradigm shift in the way APP training is conducted around the country.”

The Surgical Quality Alliance (SQA) and the American College of Surgeons (ACS) released Surgery & Public Reporting: Recommendations for Issuing Public Reports on Surgical Care. This resource document is intended to provide organizations that publicly report on surgical quality measures with a better understanding of the considerations that must be made when reporting on these important aspects of surgical care. The document addresses issues surgical teams should take into account when defining specialty-specific reporting metrics – noting that surgical specialists, in consultation with their patients, are uniquely qualified to provide input on quality measurement and defining clinical excellence in surgery. The ACS says the report is an important component of its “Inspiring Quality” initiative launched in 2011 to drive awareness of its proven models of care that measure and improve quality and increase the value of health care services. While other recommendations are available regarding best practices in public reporting of quality measurement, this new document is the first report of its kind to be issued by surgical associations with a focus on public reporting of surgical care. "A guidance document of this magnitude can carry significant weight with health care organizations," said SQA chair Frank Opelka, MD, FACS. "We're issuing this report in an era when federal legislation now mandates that components of care be measured and publicly reported. Many organizations are just beginning to explore how to specifically report on surgical care. This document is designed to directly provide guidance on those organizational efforts, not just so that they comply with federal requirements, but so we can collectively ensure the information that patients want and need about their surgeons is available to them." The report also addresses the importance of coordinated teamwork in clinical care – saying this effort involves teambased surgical care that is safe, effective and efficient. The document stresses that public reports about the quality of care should not only follow individual surgeons, but also the reality of how care is delivered, and the teams of providers that deliver care. The document is available online at sqa/index.html . The SQA is a collaborative effort of more than 20 surgical and anesthesia specialty societies to define the principles of surgical quality measures, collaborate in the development of meaningful tools for quality improvement, and provide a forum and coordinated effort among the specialties to monitor and respond to public and private sector initiatives. M EDSI M M A G A Z I N E 2 . 2 0 1 4


World News & Analysis New Products and Developments

New Products and Developments

MammaCare Simulator Produces Smart Fingers

Simbionix Releases LAP Mentor III and ANGIO Mentor Suite


a company that works to provide breast examination proficiency for clinicians and women introduced a self-administered clinical breast examination technology. MammaCare says its news series of tactually accurate breast models improves and objectively confirms a practitioner’s ability to detect very small breast tumors while reducing false positives. They contain small, simulated breast cancers that are considered the standard for measuring breast examination proficiency. Supported by the National Science Foundation, MammaCare scientists found a way to link the models to an intelligent device that could accurately translate the examiner's subjective, tactual sensations into digital code. It is a sort of engineering breakthrough that digitally replicates and displays the sensations fingers experience while palpating breast tissue and detecting tumors. A laptop-controlled interface guides trainees palpating fingers through exercises on a series of breast models until they are able to find the tiny simulated tumors without falsely "detecting" non-existent ones. "Breast cancer screening depends on the quality of manual examinations and mammograms. Both must be performed skillfully. We finally have the method to reach and teach every hand that examines women," said Dr. Mary Mehn, MammaCare's Director of Education. Initial trials of the simulator at Mayo Clinic found significant gains in sensitivity (finding tumors that are present) and specificity (not finding tumors that are absent) – findings the MammaCare and Mayo Clinic teams presented at an international breast cancer congress in July. Dr. HS Pennypacker designed the training software that incrementally shapes each component of breast examination and detection skill required to meet proficiency standards. The pioneer in developing instructional technologies and co-founder of MammaCare, Pennypacker said, "If we can teach fingers to read Braille dots, we can surely teach fingers to find suspicious lesions in breast tissue." 34

Simbionix USA Corporation; a provider of medical simulation, training and education products; launched the LAP Mentor™ III and the PELVIC Mentor™ (highlighted in Issue 1 News) at IMSH 2014. The company says the LAP Mentor III, a new platform for laparoscopic training, has a sleekly designed platform and an ergonomic solution for maximum efficiency. It includes a work deck with adjustable height, a large monitor in an optimal position, a touch screen control panel and superior haptic feedback. Clarification MEdSim has become aware that The Chamberlain Group is the patented developer of the Beating Heart, pictured in the article “Perfect Practice Makes Perfect” (Issue 1/2014 page 08). MEdSim notes the omission of this fact on the imagery and text supplied by the author. The Chamberlain Group has been manufacturing lifelike anatomical models for surgical and interventional training for 15 years. Products are available on their website,

Index of Ads ASPE Annual Conference 31 B-Line Medical 5 CAE Healthcare OBC HEATT 2014 15 IngMar Medical 11 ITEC 2014 IBC MEdSim Subscriptions 13 Laerdal Medical 9 Mimic Technologies 17 Simbionix IFC SimGHOSTS 27 The Society for Simulation in Healthcare 18 & 19

Calendar 28-30 March 2014 ASiT - Association of Surgeons in Training Conference (UK) Belfast, Northern Ireland 2-5 April 2014 SAGES 2014 Annual Meeting Salt Lake City, Utah, USA 8-12 April 2014 APDS/ARCS/ASE Annual Meeting (Surgical Education Week) Chicago, Illinois, USA 23-25 April 2014 IPSS 2014 - International Pediatric Simulation Society Vienna, Austria


29 April-1 May 2014 HPSN Sarasota, Florida, USA 14-16 May 2014 16th Annual NPSF Patient Safety Congress Orlando, Florida, USA 16-21 May 2014 AUA Annual Meeting Orlando, Florida, USA 22-24 August 2014 Healthcare Education Assessment Training and Technology Orlando, Florida, USA

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20 - 22 May 2014 Cologne, Germany

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