MEdSim Magazine - 3/2012

www.halldale.com Advancing patient safety through Education AND training

SIMULATION PROGRAMS

Development of an ECMO Simulation Program INTERVIEW

Rear Adm. Elizabeth S. Niemyer

LOW COST MEDICAL SIMULATION

The Movie Set Approach to Creating a Simulation Environment ISSN 2165-5367

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US $7.50

Issue 3/2012

Editorial Comment

Editor's Comment

obesity and responsible health choices should be high on the political agenda."

On the cover: Simulation specialists prepare the ECMO mannequin for multidisciplinary team simulations.

Image credit: Yale University School of Medicine.

Judith Riess Editor in Chief MEdSim Magazine judith@halldale.com

ISSUE 3.2012

prevention of

obesity actually accounts for 17 per cent of all medical costs, at approximately $170190 billion annually. Health consequences of obesity include diabetes, mellitus, asthma, sleep apnea, gall bladder disease and a range of cancers. Among children and adolescents, annual hospital costs related to overweight and obesity more than tripled over the past two decades.

A primary goal of the 2010 health-care overhaul is to reduce hospital readmissions. How are hospitals going to reduce readmissions if patients do not take responsibility for themselves?

Why should patients follow their doctor's instruction and advice? Readmissions culminate in bad outcomes for the patient but they refuse to see just as they refuse to contemplate the effects of their smoking, obesity, and other lifestyle choices that directly affect their health. If the resources are there, it's somebody else's problem.

If there is a bad outcome, it's the doctors' fault, not the patient's decision(s). Patients have to be responsible for their health and follow through with the advice and direction they are given.

The vast majority of hospitals are not currently configured to deliver “wellness.”

Developing those capabilities will require significant time and capital investments, and new kinds of community partnerships.

Primary prevention of obesity and responsible health choices should be high on the political agenda.

03 MEdSim Magazine

" Primary

Regardless of attitudes about the ACA, the goals of the federal and private sector healthcare reform efforts – driving down cost and improving quality – are creating a need for healthcare transformation.

This is most apparent for hospitals, as they are regarded as the most expensive part of the healthcare delivery system.

As my next door neighbor, a surgeon said to me many times, “Hospitals are dangerous places, people die there”.

That is unfortunately all to true. According to Houle and Fleece three times as many people die in hospitals due to medical errors each year than on highways -100,000 compared to 34,000.

How many 747 airplane crashes would it take to equal 100,000 avoidable deaths?

Can you imagine the hue and cry of the US public if airlines were crashing on a daily basis? Yet, almost a year ago the major television networks said that one out of three patients admitted to hospitals had some other complication. There was no noticeable reaction. Worse, there are many lessons that could be learned from the airline industry and put into practice that would improve patient outcomes. Some of these practices are slowly making their way into the healthcare field. Team training, crew resource management, and checklist are becoming part of medical education and training programs.

The business model shift from volume to value is the most important and most challenging issue facing hospitals.

Hospital CEO’s must guide their organizations in figuring out how to provide more affordable, higher quality care at lower reimbursement rates – probably under a fixed or bundled payment model.

Decreasing federal reimbursement levels are a fundamental issue of concern, with broad implications for the quality of care providers are able to deliver. Despite the challenges there is an air of optimism and hospital administrators see an opportunity to develop a framework to provide more affordable higher quality care.

Our health is our most valuable asset yet people squander it every day. In the US

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CONTENTS

MEdSim Magazine The Journal for Healthcare Education, Simulation and Training

Editorial

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

Group Editor Marty Kauchak

e. marty@halldale.com US & Overseas Affairs Chuck Weirauch e. chuck@halldale.com US News Editor Lori Ponoroff e. lori@halldale.com RoW News Editor Fiona Greenyer e. fiona@halldale.com

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06 03 Editorial Comment Editor in Chief Judith Riess discusses the need to lower healthcare cost and increase awareness that patients have a responsibility for their health.

06 LOW COST MEDICAL SIMULATION INTENSIVE CARE TRAINING The Movie Set Approach to Creating a Simulation Environment. Drs Liz Steel, Carol Foot and Nurse Educator Sarah Webb from Royal North Shore Hospital, Sydney, Australia in conjunction with Dr Kim Vidhani, Princess Alexandra and Ipswich Hospitals, Queensland, Australia describe how they have used movie and theater techniques to develop low cost simulation for training for intensive care medicine professionals.

09 INTERVIEW Interview With INACSL President. Dr. Valerie Howard, President, International Nursing Association of Clinical Simulation in Nursing (INACSL).

12 SIMULATION PROGRAMS Development of an ECMO Simulation Program: Experience at Yale New Haven Hospital.

Lindsay Johnston, M.D. and Stephanie Sudikoff, M.D. examine the logistics of establishing an Extracorporeal Membrane Oxygenation simulation program.

16 INTERVIEW Interview with Director, Navy Nurse Corps. Rear Adm. Elizabeth S. Niemyer, Deputy Chief, Wounded, Ill, & Injured, U.S. Navy Bureau of Medicine and Surgery, and Director, Navy Nurse Corps.

20 RESIDENT SURGICAL TRAINING

22 CONFERENCE Report All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise – especially translating into other languages – without prior written permission of the publisher. All rights also reserved for restitution in lectures, broadcasts, televisions, magnetic tape and methods of similar means. Each copy produced by a commercial enterprise serves a commercial purpose and is thus subject to remuneration.

MEdSim Magazine, printed January 2012, is published 4 times per annum by Halldale Media, Inc., 115 Timberlachen Circle, Ste 2009, Lake Mary, FL 32746, USA at a subscription rate of $25 per year.

MEdSim is distributed in the USA by SPP 75 Aberdeen Road, Emigsville PA 17318-0437. Periodicals postage paid at Emigsville PA. POSTMASTER: send address changes to: Halldale Media Inc., 115 Timberlachen Circle, Ste 2009, Lake Mary, FL 32746, USA.

Patient Safety Is The Universal Theme At Conferences. Editor, Judith Riess, gives a brief summary of medical conferences attended by Halldale staff.

25 Medical School Simulation Training Medical Student Simulated Surgical Training Reduces Stress Improves Competence.

Second year medical students (MS2) at Rocky Vista College participate in Intensive Critical Care Surgical Course.

29 News Medical News. Updates from the medical community. Compiled and edited by the Halldale editorial staff.

ISSUE 3.2012

Simulation Laboratory a Cutting Edge Tool in Training Surgeons To Be (HealthMattersSimulat). Helen Branswell, The Canadian Press.

05 MEdSim Magazine

www.halldale.com/medsim

LOW COST MEDICAL SIMULATION

The Movie Set Approach to Creating a Simulation Environment Drs Liz Steel, Carol Foot and Nurse Educator, Sarah Webb from Royal North Shore Hospital, Sydney, Australia in conjunction with Dr Kim Vidhani, Princess Alexandra and Ipswich Hospitals, Queensland, Australia describe how they have used movie and theater techniques to develop low cost simulation for training for intensive care medicine profesionals.

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n the current climate of stretched resources, innovative, creative approaches for delivering high value, low budget programs to meet clear educational goals are needed1.

Simulation centres and in-situ simulation set-ups in clinical settings are established environments for creating realistic, experiential learning opportunities2-3.

Utilisation of these environments, however, may be limited by administrative costs and clinical workload4.

The ability to deliver effective simulation based learning anywhere is attractive. A major obstacle to this is the need to provide an experience for learners that is sufficiently realistic to generate immersion and emotional activation.

The degree of fidelity required to achieve effective learning remains a topic of much debate in the medical simulation world.

Influences of Theatre and Film Industries The theatre and film industries arguably have rivaled the aviation industry as

sources of influence on the development of simulation in healthcare. Practitioners of the performing arts create fictional contracts with participants as a matter of course. It is well documented that convincing environments may be created with the suggestion of reality rather than providing every detail5. Scenography is the process whereby set designers (for film, theatre or TV) create the physical world and mood of a production. Backgrounds or “sets” can transport the observer to another time and place.

Movie directors traditionally worked with set designers to create artificial realities to minimise production costs.

On ‘Sabotage’ (1936) it was cheaper for Alfred Hitchcock to have a set built for one shot rather than go to London to film the real event in the script6.

Healthcare simulations are also “performances” and in our industry theatrical features create what we call the “fidelity” of the scenario. The popular and engaging Sim Wars concept has been effectively carried out in conference facilities as part of the Simulation In Healthcare

Above Photograph 1 – Dr. Foot directs ICU simulation.

Image credit: Author.

Conference for a number of years. In a competitive but friendly and educationally unique context, engaging scenarios are created for teams, who perform in front of large audiences. Simple but visually interesting props are used to draw both the teams and audiences into the sessions. This has demonstrated the achievability of running mannequinbased scenarios outside a healthcare setting and arguably the power of theatrical events as learning episodes.

We are a group of clinicians with a passion for education who have benefited greatly from these insights. Due to a lack of resources, our experience over the last three years has been one of necessity driven solutions for designing and delivering low cost but effective educational programs for Intensive Care

Medicine professionals. Unable to utilise the expensive and therefore inaccessible simulation centre at our institution, we turned our efforts to expanding our expertise, firstly in in-situ simulation and then adopting a “simulation anywhere” approach. This has been an exciting venture, which has enabled us to express our creativity and reinvigorate our teaching by delivering simulation based learning with a fresh approach.

In 2009, we established an in-situ, multidisciplinary simulation program in our ICU under a mandate of utilising only existing resources. This was called ICU STAR – Simulation Training at Royal North Shore Hospital ICU. A simulated ICU bed space was recreated in a room previously used for equipment storage using an existing Mega Code Kelly with Vital SimTM, supplemented by common ICU equipment and simple moulage (see photograph 1). Junior and senior ICU doctors manage a simulated patient through realistic events for five consecutive days as part of their usual ward round. Prior to the ward round, nurses make an assessment, then interact on the round when the medical team arrives. A management plan is reached as a team, then

a debrief follows. The emphasis is on technical skills and knowledge development, particularly regarding teaching of longitudinal care of a critically ill patient.

This means that each chapter reflects the expected course of an ICU patient over a week. Medical crises, “housekeeping” issues, such as attention to care bundles, and other topics ranging from strategic thinking to progress patient care are covered. Although this is not the primary focus of the sessions, there is some attention to non-technical skills and discussion about topics such as inter-professional communication teamwork. By adding the extra patient to the clinical teams’ workload, the temptation to abandon daily teaching due to time pressures is overcome, as a “real” patient would never be neglected. The environment evolved, with exploration of varying levels of fidelity coupled with feedback from large numbers of participants guiding “titration” of complexity of the moulage and “set” design.

CIT Course The CIT (Consultant Intensivist Transition) Course was developed in 2010 for new Australasian Intensivists transition-

ing in their role from registrar to consultant. This not-for-profit management program was designed as a three-day course utilizing four clinical scenarios on the first day. These scenarios are set in an ICU to create a context and buy-in for the subsequent modular program that explores the various skills needed to deal with the complex challenges raised by each case. These include non-technical skills for managing clinical crises, understanding self and interpersonal personality differences including the utility of the Myers Briggs Type Indicator, Conflict Management and the Thomas Kilman Conflict Styles Inventory, team work concepts and Belbin team roles, negotiation skills, managing politics and sociograms, managing committees and meetings, legal and ethical dilemmas, clinical governance, patient quality, safety and change management principles. These topics are subsequently taught using various educational approaches including table-top simulations, role plays and games.

The faculty decided initially to utilise a simulation centre for the first day and then move to a venue away from the hospital environment for the remaining

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Bridging the gap between simulations and the real thing.

www.blinemedical.com | info@blinemedical.com | 1.888.228.3838 ©2012 B-Line Medical, LLC an Atellis® company. All rights reserved. Patented technology.

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two days of the course. The expense of the simulation centre was significant.

The need to reduce costs, prompted the search for a less expensive but effective solution for the manikin-based clinical simulations.

The entire program was subsequently held in hotel conference facilities designed for corporate clients. The clinical scenarios are now carried out using a theatre-in-the-round approach with a highly transportable, inexpensive "set". Free-standing conference posters of high quality clinical environment photographs create the back-drop. These posters are very light-weight and conveniently retract into the base and along with backing structural posts fit into a small carry bag.

Using experience from our ICU STAR program, a moulaged mannequin with ICU equipment, creates the foreground.

“Actors” playing key roles assist us in meeting specific scenario driven learning objectives. Scenario agendas are then debriefed. Observers watch the scenarios sitting in comfortable couches at the edge of the set. There is an intimate feel to the experience created by the close proximity of the “audience” as well as the lighting style, which is focused on the set.

Our faculty has significant experience in simulation centre-based program development and have worked in state-of-the-art major centres, including Queensland Health Skills Development Centre and leading UK centres. Buy-in by participants to the clinical scenarios has been equal to that experienced in other simulation environments, and the course evaluations supported the conclusion that created scenarios met the curricular objectives. Feedback has included comments such as "I normally hate simulation but I felt really comfortable with my colleagues all around me in this intimate environment", "It felt very real", "I prefer it to the big brother is watching, video camera, one way glass approach".

The hotel approach has significantly

Above Debriefing after clinical simulation.

Left Simulated Learning in Critical care Emergencies (SLICE).

All images: Author.

reduced course costs and provided more comfortable facilities for learning while meeting the goals of the program.

In 2011, a multidisciplinary team Crisis Resource Management course was created in our ICU at Royal North Shore Hospital called SLICE (Simulated Learning in Critical care Emergencies). Building on the previously described courses, this one-day program was carried out entirely in our large ICU conference room, a non-clinical setting, previously used almost exclusively for lecturebased teaching sessions and team handover meetings, using the same approach as the scenarios in the CIT course. The feedback for this program continues to be positive.

We will continue to develop this approach. It has enabled our educational course costs to be significantly minimised. Entire courses can be run in non-hospital and non-clinical environments, enabling a blend of clinical and

management topics to be addressed in a single venue. More formal exploration of the utility of such an approach is warranted. It appears to be another attractive and feasible alternative for running mannequin-based scenarios. Looking outside healthcare to other industries may be a key driver of ongoing innovation and inspiration. medsim About the Authors Professor Dr. Carole Foot, and Dr. Liz Steel are Intensive Care Specialists at Royal North Shore Hospital, Sydney, New South Wales, Australia. Sarah Webb is a Nurse Educator. Dr. Kim Vidhani is an Anaesthetist and Intensive Care Specialist at Princess Alexandra and Ipswich Hospitals, Queensland, Australia. All have extensive training and simulation backgrounds. Foot, Steel and Vidhani wrote the examination, Intensive Care Medicine for community members in Australia and Europe.

REFERENCES 1. Ker J, Hogg G and Maran N. Cost effective simulation, p61-71. In Walsh K (editor), Cost Effectiveness in Medical Education. Radcliffe Publishing, 2010.

2. Weinstock P, Kappus L, Garden A, Burns J. Simulation at the point of care: reduced-cost, in situ training via a mobile cart. Pediatr Crit Care Med. 2009; 10: 176-81.

3. Kobayashi L, Patterson M, Overly F, et al. Educational and research implications of portable human patient simulation in acute care medicine. Acad Emerg Med. 2008; 15: 1166-74.

4. Bressan F, Buti G, Boncinelli S. Medical simulation in anesthesiology training. Minerva Anesthesiol 2007; 73: 1-11.

5. Brockett O, Mitchell M, Hardberger L. Making The Scene: A History of Stage Design and Technology in Europe and the United States. Tobin Theatre Arts Fund, 2010.

6. Duncan P. Alfred Hitchcock The Complete Films. Citadel Press Film Series; 2002.

INTERVIEW

Interview with Valerie M. Howard, Ed.D., RN, President International Nursing Association for Clinical Simulation and Learning Dr. Valerie Howard was interviewed by group Editor Marty Kauchak on June 21, 2012 at the 2012 INACSL conference in San Antonio Texas. The interview addressed a wide range of policy, technology and other areas of interest.

Above INACSL's mission is to promote research and disseminate evidence based practice standards for clinical simulation methodologies and the learning environment.

Image credit: INACSL.

educational institutions, medical simulation centers and other learning sites?

VH: We've published the first set of standards – there were seven – last year.

The document is the Standards of Best Practice-Simulation. These standards for simulation apply to any discipline medicine, nursing, respiratory therapy and others. They have been published and widely accepted. We are now in the process of publishing guidelines, the last step in the process of developing standards. So, we've released the standards and published them. We're due to have guidelines for each of the standards and those are to be released next year, in 2013.

MEdSim: Are the standards applicable to the private and public sector health care communities?

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This INACSL conference used to be a skills lab conference, but our co-founding presidents realized the power of this educational strategy and had the foresight 11 years ago to include simulation as the thread throughout.

MEdSim: During your opening conference remarks this morning, you said there is record attendance at the 2012 INACSL with significant international participation. That appears to be yet another metric of the healthcare professions' rising interest in simulation.

VH: Yes, absolutely. We have 850 attendees and delegates from 21 nations, including Oman, Lebanon and Switzerland, among others.

Our membership has increased 50 percent during the past two years – from 1,000 to 1,500 members. This is really due to the strategic planning of the past president, Kim Leighton, Ph.D. She started the process to build the organization and move it forward.

MEdSim: Here's a follow up to your stated organization mission. What is the status of establishing those standards in

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MEdSim: First, thank you for taking time from your very busy schedule at the INACLS conference to meet with us. Let's start by learning more about INACSL in terms of its mission, organization and members.

Valerie Howard: This is INACSL's 11th year of operation. Our mission: to promote research and disseminate evidence based practice standards for clinical simulation methodologies and the learning environment. And we would like to be nursing's portal to the world of clinical simulation pedagogy and learning environments – that’s our vision.

As I stated earlier, we started 11 years ago with two co-founding presidents, Teri Boese and Debra Spunt. They had the vision for the organization, believing that simulation was certainly on the rise.

Using simulation was an innovative, new creative way to teach, certainly in alignment with all of the educational theories.

Simulation was a way of applying what participants learned in the classroom, which aligns with experiential learning theories.

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VH: Certainly, nothing like this has ever been done as far as the publication of standards. It has been very hard to get people to agree and to reach consensus. Our INACSL Board led the development of the standards, but we also included our membership's inputs, and included expert peer review outside of our organization before these were published.

And we continue, we know that revisions will have to be made because our environment and simulation are rapidly changing. They'll need to be revised and revisited. It's all part of an ongoing process. We also have a Standards Chair on our board to guide the process.

MEdSim: I also saw several of your members in military uniforms on the conference floor. That's a lead to learning about INACSL's level of collaboration with the public sector – the U.S. DoD, VA, and other organizations.

VH: We certainly accept members from any sector, we have some members from the military and we have a strong VA presence. We are an affiliate of the Society for Simulation in Healthcare, as well as the Association for Standardized Patient Educators, although we haven't had formal collaborative efforts. Our healthcare experts from the military can certainly be members.

MEdSim: Can you provide a very broad overview of the technologies your members use in their simulation centers and other venues?

VH: As far as simulators go, we're mainly talking about the high fidelity, human patient simulators – the ones that are highly technical, but can be physiologically programmed to respond in that manner. Simulation also includes an audiovisual component, as many facilitators record the sessions and play them back during debriefing. This adds another layer of technological complexity to simulation. And, we do know that gaming and computer-based simulation are emerging.

Technology is one of the challenges.

Essentially, nursing faculty members are not technology gurus. We're not IT specialists, but suddenly we find, as a result of a donor, a $75,000 high fidelity simulator placed in front of us. We know with all of those technologies, as wonderful as they are, they don't run by themselves.

When you teach with them, we're talking about good academic teaching prin-

Above Valerie M. Howard.

Image credit: INACSL.

ciples – that is really behind everything that we are doing. So, not only do you have to have an understanding of the technology, you have to have an understanding of how to teach, how to evaluate, how to develop objectives and create a clear learning plan for that simulated experience. We try to provide support for both of those areas – for the technology and the educational experience, and the research that is behind all of this.

MEdSim: And what about the basic and more complex skillsets these technologies help your nurses obtain through the continuum of learning?

VH: When simulation first began, many people thought this was just a method for teaching psychomotor skills: skills like IV insertion; collecting vital signs; assessing lung and heart sounds; inserting a foley catheter. However, we’re finding more opportunities related to simulation training. We found that with simulation we can really make significant improvements with team training, communication and other issues related to patient safety. These techniques will help decrease medical errors and enhance our patient outcomes.

MEdSim: We also heard during several presentations the community’s increased emphasis on team training and debriefing. These are long standing areas of interest to the users of simulation in the military and civil aviation sectors.

VH: That is one of our standards – debriefing. We feel that every simulation

experience should have a debriefing component, whether it’s computer-based, mannequin-based or whether you’re using a standardized patient. The debriefing is where the learning occurs.

It’s not simply in the action but the participants review and reflect upon their performance. That’s where the learning occurs and is solidified, and that’s where our learners can really understand how they can improve their performance. If we just simulated and sent the participants out without providing an opportunity to reflect upon their performance, we are doing them a disservice, we feel very strongly that debriefing is needed.

MEdSim: Your “help wanted list” for the simulation and training system vendors – the new and enhanced technologies and products your community needs.

VH: Yes, definitely culturally diverse simulators. They seem to be white, male and English speaking. Ways that we can enhance the realism would be through skin color changes, but also culturally relevant features. I believe the vendors and simulation facilitators need to continue to have conversations and develop new technologies jointly, to ensure that the needs of our participants, faculty, and educators are being met.

Also in computer-based simulation and gaming. As we look at this age of new learners coming up, how they learn and multi-task, and the importance of gaming and what we can do through gaming, we need to ask how we can we really enhance the realism and ease of use with some of those games. And we need to look at the cost, too. The costs tend to be very expensive. If I want to buy a game to use with 100 students, what’s the cost of that: 100 times the cost of one game?

It has to be cost-effective. Let’s face it.

Institutions are not designating a lot of money for education and training. It’s unfortunate.

MEdSim: You’ve mentioned gaming.

Another positive development is serious gaming’s maturing in the adjacent military sector – which we follow in MEdSim’s sister publication MS&T. VH: Absolutely, this is unchartered territory – games for learning. I am not simply talking about Call of Duty. I am talking about students learning through other gaming – and through YouTube and other delivery methods. They are doing these things and not even realizing that they are learning. This is a huge,

educators and education – all areas of service.

The other thing we would like to do, and we are branching out into the international arena, is we’re establishing our first European chapter of INACSL. This was just decided on this week, so this is “hot news.” We have a group of people in Europe who are willing to run this chapter. You still join INACSL but it gives people a more local feel. We know the “American” way is not always the “global” way, we think there is value in having chapters in different pockets of the world to meet those members’ needs.

MEdSim: Well, this is more evidence that simulation is of ever-increasing interest to your community around the globe.

VH: Yes, it really is. People are just searching for something to help, for some sort of standards. That’s why our standards are so important. I have heard that people are translating them into different languages. I don’t think it’s a formal translation, but people are sharing these standards within their own environments. It’s very exciting. We’re an international organization and we had international input when we created the standards.

huge opportunity. But the problem now in some games, it is very hard to learn with that technology and then integrate that in the classroom, which is what we found with simulation, too. We were first led to believe that you push a button on the mannequin, it takes you through a scenario down a decision tree and your students learn. That’s not what happens.

You still need that guidance from faculty.

MEdSim: INACSL’s priorities for the next several years, please.

VH: We just completed our strategic plan. In the next four to five years we want to increase our educational offerings to our members, so essentially everything we do will support the needs of our members. We also plan to increase our research support and mentoring opportunities for our members, and extend our reach globally. We did a needs analysis last year, so, we’re basing a lot of our decisions on what our members wanted.

MEdSim: Are those educational offerings through continuing education?

VH: It could be continuing education, webinars, conferences, or faculty development opportunities. But not just for educational institutions, also for hospital

Advancing

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Here’s another really exciting thing we’re doing.

Currently there are not a lot of frameworks out there – models – that people can use to design the simulation experiences. One of the models out there was developed in 2006 by Dr. Pamela Jeffries and the National League for Nursing – The NLN Jeffries Framework. What we’re doing during this session is analyzing all the constructs. We’re seeing what information has been published about each of the constructs of the model. We’re going to report on them during this meeting, and also publish some manuscripts on that and try to move that forward into a framework.

MEdSim: Any final thoughts?

VH: People need to know that while “nursing” is in the INACSL name, that we welcome any members from outside the nursing community and we do have them. We have some physicians, EMTs and others. It’s a bit deceiving to see “nursing” in the title, but we welcome that interdisciplinary membership, and certainly feel that INACSL can assist them as they implement simulation teaching modalities into their own education and training programs. medsim

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MEdSim Magazine is dedicated to provide the latest news, information and commentary on healthcare education, simulation & training.

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It is indispensable reading for healthcare training professionals working in hospitals, universities, the military and veterans’ organisations.

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Simulation Programs

Development of an ECMO Simulation Program: Experience at Yale New Haven Hospital Lindsay Johnston, M.D. and Stephanie Sudikoff, M.D. present the first of a two-part overview on establishing an Extracorporeal Membrane Oxygenation simulation program. This first installment focuses on the logistical issues supporting this program. Part 1: Logistics.

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hat is ECMO? Developed in the 1970s, Extracorporeal Membrane Oxygenation (ECMO) is used in the management of the most critically ill patients, and allows for temporary support of cardiac and/ or pulmonary function using a mechanical circuit, including a pump, a membrane oxygenator, and a heat exchanger. ECMO was initially utilized for short-term support for newborns with acute, potentially reversible causes of respiratory failure, such as meconium aspiration syndrome, persistent pulmonary hypertension of the newborn, and congenital diaphragmatic hernia. (K Van Meurs et al, ECMO Extracorporeal Cardiopulmonary Support in Critical Care, 3rd Ed 2005) It is typically offered as an option for therapy when predicted mortality with conventional management is estimated to be >80%.

Its use has been expanded to include respiratory and cardiovascular support for children and adults with other potentially reversible conditions.

Initiating therapy with ECMO requires surgical cannulation of the great

vessels, most often the carotid artery and internal jugular vein in neonates. Blood is drained from the patient through the venous cannula, and flows to a collection chamber, called the bladder. The blood is then pumped to the membrane oxygenator, where oxygenation and CO2 elimination occur. Blood is returned to the patient via the arterial cannula, after passage through the heat exchanger, which allows for maintenance of normothermia.

Appropriate levels of oxygen and CO2 in the patient’s blood can be maintained by titrating the pump flow and adjusting the gas flow across the membrane oxygenator. This allows for support of much of the patient’s cardiopulmonary function.

Traditional Methods for Training ECMO Teams Traditional training in ECMO management typically consists of didactic lectures supplemented with hands-on training using a water-filled ECMO circuit. In this model, trainees are not given the opportunity to incorporate real-time changes in the patient’s clinical status

Above ECMO team members during an intrahospital transport.

Image credit: Yale University School of Medicine.

into their plan of care. Additionally, and perhaps most importantly, this method does not address the issues of team behavior and effective communication among a multidisciplinary group of providers.

Drs. Anderson and Halamek were the first to publish on ECMO simulation.

Their group linked a neonatal mannequin with a standard neonatal ECMO circuit primed with artificial blood. Participants preferred the degree of realism achieved when training included simulation, as the circuit could demonstrate physiologically appropriate pressures and vital signs could be adjusted to reflect the particular clinical scenario. Compared with traditional methods, learners spent much more time engaged in active learning (78% vs. 14%), and could develop cogni-

tive, technical and behavioral skills that would have been challenging to recreate with traditional didactic training. (JM Anderson et al, Simul Healthcare 2006; 1:220-227)

Above Physicians, perfusionists, practitioners and nursing staff discuss potential etiologies for the decompensation of the ECMO patient.

Image credit: Yale University School of Medicine.

agement decisions to rare but potentially catastrophic events.

Additionally, new technologies are frequently developed to enhance the ECMO circuit. Centrifugal pumps have been taking the place of the standard roller-head pumps, and new oxygenators have been developed to replace the silicone membrane oxygenator. It is essential that staff members have an opportunity to familiarize themselves with the new equipment, and it is desirable that this learning occurs prior to utilizing the new equipment on patients.

ECMO simulation allows for this orientation to occur without potential danger to patients.

Multidisciplinary Team Practice. An ECMO team is, by necessity, multidisciplinary and includes intensive care physicians, surgeons, perfusionists, nurse practitioners, physician’s assistants, respiratory therapists, and nursing staff.

Each discipline is educated in an individual silo, but providers are expected to function well with all other members of the healthcare team. Historically, medical training programs did not cover communication and teamwork behaviors, but these skills are not innate; they must be learned and practiced. Since the 1999

Institute of Medicine Report “To Err is Human” revealed that communication issues exist at the root of many sentinel events, initiatives to improve team behaviors have been stressed to improve patient safety. Key principles of teamwork include: clear team structure and role clarity, leadership, situation monitoring, mutual support, and communication.

Simulation has proven ideal for stressful situations that occur infrequently and are high-risk for human error – ECMO certainly fits into this category.

Utilizing simulation to train ECMO teams is particularly beneficial for the ability to recreate low frequency, high-risk situations where clear, concise communication could mean the difference between life and death. This can also provide a forum to improve team behaviors among members of the multidisciplinary group of providers, which are vital for patient safety efforts.

Extracorporeal Life Support Organization: Center of Excellence in Life Support. ELSO, the Extracorporeal Life Support Organization, is an international consortium of health care professionals and scientists dedicated to the development and evaluation of novel therapies to support failing organ systems. ELSO recognizes selected ECMO programs with the designation “Center of Excellence in Life Support,” an honor currently bestowed upon approximately 48 programs internationally. This award recognizes programs that promote quality and exceptional care in ECMO. The “Excellence in Life Support Award” signifies

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Patient Safety. ECMO teams care for the most critically ill patients using a highly complex technology that is significantly different than conventional critical care equipment. To be effective, providers require specialized training to be able to appropriately manage a patient on this type of support. There are a multitude of factors that increase the risk of medical errors in these cases, and a robust curriculum for initial training and continuing education are vital to help protect patients from possible adverse outcomes.

The frequency of ECMO cases at a given institution is unpredictable and can vary significantly from year to year. With advances in medical care for hypoxic respiratory failure and pulmonary hypertension, the incidence of neonatal respiratory ECMO runs has been decreasing over time. There was a peak of approximately 1,500 cases per year in the early 1990s, and this has decreased to less than 600 cases in 2010. (ELSO Registry Report, International Summary January 2011) As the volume decreases, the time interval between ECMO cases increases. This could potentially lead to a decrease in the care team’s comfort with this complex technology.

Furthermore, true emergencies on ECMO occur infrequently. For example, raceway rupture, cardiac tamponade, air entrainment in circuit, pneumothorax, and oxygenator failure occur in about 0.3%, 0.5%, 4.9%, 6%, and 6% of ECMO runs, respectively. There is an extremely low likelihood that a particular healthcare provider would have personal experience dealing with any one situation. However, in emergencies on ECMO, prompt and correct steps to rectify the situation are vital. The rate of patient survival for the conditions above ranges from 32-70%, and depends heavily on the provider’s management of the problem. (ELSO Registry Report, International Summary January 2011) An ECMO simulation program allows each provider to have a standardized experience and gain confidence managing a wide variety of scenarios, ranging from routine man-

ISSUE 3.2012

Why Start an ECMO Simulation Program?

Simulation Programs

to patients and families an institution’s commitment to exceptional patient care.

It demonstrates to others in the health care community an assurance of high quality standards, defined patient protocols, and continuing education of staff members. Centers may use the award to market themselves as distinguished leaders in critical care, and it is recognized by US News and World Report and Parents magazines as one of the criteria for highly ranking institutions.

A designated Center of Excellence has demonstrated extraordinary achievement in several categories, including excellence in training and education.

Development of an ECMO simulation program fulfills one of the requirements for consideration of this award, a reliable forum for continuing education of ECMO teams.

ISSUE 3.2012

Who should participate in the development of the ECMO simulation program?

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When developing an ECMO simulation program, it is imperative to have representation from all members of the actual multidisciplinary ECMO team, including physicians from all involved specialties (e.g., Neonatology, Pediatric Critical Care Medicine, Adult Critical Care Medicine or Cardiothoracic Surgery), perfusionists, nurses, and respiratory therapists. These individuals will help to ensure that the experiences are relevant and as realistic as possible for their staff.

Having these “champions” also allows for “buy-in” from the other members of the team and can improve rates of participation.

Additionally, early involvement and commitment from an institution’s simulation center is vital to the success of the endeavor. The simulation specialists are vital to the initial adaptation of the mannequin to allow for “cannulation” and interaction with the ECMO circuit. To allow for simulation of a wide variety of clinical scenarios and ECMO emergencies, the specialists adjust the circuit pressures, patient monitoring equipment, and vital signs in real-time, thereby enhancing the overall realism of the setting.

ing environment with minimal financial investment. The initial cost depends mainly upon the modifications made to the mannequin to allow for interaction with the ECMO circuit, which will be discussed below. At Yale, the initial cost was minimal and covered the purchase of a low-fidelity mannequin with a realistic airway.

The ongoing costs for supporting an ECMO simulation program can be variable. A new circuit is required each time a new scenario is planned, and the cannulae need to be replaced frequently. In most cases, expired circuits and cannula have been utilized for the ECMO simulations at Yale, so the program can be sustained with little ongoing investment by the institution. Budgetary information, if equipment is purchased new, is listed in Table 1. The cost for consumables (e.g., syringes and IV supplies, teaching medications, airway equipment, teaching code cart) can vary widely. Many institutions have supplies, such as intubation equipment, set aside for teaching. At Yale’s neonatal intensive care unit, intubation equipment, syringes and tubing,

ECMO simulation programs vary widely with respect to their budgets, but it is possible to create a very realistic learn-

mannequin for multidisciplinary team simulations.

Image credit: Yale University School of Medicine.

and teaching medications dedicated for simulation are utilized for all sessions. If the team needs to replenish this equipment, it is typically incorporated into the unit’s operating costs.

Since the program at Yale is deemed important for ongoing training of staff and results in significant improvements in patient safety, the costs for utilizing the staff and resources of the simulation center are supported by the health system.

Staff members are typically compensated for their time spent participating in ECMO simulation. Perfusionists, nurses, and practitioners are typically scheduled for sessions during a regular shift, and their clinical responsibilities are covered for the duration of the simulation. If staff choose to come in when they are not

Table 1. Potential Costs for Equipment for ECMO Simulation Program.

Item

Cost

One-time or Recurring Cost?

Laerdal Nursing Baby

$ 2,321.00

Quadrox iD Oxygenator

$1,800.00 Recurring*

One-time

Circuit Tubing

$850.00 Recurring*

Better Bladder

$350.00 Recurring*

Standard VA cannula

Budget

Above Simulation specialists prepare the ECMO

Origen VV cannula

$244.00 each (x2) Recurring* $195 each (x1) Recurring* * If unable to utilize expired equipment

scheduled to work, they are compensated. Physicians have not been financially compensated for their time, but have been eager to participate given the significant benefits to their knowledge and to patient care. Additionally, participation in these sessions is required for continuing education of ECMO team members, and is utilized by the hospital in credentialing physicians to use this technology.

Adaptation of Mannequin

Conclusion ECMO is a mode of cardiopulmonary support for the most critically ill patients, and inappropriate management decisions can be catastrophic.

Traditionally, training of ECMO teams has involved didactic lectures and hands-on practice using a water-filled ECMO circuit. This method does not allow for the interpretation of real-time changes in patient status or multidisciplinary team practice. An ECMO simulation program can provide a forum for practice in the management of routine and of low frequency, high-risk emergency situations. This can lead to benefits in patient safety, improved team behaviors and communication, and can demonstrate a commitment by the institution to high quality standards and

Above Drs. Lindsay Johnston and Stephanie Sudikoff beside a baby HPS (human patient simulator) at Yale New Haven Hospital.

Image credit: Yale University School of Medicine.

the provision of excellent patient care.

Developing an institutional ECMO simulation program requires representatives from members of the multidisciplinary ECMO team and the simulation center, as well as commitment from the hospital or health system’s administration. The financial investment can vary depending on the plan for adapting the mannequin to interact with the ECMO circuit, but even simple, low-tech solutions can lead to an excellent learning environment for members of the medical team.

Part II of this article will be published in MEdSim on line and will contain information on the structure of the ECMO simulation program at Yale, scenarios, and examples of how ECMO simulation can be utilized for patient safety and quality improvement. medsim About the Authors Lindsay Johnston, M.D. is the Co-Director of Pediatric Simulation and a faculty member in the Department of Pediatrics at the Yale University School of Medicine. Stephanie Sudikoff, M.D. is the Medical Director of the SYN:APSE Simulation Center, Yale-New Haven Health System.

ISSUE 3.2012

SimBaby software is used to display and alter clinically relevant vital signs.

Therefore, even though this program is not interacting with the mannequin, the medical team can still utilize this information.

The pressure readings from the ECMO circuit can also be adjusted to reflect various medical emergencies. To accomplish this, flowsheets were initially used to display the desired circuit pressures, and the perfusionists were used as confederates. The simulation specialists then devised a system in which extra tubing is attached to the pressure transducers, and small amounts of fluid can be injected into the system to titrate the pressures to the desired values.

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Centers with ECMO simulation programs have a variety of different solutions to allow the mannequin to interact with the ECMO circuit and be placed “on bypass.” These options cover a wide range of fidelity, and include permanent changes to the mannequin to allow for cannulation of an indwelling fluid reservoir to utilization of a high-fidelity mannequin positioned on top of ECMO circuit tubing, without requiring any permanent alteration of the mannequin.

The simulation specialists who created the ECMO mannequin for the program at Yale started off by reviewing the pertinent anatomic structures and procedure for cannulation, as well as ideal cannula placement, normal cannula size and flow rates. The mannequin selected was a Laerdal Nursing Baby (Laerdal Medical, Wappinger Falls, NY). The airway was left intact, and the remaining internal structures were removed to accommodate a fluid chamber (a bladder from an expired ECMO circuit) and tubing into which ECMO cannulae could be inserted. The connection points were secured with zip ties and rubber tubing to minimize leakage. The cannulae are connected to a standard neonatal or pediatric ECMO circuit, which is filled with an artificial blood solution.

The mannequin’s cannulas are typically replaced prior to each simulation session, as the connections can sometimes leak due to high pressures from the ECMO circuit. Additionally, both Venoarterial (VA) and Venovenous (VV) ECMO can be simulated, and the cannulae are changed to reflect the appropriate scenario.

At Yale, the mannequin used for ECMO simulation does not have an associated patient monitor. Since it was imperative to have changes in the patient’s clinical status readily available to the team, a monitor with input from

Interview

Interview with

Rear Adm. Elizabeth S. Niemyer

ISSUE 3.2012

Rear Admiral Niemyer, Deputy Chief, Wounded, Ill, & Injured, U.S. Navy Bureau of Medicine and Surgery, and Director, Navy Nurse Corps, was interviewed by Group Editor Marty Kauchak. The interview addressed a wide range of learning technology and related training topics in the admiral’s expansive portfolio.

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MEdSim: Provide some examples of how simulation, simulators and other technology support your nurses’ continuum of learning for individual and team skills.

Rear Admiral Niemyer: As key members of multidisciplinary treatment teams, Navy nurses are essential to the provision of outstanding care and optimal patient outcomes for beneficiaries and wounded warriors here at home serving in various clinical and leadership roles within our military treatment facilities (MTFs) and ambulatory care clinics.

The clinical expertise and leadership of Navy nurses ensures a fit and ready fighting force vital to the success of Navy and Marine Corps operational missions at sea and on the ground. Navy nurses are key players in Humanitarian Assistance/ Disaster Relief efforts, medical stability operations and deployment of hospital ships and large-deck amphibious vessels around the world. The Navy Nurse Corps recognizes its people as our most vital asset and we are committed to maintaining a force of highly-skilled and adapt-

able nurses ready to meet these diverse challenges. From newly graduated novice nurses to extremely experienced advanced practice nurses, medical simulation technology provides a realistic training forum to develop, refine and sustain critical thinking ability, hands-on procedural skills and effective team communication techniques in a safe and controlled environment conducive to continued learning and professional growth.

Medical simulation technology is currently being utilized within our MTFs and training sites as an adjunct for beginning and advanced resuscitation courses such as Basic and Advanced Cardiac Life Support (BLS, ACLS), Pediatric Advanced Life Support (PALS), Pediatric Emergency Assessment, Recognition and Stabilization (PEARS), Neonatal Resuscitation Program (NRP), S.T.A.B.L.E. for neonates, Advanced Life Support for Obstetrics (ALSO) and Trauma Nurse Core Course (TNCC), and Operational Emergency Response Training. Medical simulation technology is also being added to the clinical

Above Naval Medical Center San Diego staff members practice cardiopulmonary resuscitation (CPR) on a mannequin during an Advanced Cardiac Life Support (ACLS) course.

Image credit: U.S. Navy/John O'Neil.

orientation process for new nurses, physicians and Hospital Corpsmen providing additional training and markedly enhancing the clinical expertise gained from direct patient care at the bedside.

Nurses working in high-risk, high-acuity clinical environments such as emergency/trauma, critical care, pediatrics and obstetrics have readily recognized medical simulation technology as essential to adequate preparation and effective response for emergent patient situations conducting frequent training evolutions and impromptu drills utilizing high-fidelity simulators such as the Mobile Obstetrical Emergency Simulator (MOES), SIM Man, SIM Baby and MATT Man. We also utilize simulation technology to train to specific tasks such as

Rear Adm. Elizabeth S. Niemyer.

Image credit: US Navy.

of our fighting forces for a nation at war for the past decade. Navy nurses must be clinically proficient and ready to meet the challenges of the diverse assignments they are given anytime, anywhere while setting the standard for excellence not only as outstanding clinicians, but as patient advocates, mentors and leaders in the provision of compassionate and holistic care even in the most austere conditions. Although there is no substitute for direct patient care at the bedside, medical simulation technologies offer an extremely desirable method for further enhancing the clinical knowledge, skill and expertise gained through the provision of hands-on care at the bedside. The implementation of medical simulation technology has increased confidence, knowledge, skill, and effectiveness of communication for nurses to be at “the top of their game� and stay there, providing state of the art nursing care no matter what environment they are working in . I would like to share just a few of the significant accomplishments of Navy nurses serving in unique roles and environments throughout Navy Medicine to bring some real-life perspective to what I feel is the return on investment and benefit of medical simulation technology.

Navy nurses are respected health care professionals involved in all levels of professional nursing organizations,

ISSUE 3.2012

MEdSim: As a follow-up, tell us about the returns on investment and other benefits your community expects from learning technologies.

RN: Clinical excellence in the provision of holistic and compassionate patient and family centered care is the cornerstone of Navy nursing. The benefits of medical simulation training are evident in all facets of Navy nursing and the roles in which they serve. The expected return on investment and benefits of learning technologies within the Navy Nurse Corps is high. Over the past several years, emphasis on preventive health care and wellness promotion coupled with the increased medical capability to provide surgical and procedural interventions as an outpatient has resulted in decreased volume and length of stay for inpatients within our MTFs. Additionally, we have felt the additional challenges of growing and sustaining clinical experts in support

Above

the advancement of nursing practice and sustainment of clinical excellence. Central to the provision of outstanding care are those nurses providing direct patient care at the bedside within our MTFs, as well as, our ambulatory care clinics stateside and overseas. Nurses new to the Navy face many unique challenges from learning the intricacies of patient care and becoming competent in the application of newly acquired knowledge, skills and abilities to integrating into the Navy culture as a commissioned officer. Medical simulation technology provides an avenue for novice nurses to develop and enhance their competence, confidence, and comfort in the care of patients in a myriad of clinical settings such as medical-surgical, pediatrics, obstetrics, critical care, and emergency/trauma. It also facilitates the sustainment of clinical knowledge and skills of experienced nurses. This strong clinical foundation is pivotal to continued learning and the development of advanced knowledge and skills required of our more autonomous and arduous assignments.

In addition to the more traditional role of nurses, Navy nurses also provide a vital portion of the medical care provided in the operational arena. Navy nurses provide medical support to civil-military operations and health-related activities such as the Combined Joint Task Force Team-Horn of Africa in Djibouti, Africa, long-standing humanitarian deploying our hospital ships such as CONTINUING PROMISE and PACIFIC PARTNERSHIP, disaster relief efforts such, and routine maritime operations aboard aircraft carriers and amphibious vessels caring for our Sailors and Marines. They are also integral members of diverse units and teams throughout Afghanistan as members of Shock Trauma Platoons and Forward Resuscitative Surgical Systems assigned to Marine Corps and Medical Battalions, Expeditionary Forces and Logistic Groups supporting the immediate pre-, intra-, and post- operative phases of care for traumatically injured patients. These nurses are providing life saving trauma care on the battlefield immediately following injury. They are also trained and qualified to provide en-route care and medical support in rotary wing airframes during the transport of our war injured to higher levels of care. Following initial life-saving stabilization on the battlefield, critically injured patients are transported to com-

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placement of intravenous catheters and central lines, as well as, virtual trainers.

And most importantly, the value in having the various types of medical simulation technology available and utilized for preparing and training our nurses (in conjunction with all members of our health care team) for the most arduous and challenging assignments in support of our frontline operational forces on the battlefield cannot be emphasized enough. Training our nurses and health care personnel for operational missions has become one of the major focuses in utilizing medical simulation technology.

Numerous patient scenarios and simulation training modules have been developed to provide a realistic replication of the types of traumatic injuries sustained on the battlefield to familiarize and prepare our nurses and health care personnel for rapid identification and treatment of these life-threatening, traumatic injuries prior to their deployment into the chaotic and stressful battlefield (pre-hospitalization) and trauma care environment.

Overall, the training capability and continued learning forum afforded to nurses and all members of our health care team through medical simulation technology has become absolutely vital to developing and sustaining the clinical acumen and team communication skills necessary to ensure optimal patient safety and the delivery of the highest quality care to those entrusted to us.

Interview

prehensive medical facilities such as the Role 3 Multinational Medical Unit in Kandahar, Afghanistan. The clinical expertise and technical skills gained through experience and simulated training have ensured nurses capability to effectively function in a chaotic, high-complexity, high stress environment often inundated with several casualties simultaneously.

The casualties treated at this facility commonly suffer injury severities scoring twice as high as the average patient seen in a Level 1 trauma center in the United States. Navy nurses are making a tremendous contribution to the unprecedented survival rate of our war casualties of greater than 95 percent. It is extremely probable that the majority of these experienced emergency/trauma and critical care nurses filling these assignments benefited from medical simulation technology as an integral piece of their deployment preparation and training. The return on investment is self-evident.

ISSUE 3.2012

MEdSim: What is the U.S. Navy Bureau of Medicine and Surgery's funding for learning technologies contained in the president's FY 2013 defense budget request?

RN: While there is not a specific line item on BUMED's budget for learning technologies, Navy Medicine has $92.8M programmed in the FY13 budget for the overall education and training of the patient population and workforce through various learning venues.

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MEdSim: You are also monitoring advancements in virtual reality treatment to help treat traumatic brain injury and post traumatic stress disorder in the services' wounded warriors. What are some of the recent advancements in this field that have gained your attention?

RN: Yes, virtual reality in the treatment of PTSD continues to be utilized clinically and to be studied in research programs.

Results indicate that it has similar efficacy when compared to Evidence Based Treatments (EBT) such as Prolonged Exposure or Cognitive Processing Therapy. The emerging research is examining the different aspects of EBTs across different symptom presentations. The ultimate goal is to match particular EBTs to particular symptom presentations.

That is, we are theorizing that more fearbased symptom presentation of PTSD may respond best to exposure therapy.

The vast majority of TBI patients recover without a need for long-term care or intervention. However, those that do require continued care often need uniquely tailored treatment plans that capitalize on a variety of modalities available. With this in mind, through ongoing research, enhanced training, and implementation of state-of-the-art tools, Navy Medicine and the Department of Defense (DoD) continue to advance virtual reality (VR) technology and the availability of virtual reality treatment for service members. Navy Medicine strives to offer VR technology as a treatment modality for Wounded Warriors when appropriate.

Throughout the DoD, there are several Computer Assisted Rehabilitation Environment (CAREN) systems in use (Naval Health Research Center, National Intrepid Center of Excellence, Military Amputee Treatment Center, and Center for the Intrepid). The CAREN uses virtual reality environments, such as a war-fighting experience, to aid in the assessment and rehabilitation of Wounded Warriors, including those with TBI and amputation. The CAREN has an eight-foot tall, 180- or 360-degree screen whose images are synchronized with movement of a central platform and input from the user.

At the Naval Health Research Center (NHRC), they are currently using the CAREN to investigate head stabilization in TBI and amputee populations.

MEdSim: As another follow-up, provide some suggestions to allow the professionals in this field to more effectively meet the needs of the wounded warriors.

RN: Mental Health providers are passionate about helping our warriors and they are doing excellent work in their therapy rooms. Unfortunately, sometimes the overall system can be fragmented. Initiatives such as the Psychological Health Pathways (PHP) are being deployed to provide more comprehensive standardized care. PHP is a best practice psychological health treatment and care management system. Its goals are to improve continuity and collaboration between and across disciplines and clinics, improve access to evidence-based treatments, and provide a comprehensive Web-based registry and patient-tracking tool.

MEdSim: What are some of the new learning technologies the Navy nursing

community may see delivered during the next 12 months?

RN: As new technologies are developed and available, the Department of Navy Medicine will continue to support implementation of these technologies into the professional development and clinical sustainment of our health care personnel.

The potential is unlimited as we continue to explore options for incorporating newly developed technologies into the development and clinical sustainment of Navy nurses. Nurses, in particular, have to learn very early on to effectively address a huge variety of requests, demands, questions and problems that arise in the care of unique patient populations experiencing a myriad of conditions. The ability to provide training that addresses each and every possible patient scenario that might arise can become extremely costly and create scheduling and staffing challenges. The availability of virtual training and “serious gaming” providing realtime, 3-D modules or online training scenarios that are accessible to nurses and healthcare professionals any time could become a very viable option in meeting the professional development needs of an extremely versatile and mobile Navy Nurse Corps.

In the meantime, our current efforts will continue to focus on maximizing the utilization of existing technology to its fullest capability. Currently there are efforts underway to incorporate the various medical simulation modalities to create “hybrid” types of simulation training using both high fidelity simulation which provides a complex and comprehensive patient scenario and task training simulation to focus on specific procedural skills (“tasks”) that may be vital to the treatment of the patient in that particular scenario (i.e. blood draws, intravenous catheter insertion, etc.). Nurse clinical experts and educators will continue to collaborate on the utilization and development of Web-based training in conjunction and follow-on curriculums using medical simulation that targets the development and sustainment of core competencies specific to each nursing practice specialty, as well as, those unique to our operational roles on the battlefield and within the fleet.

MEdSim: How have your nursing professionals’ lessons learned from supporting 10 years of war in Afghanistan and

MEdSim: Your “help wanted” list: What other advice do you have for the medical training systems community to help it meet your nurses learning needs?

RN: Medical simulation technology has clearly proven itself to be a very effective component to the education, training and ongoing professional development and clinical skills sustainment of today’s health care professionals. Students now entering the field of nursing are very familiar and comfortable with current technology as it is commonly used as an adjunct to clinical experience in their nursing programs. They also expect to see this technology used to enhance their continued professional growth

MEdSim: Anything else to add?

RN: In addition to the Navy Nurse Corps’ focus on clinical excellence as its cornerstone, we are also extremely committed to advancing the science of nursing practice through research and evidencebased practice to improve the health of our patients. Medical simulation technology opens up unlimited possibilities to expand nursing’s body of knowledge through research. Currently, there are nursing research proposals being developed and/or submitted for funding specifically geared toward medical simulation technology. We look forward to research outcomes surrounding this important learning modality. medsim

Examination of a simulated patient during Naval Medical Center San Diego's (NMCSD) command-wide mass casualty drill.

Image credit: U.S. Navy/Anastasia Puscian.

ISSUE 3.2012

(CPGs). Nurses serving in roles supporting our warriors have become extremely well-versed on these CPGs, not only utilizing them while in theater, but sharing their expertise. Returning nurses work to improve and tailor our pre-deployment training and serve as instructors for medical simulation training providing handson, customized education and training based on real-life scenarios incorporating the CPGs nurses will utilize within theater. The nurses who have received pre-deployment training that incorporates medical simulation have provided extremely favorable comments regarding their satisfaction with and effectiveness of this type of training.

Above

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Iraq influenced the type and scope of learning technologies they require?

RN: As I touched upon previously, Navy nurses provide medical support to our operational forces serving with Marines on the battlefield, forward operating bases and treatment facilities throughout Afghanistan, as well as, aboard Navy ships and amphibious vessels supporting maritime operations, and aboard hospital ships and within medical units providing care during humanitarian and disaster relief missions. They are also pivotal in the provision of care, treatment, and rehabilitation of our wounded warriors who have returned home. Medical simulation has become an essential and effective component in training and preparing our nurses for arduous assignments in support of our operational forces, as well as, the overall mission of Navy Medicine. Incorporating lessons learned based on wartime experiences brought back by those who have served in those roles has resulted in the development of numerous training scenarios incorporating medical simulation technology. Some of these include: Tactical Combat Casualty Care (TCCC), various scenarios incorporating knowledge and skills required in critical care and trauma arenas, en-route nursing care on rotary wing aircraft during patient transport and Operational Emergency Response Training.

Throughout the war, collaboration and resource sharing among all branches of service has continued to expand.

Within the medical departments, this collaboration has resulted in the development of the Joint Theater Trauma System (JTTS) Clinical Practice Guidelines

to improve the quality of care they are able to provide their patients. However, nursing is among the professions with a multi-generational workforce and those with significant experience in the field are attempting to rapidly come to terms with the fast-paced development and implementation of medical technology.

It is imperative to seek input from the “end users”, that is, the clinical personnel and educators utilizing the simulation technology. The more realistic and “user-friendly” the technology, the more likely the continued implementation of medical simulation technology will remain an important and viable component for continued learning and clinical skills sustainment.

At the rapid pace simulation technology is developing and being implemented, I also believe that medical simulation technology is here to stay.

As medical simulation continues to gain momentum, it will be imperative that we continue to invest the time and training necessary for our personnel to become and remain subject matter experts in curriculum development, as well as, operation of the medical simulators during training evolutions. Medical simulators are no different than any other advanced piece of medical equipment introduced into the work setting. It requires trained personnel who remain current in the technological advances of medical simulation to effectively operate the simulators. Personnel specifically dedicated to and trained in curriculum development and operation of medical simulators will ensure our healthcare personnel receive the maximum benefit from this state of the art training modality .

Left

Resident Surgical Training

Dr. Teodor Grantcharov poses with a mock patient in an operating room in Toronto.

Image credit: The Canadian Press/Nathan Denette.

Simulation Laboratory a Cutting Edge Tool in Training Surgeons To Be

By Helen Branswell, The Canadian Press.

ISSUE 3.2012

I

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t's a pivotal event that comes in the education of all would-be surgeons. At some point, medical students who plan to make a career of opening up and fixing other human beings have to make that first cut.

If Drs. Teodor Grantcharov and Vanessa Palter have their way, however, that first application of scalpel to skin will occur on a computer screen, not on the torso of a living, breathing person.

And not just the first cut. They believe surgical residents ought to achieve an established level of proficiency in a virtual operating room before they start plying their scalpel in a real OR. “There are studies that show that in the first 50 cases, the risk of major complications is significantly higher than after the next 30 cases. And all these studies are done on real patients,” says Grantcharov, an associate professor of medicine at the University of Toronto and a surgeon who specializes in minimally invasive procedures at St. Michael's, one of the university's teaching hospitals.

To Grantcharov, the idea of allowing surgical residents to operate before they've met a set skill level in a virtual OR is outdated.

Simulation tools are now available and are found with increasing frequency in medical schools across North America.

They provide an alternate route for surgical residents to climb the early – and riskfilled – part of the learning curve.

“I always found it ridiculous to talk about learning curves on real patients,” says Grantcharov, a towering figure decked out in clogs, scrubs and a Toronto Maple Leafs surgical cap.

“We want to see the learning curve in the simulation theatre or on the computer. Talking about learning curves of procedures on patients – I think it's unethical.”

And inefficient. Grantcharov and Palter – a surgical resident who is also working on a PhD – recently published a study showing that surgical residents who train first in a simulation lab significantly outperform colleagues who receive only standard surgical training.

The study compared University of Toronto surgical residents who completed a five-month long simulation training module to residents who received conventional surgical training. All the residents performed a laparoscopic right hemicolectomy – an operation where a tumour is removed from the right side of the colon using small incisions, not the large cuts commonly used for operations in the past.

The procedures were videotaped and graded by outside experts. Residents who had trained on the simulators scored an average of 16 points (out of 20) where surgical residents who didn't get the additional virtual training scored an average of eight.

The findings were published this month in the journal Annals of Surgery.

But the results were so persuasive the University of Toronto's medical school made the virtual training program mandatory for surgery students even before the study was published.

Grantcharov says the program was first offered in February and was hugely popular among students. He says it's critical to offer the virtual training as part of a curriculum; letting students work on simulators on their own doesn't achieve the goal.

The module they've developed compares students' efforts to those of expert surgeons, allowing residents to see where they need improvement. “So that way, instead of just mindless practice on the simulator, you're actually practising to a specific goal, to essentially be as good as the expert,” Palter says.

Dr. Steve MacLellan took the virtual training course. He says it made a difference to be able to practise in a lower stress environment.

“Not having a patient on the table, being able to think through the steps of an operation and physically do it with the simulators – I think it gives you a leg up in the operating room when it comes to actually operating on real patients for sure,” says MacLellan, who is now a clinical fellow at the University

The simulators have a pulse that can speed or slow. Their chests rise and fall as if they are breathing. They can sweat. They can bleed. They can even die – though Grantcharov says instructors monitoring a simulation will stop it before the virtual patient meets its virtual maker.

Studies have shown residents who “kill” their virtual patients can suffer a real crisis of confidence. Palter says it's easy to forget in these exercises that you aren't working on a real patient – the lessons are that true to the real-life experience. “It's very stressful,” she says.

Instructors watch simulations from behind one-way mirrors. They can intervene, tossing a wrench into the proceed-

ings by programming in an unexpected finding or complication. They can also speak for the dummies, projecting a moan, say, if a procedure would have caused pain.

Palter says training on the simulators doesn't simply raise proficiency levels among surgical residents – it also raises their confidence.

“I think knowing that you can do something already, in a dry run and a safe environment and knowing that you've been able to do it once certainly gives you the confidence in the operating room,” she says.

“But more importantly, it gives them the skills in the operating room. And our data show that.” medsim

www.MimicSimulation.com

VALUE

Reduces need for training robot; does not require expensive training instruments and materials; saves operating room time

EFFICIENCY

Encourages surgeon adoption of da Vinci ® system; frees up clinical robot for revenue-generating procedures

FLEXIBILITY

Quickly moves new surgeons up the learning curve on both S and Si platforms with customizable training options

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Proven, Highly Realistic Simulation Training for the da Vinci® Surgical System

SAFETY

Extensive, validated training prior to da Vinci ® robotic surgery can improve patient outcomes

21

ACCESS

Increases training access for residents, fellows and novice surgeons; minimizes proctor supervision

Mimic, dV-Trainer, MSim, and Mscore, are trademarks of Mimic Technologies, Inc. Intuitive Surgical and da Vinci are registered trademarks of Intuitive Surgical, Inc. dV-Trainer is not a product manufactured, sold or distributed by Intuitive Surgical, Inc.

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of Toronto studying a surgical sub-specialty.

For him, the biggest gain was in developing muscle memory, learning how the instruments worked and practising different tasks.

“I think it helped expand the repertoire of skills and provided an ability to test out some techniques that I may not have tried on a patient before.”

The idea of requiring residents to show they are competent before they are allowed to operate on people mirrors the approach taken by the aviation industry, where would-be commercial pilots have to prove their proficiency before taking to the skies. “If they fail they don't fly a real aircraft until they've passed,” Grantcharov says.

He acknowledges some surgical residents may never reach that level. A study he co-authored a few years ago in Denmark found that eight per cent of surgical residents did not show evidence of a learning curve.

“They did not get any better,” he says. “And I checked five years later ... what happened to these people because you can check it on the website of the Danish Medical Association, and none of them is a practising surgeon now.”

What will happen if that also proves to be the case with the University of Toronto surgical simulation program?

“That's a whole new question that I don't think we're ready to address yet,” he admits.

The simulation labs themselves offer a range of training opportunities.

Some allow residents to practise laparoscopic procedures, using tools connected to computers. On the screen are realistic looking computer graphics displaying, for instance, an appendix that needs to be removed. Manipulating the instruments, the residents can run through all the steps required to remove the organ laparoscopically.

Missteps provoke the types of problems they would in an operating room. If a student nicks surrounding tissue, the area will be infused with virtual blood.

The program measures how much blood loss the error triggered and how much discomfort the virtual patient would experience as a result.

In addition, simulation theatres contain what are known as full body simulators – life-like mannequins like Harvey, who belongs to St. Michael's.

Left

Confererence Report

Rollin J. (Terry) Fairbanks, MD, MS, (left) and Jeff Skiles discuss airline training and its application to healthcare.

Image credit: Joseph Prezioso, NPSF.

World Healthcare Focus on Patient Centered Care Editor, Judith Riess, gives a brief summary of medical conferences attended by Halldale staff.

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he Halldale Team has attended a number of medical conferences in varied locations during the past few months. While each conference had a different theme/s, different program and different international speakers they were all ultimately focused on patient care and safety. Better patient care and safety is the banner theme for the transformation of health care. Transforming healthcare through education and training of healthcare professionals using simulation was discussed at each conference with evaluation, feedback, and standardization of curriculum, devices and procedures being key components. New technologies that enhance diagnostic capabilities and medical training were discussed and demonstrated. At each of the conferences patient care and safety was a priority.

• Medical Technology, Training and Treatment, (MT3) Conference theme was Benchmarking Quality Care and Enhancing Patient Safety through Better Education and Training. Innovative solutions for healthcare education and training were provided by individual speakers, panelist and technol-

ogy demonstrations. Dr. Daniel Kelly, Sanford-Burnham shared his research in diabetes, heart disease and cancer that will someday lead to earlier detection, mitigation and hopefully eradication. Dr. Mark Bowyer, stated that medical education will be transformed through the use of simulation and gave specific examples of how trauma training via simulation has and is being transformed. Dr. Robert Rush shared the military's simulation based training centralization and standardization strategy which is being used in all military medical simulation centers.

Dr. Howard Champion’s presentation on open surgical simulation technology using VR demonstrated another advance in trauma training. Robert Soto raised issues about research and evaluation of simulation and its effects on learning.

Dr. Dan Clinchot explained the steps taken and the principles used to revise the Ohio State Medical undergraduate curriculum and Angela TenBroeck and two of her high school students shared the rewards of early anatomy training for students. A distinguished panel of nurses led by Tom Doyle shared their experiences in simulation development

in nurse education programs. Ruby Wesley Shadow, Valerie Howard, Sue Crockett and Major Chad Corliss discussed the role of simulation in their respective center‘s education programs and what they believe the future of simulation training will be. Dr Howard discussed the rapid growth of simulation technicians and how centers could not run without them and suggested that someone develop a “Leadership in Simulation Instruction and Management“ course and train the trainers for center directors who she says are nurses, doctors, not necessarily teachers.

Dr. Al Moloff’s panel focused on disaster management for combat and civilian casualty care and Dr. James Geiling shared his Haiti and Pentagon experiences and discussed the planning and preparation needed to confront a disaster situation.

Four medical simulation center directors shared how their centers were organized, the centers’ design, curriculum development, return on investment strategies and performance assessments.

Dr John Armstrong stressed the importance of planning, curriculum design and development and how each step in the process needs to be verified and validated from core objectives, through attainment of knowledge and skills to patient outcomes. He stated that 10,000 iterations of deliberate practice makes an expert, therefore we need maintenance of certification and standardization of procedures; Dr. Don Combs shared Eastern Virginia’s ROI model for their simulation center and declared that for smaller medical schools that did not receive big research dollars, collaboration was key to survival. They are setting up a National Center for Collaboration in Medical Modeling and Simulation; Dr. John Schaefer discussed his strategy and steps in developing MUSC’s statewide network of seven simulation centers and 20 affiliates across South Carolina. He said simulation is key to saving dollars. As an example, he said it cost $30 per minute to train in the OR and $65 an hour in a sim lab; Paul Pribaz outlined Northwestern’s

L-R Major Chad Corliss, Ruby Wesley Shadow, Sue Crockett, Valerie Howard and Tom Doyle, discussed simulation in nursing.

Image credit: Terri Bernhardt.

symptoms because the mother told him he had seen a certain pediatrician. Dr. Okuda trusted the pediatrician, knew he was an excellent doctor and because he was getting phone calls, and because he was distracted by other ER emergencies failed to gather all the facts and misdiagnosed the patient. The skit was replayed with the mother being much more insistent about symptoms and the child never being this listless or missing school and the proper diagnosis was made. By using a simulation vignette and audience participation attendees experienced firsthand how simulations can be used to teach new concepts.

Was it Really a Miracle on the Hudson? In the plenary session Jeff Skiles the first officer on US Airways Flight 1549 when it made an emergency landing in the Hudson River offered insights as to why the famous incident was not a miracle, but the result of years of culture change and safety advancements in aviation. Skiles and Rollin J. (Terry) Fairbanks, MD, MS, an emergency physician, human factors engineer/safety scientist, and a private pilot discussed safety from the perspective of the aviation industry and the health care environment. Terry said it was hard to prepare teams for codes in hospitals because you didn’t know the other team members. Skiles said he had never met, nor flown with “Sully” until that flight. He stressed that each knew exactly what they had to do, had split seconds to do but were so well trained that it came naturally. He talked about how the airline industry reached stand-

ardization in training and why it was so important. Fairbanks said as a pilot and doctor the same systems approach and standardization could and should be used in healthcare and he talked about central line as an example. He said checklist were being used in ORs . Skiles talked about near miss reporting and how crucial it was in the airline industry and Fairbanks felt that would be more difficult in healthcare because of malpractice, etc.

They both agreed a number of lessons learned in aviation could be used very successfully in healthcare.

The Patient Safety Culture Proposition presented by David Marx, chief executive officer, Outcome Engenuity, LLC, introduced attendees to key concepts about our ability to collectively produce better outcomes and the five skills: 1. Values and Expectations; 2.

System Design; 3. Behavioral choices; 4. Learning systems; and 5. Justice and accountability needed to produce those outcomes. He related each to a hospital incident and how it could be handled.

Lucian Leape Town Hall was a roundtable discussion led by an NPSF executive, Leape and representatives from the Department of Health and Human Services and the Center for Medicare and Medicaid Innovation. Attendees were asked to identify new approaches, innovations and methods to create and sustain improvements in culture, process, and outcomes by sharing their experience and what they were doing in their hospitals, schools or medical clinics.

The conference breakout sessions covered six themes: Embracing the Team, Engineering Workflow and Leveraging Technology, Hot Topics, Integrating Care Continuum, Reforming Healthcare/Advancing Quality and Safety and Shaping the Culture. Hot Topics included Improving Patient Outcomes through

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Above

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assessment criteria for clinical simulation and training. Through the use of their catheter related bloodstream infections simulation training they reduced infections from 3.2 per 1000 to 0.5 per thousand and prevented ten incidents at a savings of $82K per incident.

Dr. Richard Satava’s Medical Technology panel included Dr. Eric Allely, Dr Ben Bodeker and Dr. Christopher Basciano. Dr. Satava, a simulation pioneer, stressed standardization and the fact that to proceed we must make errors.

With simulation errors can be made and lessons learned without harm. He talked about the development of surgical simulation standards(ASSET) and the development of a fundamental robotics curriculum(FRS) that are being developed with membership of all key stakeholders; Dr Eric Allely, a trauma surgeon, said the greatest need is in chronic care.

There are approximately 5,000 lab test that a medic/doctor could order and that there is no way to interpret all the data received. They have developed a system to provide expert interpretation of complex lab data and it is being tested in five major hospitals across the US; Dr. Ben Boedeker demonstrated live intubation training conducted at a Spanish army military site in Madrid and taught to an MT3 conference attendee.

John Qualter, BioDigital, David Hadden, Thera Sim, and Ed Sims, Vcom3D showcased advancements in gaming technology for healthcare. Dr. David Metcalf demonstrated I-phone training capabilities and stated that future use will be phenomenal since the US has 100 per cent coverage.

• National Patient Safety Foundation's 14th Patient Safety Congress had four plenary sessions: Engaging Patients: A Simulation; Was it Really a Miracle on the Hudson?; The Patient Safety Culture Proposition; and The Lucien Leap Town Hall.

Engaging patients was a skit sponsored by Kaiser, put on by doctors and nurses, Haru Okuda playing the harassed emergency room physician, the young patient (dummy) mother (a nurse) and an emergency room nurse from Kaiser assisting. The interactive experience demonstrated how to help patients be more involved with their own or their family’s healthcare, in particular learning about the possibility of misdiagnosis. (Dr. Okuda mis-diagnosed the young man’s

Confererence Report ISSUE 3.2012 MEDSIM MAGAZINE

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Inter professional Education and Leadership. Many of the sessions dealt with teamwork, building teams, strategies and tactics to improve safety and strategy and tactical steps needed to develop a first class healthcare system • SESAM 2012’s conference program focused on safer practices in healthcare with three main themes: Patient safety – the connection between patient safety and simulation; Education – the educational aspects behind simulation; New Frontiers – simulation in healthcare in the next decade There were three keynote speakers and each addressed one of the themes.

Tanja Manser addressed patient safety by reviewing examples of patient safety research focusing on challenges in methodological and measurement issues and the implications for simulation based research and simulation training. She compared the audience to snails (those who wanted to hold back and make sure everything was working properly before rushing headlong into development, change, etc.) and the other half- evangelist (who would rush headlong into new pursuits and be optimistic that it would all sort itself out). She said healthcare communities are using simulation to improve outcomes. However, according to her team performance research, 30 per cent of the problems/incidents are related to teamwork, coordination and communication.

Suzan Kardong-Edgren talked about New Frontiers. She highlighted many of the technological advancements that are available to us. An example she used was using an imaginary student (avatar) to teach ethics. Kardong-Edgren said avatars are becoming so advanced that one day they may replace standardized patients. She said she was definitely an evangelist and got very excited about all the apps that were available. She referenced the University of Minnesota’s Real Cause Analysis learning program for students and the University of Washington’s Team Challenge programs for students.

She said that you can now play screen based games in Second life and how students today naturally work in teams.

She feels future nurses, doctors and other healthcare professionals will just naturally work in teams.

Charlotte Ringstead discussed Education. She talked about the benefits of simulation based training, and effects on learning outcome, quality of practice and

patient safety. She felt if you are going to discuss healthcare you have to realize that it is a huge, complex, complicated system that is unaware of its power and potential. Ringstead said one of the areas we are not sure of in simulation training is post training transfer and adaptive training transfer. The results need to be verified and validated. She also stressed that in simulations, learners should be learning from errors not practicing error avoidance.

In addition to the keynote sessions there were 200 presentations or poster sessions from 25 countries covering the broad categories above but also dealing with simulation scenario development, curriculum to return on investment in developing a simulation center. Presenters discussed curriculum development, standards, evaluation, knowledge transfer, learning objectives, decision making, team training and CRM .There were some outstanding research projects presented by young doctors. One was on patient noncompliance and how you try to change behaviors and another dealt with using simulation to train doctors in acute care.

• UK Simulation Nursing Education Conference’s theme was International Simulation Standards: The Impact on Educators. The conference featured master classes, concurrent sessions, interactive workshops, and three distinguished keynote speakers. Dr. Bryn Baxendale, Director of the Trent Simulation and Clinical Skills Centre (TSCSC) and President of the Association for Simulated Practice in Healthcare (ASPiH) gave an excellent presentation talking about perceptions and attitudes and how thinking must change if we are to develop a patient centered healthcare system. Professor Judith Ellis MBE, Executive Dean for Health and Social Care at London South Bank University discussed the changes in nursing education that simulation has wrought but the need to verify and validate knowledge transfer. She discussed changes in the UK system and the impact it will have on training. Dr Jay K. Ober, National Director of Nursing Operations and Regional Dean of Nursing, Education Affiliates Inc., USA. Discussed how you motivate and train with the use of simulation and his experience in setting up networked simulation training facilities.

All three conference speakers discussed safe practice in fundamental aspects of care, high fidelity simulation training for patient safety and perceptions and atti-

tudes that have to be addressed to transform healthcare.

The master classes were round table discussions led by a nurse or simulation technician who facilitated discussion and answered questions on setting up simulation centers, key players’ roles and responsibilities and how you motivate practitioners to use.

Concurrent workshop sessions included sharing best practice and innovation through a clinical skills network to debriefing by using a toolkit of techniques. Others included standardization of training and assessment tools to a pilot study of low fidelity simulation for first year nursing students • International Association of Clinical Simulation and Learning Conference served notice that the nursing community is seeking to expand its use of simulation throughout its continuum of learning, for individual and team training skills.

A spirited and well-received conference keynote by Jennifer Arnold, M.D., provided a compelling case for the use of simulation in the healthcare community’s learning environments. Arnold parsed no words when she built a case for simulation as one tool to help increase patient safety, bolster learning efficiencies and obtain other returns on investment.

The conference schedule of events provided insights into the rapidly evolving state-of-the-art of simulation. Indeed, one of the many lessons learned from the conference, was the expanding scope of the term “simulation.” While the community uses part-task trainers and higher fidelity training devices, it is also grappling with the promise of virtual worlds and other technologies.

To the conference organizers’ credit, delegates were able to attend breakout sessions for an array of topics ranging from simulation theory to the brick-andmortar aspects of planning and building a simulation center. Indeed, one of the more interesting sessions was a discussion on the planning and design, of medical simulation laboratories and centers to meet today’s needs and 20 years beyond.

Leland Rockstraw, Ph.D., RN and Jonathan Fishman, M. Arch., noted these facilities must be built to accommodate current and planned learning technologies, and instructional requirements, in particular, accommodating after action reviews. medsim

MEDICAL SCHOOL EDUCATION AND TRAINING

New Methods of Early Surgical Training Using the Human-Worn Partial Task Surgical Simulator in Scenario-Based Stress-Immersion Training Bonnie B. Hunt, MS IV, 2LT, USA, Van G. Wall, MS III, 2LT, USA, Anthony J. LaPorta, MD, FACS, COL (Ret.), USA, Robert M. Rush, MD, FACS, COL, USA, Alan Moloff, DO, MPH, COL (Ret.), USA, Jon Schoeff, MD, FACS, LCDR, MC, USN, Michael Tieman, MD, FACS, Mark S. Lea, MD, FACS

Background Rocky Vista University College of Osteopathic Medicine (RVU), in Parker, Colorado, has over 100 Army, Navy, and Air Force students enrolled through the Health Professions Scholarship Program (HPSP). This represents the largest population of military medical students outside the Uniformed Services University of the Health Sciences in Bethesda, Maryland. The Military Medicine Honors Track (MMHT) at RVU is a distinctive medical school program that is tailored to the unique careers of military physicians. This year, the MMHT curriculum for second-year medical students (MS2) concluded with a week-long Intensive

Above Dr. Mark Lea teaches second-year military medical students using the Cut Suit in RVU’s hyper-realistic operating room.

Image credit: Rocky Vista University.

Surgical Skills Course (ISSC) that sought to better prepare students for clinical rotations through hyper-realistic scenario-based stress-immersion training with the use of a new surgical simulator, the Human-Worn Partial Task Surgical Simulator (“Cut Suit”). The ISSC reduced stress and improved performance in RVU’s HPSP MS2s, benefiting not only the students’ acquisition of skills and knowledge, but also increasing the quality of patient care.

Strategic Operations, Inc. (STOPS) initially developed the Cut Suit for Tactical Combat Casualty Care (TCCC) training and later as a surgical simulator for medical education. Individual components of the Cut Suit simulate the organs of the thoracic and abdominal cavities, neck, and proximal lower extremities. A

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be lessened by a firm grasp of basic procedures and surgical technique. Reducing the stress to a beneficial level is critical to effective learning. Ultimately, improved medical student training leads to improved safety and quality of patient care in hospital settings and especially in austere combat settings experienced by military physicians.

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delicate balance exists between a beneficial stress response that enhances memory and recall and a detrimental high stress response that impairs the ability to perform learned skills. A weeklong Intensive Surgical Skills Course at Rocky Vista University College of Osteopathic Medicine is using a groundbreaking surgical simulator to improve learning outcomes in high-pressure situations while mitigating negative stress effects.

Attention, decision-making, and response time of medical personnel are compromised under high levels of stress, but can be reduced with appropriately learned coping skills. Repetitive training in stressful situations enables people to override the negative effects of stress, optimizing performance under challenging conditions.1 This is particularly true for medical students as they develop advanced skills during early exposures to surgery and emergency medicine in their third and fourth-year clinical rotations. The stress of these exposures can

MEDICAL SCHOOL EDUCATION AND TRAINING

Table 1 Weighted average of all students’ daily self-reported

Table 2 Above The Cut Suit (Human-Worn Partial Task Surgical Simulator) prior to the skin covering put on (left), and after skin and uniform are put on.

Image credit: Rocky Vista University.

Kevlar shield behind the simulated organs protects the wearer from surgical instruments. The Cut Suit is complete with organs, vessels that bleed, accurate odors, and an outer layer of skin.

Training scenarios utilizing the Cut Suit provide the realistic stress of performing procedures on a live patient, whether in a simulated battlefield, emergency department (ED), or operating room (OR). All organs and the skin can undergo repeated simulations of open operations and lifesaving procedures. For example, a penetrating abdominal trauma can be opened to reveal bleeding and injured bowel, the appropriate vessel and bowel repairs can be made, the skin can be closed, and all organs and skin involved can then be repaired and reset with the pathology of the next training case. The Cut Suit facilitates learning and management of common causes of preventable death on the battlefield, including tourniquet application and arterial ligation/ clamping in extremity hemorrhage, surgical cricothyroidotomy for airway control, needle decompression and tube thoracostomy for pneumothorax.2-3

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The Cut Suit fills a major gap in simulation technology by providing a training model for open surgical procedures. Students learn surgical techniques of organ exploration, repair and resection, hemorrhage control, suturing and stapling organs and skin on a model with accurately represented pathology, bleeding, and surgical diseases’ smells.

The week-long ISSC enrolled twenty-two HPSP students at the end of the MS2 year. A hyper-realistic simulated ED saw 40 patient scenarios, encompassing commonly seen cases ranging in acuity from respiratory infections to acute cholecystitis and traumatic burns. Students alternated playing the roles of patients and emergency medicine (EM) residents. After performing histories and physicals and ordering appropriate labs and imaging (prepared test results were provided by the patient), patients were triaged for ED management or surgical intervention. The EM resident presented the case to the EM attending physician and proceeded accordingly.

If the patient required surgery, the patient was taken to the hyper-realistic OR while wearing the Cut Suit. Another student

acting as surgical resident was first assistant to the attending physician during the operation performed on the Cut Suit. Surgical procedures included appendectomy, cholecystectomy, tumor resections, splenectomy, penetrating abdominal trauma, control of hemorrhagic liver, tube thoracostomy, thoracotomy and exploratory laparotomy for traumatic rupture of the aorta.

During OR cases, all students were present, either assisting or observing, and were expected to be prepared to discuss all aspects of the case the following day during morning report.

Both the ED and the OR hyper-realistic scenarios were overseen by the corresponding attending physicians who contributed to creating accurate levels of stress. Students perceived stress and confidence levels were tracked daily with student surveys.

The Cut Suit provides a model for simultaneous assessment of technical and non-technical skills required of surgical teams.4 Technical skills include suturing, instrument tying, two-hand knot tying, peripheral IV access, tube thoracostomy, and surgical cricothyroidotomy. Non-technical skills include teamwork, effective and respectful communication, leadership, and performance under stress.

Students received didactic and functional instruction in surgical instruments identification throughout the week. Education in pathophysiology and management of surgical disease was achieved through student presentations on assigned topics.

Knowledge of surgical instruments and surgical disease, were assessed by a written pre-test examination the first day and a post-test on the final day of the ISSC.

Outcomes The impact of stress on learning was evaluated through daily surveys in which students reported their perceived stress level

Table 3 Technical Skill Evaluation

Instrument Two-hand Mesenteric Peripheral Tube

Surgical

Tie

Cricothyroidotomy

Knot Tie

Suturing

IV Access

Thoracostomy

Pre-test 73% 55% 82% 55% 18% 73% Post-test 95% 91% 100% 100% 100% 100% Table 4 Individual Surgical Instrument Identification

dent presentations, was given as a pretest and post-test (Table 5). A modest yet statistically significant improvement in scores was observed (paired t-test, p < 0.0025) in the pre-test average (43.0%) versus post-test average (49.3%).

Discussion The data we collected supports our hypothesis of improved confidence and technical and non-technical proficiencies from training under stress with hyper-realistic surgical simulators. We anticipate administrating the ISSC for second-year military students each

year, as well as collaborating with other medical schools nationally to standardize the course for use on a broader scale.

However, aspects of the ISSC need continuing development. To complete the data set of our first course, we will be following board scores of participating MS2s, as well as objective (shelf exam scores) and subjective (preceptor evaluations) measures of their performance on MS3 general surgery rotations, all of which will be compared to control sets of students who were not enrolled in the ISSC.

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Table 5 Individual pre-test (Day 1) and post-test (Day 5)

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in each training component, total overall perceived stress level, perceived impact of stress on learning, and overall confidence for task performance (Table 1).

Throughout the ISSC, we observed an inverse relationship between stress and confidence. With each day of exposure to stressful training scenarios, students reported feeling incrementally less stressed and more confident.

We utilized 360° evaluations adapted from the ACGME Competencies and Toolbox of Assessment Methods5 to evaluate the non-technical proficiencies of students. Non-technical skills were evaluated by peers in both patient and co-worker roles, and by attending physicians (Table 2). A 1-5 rating scale assessed five non-technical skills: teamwork, effective communication, respect of co-workers and patients, facilitation of knowledge, and leadership skills.

Studentsâ&#x20AC;&#x2122; ratings increased each day of the ISSC, showing improvement in nontechnical skills.

Technical skills evaluated during the ISSC included suturing, instrument tying, two-hand knot tying, peripheral IV access, tube thoracostomy, and surgical cricothyroidotomy. For each of these measures, students were given a pass/ fail practical examination on the first day of the ISSC and again on the final day (Table 3).

Students received both didactic and functional instruction in identifying surgical instruments throughout the ISSC, with a fill-in-the-blank pre-test and posttest evaluation (Table 4). In comparison to the pre-test scores and to the scores of a control group of 22 third-year students (MS3) who took the same instrument exam after completing the required four-week general surgery core rotation, the post-test scores show that the ISSC prepared students to be a functional member of an OR team by understanding instrumentation, significantly exceeding the preparation achieved in core MS3 rotations.

A written examination covering pathophysiology and management of surgical disease, as taught through stu-

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Additionally, because of its preliminary nature, the ISSC was rapidly evolving during the week’s planning stages.

As a result, not all of our evaluation metrics were maximally aligned to reflect the course objectives and offerings. Therefore, we will improve the metrics to more closely reflect objectives in future courses by doing the following: Baseline stress testing was measured using the State-Trait Anxiety Inventory (STAI)6 intended to evaluate stress while canceling out individual’s baseline stress levels, but we used our own five-point stress survey to evaluate the daily training stress, and were thus unable to incorporate the baseline stress levels into our data. In the future, the STAI will be used consistently.

In the 360° Evaluation, patients used a different evaluation form than peers and attending physicians. This was meant to reflect aspects of physician behavior that differ in importance for patients and for medical professionals, but it proved difficult to incorporate the patient evaluation into a combined 360° Evaluation from all three perspectives. In the future, the patient evaluation form will be revised for greater compatibility with the overall 360° Evaluation.

The evaluation of technical skills

Above A student wears the Cut Suit while presenting as a patient with extremity hemorrhage in need of treatment.

Image credit: Rocky Vista University.

could be improved by using a more complex metric than pass/fail. The revised evaluation checklist would rate the student on individual aspects, such as procedure order, technical accuracy and timing.

The surgical knowledge written exam shows the greatest need for refinement. While we did see statistically significant improvement (Table 5) in scores, the improvements were modest. We feel this reflects greater emphasis on technical and non-technical skills rather than textbook knowledge. The smaller margin of improvement in textbook knowledge than technical and non-technical skills suggests that in a one-week period, the ISSC may not be able to effectively teach both technical and non-technical skill training and also textbook knowledge. We propose that the teaching of textbook surgical knowledge is redundant to the existing medical school curriculum, and the ISSC is better suited to

focus on developing strength of technical and non-technical skills.

Going forward, our primary metrics will be the STAI for baseline and training stress evaluation, a revised 360° evaluation that incorporates the patient perspective, a more comprehensive technical skill evaluation, continued use of the surgical instrument exam, and long-term follow-up evaluation of participating students as they progress in medical training. Additionally, a control group of students involved in the traditional medical school curriculum but not the ISSC will be incorporated.

Conclusion The ISSC at RVU is the first medical school program to use the new open surgical simulator, the Cut Suit, in hyperrealistic stress-immersion training to improve second-year military medical student preparedness to overcome the negative effects of stress during medical education and practice. While there are ways that we plan to improve the ISSC, the initial outcomes show clear improvement in all metrics. This provides support for expanding this training at our medical school and in collaboration with other medical schools and residency programs throughout the nation. medsim

References 1. Harvey A, Bandiera G, Nathens AB, LeBlanc VR. (2011) Impact of stress on resident performance in simulated trauma scenarios. Journal of Trauma 72(2):497-503.

2. Bellamy R. (2007) A note on American combat mortality in Iraq. Military Medicine 172(10):1023.

3. Holcomb J, Stansbury L, Champion H, Wade C, & Bellamy R. (2006) Understanding combat casualty care statistics. The Journal of Trauma: Injury, Infection, and Critical Care 60(2):397-401.

4. Arora S, Sevdalis N. (2010) The impact of stress on surgical performance: a systematic review of the literature. Surgery 147:318-330.

5. Swing S, Bashook P. (2000) ACGME/ABMS joint initiative toolbox of assessment methods. ACGME Outcomes Project. Version 1.1:1-19.

6. Spielberger CD. (1977) State-trait anxiety inventory for adults. Retrieved May 30, 2012 from publisher website.

Website: http://www.mindgarden.com/products/staisad.htm.

Florida Hospital, Mimic Partner for da Vinci Training – A new collaboration between Florida Hospital Celebration Health and Mimic Technologies will add the latest robotic simulation training technology to the now world-recognized Nicholson Center. The agreement will result in improved surgical training for physicians using the da Vinci robot.

Mimic Technologies, the company responsible for da Vinci robot simulation, has provided the latest simulation technology to Florida Hospital to help meet the demand for better training.

Mimic will help develop simulationbased curricula that will accelerate the adoption of the latest robotic technologies and techniques. Research and development projects focused on medical robotics will advance training and innovation for the global community. The Nicholson Center headquarters is located at Florida Hospital Celebration Health, Celebration, with additional locations at Florida Hospital, Orlando and numerous other Florida Hospital campuses and international facilities.

The new simulator technology will also reduce training time spent on the actual da Vinci device, freeing up the surgical robot for elective patient surgeries. Robotic simulation training also reduces costs, as simulation training does not consume disposable instruments or training material. There is also the potential for improving the efficiency of novice surgeons when performing their first robotic cases. The comparisons listed here are similar to the savings resulting from laparoscopic simulation training, as demonstrated by the Frost & Sullivan ROI study for Medical Simulation Training.

Above Mimic Technologies will provide Florida Hospital with numerous dV-Trainers to support robotics classes.

Image Credit: Mimic Technologies.

iPad-based Clinical Decision Support System for CHRISTUS St Michael’s – The Center for Medicare and Medicaid Services (CMS) announced that CHRISTUS St Michael’s Health System in Texarkana, Texas has been awarded $1.6 million for an Integrated Nurse Training and Mobile Device Harm Reduction Program (INTM).The INTM system is an iPadbased clinical decision support platform that utilizes advanced analytics.

The INTM is conceptualized, developed, and piloted by Ringful Health, an early-stage health technology company based in Austin, Texas. The firm employs teamwork-based solutions to help hospitals and communities improve

healthcare outcome, patient safety, and reduce cost through mobile and decision support technologies. The CMS recognizes that this innovative platform will save Medicare millions from just a single hospital in only three years.

UniHealth Grant for Simulation Training – Providence Little Company of Mary (LCM) Medical Centers in San Pedro and Torrance, California was recently awarded a $991,770 grant from the UniHealth Foundation to fund a three-year program of Interdisciplinary Simulation to Advance Quality & Safety (ISAQS).

The funds will be used to train physicians as simulation faculty; provide advanced training for registered nurse simulation faculty and support the advancement of physicians, nurses, pharmacists, therapists and technicians.

The grant follows a previous multi-year award from the UniHealth Foundation, which focused on the needs of nursing.

Training scenarios, based on real

ISSUE 3.2012

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

29 MEdSim Magazine

News & Analysis

Medical News

News & Analysis ISSUE 3.2012 MEDSIM MAGAZINE

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patient situations, will incorporate all aspects of a patient’s medical care from the physician, nurse and therapist.

Pennsylvania Hospital Adds New Patient Simulators – The Medical Skills Learning Center at Conemaugh Health System’s Memorial Medical Center in Johnstown, Pennsylvania added a toddler patient simulator and an infant patient simulator to the medical center’s education training program.

The new child simulators will allow medical training for Pediatric Advanced Life Support, Advanced Pediatric Life Support, Emergency Nursing Pediatric Course and Team Code Training. Skills that are practiced on the simulators include ventilation, chest compressions, ECG rhythm monitoring, defibrillation, chest tube insertion, IV and IO insertion, needle decompression, intubation and pulse palpitation.

CMU’s College of Medicine Opens Admissions – Central Michigan University’s College of Medicine in Mount Pleasant, Michigan is now accepting online applications for its inaugural class. Students will begin course work in the summer of 2013.

CMU’s first class of students will have the opportunity to learn in a brand new, state-of-the-art facility, featuring clinical exam rooms, group study areas, and simulation and anatomy labs. The $24 million, 60,000-square-foot building addition is designed for silver-level LEED certification from the U.S. Green Building Council. This new medical college will help to fill a critical shortage of physicians in the region, particularly primary care physicians and those practicing in rural areas. This shortage is expected to increase to 6,000 physicians statewide by 2020.

SSIH launches new certification program – The Society for Simulation in Healthcare (SSIH) has launched its new pilot program to certify healthcare simulation educators. Individuals who complete the certification process will receive their Certified Healthcare Educator (CHSE) endorsement. The CHSE pilot project is currently accepting 200 applicants at a cost of $350 per applicant. To qualify, applicants must have two-years of healthcare simulation experience in education, research or administration.

For more information visit ssih.org/certification.

Above Sir Bruce Keogh (r) received a tour to meet staff and see demonstrations of the facilities.

Image Credit: Sheffield Teaching Hospitals NHS.

New Medical Studies Obese Benefit from Minimally Invasive Appendectomies – Obese patients who need to have their appendixes removed fare better after a minimally invasive surgical procedure rather than an open operation, according to a new study published in the July issue of the Journal of the American College of Surgeons.

While the traditional open operation (appendectomy) and minimally invasive procedure (laparoscopic appendectomy) are known to have similar outcomes for people of normal weight, surgeons at the University of Southern California’s Keck School of Medicine found that obese patients had fewer complications 30 days after a minimally invasive laparoscopic operation, in which surgeons make one to three small incisions in the abdomen and remove the appendix through one of the small openings. The obese patients had longer hospital stays and higher rates of infectious complications if they underwent the open procedure, whereby a surgeon removes the appendix through a 2-to-4-inch incision in the right side of the abdomen.

“There are early studies that suggest the laparoscopic approach may be less risky in obese patients, but there’s not much recent information available to strongly prove it,” said lead study author

Rodney J. Mason, MBBCh, FACS, associate professor of surgery at Keck School of Medicine.

New International Sim Centers UK’s Royal Hallamshire Hospital opens new medical training center – One of the UK’s’s top health bosses has opened a hi-tech education centre in Sheffield to train the next generation of medics. Sir Bruce Keogh, medical director of the National Health Service, yesterday launched a new £3.5 million clinical skills centre at the Royal Hallamshire Hospital. The unit will be used to teach specialist skills to student doctors, nurses and midwives, as well as more experienced doctors.

The state-of-the-art centre uses simulation equipment to allow staff to practise techniques thoroughly before working with patients. Rooms can be kitted out to simulate an entire operation or medical emergency, with hightech dummies which react to doctors’ treatments. Other suites can be used to develop specific skills such as brain surgery, stitching and neonatal care.

New University Simulation Center Opens in Australia – life-sized medical manikin that can repeatedly give birth will be used to teach the next generation of medical students at a new University training centre at the John Hunter Hospital in New Lambton, Australia.

The $2 million Chameleon Clinical Skills Training Centre that officially opened this month will be used by University of Newcastle and University of New England students enrolled in the

gathered for a groundbreaking ceremony to commemorate the start of the initial phase of an extensive expansion of the St. Maarten campus.

The first phase of the campus project, budgeted at around $30 million, will include construction of two new academic buildings housing an anatomy lab, clinical skills training lab, and simulation center, as well as additional study and learning spaces for students.

It is the single largest building project in the history of DeVry, which acquired AUC last summer and immediately committed to significant investments in the campus infrastructure. The two new academic buildings are slated for completion by August 2013, in time for AUC’s fall semester.

New US Sim Centers

Nursing Sim Centers SWOSU Receives $75,000 for Nursing Simulation Lab – Dr. Carl and Sandra (Combs) Hook have donated $75,000 to the Southwestern Oklahoma State University Foundation to establish the Dr. Carl and Sandra Hook Nursing Simulation Lab in the School of Nursing on the SWOSU campus in Weatherford.

The state-of-the-art lab will feature eight manikins that simulate real, living patients – including four Nursing Annes,

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ISSUE 3.2012

Columbia University Med Center to Build Education Building – Columbia University Medical Center (CUMC) is planning to build a new, state-of-the-art medical and graduate education building on the CUMC campus in the Washington Heights community of Northern Manhattan, New York.

The new building is a 14-story glass tower that will incorporate technologically advanced classrooms, collaboration spaces, and a modern simulation center, all reflecting how medicine is and will be taught, learned and practiced in the 21st century. Construction is expected to begin in early 2013 and will take approximately 42 months. The Medical and Graduate Education Building will be used by students from all four CUMC schools (Physicians & Surgeons, Nursing, Dental Medicine and the Mailman School of Public Health), and the biomedical departments of the Graduate School of Arts and Sciences

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Bachelor of Medicine Joint Medical Program (JMP). Chameleon Centre Manager Jan Roche said the Centre, equipped with three simulation laboratories, replicated the full spectrum of medical scenarios from medical emergencies to obstetric cases.

Singapore’s Newest Medical School Unveils Simulation Training – Singapore’s newest medical school, Nanyang Technological University’s Lee Kong Chian School of Medicine, unveiled its new simulation technology training center that will be ready when the first batch of medical students starts courses in August. Students will get to perform surgery on life-like prosthetics of human organs, complete with simulated bleeding.

With simulation training a cornerstone of its medical training, the Lee Kong Chian School of Medicine hopes to cut down on the amount of lectures and seminars, to make way for more interactive and practical training.

New Medical sim training centre in Regina, Saskatchewan – The Hospitals of Regina Foundation and the Regina Qu’Appelle Health Region recently unveiled their new Dilawri Simulation Centre this June. Located in Regina General Hospital, the cuttingedge training facility allows med students to practice procedures on robotic dummies that are programmed to act, feel, and sound like real people.

One mannequin replicates the labour and delivery of a baby. Down the hall another machine replicates laparoscopic surgery.

The project was funded through the ministry of health, with the help of a $1.6 million donation from the Dilawri Foundation. Health Minister Dustin Duncan says the centre should make Regina more attractive when recruiting physicians. Duncan says it should also help with retention. Numbers show a physician is more likely to stay in the community where they trained. Those added benefits aside, the Health Region says the number one goal is achieve more positive patient outcomes American University of Caribbean Expands Medical Ed Facilities – The American University of the Caribbean School of Medicine (AUC) marked a new chapter in its history when members of the St. Maarten government, AUC leadership, and officials from DeVry Inc.

News & Analysis

one Nursing Kelly, one Nursing Kid, one PEDI Blue Baby and one Nursing Baby.

A Nursing Anne is for clinical training in women’s health, obstetrics, post-partum, wound assessment and care, and general patient care. The Nursing Kelly is designed for scenario-based training of the care and management of a wide variety of in-hospital patients.

University of Texas Opens Nursing Simulation Center – The University of Texas in Antonio opened a new $3.9 million Simulation Center and Clinical Learning Lab for its School of Nursing.

The 7,281-square-foot simulated hospital features a wide variety of settings, including a trauma center, intensive care unit, maternal/child center, pediatric care suite, ambulatory care suite and home health setting. Nursing students and interprofessional teams of students and residents will use the center to learn to appraise and respond to unique clinical scenarios and evaluate their responses.

Above Lisa Cleveland, Ph.D., RN, IBCLC, demonstrates a newborn simulation mannequin at UT’s Simulation Center and Clinical Learning Lab. Image Credit: UT Health Science Center.

ISSUE 3.2012

New Curricula

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New Simbionix Training Curricula – Simbionix USA Corporation can now provide a series of simulation-based curricula to customers of the LAP Mentor, GI Mentor, BRONCH Mentor and the VirtaMed HystSim. The simulator curriculum is an important contributor to resident learning and to the success of skills centers. the curricula cover various multidisciplinary specialties, made available via MentorLearn, the company’s web-based Simulator Management System.

Currently available curricula for the LAP Mentor include, the Imperial College Laparoscopic Cholecystectomy Training Curriculum and the Laparoscopic Surgical Skills (LSS) Curriculum developed by the LSS, an initiative by the European Association for Endoscopic Surgery. The curricula are suitable for all surgical specialties involving laparoscopic procedures.

Elsevier, CAE offer New Nursing Sim Curricula – Elsevier, a provider of scientific, technical and medical information products and services, and CAE Healthcare, have announced a new electronic nursing education solution to be made available in July.The new offering features evidence-based scenarios fullyprogrammed for CAE’s METI line of

human patient simulators, including an integrated electronic health record and a library of teaching support resources to guide the student through every step of simulation.

This is the first product to result from the Elsevier-CAE collaboration, announced in May 2011. Elsevier and CAE Healthcare have combined CAE’s METI human patient simulators with Elsevier’s suite of nursing simulation products, including the Simulation Learning System. This online toolkit helps instructors and facilitators effectively standardize and incorporate simulation into their nursing curriculum.

New EKG Training Course – Medical Training and Simulation LLC has released a free, interactive EKG training course. The course is available on the website: http://www.practicalclinicalskills.com/ekg.aspx. Drawing upon its team’s ten years of expertise in creating cardiac examination courses, this course introduces EKG fundamentals.

This EKG (ECG) course consists of eleven lessons and tracings. Complementary practice drills build skills in determining heart rate, assessing rhythm and recognizing the components of an EKG tracing. The Practical Clinical Skills website provides addi-

tional courses covering heart sounds and murmurs, lung sounds, carotid bruit evaluation and blood pressure assessment. These courses use webbased simulators to enhance learning and facilitate skills improvement.

The courses and reference are compatible with PC, MAC and iPad web browsers. Several of the reference guides are also available for iPhones and Android devices Clinical Skills Network for English Yorkshire and Humber Region – The Clinical Skills Network is an active and contemporary forum for any healthcare professional who is involved in the teaching and delivery of clinical skills across England’s Yorkshire and the Humber region. It has an interactive web site that is open to non members but there are certain areas where a user name and password are required in order to access certain areas.

Through the web site members can be contacted for help and advice on any teaching matter or best practice. The membership is made up of all health care professionals that include nurses, physiotherapists, midwives, radiographers, occupational therapists and clinical skills technicians and doctors. Up until now the network has been funded by the Strategic Health Authority so it has been free to its members but that is currently under review.

British Safety Council e-learning courses – The British Safety Council has launched a new range of instant access health, safety and environmental e-learning courses, allowing employ-

Chamberlain Group Breast Reconstruction Trainer – The Chamberlain Group’s trainer portfolio continues to expand. Of special interest to the community are three products either in development or in the early stages of production. The Group is partnering with the reconstructive plastic surgery department at NYU’s Langone Medical Center to develop the Breast Reconstruction Trainer.

The center’s project leader, Alexes Hazen, M.D., herself a plastic surgeon, approached the Chamberlain Group to develop anatomy for training surgical residents in reconstructive breast surgeries. The trainer will enable the participant to complete a number of procedures including bilateral mastectomy, breast reconstruction, reduction and augmentation. The company is also in development of a Hip Labrum Repair Trainer.

Northwestern University Showcases New TEF Simulator – Northwestern University medical personnel recently showcased their Thoracascopic Tracheoesophageal Fistula (TEF) Simulation Trainer. The trainer recreates the procedure performed by pediatric surgeons on infants to repair a disconnect in the upper and lower esophagus, which prevents the normal passage of food from the mouth to the stomach.

The disorder occurs in approximately one out of every 4000 births. The goal of the trip was to determine if the simulator could benefit medical education by having the model exhibited and tested by pediatric surgeons and fellows attending the conference.

New Moulage Kits for U.S. Army – Winter Park, Florida-based SIMETRI is completing a subcontract to deliver 91 moulage kits to prime contractor Moulage Sciences and Training, as part of a contract awarded by U.S. Army PEO STRI. Angela Salva, SIMETRI’s

bladder so that the physician/user actually ‘feels’ the resistance to the needle as it penetrates the detrusor muscle of the bladder wall,” said Vic Spitzer, CEO of ToLTech.

Simbionix Introduces Next Generation Simulator Platform – Simbionix USA Corporation has announced the release of its next generation simulator platform for its endovascular training, the ANGIO Mentor Sim. The ANGIO Mentor, an innovative virtual reality training simulator, provides hands-on practice in a comprehensive simulated environment for endovascular procedures. This unique system provides a solution for a variety of training programs, including Neruoradiology and Thoracic Surgery. An ever-expanding library of modules supports the acquisition and honing of essential skills to build confidence and proficiency in a variety of endovascular technicques and procedures.

The new simulator platform is based on newly developed technology, offering advanced device tracking capabilities and more robust performance. Adding an addition hardware unit to the ANGIO Mentor Slim creates the ANGIO Mentor Dual Slim, which is used to provide realistic simulation of challenging endovascular procedures which require two simultaneous access sites, such as EVAR (Endovascular Abdominal Aortic Aneurysm Repair), TEVAR (Thoracic Endovascular Aneurysm Repair), Transseptal Puncture and ASD/PFO (using the ICE handle and the deployment device handles simultaneously). All ANGIO Mentor modules and PROcedure Rehearsal Studio™ modules can be used on this new platform.

Laerdal Introduces SimPad EMS Simulator Controller – The SimPad is a powerful hand-held wireless simulation controller and mobile teaching tool like a tablet computer for EMS instructors. It offers an expandable selection of individual training scenarios clustered in core EMS learning competencies. The 5.7-inch color touch pad screen is easy to use and the SimPad’s programming is highly intuitive. If you own a smartphone, you can probably use the SimPad right out of the box. The SimPad offers a comprehensive library of physiological patient parameters, including vital signs, ECG recordings, and organ and patient sounds.

ISSUE 3.2012

New Products

president and CEO, told MEdSim that her company will deliver the 91 kits not later than this September, and noted the potential for additional kits and options under this contract.

When asked what is new and different about the moulage kits in production, Salva pointed out the synthetic material and associated technology was developed through recent research sponsored by the Army Research Laboratory Simulation and Training Technology Center (formerly RDECOM-STTC).

The moulage kits to be delivered under this contract are expected to be used by service health care professionals at 23 Army medical simulation centers throughout the continental U.S. and abroad.

Simulaids’ Xtreme Trauma Casualty Simulation Kits – Simulaids is responding to the need for combat medics to more effectively treat the horrific wounds experienced by U.S. service members during the 10 years of combat in Iraq and Afghanistan.

To make the whole selection of wounds, including several created by chemical explosion available in one kit, the Deluxe Xtreme Moulage Kit is on the market with a full complement of accessories and makeup. Two of the 25 wounds that may be treated with the kit include a wound from an impaled object and eviscerated intestines. Combat medics and other first responders may learn to treat 13 wounds, including an All three kits are in production and have a three- week lead time.

ToLTech’s New Cystoscopy and Bladder Injection Simulator – Touch of Life Technologies (ToLTech) has developed a virtual reality-based cystoscopy simulator to train and evaluate urologists on the procedure of injecting Botox into the detrusor muscle of the bladder to treat leakage of urine (incontinence) in adults with overactive bladder.

Candidates would include adults with conditions such as multiple sclerosis or spinal cord injury - who still have leakage due to a neurologic condition or experience too many side effects after trying an anticholinergic medication.1 Botox was approved in August of 2011 by the United States Food and Drug Administration for this indication.

“The cystoscopy and injection trainer manipulates image data to simulate the look and feel of a human

33 MEdSim Magazine

ers to quickly and easily purchase and provide online training to employees from as little as £10 per course. The new e-learning courses are available on a ‘pay-as-you-go basis’, meaning they can be immediately purchased online using a credit card. Further information on the new e-learning courses can be found at: www.britsafe.org/instantaccess

News & Analysis ISSUE 3.2012 MEDSIM MAGAZINE

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The SimPad system can be operated in automatic mode, using existing pre-designed scenarios, or in manual mode, allowing instructors to customize simulations. The log function allows instructors to keep track of and review simulation performance. It records when each task or objective is performed and can be used as a debriefing tool.

New VR sim for knee arthroscopy – VirtaMed is launching ArthroS, a new virtual reality training simulator for knee arthroscopy. Surgeons will get the chance to practice different operations numerous times before actually performing them on live patients – just as pilots improve their skills on flight simulators.

ArthroS is the first surgical simulator worldwide to combine the best traditional training model with virtual reality benefits.

The new virtual reality simulator offers surgeons training in knee arthroscopy. This is a common surgical procedure where doctors view the inside of the knee using a small camera to diagnose and treat knee problems.

According to the American Orthopedic Society for Sports Medicine, more than 4 million knee arthroscopies are performed worldwide each year.

Video Game for Drug Abuse Recognition – A video game is helping doctors at Northwestern University Hospital recognize drug abuse among patients The game has been designed based on the research of Dr. Michael M. Fleming of Northwestern University Feingberg School of Medicine, and utilizes the same technology used by to train FBI agents in interrogation tactics: a combination of self-disclosure (a family history of drug-abuse, say) and non-verbal cues (fidgeting, nervous finger drumming, broken eye-contact, etc.).

The game is soon to be made available online for free to medical schools and health care providers, reports the New York Times. Not only will this new technology help patients receive the best need-based care from their doctors, but it will help doctors to better interact and engage with their patients, an oft over-looked side of the relationship.

East Surrey Hospital opens first med sim suite – Health chiefs at East Surrey Hospital in Redhill,UK, have opened its first dedicated medical simulation suite. The Newman Suite will give trainee doctors the chance to put

their skills to the test in a state-of-theart facility acting as the hospital’s stage for recreating common and uncommon clinical scenarios. It was officially opened by the family of the late Valerie Newman, who the suite is named after.

The suite will be used to train FY1 (Foundation Year 1) and FY2 junior doctors, anaesthetists, medical and nursing students, to help them improve their understanding of clinical management, and to develop non-technical skills and improved awareness of patient safety.

The simulation facility is particularly important in light of East Surrey Hospital recently being awarded the title of ‘An Associated University Hospital with Brighton and Sussex Medical School New Cataract Surgery Trainer – Massachusetts Eye and Ear Infirmary, a Harvard Medical School affiliate, has released a new system for learning how to perform and deal with the various issues that arise during phacoemulsification cataract surgery. Cataract Master is an interactive simulator that presents students with various real-world scenarios, has them make decisions on the necessary steps, and plays out the chosen scenario to demonstrate the process and the end results.

The Cataract Master is different in that it offers a self-guided, self-correcting curriculum that requires trainees to make decisions based on realistic surgical situations. The simulator, which can be accessed from any personal computer, contains realistic animations along with videos of actual surgeries – complete with expert discussions of each phase of the procedure. medsim

Index of Ads ACEP Scientific Assembly 2012 www.acep.org/sa 4 B-Line Medical www.blinemedical.com 7 CAE Healthcare www.BigDummyBuyBack.com OBC MEdSim Magazine www.halldale.com/medsim

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Events Calendar 13-16 August MHSRS 2012 Conference Ft. Lauderdale, Fl www.ATACCC.org 21-23 August Serious Play Redmond, WA www.seriousplayconference.com 23-24 August 2012 World Society of Disaster Research Nursing Conference Cardiff, Wales, UK www.wsdn2012.com 4 September 5th Clinical Skills Conference Sheffield, UK a.hope@hud.ac.uk 5-8 September Minimally Invasive Surgery Week Boston, MA. www.SLS.org 14-15 September ACS AEI Postgraduate Course LSU, New Orleans, LA www.facs.org/education/ accreditationprogram/news 30 Sept-4 October ACS Clinical Congress Chicago, IL www.facs.org 8-11 October ACEP Denver, CO www.acep.org 9-11 October MODSIM Hampton Roads, VA www.modsim.org 18-20 October Int. Conf on Residency Education Ottawa, Canada www.royalcollege.ca

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