MEdSim Magazine - Issue 5/2014 by Halldale Group

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Issue 5.2014

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Future of Medicine

The Virtue of Seamless Health Care

Training Technology

Obtaining the Patient’s Point of View SIMULATION CENTER

The Center for Medical Simulation Nursing Training

Fixing the Nursing Shortage with Scholarships and Grants

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ISSUE 5.2014

Editorial comment

Editor's Comment Those involved in training – whatever the industry – understandably have a focus on performance. In fact, obtaining appropriate human performance, and measuring it, is at the heart of all that we do. Communication with industry will be key, including a common vocabulary and taxonomy, as well as the ability to accurately measure safety outcomes and efficiencies. The prior paragraph was shamelessly borrowed from my colleague Chris Lehman, editor of CAT (The Journal for Civil Aviation Training) and he was talking about the airline industry. As we know the US aviation industry has a remarkable safety record. In the last MEdSim issue our publisher, Andrew Smith, talked about a week in July 2014, when there were three airplane crashes. In all 462 passengers were killed and it was on every television channel for days. Yet 1,000 avoidable deaths a day occur in the US health system and countless others around the world and there is limited television, newspaper or internet coverage. The same day as the first airline crash, July 17th, there was a Senate Subcommittee hearing on the need to improve patient safety and discuss why the third leading cause of death in the United States is avoidable error. The following expert witnesses were called to testify before the committee: • John James, PhD, Founder, Patient Safety America, Houston, TX • Ashish Jha, MD, MPH, Professor of Health Policy and Management, Harvard School of Public Health, Boston, MA • Tejal Gandhi, MD, MPH, President, National Patient Safety Foundation; Associate Professor of Medicine, Harvard Medical School, Boston, MA • Peter Pronovost, MD, PhD, Senior Vice President for Patient Safety and Quality and Director of the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD • Joanne Disch, PhD, RN, Professor ad Honorem, University of Minnesota School of Nursing, Minneapolis, MN By anyone’s estimation a distinguished group that certainly knows about patient safety. Unfortunately only three members of the subcommittee attended. We encourage you to download their expert testimony at www.help. senate.gov/hearings/hearing/?id=478e8a35-5056-a03252f8-a65f8bd0e5ef Members of this distinguished panel have written countless articles on performance, assessment, outcomes and patient safety. Perhaps one of the most widely distributed was Achieving the Potential of Health Care Performance Measures: Timely Analysis of Immediate Health Policy Issues, May 2013 by Robert Berenson, Peter Pronovost and Harland Krumholz. In the report they stated that, “measures have altered the culture of health

care delivery for the better, with a growing acceptance that clinical practice can be objectively assessed and improved. There is a consensus that scientifically rigorous and valid measurement of performance can be instrumental in improving value in US health care.” However, in their report they cautioned that, “in an environment where both reputation and dollars depend on measured performance, it is often difficult to disentangle the legitimate concerns of those being measured from self-serving defenses of the status quo. Despite the broad demand for performance measures and the recognized limitations of current measures, the United States lacks an organization charged with advancing the science of performance measurement, developing standards for performance measures, setting parameters for how accurate the measures must be before they are used in pay-for-performance or public reporting initiatives, and coordinating the development of the large number of measures required to inform patient choice and monitor performance.” This is where healthcare could learn a lot from other high risk industries such as the airlines, where ‘no fault reporting’ is mandatory and works, and is in place to ensure safety. Healthcare needs an equivalent to ‘no fault’ but because healthcare does not have a system for reporting or a framework to deal with reporting errors it cannot happen. Healthcare needs to standardize how they report outcome and measurements. As Jerod Loeb stated in 2004 “it is imperative that performance measures are standardized so that data collection efforts can be minimized.” If the following Policy Recommendations from the above report are acted upon, healthcare will move more rapidly toward a culture of safety. 1. Move from process to outcome measures. 2. Adopt other quality improvement measures when measures fall short. 3. Measure quality at organizational rather than clinician level. 4. Measure patient care experience and reported outcomes as their own measure. 5. Use measurement to make care safer. 6. Invest in the “basic science” of measurement. 7. Task a single entity with defining standards for measuring and reporting quality and cost data, similar to the role the SEC serves for the reporting of corporate financial data, to improve the validity and comparability of publicly-reported quality data.

Judith Riess Editor in Chief, MEdSim Magazine

e judith@halldale.com MEDSIM MAGAZINE 5.2014

Contents

ISSUE 5.2014

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

Operations Design & David Malley Production t. +44 (0)1252 532005 e. david@halldale.com

Distribution & Stephen Hatcher

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03 Editor's Comment. Editor Judith Riess looks at the culture of safety and healthcare delivery. 06 The Virtue of Seamless Health Care. Dr. Cole Zanetti describes the future of medical education and training in 2050 and the resource they have in patients. 10 Obtaining the Patient’s Point of View and Its Impact on Simulation Design and Implementation. Jessica Ray, PhD, Stephanie Sudikoff, MD and other simulation center staff share their use of google glass to enhance simulation for patient and family care. 14 The Center for Medical Simulation. Group Editor Marty Kauchak discusses the Center’s history and accomplishments with Jeffrey B. Cooper, PhD, the founder and executive director. 18 Fixing the Nursing Shortage with Scholarships and Grants. US News Editor Lori Ponoroff discusses national and state government and private organizations and corporations funding to encourage the pursuit of nursing as a career. 22 Bridging the Chasm: The Role of the SBIR Program. Drs. Dan Katz and Eric Savitsky with Brian Bernstein describe developing a commercial product through the government’s SBIR program. 28 Beyond a Legislative Disconnect. In the first of several articles, Group Editor Marty Kauchak reviews efforts to improve the US healthcare community’s performance in patient safety. 31 Seen & Heard. Updates from the medical community. Compiled and edited by the Halldale editorial staff.

MEDSIM MAGAZINE 5.2014

On the cover: Virtual and augmented reality platforms will contribute to diagnosis, surgical planning and educating future healthcare professionals.

Artworker Daryl Horwell

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Halldale Media Group Publisher & Andy Smith CEO e. andy@halldale.com

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future of medicine

The Virtue of Seamless Health Care Cole Zanetti, DO, provides a view of a seamless healthcare education system based on competency and empowering patients to manage their chronic diseases.

n 2050, people will manage most of their health care within the convenience of their routine daily activity. Information will be freeflowing; data will be collected from any data stream that is naturally produced by daily living. Examples include purchasing habits through credit or debit card expenses, activity levels of sleep and physical activity, social network data (Facebook, Twitter, text messaging and phone call information), health care data such as claims data, medication compliance, etc. Real-time analytics programs will be customized by personal priority, timing and location. Medical students will learn science and medicine using virtual gaming and augmented reality. This method of learning will allow for greater gains in health outcomes, which will have been redefined through quality-of-life parameters over time. The triple aim between now and 2050 is to transform health education from a focus on quality, cost and population to a new focus on seamlessness, usability and customization. By 2050, doctors will have 06

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realized that the greatest resource not being tapped in health care is the patient. The greatest injustice that exists at the present time is that physicians are not empowering patients with their own information and the learning tools to manage most chronic diseases. The “patient practitioner” movement that we expect to see in 2050 will come to pass when family doctors create patient-training initiatives that provide learning tools and medication kits for patients to manage their chronic diseases at home. The movement will start with non-invasive management of asthma, chronic obstructive pulmonary disease, hypertension and congestive heart failure and then progress to more complex diseases with the advent of home testing and analysis systems. Lab tests will become easily accessible and data analytic systems will be able to provide personalized recommendations.

Optimize Me Another great change in medicine will arise from the personalized medicine movement. This will ultimately provide access to one’s own genome, microbiome and all biological activity throughout the day. All of this personalized data will be constantly monitored by an ambient intelligence system and will allow for the vast majority of chronic and acute disease issues to be managed at the patient’s own home, at his or her convenience. The system will automatically verify data and will provide patients access to appropriate medications; they will no longer need a physician for every prescription. Doctors in 2050 will help

Above The future medical school will consist of an integration of simulated and realitybased learning scenarios.

build patient-training modules and help contribute to a communal virtual and augmented reality platform that answers patients’ questions and allows them to learn more about optimizing their health and health-management skills. Patients will work with a care team to establish goals and analyze all their medical data to optimally achieve their desired outcomes. Individuals will get daily updates that compare their progress to that of others, in both their community and in the world, who are striving for the same goal and fit the same demographic. Information could be shared within these groups so that patients with similar situations can network and help each other improve their attributes. Community health assessments will become a source of local and national pride, and may become a major priority in the United States. The transparency of information will drive now-unforeseen creative movements that will allow people of all ages to tackle the most challenging health issues.

Physician Redefined The physician’s job during this time will

be to help create capable patients that are masters of their own health and wellbeing, aiding patients in the pursuit to optimize personalized attributes that are targeted, based on their individual life goals. Medical training during this time will center on helping trainees become the most effective teacher possible. The role of physicians will be to work as part of a team of providers who facilitate information management and learning related to an individual's quality of life goals in the context of health, wellness, and community. Informatics at this time will become a physician's lifeblood. Every patient will be viewed through both a micro and macro lens, using his or her data fingerprint and predictive analytics to help guide clinicians towards optimizing the patient’s care. Medical school will consist of an integration of simulated and reality-based learning scenarios. There will be no time requirement associated with medical school; at this time the assessment of trainee skills will be completely competency-based. If one is able to prove mastery through dynamic understand-

ing of core concepts of care, a student will pass regardless of the time spent in developing their mastery. In order to develop mastery, the student physician must learn to live a life of health and wellness for him- or herself through this care lens. This pursuit would be essential for doctors to understand the commitment and challenges to maintain health and to provide better care for the rest of the population.

The Evolution of Medical Training In 2014, a perfect storm is brewing in medical education. The trickle-down impact of innovation is crippling the brick-and-mortar schools’ ability to effectively train doctors for the future. With the advent of a new health care policy, the foundation of medical education is beginning to crack. The areas of quality improvement, systems theory, informatics, learning science and communication have very limited experts, at this time, to fit the traditional model of training. Third- and fourth-year rotation slots are limited due to the increase in class sizes,

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future of medicine and at the same time, hospitals and clinics have started charging medical schools to send students for rotations. The combination of these factors has caused tuition to skyrocket and has challenged schools to reassess their approach to education. One of the greatest challenges to be faced is operating within the ocean of medical information that currently exists. Questions of how to change from time-based to competency-based training, to decrease costs and increase innovation are starting to arise. The generational gap between students and their professors may be revealed in the next few years when medical students, undergraduates, high-school students and many others may be the first to develop a creative answer to this problem. They will begin to create a virtual and augmented reality gaming commons. Initially, the greatest obstacle for implementation of this new form of training may be the organizations that run nationwide licensing exams. The legitimacy of these organizations may be challenged due to their lack of ability to prove that performance on their exams has any correlation to the best patient outcomes. This lack of foresight pinpoints the problem of much of our medical education now – that the medical education industrial complex is aiming at the wrong targets. Without the goal of improving patient outcomes as endpoints for trainees, arguments for continuation of the old training model will begin to crumble. Eventually, a blended curriculum of virtual and augmented reality gaming, along with real world experience, will become mainstay. The training commons will allow for timely updates to create new innovation scenarios to train doctors for the future of medicine. Experts in key fields will help create gaming challenges for learning for the greater community. This will decrease the traditional need for professors in all areas at each school. Access to this gaming world will be provided 24 hours a day to all health care professionals in training. Soon, this access will trickle down to patients as more training scenarios create digestible learning experiences for all people, not just those in health care. The gaming world will be able to provide continuity experiences; it will apply real-world data to virtual and augmented reality patients and hone in on the importance of mastering the most common health issues. This will help medical trainees develop the skill of agility when they are confronted with uncommon scenarios. The program will apply real-time evidence-based research through clinical decision support, and will use predictive analytics to demonstrate probable impact. This new method of training will help drastically close the current translational research gap of 17 years from bench to practice. The predictive analytics decision support will be key in providing the impact of high correlation between the virtual/augmented reality gaming training model, and yielding good patient outcomes for trainees. The training will also provide a consistent curriculum for students nationally. All health care professionals will be trained in fundamental experiences before graduating, and will be deemed competent in such before graduation. The end point of this training will be to create improved patient outcomes in key areas of health and wellness, to be proven over time when compared to the current, outdated system of training. It will also enhance training by empowering patients themselves to improve their own outcomes. 08

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Where We Are Today This anticipated future of medicine in 2050 is not a stretch of the imagination. In fact, much of this work is already underway. Both the American Association for Colleges of Osteopathic Medicine and the American Association for Medical Colleges, the two medical education training bodies in the United States, are working to address the issues of competency vs. time, increased cost for education, and the educational deficits of their graduates given the new health care climate. In terms of using medical education gaming to address these difficult issues, the game has already begun. Texas A&M University in Corpus Christi created Pulse!!, a medical education computer-gaming system that allows players to respond to emergency situations and to diagnose and treat patients. The Imperial College of London Medical School has created medical training opportunities in the virtual gaming platform Second Life. The Imperial College’s training platform has already been studied and deemed effective for continued medical education credit. Imperial College also created simulations that provided educational opportunities for the public to learn about preventive health care planning. The College recently created a virtual hospital and clinic that are open to the public. The hospital was based on the London Strategic Health Authority Report, “Health Care for London: a Framework for Action,” which was written as a concept paper for the future of health care delivery. The virtual hospital was created to provide health care providers and the public an opportunity

PalpSim – Integrating Haptics with Augmented Reality in a Medical Training Simulation. Image credit: Real@Real.com

to experience the future before it arrives. The virtual program also allows for opportunities to provide feedback and comment on the experience, creating an opportunity for clinicians and product developers to obtain invaluable information from users. Andrew Taylor Still University School of Osteopathic Medicine in Arizona is designing a virtual community health center gaming system for medical education and interprofessional training. The University has also been using computer and iPhone gaming applications, along with board games, to facilitate learning. In regards to data analytics and augmented reality, new horizons have begun to emerge. The recent production of IBMâ&#x20AC;&#x2122;s Watson is demonstrating the impact of predictive analytics mixed with real-time data and evidence-based medicine. The introduction of Google GlassTM is an example of creating an augmented-reality infrastructure for society, and has the potential to bring on a cultural change in how we interact with information. These are a just a few examples of initiatives that are advancing our medical education models toward 2050.

Conclusion The problems we face today and the ones we will face in the future in medical education are immense. In order to train health care professionals for the future of medicine, to create an educational end point of better patient outcomes, and to create a potential platform to help educate patients to care for themselves, a software update is already underway. The creation of an entertaining and engaging educational platform that allows for our

greatest challenges in health care to intersect with our most creative minds will enhance our ability to build a better future. Let this be known as a call to arms. Let us create a future together, and let the gaming begin. medsim About the Author Cole A. Zanetti, DO, is a Family Physician and Leadership Preventive Medicine Resident at Dartmouth Hitchcock Medical Center. Dr. Zanetti is a recipient of the American College of Physicians, Primary Care Innovation Award for his proposal on the use of positive deviance as a value based approach to patient engagement. He has worked with the Positive Deviance Initiative on new applications within healthcare, the Dartmouth Center for Health Care Delivery Science on innovative mobile health initiatives in Haiti, was a Robert Wood Johnson Foundation Thought Leader for their symposium on Health and Health Care in 2032, and was selected for a National Library of Medicine scholarship for a biomedical informatics training course. He served as a member of the Blue Ribbon Commission for Transformation of Osteopathic Medical Education and is a member of the medical education game development team for the AT Still University's School of Osteopathic Medical in Arizona. Dr. Zanetti completed his family medicine residency at NH Dartmouth Family Medicine at Concord Hospital. He is currently an MPH candidate at the Dartmouth Institute for Health Policy and Clinical Practice. He received his Osteopathic Medical Degree from the Texas College of Osteopathic Medicine.

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Training Technology

Obtaining the Patientâ&#x20AC;&#x2122;s Point of View and Its Impact on Simulation Design and Implementation Jessica Ray, PhD, Simulation Learning Consultant, Dr. Stephanie Sudikoff and others from SYN:APSE Center for Learning, Transformation, and Innovation at Yale New Haven Health System discuss the use of Google Glass to enhance patient safety.

rom training in the simulation laboratory to direct patient care, technology is rapidly advancing how we prepare for and deliver services across the health care continuum. With the introduction of wearable technologies such as Google Glass we are now able to capture multiple perspectives of our complex environment from healthcare professionals, patients, and family members, each representing a unique and valuable view. This article is the first in a series that will explore how the emerging technology of Google Glass advances medical simulation and ultimately the delivery of health care. The current article examines how Google Glass enhances simulation design by providing tangible data about the patientâ&#x20AC;&#x2122;s point of view during medical care and treatment. Subsequent articles will illustrate the power of this new technology in provider and team training as well as privacy and use considerations when implementing Google Glass in simulation and in clinical settings.

The Patientâ&#x20AC;&#x2122;s Perspective As I walked through the doors of our hospital today, I paused to watch some of the 10

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people that walk through our halls each day. There was a new father so excited, yet scared, heading home for the first time with a life so small yet so full of promise. A young girl, no more than 10, frail of body yet still with a smile so full of life. A woman in a reversal of roles, guiding her elderly father hand in hand through the entry doors. Each of these people represents the fabric of our hospital. Yet, how seldom we stop to reflect on what our patients, visitors, and volunteers see and feel when they enter our environment. We look to patient satisfaction scores and comments for metrics of success. But are we missing other pieces of the story? Patient and family centered care and the patient experience are now leading topics across our health care system. As such the demand for training in these domains has increased. Achieving high quality patient and family centered care requires more than technical skill, it requires a deep understanding of what a patient and their family experience traversing the complexities of our health care environment. As simulation educators we are challenged to recreate training experiences that address both clinical skills and the complex interpersonal skills necessary for successful team interactions and patient engagement. Whether interacting with team and family members during a simulated resuscitation or in a simulation focused on teaching interpersonal and communication skills, today our trainings are designed as opportunities to practice and develop the empathy and rapport necessary to deliver high quality patient experiences. Until recently, capturing the patient or family perspective in simulation relied on feedback provided by confederates playing roles in a scenario. Now we can have these confederates wear Google Glass to collect their perspective during the scenario. These different points of view coupled with instructor observation and static camera feed yield a more robust debriefing.

Above Wearable technologies such as Google Glass advances simulation training by allowing us to take new perspectives of our health care environment. Image credit: Jason Fenstermaker.

This article describes a few of the ways we are currently utilizing Google Glass to understand the patient perspective and translate that into practical training for caregivers. As we and our health system partners become more versed in the deployment of Google Glass, the range of possible uses will expand.

Impact on Simulation

Nasco HealthCare Division As the simulation resource for a large health care system, the past year has brought our center an increasing number of requests for MedSim simulation training sessions specifically targeting improvements Nov 2014 in interpersonal communication skills and the patient’s experiMS1411 ence. As professionals in the healthcare setting it is often easy to think of a patient experience as restricted to the face-to-face patient-provider interaction, yet this is only a brief snapshot of the complex patient. For the patient or family member their experience with our system begins before they enter the doors of our offices or hospitals. Conversations, paperwork, and directions received prior to a visit set the tone for the remainder of the encounter. Once a patient arrives, tasks such as parking and navigating the entrances of the facility to finding assistance can range from routine to frustrating. Once in the hospital or office, how and when a patient or family member is greeted often makes a lasting impression. Healthcare employees ranging from physicians and nurses to environmental and food service workers each have a key role in the patient experience. Ensuring that a patient’s interaction with our system is a positive one requires a culture dedicated to service excellence and training in interpersonal skills. To meet the newly identified training needs specific to patient and family centered care we are partnering with individual units as well as staff from patient relations to develop simulations recreating many types of patient and family experience. Scenarios for these simulations range from entering a unit, being introduced to the room and unit, to discharge. In each we strive to create many realistic, interprofessional interactions with the patient and family. Strategically placing Google Glass on high fidelity mannequins, volunteer patients or confederates, playing the role of family members, allows us to capture and debrief important facets of both the patient and family experience. We have also used Google Glass to enhance our ability to follow scenarios that start in one patient unit and require transport to another unit. The perspective from Glass often highlights clinical and environmental changes that may be missed by the participants and the simulation staff. The Google Glass wearer captures seemingly small yet important behaviors, such as, how family members are greeted upon entering a unit, if direct eye contact is made when greeting a family member, if assistance is offered for navigating the unit; each set the tone for a visit. As a patient and family member enter the room, Google Glass allows us to see their first impression of the room’s appearance and how both the patient and family member are oriented to their new space and the processes of the unit, for example, ordering food and schedules. As nurses begin their routine accompanied by an electronic charting workstation on wheels (WOW), Glass can capture how providers and staff position themselves and their equipment during patient and family interactions. This view also helps us develop a better under-

standing of how and when patients are included in care planning, bedside reporting, and bedside charting. As providers visit the patient, the perspective from Glass demonstrates the importance of nonverbal communication including eye contact and physical positioning (i.e. sitting, standing, hand and arm placement, etc.) during important conversations. When viewing the video stream, we are able to illustrate how overheard conversations in the hallway, personal conversations between staff, and environmental factors such as noise level impact the patient’s care, comfort, and satisfaction. For staff accustomed to the unit, their sensitivity to these background factors can lower across time. Utilizing Glass during simulations to show the patient’s view of the environment can help improve staff mindfulness. Google Glass allows us to capture and embed the perspectives of patients and family and the impact of teamwork and communication in both emergent and routine clinical simulations. In real world environments successful communication skills are necessary both across the team of providers and with family members. Simulations often include a role player as a family member, who can capture a recording of the scene as a family member. Video from this vantage point brings a new and powerful perspective not readily available from the traditional stationary birds-eye view camera. In these situations, we have found Google Glass to be a powerful feedback tool for training staff and practitioners in ways to speak with family. While a birds-eye capture of a scene can provide powerful images of an individual’s MS1411

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Training Technology actions, Google Glass captures a perspective that provides detailed feedback on eye contact, voice tone, intonation, and the use of confusing terminology. Utilizing recordings from Glass during debriefings allows us to address how family members viewed an unfolding emergency. In these simulations we are now able to train for family centered care by examining how team members are designated to stand with the family member and how the actions of the team are explained to the family member as an emergency response progresses. Similar to the larger patient-family centered care simulations, Glass allows us to explore the nuances of communication in the emergency settings. In the high energy emergency setting viewing the family perspective highlights for care givers the importance of avoiding clinical jargon as well as the need for attending to the speed and tone of their explanations. Capturing a view broad enough to include the commotion and energy of the emergency situation, Glass illustrates the importance of providing time and space for crucial conversations. During debriefings, Google Glass allows participants to see and hear these interactions through the eyes of the patients and family members adding a new perspective and dynamic. This new view provides instructors greater granularity in the debriefing videos and allows for deeper reflection on specific behaviors demonstrated during the scenario that directly impact patient and family experiences. Much like traditional video debriefing, we are finding that video from the eyes of patients and family members provides participants a powerful, objective prompt for reflecting upon their actions.

Looking Forward Moving forward we see expanding opportunities for Glass as part of our simulation program. As requests for our services continue to diversify and expand we envision utilizing Glass to understand the patient experience across the health system continuum. A growing segment of our simulations now focus on system workflow and process improvement. While workflow is most often considered from the workerâ&#x20AC;&#x2122;s perspective, a systems approach 12

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recognizes that the patient and family perspectives should be included. As captured in both of the examples above, communication is a key feature of success in all facets of health care whether examining patient satisfaction or clinical care. Closely coupled with successful communication is the coordination of care across the interprofessional health care team. From a patient perspective we find the health care experience often seems disconnected. Examining the flow of information from the eyes of the patient we are now able to identify areas for improved coordination and communication of care planning between providers and their patients. While solutions are often unit and team specific, simulations demonstrating how and when patients and family are included in the care conversation allow care teams to discuss how their workflows can improve from a patient and family perspective. Utilizing Glass to follow processes such as admission and discharge through the eyes of the patient and family would allow us to capture communication and the perspective of time. Building an appreciation of the patient experience and training for improved patient-family centered care is but one of the many ways we see wearable technologies advancing health care. In the next article in this series we will explore ways in which capturing the provider experience with Google Glass advances training and patient care. Thus far our simulations have captured and modeled patient experiences based on comments from patient satisfaction reports along with guidance from patient and family advisors. We are

Strategically placing Google Glass on patients and family members during simulation captures key interactions for teaching patient and family centered care. Image credit: Jason Fenstermaker & David Dias.

exploring other ways in which Glass can allow us to capture and embed actual patient experiences into simulation. As we continue to insert Google Glass into our simulation work, there are challenges that need to be addressed including careful consideration for patient privacy, employee privacy and lack of interference with clinical care. In the final article of the series we will discuss security and privacy issues and other technical considerations for utilizing new media technologies such as Glass. medsim About the Authors Jessica Ray, PhD, is a Simulation Learning Consultant at SYN:APSE Center for Learning, Transformation, and Innovation at Yale New Haven Health System. Cheryl Mayeran, MPH, is a Simulation Learning consultant with experience in program development, project management, emergency medical services education, emergency management operations and planning and public health administration. Jason Fenstermaker is the simulation supervisor. He has an associate's degree in science with a concentration in recording arts and audio engineering. Jason came to SYN:APSE from ESPN. Stephanie Sudikoff, MD, is the director of simulation for Yale-New Haven Health System, as well as an associate professor of clinical pediatrics in pediatric critical care at Yale Medical School.

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Simulation Center

The Center for Medical Simulation Entering its third decade of service to the international healthcare community the Center for Medical Simulation is expanding the simulation and training envelope for healthcare practitioners, reports Group Editor Marty Kauchak.

he Center for Medical Simulation (CMS), one of the world’s pioneering simulation organizations, is this year celebrating its 21st anniversary. CMS has an array of simulation activities, all focused on its mission to use simulation to improve safety, quality and education in healthcare. Founded first to serve the main academic medical institutions affiliated with Harvard Medical School (HMS) (Massachusetts General Hospital, Beth Israel Deaconess Medical Center, Boston Children’s Hospital and Brigham and Women’s Hospital), CMS has expanded its reach over the past two decades and now serves an international community of simulation educators. Jeffrey B. Cooper, PhD, the founder and executive director of the Boston-based CMS, has dedicated his career to patient safety, having won many national honors for his leadership. He founded CMS because he saw that simulation was a great way to train clinicians to be safer and improve the overall system safety, as well as the process of education and training. Cooper, a biomedical engineer, is also Professor of Anaesthesia at Harvard Medical School and faculty member in the Department of Anesthesia, Critical Care and Pain Medicine at Massachusetts General Hospital. Cooper completed a wide-ranging interview with Marty Kauchak, Halldale Media Group Editor, on August 15, 2014. An extract of the interview is provided.

Earliest Adopter of Simulation CMS is an unusual healthcare simulation organization. It is an independent non-profit organization, with its own board of 14 trustees, who represent various Harvard Medical School-affiliated institutions. The Center’s “employees” are actually em14

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Above CMS is also focused on team training. Here, hospital nonclinical management team participate in simulation as part of the CMS Healthcare Adventure program. Image credit: Jeffrey B. Cooper, PhD.

ployees of the Massachusetts General Hospital organization leased back to the non-profit. CMS uses its status as an independent non-profit for flexibility in being a neutral source of expertise for the independent HMS organizations. But, CMS’ status has also allowed it “to do things that were more broadly disseminated and not just local,” Cooper said. That status also permitted the Center a helpful degree of entrepreneurial freedom. Indeed, this is the author’s first instance

Left Jeffrey B. Cooper, PhD, founder and executive director of the Boston-based CMS. Image credit: Jeffrey B. Cooper, PhD.

of a simulation center official attributing entrepreneurial freedom as important to his or her organization. “While we are a complicated organization,” Cooper said, “this is the way we bridge these really innovative, vibrant hospitals and the medical school, by working with all of them in creative ways.” When MEdSim spoke with Cooper, the Center was preparing to celebrate its 21st anniversary with what promised to be a festive party and learning experience (including juggling and salsa dancing) on September 19. Cooper, as the facility’s founder and Executive Director, recounted three of many instances through the decades in which CMS helped introduce and advance learning technologies in the healthcare professions. Cooper initially pointed out that CMS was one of the “earliest adopters of simulation in the modern era.” It wouldn’t have happened without the ideas and support of David Gaba, MD, a founding father and pioneer in healthcare simulation and now a close colleague of Cooper’s. “We borrowed shamelessly from the concepts that David Gaba and his team developed at Stanford. I realized that by doing so, we sent a message: ‘Hey, if the Harvard-affiliated hospitals are adopting this concept from Stanford, this is important.” The community leader recalled that CMS “received the first mannequin off the CAE-Link production line.” Another of the Center’s leading contributions to healthcare learning was establishing the Institute for Medical Simulation (IMS). “That came about from our recognizing that for simulation to be effective, the world needed teachers who could use simulation effectively.” IMS was developed with support of a grant from the Josiah Macy, Jr. Foundation (http://macyfoundation.org/) which focuses its support on improving education and training of healthcare professionals. Cooper believes that the Institute for Medical Simulation is “the world’s premier simulation instructor program,” now having more than 2,700 graduates. Indeed, instructor training has become an academic focal point for CMS. We’ve become an international organization with graduates representing over 30 different countries and instructor programs being offered in Spain, Australia, Hong Kong, Singapore and in South and Central America (via CMS’ affiliated Hospital Virtual Valdecilla in Santander, Spain). From a broader perspective, the Center also viewed simulation as an enabler for developing healthcare faculty of all types and interests. “Generally, healthcare educators don’t take the time to get educated as educators, and then practice and train. Yet simulation created this feeling: We need to learn how to do that.” MEdSim watches its sister publications examine simulation and training developments in other high-risk communities, MS&T for the military and CAT in civil aviation. One nexus among the healthcare, military and civil aviation communities is the effort to strengthen the feedback (debriefing) process following a learning technology-enabled scenario. CMS has developed sophisticated models of debriefing for its training audiences – and with good reason. Cooper stated that debriefing effectively after simulation experiences is not a natural talent for most faculty. “If you aren’t trained or have a lot of experience, many people start out with a very simplistic idea about how to tell the student what they have to do to perform

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Simulation Center better – that is not the best way for us adults to learn new behaviors,” he pointed out, and continued, “Doing a good debriefing is the toughest part of making simulation effective.” CMS is also focused on team training, which it has done for years for various teams that work in areas requiring quick responses to critical situations. But, CMS has taken the state-of-the art beyond the healthcare teams in ORs, intensive care units and emergency rooms. To expand this learning focus, the Center has programs for administrators, leaders and managers in this field.” I am not alone in thinking that the key to healthcare working well, not just for patient safety but for all of healthcare, means healthcare teams working more effectively – moving beyond independent practice of people working on their own. Creating good teamwork is especially challenging in healthcare because physicians specifically have been trained to be independent and work on their own,” Cooper remarked.

Business Models When asked how CMS obtained its funding through the years, Cooper said the organization has not been highly dependent on grants during its more than two decades of existence, but it had received key funding at pivotal points along the way with grants from the Fannie E. Rippel Foundation (http://rippelfoundation. org) and the Josiah Macy Jr. Foundation. In a broader discussion about the Center’s business model, Cooper pointed out that any simulation center, whether a non-profit, state-funded or organized otherwise, is a business. While CMS has received important grants through the years and used the funds very effectively, Cooper reflected on the critical role of internal support of the anesthesia departments at the four hospitals affiliated with Harvard Medical School. They provided much of the support for CMS’s operations in the early years and have continued to be strong collaborators. “It wasn’t through a grant. Rather, the departments used their combined discretionary funds to pay for key faculty and staff. And, there was much volunteer effort from faculty as well. The key for us early on was really relying on internal, not external resources.” 16

The Center’s successful funding efforts from internal and external sources aside, Cooper gave some well-earned advice for the leaders of any simulation organization: “You constantly have to be networking and looking for opportunities and putting yourself out there for new ideas, and making all types of new connections and relationships – you never know when you will meet the right person where there is a connection to what you are trying to accomplish and what their interests are.” He added, “That’s where the opportunities are.”

Patient Safety and Beyond CMS’s vision for the next five years is fairly simple Cooper said: the Center wants a healthcare system where nobody practices on patients until they are really competent to do so. “This is where simulation has its strongest utility – the deliberate practice can happen in simulation, beyond ever having to try things out in the real situation until you are really ready.” Cooper further emphasized that CMS is a patient safety organization, with its basic vision that simulation is a strong element toward radically reducing adverse events of all types that can result from people not working at their maximum level of performance. He added, “We are constantly pushing ourselves toward better understanding of how simulation can best help people learn.” To that end, CMS also operates as an innovation organization, avoiding high enrollments and small return on investments. Of little surprise, the Center’s focus on instructor training is one such high leverage effort. “If you teach one instructor, that person teaches many more people,” he reasoned. And Cooper revealed the Center wants to help other simulation centers train still other instructors, since it cannot itself train “all the instructors in the world.” This author advised Cooper that returns on investment (ROIs) were becoming increasingly important in simulation and training portfolios in the military and civil aviation communities, and then asked about ROIs at CMS. Cooper indicated the Center’s primary stakeholders, its board members, are not seeking financial ROIs. He was

quick to add that what the board is asking is, “Are we meeting our mission; are we doing good for the world; and are we financially sound? The answers are all ‘Yes.’” One of CMS’s more intriguing constituents is CRICO, the provider of medical professional liability coverage, claims management and patient safety resources to the Harvard-affiliated hospitals. Cooper noted that the insurer provides lower premiums to anesthesiologists, obstetricians and surgeons in high risk specialties at Harvard medical institutions for completing CMS courses. “The insurance company is a stakeholder and looking for a return on investment. Its actuaries believe the courses we are sponsoring are sufficiently effective toward reducing adverse events to give substantial lower premiums to this very large class of physicians throughout the Harvard medical institutions.”

Eye on the Close-in Horizon The Center’s major business focus is instructor training. Indeed, “there is going to be more of that. Our goal is to have every healthcare educator in every professional domain understand and use the concepts that we have been teaching for debriefing – and we’re expanding that to giving feedback, not just debriefing after simulation. This is about how teachers can learn how best to give feedback to their students of any kind in any setting. It’s about developing that relationship between student and teacher. We’re expanding our programs in that direction. We expect to keep innovating on how best to do this”. (Cooper planned to illustrate in his party presentation, which was to be posted on the CMS website, the future of how this might be done) To establish lifelong learning and continuous self-improvement, CMS is also creating a community of practice among its graduates so they can interact and work peer-to-peer – online. And finally, the Center’s core of programs on the clinical side (anesthesiology and others) will continue and be expanded into the community. “We use those courses to push ourselves – to continually innovate and to help people learn faster and better,” the executive director concluded. medsim

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Nursing training

Fixing the Nursing Shortage with Scholarships and Grants Lori Ponoroff highlights funding sources and debt repayment programs available for nurse education.

ttracting more young people to enter a nursing career is one small step to help fix the nursing shortage, but for many it is a huge financial leap. That’s why national and state governments, professional associations, colleges and corporations are offering scholarships, grants and loan repayment programs to make it easier to get everything from entry-level to doctoral nursing degrees. So many entities offering financial aid packages for nursing mean there are more opportunities for the increasing numbers looking to nursing as a career. In fact, a New England Journal of Medicine article published in April 2013, says there has been a remarkable growth of interest in the nursing profession since 2002 and a study published in the December 2011 Journal of Health Affairs reported the number of young people entering the nursing profession is surging, providing relief from the recent nursing shortage. The study found aggressive efforts to make nursing a more attractive career choice contributed to a 62 percent increase in the number of young nurses (ages 23-26) who entered the field between 2002 and 2009. Those who want to become nurses, and nurses looking to 18

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advance their education and careers can look for assistance in their own countries with internet searches of their federal governments, local universities and multiple scholarship websites. They can also look abroad, with help from groups like the Australian Agency for International Development and the Global Scholarship Alliance in the United States and the Philippines – and from individual universities like the University of Glasgow in the United Kingdom. Scores of nursing scholarships are available for UK citizens through individual universities and from the UK’s Commonwealth Scholarship Commission that offers scholarships through schools in more than 50 countries (outside of the US) for master’s degrees, many of which are for medical or public health studies.

Above Group tour sponsored by the American Association of Colleges of Nursing in the University of Maryland simulation labs. Image credit: American Association of Colleges of Nursing's Graduate Student Academy.

In Canada, The Canadian Nurses Foundation grants more than $275,000 annually to nurses and nursing students in all areas of nursing practice – and at all educational levels. The Nursing School Canadian Guide gives links to a handful of scholarships like one of its own that is given in conjunction with Sigma Theta Tau International/ Canadian Nurses Foundation. It’s an annual, $5,000 grant for licensed, practicing Canadian registered nurses to do research on nursing care or clinical nursing. Australia offers a wide variety of nursing scholarship opportunities such as government grants and scholarships for everything from undergraduate and graduate work to re-entry and midwifery. Its military has options, too, like the Australian Defence Force University Sponsorship with a range of benefits such as a salary while studying; paid student fees, free medical and dental care – and a guaranteed entry-level job as an officer in the Navy, Army or Air Force. Professional associations like the Australian College of Nurses and individual schools like the University of Sydney join in with their own financial aid packages. Many other countries have nursing scholarships available for their countrymen, like Germany, India, Israel and Morocco. In the US, companies, universities, nursing associations, the military and government agencies work in tandem and independently to offer hundreds of nursing scholarships and grants. Federal and state-government sponsored programs address the need for qualified nurses by underwriting the education of future professionals through grants and scholarships – or arrangements that trade financial assistance for service in a government entity. The US Department of Health and Human Services’ Health Resources and Services Administration (HRSA) offers a selection of both for US citizens, nationals or lawful permanent residents through these programs: • Scholarships for Disadvantaged Students grants participating colleges money they distribute among qualified students pursuing post-secondary education in enrolled in nursing or other health-pro-

Above A University of Maryland PhD nursing student. Image credit: University of Maryland School of Nursing.

fession programs. Grant money is made available to enrolled, full-time, financially needy students from disadvantaged backgrounds. • The Nurse Faculty Loan Program (FLP) provides funding to participating nursing schools to help establish and operate an NFLP loan fund they use for loans to assist registered nurses in completing their graduate education to become nurse faculty. The program offers partial loan forgiveness to borrowers who graduate and serve as full-time nursing faculty for a prescribed period of time – where loan recipients can cancel 85 percent of the loan over four years in return for serving as faculty in any accredited school of nursing. • The NURSE Corps Loan Repayment Program for nurse faculty also requires participants to work as nurse faculty at an accredited public or private nonprofit school of nursing. Preference is given to applicants who work at nursing schools where at least half of enrolled students come from disadvantaged backgrounds. • NURSE Corps Scholarship Program helps full-time students accepted or enrolled in diploma, associate, baccalaureate or graduate nursing programs – including RN to BSN Bridge Programs.

These students can receive funding for tuition, fees and other educational costs in exchange for working at an eligible Critical Shortage Facility upon graduation; the program guarantees them a job and helps the country stem the nursing shortage. • NURSE Corps Loan Repayment Program lets registered nurses care for people in some of America's neediest communities and help build healthy communities in poor urban and rural areas as they build their careers. Registered Nurses and advanced-practice RNs must agree to work for at least two years at Critical Shortage Facilities, and in exchange, the government will pay 60 percent of any outstanding nursingrelated student loans. Participants can earn 25 percent additional loan repayment for another year of service – for a total of 85 percent of his or her outstanding nursing student loans. Last year, the NURSE Corps Loan Repayment Program received more than 4,300 eligible applications and awarded $38 million through 500 awards to RNs working at Critical Shortage Facilities and more than 125 awards to nurse faculty at eligible nursing schools. The Indian Health Service Loan Repayment Program, also administered through the US Department of Health and Human Services, helps nurses and other health professionals pay off student loans in exchange for at least two years of full-time practice at HIS-funded Indian health programs that serve American Indian or Alaska Native communities. They can qualify for up to $20,000 of qualified student loan repayment for each year of service.

Military Nurses For those considering joining the US military, already have or have served honorably in the past, there are multiple scholarships, grants and programs available to help pay for the schooling needed to start a nursing career. All US military branches have scholarship opportunities, starting with ROTC scholarships from the Air Force, Army, Navy and Marines. These three- to fouryear scholarships cover costs such as tuition, fees, books and monthly living expenses. After graduating from college, MEDSIM MAGAZINE 5.2014

Nursing training students are commissioned as officers and required to serve four years of active duty and four years in the inactive ready reserve. “Military nurses play a vital role in treating service members and their families all over the globe and including the battlefield,” according to Lieutenant Commander Nate Christiansen, US Defense Department spokesman. “They are no different than civilian nurses as they administer medication, treat wounds, and care for the sick across the spectrum of patient care.” The military ROTC scholarships play a vital role in ensuring the military is able to recruit and sustain the country’s volunteer forces for a variety of jobs they need filled, including nursing, said Christiansen. The defense forces also offer Nurse Candidate Programs for those already pursuing a nursing career and Enlisted Commissioning Programs and Nurse Corps Programs for those already enlisted. Active duty service members also are eligible for Montgomery GI Bill Active Duty (MGIB-AD) or Montgomery GI Bill Selected Reserve (MGIB-SR) benefits and veterans can look into the Post-9/11 GI Bill that provides up to 36 months of education benefits, generally payable for 15 years following release from active duty. Institutions of higher learning participating in the Yellow Ribbon Program can

make additional funds available – and the VA matches that amount and issues payments directly to the institution.

Applying The first step for any US student applying for financial aid is to submit a Free Application for Federal Student Aid (FAFSA), as it plays a huge role in determining eligibility for grants and scholarships – especially for those based on financial need. It is the source that determines a student’s eligibility for all federal student loans and state-supported student loan forgiveness programs. Banks and other private lending organizations use the FAFSA information to help decide a student’s eligibility for alternative loans. No matter what kind of help a student is looking for, there are volumes of information and links to other kinds of scholarships available on independent sites like Nursing Scholarship.us and College Scholarships.org, association sites like the American Association of Colleges of Nursing (AACN) and Sigma Theta Tau International Honor Society of Nursing, and corporate sites like Johnson & Johnson (J&J), as part of its Campaign for Nursing’s Future. The J&J site offers suggestions about how to get started in a nursing career for everyone from high-school students to students already in college looking to change majors – and those interested in

nursing as a second career. It has links to 369 nursing scholarships and more than 2,000 nursing schools, many of which offer their own financial aid programs through help from their home states or through professional associations. Companies and professional associations often provide their own scholarships, or partner to offer funds. The American Association of Colleges of Nursing (AACN), for example, partners with business to offer scholarships like the Minority Nurse Faculty Scholarship with support from the J&J Campaign for Nursing’s Future. The AACN actively seeks opportunities to partner with corporate sponsors and other stakeholders to offer scholarship programs for nursing students in baccalaureate, master’s and doctoral programs like the AfterCollege-AACN Scholarship Fund – and others, including the Hurst Reviews/AACN Nursing Scholarship that recognizes and rewards outstanding students in pre-licensure nursing programs. The AACN works with The Robert Wood Johnson Foundation (RWJF) on the RWJF New Careers in Nursing Scholarship Program designed to alleviate the nation’s nursing shortage by expanding the pipeline of students in accelerated baccalaureate and master's nursing programs. This year, in the fourth round of funding, up to $10,000 scholarships will

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be awarded to up to 400 entry-level nursing students – with preference given to students from groups underrepresented in nursing or from a disadvantaged background. This fall, the AACN launched a new scholarship program with long-time partner CertifiedBackground.com that is open exclusively to nursing students in master’s and doctoral programs that are members of AACN’s Graduate Nursing Student Academy (GNSA). Four $2,500 scholarships will be available each year over the next five years to students in good standing who have distinguished themselves in the area of innovation, leadership and/or peer mentoring. CertifiedBackground.com also renewed its $200,000 commitment to the CertifiedBackground.com/AACN Scholarship program that will give scholarships over the next five years to students in undergraduate and graduate nursing programs. Nursing and nursing education are at a critical juncture, according to AACN President Eileen T. Breslin, PhD, RN, FAAN, who said “As the leading voice for professional nursing education, AACN will continue to use its national platform to advocate for more scholarship funding, support programs, and federal resources to assist schools of nursing with their efforts to remove financial barriers to nursing education and faculty careers for all populations in need.”

Another group, The National League for Nursing (NLN), sees its job as making sure it is bringing new nurses into the faculty arena, according to its CEO, Dr. Beverly Malone, who said too many qualified applicants are turned away from nursing schools each year that don’t have the clinical space or teachers to teach them. So the NLN offers its Nursing Education Research Grants annually to individual members and faculty of NLN member schools, and the NLN Foundation for Nursing Education awards scholarships to three outstanding nurse educators currently enrolled in accredited master's or doctoral programs related to nursing education – all of this to attract seasoned and ethnically diverse nurses to nursing education by making the pursuit of advanced degrees more affordable. State associations give scholarships in their own cities, like the Florida Nurses Foundation (FNF) which offers 17 scholarships to students enrolled in nationally accredited nursing programs in Florida, and several local districts of the Texas Nurses Association that fund-raise and grant their own student nurse scholarships. State governments get in on the action too, like California, which offers a host of scholarship and loan repayment programs. Some states have programs that offer loan forgiveness for nursing faculty or

have proposed legislation to provide funding assistance to nurse educators. Others help their schools offer scholarships through programs like the Robert Wood Johnson Foundation (RWJF) New Careers in Nursing (NCIN) program that has distributed more than 3,500 scholarships to students at 130 schools of nursing since 2008 – and this year granted funding for 400 scholarships at 52 schools. The NCIN program has made great strides in helping nursing schools recruit and retain diverse students in competitive and rigorous accelerated degree programs, according to David Krol, MD, MPH, FAAP, a RWJF senior program officer. It’s just one of more than a dozen RWJF programs working to increase the number of nurses with BSN degrees and higher to meet the nation’s health care needs. It’s also a great example of national organizations working to make a difference in the nursing shortage, in part through helping nurses and nurses-tobe advance their education, and in other ways, too, such as helping nurses build leadership skills, expanding the scope of practice of nurse practitioners and advancing interprofessional collaboration with other kinds of health professionals. Great fodder for MEdSim’s next installment on “Fixing the Nursing Shortage.” medsim

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Ultrasound Training

Bridging the Chasm: The Role of the SBIR Program Dr. Dan Katz, Dr. Eric Savitsky and Brian Bernstein describe the step by step process of the government’s Phase I, II and III SBIR program to develop a successful commercial product.

his is the second installment in a three-part series that uses a case study to describe the introduction of disruptive innovation into medical education and training. This installment reports the process of successfully guiding a nascent educational technology from an idea into a successful commercial product. October 7, 2001 marked the beginning of Operation Enduring Freedom (OEF), followed by the launch of Operation Iraqi Freedom (OIF) on March 20, 2003. Thousands of devastating blast-related injuries arising from improvised-explosive devices (IEDs) were a signature injury pattern of both conflicts. The complex nature of blast-related injuries was unlike anything encountered to date by military care providers trained within United States medical centers. In an effort to track and analyze the high volume of casualties and complicated nature of injuries during combat operations, US military forces began in 2004 to develop and implement the Joint Theater Trauma System (JTTS) and Joint Theater Trauma Registry (JTTR). These measures were intended to “improve trauma care delivery and patient outcomes across the continuum of care utilizing continuous performance improvement and evidence-based medicine driven by the concurrent collection and analysis of data maintained in the Department of Defense Trauma Registry (USAISR 2014).” Their creation resulted in tremendous improvements in medical care and created unique opportunities to advance combat casualty and civilian medical care. In a seemingly unrelated event, SonoSim was the Phase III commercialization vehicle of an earlier government Small Business Innovative Research program (SBIR) that began in 2007 as a direct response to unmet medical training needs arising from OEF and OIF. Through the strength of the federal government’s SBIR program the Department of Defense was able to prompt 22

MEDSIM MAGAZINE 5.2014

solutions to improve combat casualty care and improve efficiency within the military health system. SonoSim was the end-result of a successful SBIR program that began with a Phase I award in 2007. Along the way, this effort culminated in providing thousands of military care providers the latest medical lessons learned in OEF and OIF in the form of a military textbook (digital and print-versions), training DVD, and a much-needed, groundbreaking ultrasound training solution for military and civilian health sectors.

SBIR Program Background The SBIR program was established through the Small Business Innovation Development Act in 1982 to award federal research grants to small businesses. The program originally had several objectives: (1) spurring technological innovation in the small business sector; (2) meeting the research and development needs of the federal government; and (3) commercializing federally funded investments (OSD 2014). SBIR program founder Roland Tibetts described the program as a method “to provide funding for some of the best early-stage innovation ideas - ideas that, however promising, are still too high risk

Doctors in military field hospitals use ultrasound for diagnosis and treatment. Image credit: Pelagique, LLC.

for private investors, including venture capital firms." (Congress 2009). The Department of Defense is the largest recipient of SBIR monies and receives approximately $1 billion in SBIR grants annually (OSD2014). The SBIR program is divided into three phases: • Phase I awards deliver up to $150,000 over a six-month timeline with the intent that recipients explore the technical merit or feasibility of an idea or technology. • Phase II awards deliver up to $1 million over a two-year timeline, with the intent that recipients expand upon Phase I efforts and evaluate the potential for commercialization. • Phase III involves having recipients transition innovative solutions from research and development stages into the commercial marketplace (i.e., market and sell product). Historically, about 15 percent of SBIR proposals are awarded a Phase I contract, and approximately 50 percent of Phase I projects are subsequently awarded a Phase II contract (DoD 2014). The SBIR program has enjoyed numerous successes; one of the most notable is Qualcomm. Qualcomm co-founder, Dr. Irwin Mark Jacobs, credited the SBIR program with providing critical early-stage support during Qualcomm’s formative years. Today, Qualcomm is a global publicly traded behemoth with a market capitalization of $90 billion and over 17,500 employees. However, the SBIR program has yet to enjoy similar success supporting medical modeling, simulation, and training technologies. Numerous unique challenges have made launching successful startups in this space elusive.

Responding To An Unmet Need While combat operations in OEF and OIF were at a crescendo, half a world away at the University of California at Los Angeles (UCLA) Medical Center, UCLA Professor Dr. Eric Savitsky was working with his colleagues to create innovative computerbased medical education and training programs. Much of his early work involved creating computer-based “train-the-trainer” programs that were funded and used by a variety of international and non-governmental organizations, including the United Nations, International Rescue Committee, and Project HOPE. Concurrently, Savitsky was engaged in seed-stage technical research aimed at developing computer-based “hands-on training” technologies at the UCLA Center for Advanced Surgical and Interventional Technology (CASIT), which was supported by the Department of Defense. In 2007, Savitsky and his colleagues decided to launch a startup called Pelagique, LLC with the hope of transitioning promising university-based research into the commercial marketplace. While presenting some of his research at an Advanced Technology Applications in Combat Casualty Care (ATACCC) conference in 2006, Savitsky gained insights into the military’s pressing need to improve pre-deployment training for first-time combat casualty care providers and learned about the SBIR program and its intention to spur innovation by small businesses.

The Start of an SBIR Journey Fortunately, the severity and spectrum of battlefield injuries seen in military conflict is rarely encountered in the civilian

sector. As a result, it was exceedingly difficult to deliver adequate training to care providers before their combat-zone deployment. This prompted the Defense Health Program to begin drafting a Phase I award solicitation in 2006, which was initiated by Robert Foster PhD, former Director of Biosystems (Office of Secretary of Defense), in consultation with senior military medical leadership. Foster identified the need to develop a training curriculum based on lessons learned in OEF and OIF, coupled with a rapidly deployable method of providing training for combat casualty care providers. The newly developed JTTR database provided a unique opportunity to formulate evidence-based recommendations on best practices, which would stand in stark contrast to traditional anecdotal or expert opinion-driven approaches. Savitsky and his Pelagique colleagues responded to this Phase I SBIR solicitation and Pelagique’s submission was selected for funding. Phase I work commenced in 2007. During Phase I, the major elements included: (1) determining curriculum requirements and priorities for inclusion in the Combat Casualty Care Training System; (2) selecting training technologies that fulfill didactic requirements; and (3) designing a Combat Casualty Care Training System that could be widely distributed, allowing delivery of high-quality training capability to military medical care providers at varying stages of deployment.

Military physician performing a Focused Assessment with Sonography for Trauma (FAST) examination Image credit: Pelagique, LLC.

MEDSIM MAGAZINE 5.2014

Ultrasound Training Combat Casualty Care Training Pelagique’s Phase I program was selected for a Phase II award in 2008. The Phase II SBIR program led to the creation of two integrated technologies, a personal computer-based multimodal Combat Casualty Care Training System and a research prototype alpha-version SonoSimulator®. The technical objectives of the Phase II effort are detailed in Table 1. The most challenging initial element of the Phase II effort was gaining entry into a military medical facility within a war zone during peak combat operations. While the SBIR program provided financial support and technical points-of-contact to assist with program execution, there was no direct method of facilitating civilian team member travel to a war zone. Obtaining access credentials (i.e., CAC cards or DBIDS credentials), coordination of transportation, lodging, and security with the military were substantial barriers to travel. Ultimately, travel arrangements were secured and Pelagique team members were embedded within an echelon Level III facility, the 31st Air Force Theater Hospital in Balad, Iraq. The team was able to acquire video footage of the management of severe battlefield injuries cared for at this Level III facility (e.g. IED-related injuries). The video footage was used to create a real case-based training curriculum to prepare military care providers for future deployments.

Combat Casualty Care Training DVD The Combat Casualty Care Training System used a Flash®-based program to present text chapters, video cases, and procedural tutorials on 13 topics, which were carefully developed in collaboration with over 35 Department of Defense Joint Services subject matter experts (SMEs) through field-data collection, and by filming in the 31st Air Force Theater Hospital in Balad, Iraq. These training resources were distributed at the 2010 ATACCC conference, and subsequent distribution of training DVDs was managed by the Army’s Combat Casualty Care Research Program. Enthusiastic reviews and the high-quality curriculum motivated the Borden Institute, with support from the Telemedicine and Advanced Technology Research Center (TATRC) to publish and distribute thousands of copies of a companion textbook. The book, Combat Casualty Care: Lessons Learned in OEF and OIF, received a Washington Book Publishers Award in 2012. The curTable 1 – Phase II Combat Casualty Care Training System Research Objectives • • • • • • • • • • • • • • 24

Field Observation Combat Injury SMEs Collaboration Evidence and Approach for Training Efficacy Assessment Digital Media Assets Assessment Narrative Storyline Creation Multimodal Trainer Production Plan Identify Optimal Hands-On Procedural Training Topics Identify Procedures for Real-Time Procedural Reference Toolkit Technology Assessment Design System Architecture Design for Widespread Deployment Ensure SCORM Compliance Create After Action Review Process Finalize System Design MEDSIM MAGAZINE 5.2014

Combat Casualty Care Training DVD Image credit: Pelagique, LLC.

riculum was integrated into standard pre-deployment training for US Army medical personnel and was translated into foreign languages in support of allied nations. Hand-carried ultrasonography was identified as an important frontline tool for military care providers in Iraq and Afghanistan during Phase I research. The creation of a hands-on, virtual ultrasound training program was a major component of the Phase II Combat Casualty Care Training System. This ultrasound training program leveraged an earlier patented invention by Pelagique members. The application selected for hands-on ultrasound procedure training was the Focused Assessment with Sonography for Trauma (FAST) examination, which was delivered via a laptop personal computer-based interactive simulator called the SonoSimulator. An efficacy study performed in Phase II documented that a pre-commercial release of the SonoSimulator resulted in remarkable improvements in pre- and post-test knowledge and performance measures and even outperformed a live-instructor led ultrasound training session (Chung 2013).

The Commercialization Phase Hand-carried ultrasonography is an integral part of the Military Health System (MHS), both in combat casualty care during deployment and in the delivery of care to the beneficiaries of the TriCare system. It has key applications in the care of wounded warriors from in-theatre point-of-injury through their return to the continental United States. The need for MHS-wide ultrasonography training has grown in parallel to more widespread ultrasound imaging and image-guided interventions. Feedback regarding the utility and training value of the SonoSimulator from ultrasound manufacturers (future strategic channel partners) coupled with interest from academic institutions (medical and nursing schools), major medical centers, community hospitals, and individual care providers established a significant military and civilian sector commercialization opportunity. Pelagique received a Phase III award intended to facilitate commercial-grade development and deployment of the SonoSimulator in 2011. As part of Phase III efforts, Pelagique created SonoSim Inc. for purposes of fully commercializing the SonoSimulator. The SonoSim Ultrasound Training Solution® was a direct extension and integrated component of the Combat Casualty Care Training System created in Phase II.

Ultrasound Training Crossing the Chasm The SonoSim Ultrasound Training Solution overcame traditional barriers to ultrasound education and training. It validated using a low-cost personal computer as a platform for advanced medical training and simulation. In doing so, it upended traditional medical simulation paradigms and approaches to medical education. As such, it was widely viewed as a form of “disruptive innovation”. Despite all the plaudits and early successes, SonoSim faced another formidable commercialization obstacle: the need to move beyond selling to early adopters of technology and achieve crossover success by selling to the early majority of technology adopters. The inability to bridge this adoption gap results in failure of countless companies and products. In his book Crossing the Chasm, Geoffrey Moore describes the intrinsic challenges of commercializing such “disruptive technologies” (Moore 2014). Concurrent to these marketing challenges, the company still needed to upgrade its existing SonoSimulator prototype into a commercial-grade product. Like most start-up companies we had limited funding options. Traditional sources of federal funding that support proof-of-concept projects (e.g. National Science Foundation) did not support refining late-stage technologies. Diminished corporate interest in supporting advanced research and development efforts further shifted the burden of financing product development. Consequently, start-up companies are often reliant upon venture capital (VC) firms for financing. Such early-stage dilution of equity and fragmentation of leadership compromises the future trajectory of such companies. Since private equity firms are motivated by company valuation and maximizing returnson-investment, the objectives of the original SBIR solicitation often become secondary priorities.

SBIR Program Challenges While early-stage SBIR efforts, such as Pelagique’s Phase I and II work, are well understood by program managers and staffers, Phase III efforts pose unique challenges. Phase III companies are attempting to become profitable and self-sufficient businesses. However, the majority of these companies are still heavily reliant upon SBIR funding to develop commercial-grade products. The ability of such businesses to withstand delays in government contract execution is quite limited. Delays resulting from prolonged congressional inaction, inefficient contracting processes, cyclical turnover of program officers leading to loss of institutional knowledge or memory of earlier stage SBIR efforts are potentially disastrous for start-up companies. An increased awareness and sensitivity to the challenges Phase III start-up companies face would improve the odds of the federal government reaping a reward on earlier investments.

Conclusion Pelagique’s SBIR program journey was notable for its progression from innovative concept, to creation of a consumer product, and ultimately to commercialization. The step-wise progression of the phases allowed the team time to transition from research and development-focused activity to product commercialization. This was a dramatic evolution. The challenges companies face 26

MEDSIM MAGAZINE 5.2014

The SonoSim Ultrasound Training Solution. Image credit: SonoSim, Inc.

in Phase III are dramatically different than early Phase I and II efforts. Consistent support provided by the SBIR program was of immense value helping to navigate this complex and challenging landscape. Overall, the SBIR program was an invaluable asset that met its founder’s original objectives. medsim About the Authors Dr. Dan Katz is an Emergency Medicine Physician at Cedars Sinai Medical Center in Los Angeles, CA and is VP of Business Development for SonoSim. Eric Savitsky, MD is a Professor of Emergency Medicine at the University of California at Los Angeles (UCLA) and is the inventor of the SonoSimulator. Brian Bernstein is a Marketing Associate at SonoSim, Inc. REFERENCES 1. United States Army Institute Surgical Research Home Page. www. usaisr.amedd.army.mil/joint_trauma_system.html. Accessed on September 26, 2014. 2. US Department of Defense. Small Business Innovation Research. Small Business Technology Transfer page. www.acq.osd.mil/osbp/ sbir/about/index.shtml. Accessed on September 26, 2014. 3. The Role of the SBIR and STTR programs in stimulating innovation at high-tech small businesses. Hearing before the subcommittee on technology and innovation committee on science and technology House of Representatives one hundred eleventh Congress First Session. April 23, 2009. Serial No. 111-120. www.gpo.gov/fdsys/pkg/ CHRG-111hhrg48735/pdf/CHRG-111hhrg48735.pdf 4. SBIR/STTR. Small Business Innovation Research. Small Business Technology Transfer Home Page. www.sbir.gov/about/about-tibbettsawards. Accessed on September 26th, 2014. 5. Chung GK, Gyllenhammer RG, Baker EL, et al. Effects of simulation-based practice on focused assessment with sonography for trauma (FAST) window identification, acquisition, and diagnosis. Mil Med. 2013; 178:87-97. 6. Moore Geoffrey A. Crossing the Chasm, 3rd Edition: Marketing and Selling Disruptive Products to Mainstream Customers. New York. HarperCollins Publisher. 2014. Print.

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Patient Safety

Beyond a Legislative Disconnect In the first of several articles, Group Editor Marty Kauchak reviews efforts to improve the US healthcare community’s performance in patient safety.

his July 17, the US Senate’s Health, Education, Labor and Pensions (HELP) Committee’s Subcommittee on Primary Health and Aging conducted a hearing on Patient Safety and Medical Errors entitled “More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety.” The event was touted by the committee’s media team and others inside the Washington, DC Beltway as another opportunity to allow patient safety to move to the policy forefront. And with good reason! As subcommittee chairman, Bernard Sanders of Vermont, reminded the hearing’s attendees during his opening remarks, it is time to “start focusing attention on the third leading cause of death in the United States of America and that will come as the great surprise. The third leading cause of death in this country has to do with preventable medical errors in hospitals.” Emphasizing one estimate that as many as 400,000 people a year may die from preventable medical errors in hospitals, “that could be more than a thousand a day. Tens of thousands also died from preventable mistakes outside the hospi28

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tal such as that from misdiagnoses or injuries with medication,” he added for effect. Sanders, who is acclaimed on both sides of the political aisle and on both sides of Capitol Hill as a proponent for patient safety, undoubtedly deserved better in this most recent effort to elevate the topic on the legislative agenda in a bitterly divided Congress. Indeed, of 14 subcommittee members, Sanders was joined by two other Senate colleagues, Elizabeth Warren of Massachusetts and Sheldon Whitehouse of Rhode Island at the approximate one hour and thirty seven minute hearing. Left unresolved after this important hearing was a suggested legislative roadmap to address a long menu of issues to include: what is the role, if any, of the federal government in reducing the nation’s patient safety rate, and what legislation may be required to improve the community’s performance in this space? Other members of Congress and their staffs with oversight on patient safety were conspicuously absent in this watershed moment on Capitol Hill. The offices of five HELP subcommittee members who did not attend the hearing: Alexander; Baldwin; Enzi; Harkin; and Kirk did not return this author’s requests by email and telephone messages for interviews for this article. Similarly, the HELP committee’s counterpart office in the US House of Representatives, the Committee on Ways and Means, declined to respond to similar contact efforts, for the committee leadership and staff members.

Advocate Organizations’ Perspectives While there does not appear to be significant interest on Capitol Hill to allow patient safety to gain traction as a legislative issue

Above As many as 400,000 people a year may die from preventable medical errors in hospitals.

mation at all levels: among staff, between caregivers and patients, among institutions, and in clear public reporting that is useful to the lay public and meaningful to incite further improvement,” said Tejal K. Gandhi, MD, MPH, CPPS, president of NPSF and of the Institute. NPSF’s expanding role of leadership in this policy arena was further advanced this January, when the foundation developed a three-year strategic plan, with one of the goals being to help guide health care leaders and policy makers to advance patient safety in the evolving market. Thus far, however, most of the work NPSF is currently involved in or supporting at the federal level is not necessarily legislative, but rather providing feedback on initiatives coming out of federal agencies such as the Centers for Medicare and Medicaid Services (CMS), the FDA, the Office of the National Coordinator for Health Information Technology (ONC) and others. Another affirmation of NPSF’s presence as a community leader is Dr. Gandhi’s participation as a member of the

until the new Congress is seated this January, other stakeholders continue their efforts to keep patient safety alive as a policy issue. One insight on patient safety provided at the July 17 hearing was from John James, PhD, the founder of Patient Safety America (patientsafetyamerica.com). The Houston, Texas-based organization seeks to inform primarily non-medical people about the need for vast improvements in patient safety. James told MEdSim on October 7 “I do this by sending a monthly newsletter to about 500 people. The newsletter includes book reviews and summaries of pertinent articles from major medical journals. I also represent the organization through invited talks and publication of studies and books. For example, I have co-edited a book called The Truth about Big Medicine - Righting the Wrongs for Better Health Care. This book is due out in December. At specific times I ask those on distribution to support legislation or a cause that seeks to improve patient safety.” Another major community actor in the efforts to reduce accidents and mistakes in safety care is the National Patient Safety Foundation (www.npsf.org). The foundation is focusing heavily on encouraging advancements in patient engagement and transparency. A report published by the NPSF Lucian Leape Institute earlier this year included recommendations for health care policy makers to improve patient and family engagement. (See the Executive Summary.) “Early next year [2015], the Institute will publish a report on transparency, meaning the open exchange of infor-

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Patient Safety ONC’s Health IT Policy Committee Safety Task Force. This group is working to respond to the FDASIA Health IT report and provide recommendations around the formation, structure, and governance of a Health IT Safety Center. This is a joint initiative between the FDA, the ONC, and the FCC. Any uncertainty about a role for the federal government in improving US patient safety was set aside by James who asserted the federal government has a critical role in forcing change for better patient safety, but it has to start getting things “right”. “The latest example is of the website where patients in principle can learn about the payments of drug companies to specific doctors. The website is awful to try to use. The Centers for Medicare and Medicaid Services could force some improvements. For example, they could declare that all hospitals that want to continue to receive funds from CMS shall adopt a performance review system like 360-degree assessments of all professionals. This had been started at the federal agency from which I just retired and it has been used for a decade in hospitals in Alberta, Canada.” James further noted the approach is that each professional is assessed by patients, subordinates, colleagues, and staff heads using anonymous surveys. “Studies show that these do not have to be onerous. CMS could also demand job-satisfaction assessments of hospital staff,” he suggested and continued, “These would be made publicly available and associated with specific hospitals. If you had a choice, would you seek treatment at a hospital where 20% of the staff are happy with their job, or one where 85% are happy? This would provide strong leverage for hospital administrators to make positive changes.” For its part the NPSF sees patient safety issues incrementally entering the public policy arena. In one instance the patient safety community is still seeing results from the Patient Protection and Quality Improvement Act of 2005, which established Patient Safety Organizations. PSOs collect, aggregate, and analyze confidential information reported by health care providers, with the goal being to share and learn from others, without fear of discovery. 30

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Top Senator Bernard Sanders of Vermont. Image Credit: US Senate. Above Tejal K. Gandhi, MD, MPH, CPPS, president of NPSF and of the NPSF Lucian Leape Institute. Image Credit: NPSF.

But most significant is the Affordable Care Act (ACA), passed by Congress and then signed into law by President Obama on March 23, 2010. Under ACA a variety of patient-safety-related requirements and initiatives are coming into play. In one instance value-base purchasing, which began in October 2012, ties Medicare payments to hospitals’ performance in a number of process of care and patient experience measures. At the annual NPSF Patient Safety Congress in May 2014, a full-day session looked at the challenge of keeping quality and safety on the agenda when health

systems are being challenged to reduce the costs of care. “A big concern of the participants was the need for better metrics to measure and monitor safety across systems and over time, to ensure that organizations are interpreting and reporting the same events in the same way,” Dr. Gandhi said. In her transcript for this July’s Senate Subcommittee hearing, NPSF president Dr. Gandhi continued to open the aperture on patient safety – by emphasizing patients’ vulnerability during transitions in care. “These transitions occur all the time in health care – hospital to home, nursing home to emergency department, rehabilitation center to visiting nurse. Transitions are high‐risk times, when key pieces of information (such as medication changes, pending test results, additional workups that need to happen) can be lost. For example, one study found that after hospital discharge, within three to five days, one‐third of patients were taking their medications differently than how they were prescribed at discharge” she said. As any opportunity to advance safety through new legislation in this session of Congress appears to be a non-starter, Patient Safety America’s James, a selfdescribed patient activist, offered several ideas for the new Congress. “Given the inordinate complexity of the health insurance industry, I favor a well-run, single payer system. I know there is a lot of distrust of the federal government running anything. People I know are highly frustrated with the hodge-podge of insurance options. I think that once all are in the same system, there will be more push for improving safety.” James further suggested that opening up the National Practitioner Data Bank to the public would foster transparency into the possibility that doctors may be unsafe. “A national patient bill of rights like those enjoyed by workers and minorities would help level the playing field between patients and the medical industry. It should be enforced by the Justice Department. A National Patient Safety Monitoring Board, patterned somewhat like the National Transportation Safety Board would also help improve patient safety,” he added. medsim

World News & Analysis

News in Review For daily medical education and simulation news updates, visit MEdSim's online news page at www.halldale.com/news/medical

HOSPITAL

NEW PRODUCTS & DEVELOPMENTS

Automatic Delivery for SimMom

Clinical Male Pelvic Trainer Limbs & Things has launched a Clinical Male Pelvic Trainer (CMPT) to help clinicians and educators teach healthcare professionals how to perform male examinations, identify anatomy and diagnose critical pathologies in men’s health. Studies show one in 250 men will be diagnosed with testicular cancer at some point in their lifetime. Since there is no known way to prevent the disease, the best protection is regular physical examinations and early treatment for any signs of pain, lumps, lesions or swelling in the genital area. If testicular cancer is diagnosed early, the five-year survival rate is more than 95 percent. The new CMPT offers a realistic experience for those learning how to perform effective and consistent male genital examinations. This tool will help to improve competence and confidence, and ultimately contribute to improved patient outcomes.

Doctors at the Medical University of South Carolina's (MUSC) Healthcare Simulation Center have created an automatic delivery module for Laerdal Medical’s SimMom simulator that’s used to train obstetrics and gynecology students as well as midwives, nurses and emergency medical personnel. They made the new technology as an adaptation to SimMom instead of as a new simulator to help make it less expensive and more easily available. The module automates the birth process so the delivery does not have to be completed, allowing the training to be completed quicker and with fewer instructors. It also allows for greater standardization of scenarios and assessments and can be adapted through software to simulate a range of scenarios from a typical delivery to complex, dangerous situations. The MUSC Foundation for Research Development filed a patent application for the new module and licensed it for commercial purposes to Laerdal.

NEW PRODUCTS & DEVELOPMENTS

Endoscopic Simulator Launch Surgical Science has launched its endoscopic simulation system, EndoSim, which features basic endoscopic skills training modules and advanced lower and upper gastrointestinal intubation training simulations. EndoSim has a haptic hardware platform similar to the company’s laparoscopic simulator LapSim and detachable desktop haptics. It includes Basic Skills FES® Test Preparation, Therapeutic Skills, gastroscopy and colonoscopy scope software modules, and optional colonoscopy intubation and gastroscopy intubation modules. Tony Rubin, vice president of Surgical Science, says it offers a system-within-a-system functionality, meaning users can pick up the detachable haptic unit for endoscopy training almost anywhere.

ACADEMIC

Veterans BSN Degree Program The University of Southern Mississippi has received a three-year, $1 million grant to offer veterans with training as US Army or US Air Force medics, or as US Navy corpsmen an accelerated program to earn a Bachelor of Science degree in nursing (BSN). The program is supported, in part,

by the US Division of Nursing, Bureaus of Health Professions, Health Resources and Services Administration and the Department of Health and Human Services. The BSN program incorporates veterans’ military experience and training with the curriculum’s required coursework and

can be completed in as few as four semesters. Enrollment will begin in spring 2015 at the university’s Gulf Park campus near Keesler Air Force Base, the Gulf Coast Veterans Health Care System in Biloxi and the Naval Construction Battalion Center in Gulfport. M EDSI M M A G A Z I N E 5 . 2 0 1 4

World News & Analysis ACADEMIC

PATIENT SAFETY

Advancing Brain Surgery Neurosurgeons at University of California (UC) San Diego Health System have integrated advanced 3D imaging, computer simulation and next-generation surgical tools to perform a complex brain surgery to remove deep-seated tumors through a small incision. The school says it’s the first time this complex choreography of technologies was brought together in a California operating room. Tumors at the base of the skull are particularly challenging to treat due to the location of delicate anatomic structures and critical blood vessels, according to neurosurgeon Clark Chen, MD, PhD, UC San Diego Health System. He says the conventional approach to excising these tumors involves long skin incisions and removal of a large piece of skull, while the new minimally invasive approach is far less radical, decreases the risk of the surgery and shortens the patient’s hospital stay. A critical part of the surgery involves identifying the neural fibers in the brain, the connections that allow the brain to perform its essential functions, and the

orientation of these fibers determines the trajectory to the tumor, said Chen, vicechairman of Academic Affairs for the Division of Neurosurgery at UC San Diego School of Medicine who is a pioneer in tractography-guided procedures and an expert in endoscopic surgery. The team visualized the fibers with UC San Diego’s restriction spectrum imaging and used the color-coded visualization of the tracts to plot the safest path to the tumor. Then they made a 2-inch incision near the patient’s hairline, and a quarter-sized hole in the skull. The surgery was performed through a tube-like retractor that created a narrow path to the tumor – and aided by a robotic arm and high-resolution cameras – the team safely removed two tumors within millimeter precision. Bob Carter, MD, PhD, professor and chief of Neurosurgery, UC San Diego School of Medicine says they are seeing a new wave of advances in minimally invasive surgery for patients with brain cancer that permit smaller incisions and a shorter recovery. In this case, the patient went home the next day.

NEW PRODUCTS & DEVELOPMENTS

AccessMedicine App McGraw-Hill Education Professional has launched AccessMedicine App, the first offline mobile application of the company’s medical education platform and is now available for download onto iOS and Android devices. The new app lets users – doctors, residents, medical students, nurses – access AccessMedicine’s diagnostic resources in an off-line environment, an important feature for these professionals who often work in environments where internet service is unavailable. It is available to institutional subscribers to the AccessMedicine platform.

Saving Lives and Money Ten hospitals in the Tennessee Surgical Quality Collaborative (TSQC) have reduced surgical complications by 19.7 percent since 2009 – resulting in at least 533 lives saved and $75.2 million in reduced costs, according to results presented at the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) National Conference. The collaborative was formed in 2008 as a partnership of the Tennessee Chapter of the American College of Surgeons and the Tennessee Hospital Association’s (THA) Center for Patient Safety, with support from Blue Cross Blue Shield’s Tennessee Health Foundation. The hospitals collected 30-day, clinical outcome data to examine, evaluate and identify trends in best practices through the ACS NSQIP program. Between 2009 and 2012, they collected data on more than 55,000 surgical procedures and researchers examined rates of 17 kinds of surgical complications. Compared to complication rates in 2009, in 2012 the participating hospitals had 19.7 percent fewer postoperative occurrences, and the postoperative mortality rate dropped 31.5 percent. They also prevented an estimated 3.75 deaths per 1,000 surgical procedures and avoided $75.2 million in excess costs. The collaborative saw improvements in 13 of the 17 types of complications, nine of which improved significantly.

RESEARCH

Simulation Can Replace Clinical Hours The “National Council of State Boards’ (NCSBN) National Simulation Study: A Longitudinal, Randomized, Controlled Study Replacing Clinical Hours with Simulation in Prelicensure Nursing Education” found substituting high-quality simulation experiences for up to half of traditional clinical hours produces comparable educational outcomes to those students whose experiences are mostly traditional clinical hours and produces new graduates that are ready for clinical practice. 32

M EDSI M M A G A Z I N E 5 . 2 0 1 4

The study also won two awards honoring its contributions to the body of nursing knowledge: the Excellence in Educational Research Award from the Sigma Theta Tau International/Chamberlain College of Nursing Center for Excellence in Nursing Education and The International Nursing Association for Clinical Simulation & Learning (INACSL) President's Award. The study included incoming nursing students from 10 prelicensure programs across the US who were randomly placed

in a Control group of traditional clinical training where up to 10 percent of clinical time was in simulation or in groups that got either 25 percent or 50 percent simulation training. Participants were followed into their first six months of working in a clinical position, and the study found no meaningful differences between the groups in critical thinking, clinical competency and overall readiness for practice as rated by managers at six weeks, three months and six months.

ACADEMIC

Developing Portable Simulators

University of Florida (UF) and US Army Research Laboratory Simulation and Training Technology Center researchers have received a $1.75 million grant to design, develop and validate a set of portable, rugged simulators, that deployed, military medical personnel will use to acquire or practice the skills necessary to treat wounded soldiers on the battlefield. The grant was funded by the Telemedicine & Advanced Technology Research Center, a subcom-

mand of the US Army Medical Research and Materiel Command. The research team, made up of UF Health Jacksonville faculty, is building and testing mixed-reality simulators for five medical procedures based on technologies developed at UF. The first simulator lets health care workers practice central venous access – or placing a central line – to quickly introduce medication and fluids into the body. The second, originally developed for

UF’s department of neurosurgery, will help military clinicians practice a ventriculostomy, a procedure that relieves pressure in the brain after injury, and the third involves regional anesthesia to keep wounded soldiers more comfortable. The last two simulators under development are for chest tube insertion and the FAST procedure – Focused Assessment with Sonography for Trauma – that lets medical personnel pinpoint the location of and treat internal wounds. The simulators are designed to work in low-tech environments using the same hand-held equipment and tools healthcare workers use during actual medical procedures. In the event of a rapid deployment, reservists may need more training to become proficient with unfamiliar military medical procedures or equipment not routinely used in civilian medicine. With these simulators, they’ll be able to train in transit or stationed in combat zones, according to Samsun “Sem” Lampotang, director of the UF Center for Safety, Simulation & Advanced Learning Technologies.

NEW PRODUCTS & DEVELOPMENTS

ACADEMIC

Integrating Ultrasound Training

Simulation Training Direct to Providers

Laerdal Medical and SonoSim have entered a wide-ranging distribution, product development and R&D collaboration agreement to help practitioners integrate ultrasound training into patient simulation learning activities, according to Clive Patrickson, chief executive officer, Laerdal Medical. He says this partnership will provide the best learning environment for an integrated patient simulation experience and will be a great step forward in patient safety. The main limitation of ultrasound to drive adoption has been the difficulty in training users, said Derek McLeish, president of SonoSim International, “The increasing adoption of ultrasound will save lives, reduce costs, and improve patient outcomes."

A new simulation training initiative at the University of Texas (UT) Arlington College of Nursing lets educators put Neonatal Nurse Practitioners (NNPs) and physicians through the paces of an emergency scenario from hundreds of miles away. The school developed the "remote-controlled distance simulation" project in partnership with Pediatrix Medical Group, a provider of neonatal, maternal-fetal and pediatric medical and surgical subspecialty physician services. The goal is to let Pediatrix clinicians, neonatal nurse practitioners and physicians experience competency-assessment exercises with high-fidelity patient simulators in UT Arlington's Smart Hospital, without having to travel to the campus. Using Laerdal Medical's manikin baby SimNewB and a mobile system called SimView, College of Nursing Associate Dean Judy LeFlore has run more than a dozen live clinical simulation sessions in Florida and Texas from her office at UT Arlington. All the exercises focused on neonatal care emergencies, many of which providers suggested based on their experiences. The concept and its initial success are described in a paper published in the August issue of Clinical Simulation in Nursing. LeFlore coordinates work on the remote-control distance simulation project, with grant support from Pediatrix. She and colleagues in the College of Nursing design scenarios and she leads the exercises and debriefings with health care professionals in other states.

ACADEMIC

Cognitive Skills Tool Education Management Solutions (EMS) have collaborated with Drexel University College of Medicine to launch SIMULATIONiQ™ CaseMaster™, a cloud-based subscription system that lets learners practice on virtual patients to master clinical skills. The interactive, clinical-case authoring and training platform lets healthcare professionals create clinical cases for learners to practice on to improve their cognitive skills. Clinical-case authors and instructors can collaborate to create simulation cases in a variety of disciplines, such as emergency medicine, surgery and ob/gyn, with more than 15,000 real clinical orders.

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World News & Analysis NEW PRODUCTS & DEVELOPMENTS

ACADEMIC

Developing Synthetic Skin

Patient-Specific Surgical Simulator

UK Ministry of Defence (MOD) scientists at the Defence Science and Technology Laboratory (Dstl), supported by Defence Equipment and Support (DE&S), have developed a new synthetic ‘skin’ that could be used to test new decontamination procedures. They created the synthetic skin as part of ongoing efforts to develop a more realistic test procedure that would emulate the immediate decontamination process used if personnel come in contact with a liquid chemical warfare agent (CWA). The new synthetic skin demonstrated similar surface spread and absorption properties to actual skin in tests using CWAs. Jayne Ede, Hazard Management Scientist at Dstl says this synthetic skin provides a robust test to assess a decontamination

procedure, something that previously was difficult to accomplish, and it can be manufactured in large quantities and easily fixed to a mannequin head-form, so testing can take into account the contours of a face for more representative results.

NEW PRODUCTS & DEVELOPMENTS

Increasing Access to Ultrasound Simulation Point of care ultrasound is becoming widely recognized among multiple clinical specialities, as a valuable diagnostic procedure that offers far-reaching benefits in managing patient care. The new Heartworks TTE Mobile is a comprehensive educational tool designed to easily integrate into simulation programmes, enabling students from any clinical discipline to acquire both the theoretical and practical skills required to become proficient in Transthoracic Echocardiography (TTE).

“One of the challenges facing educators of TTE has been how to give students experience in recognizing pathology and seeing enough cases with abnormalities,” said Dr. Bruce Martin, Consultant Cardiac Anaesthetist at London’s Heart Hospital. “HeartWorks TTE Mobile helps us to overcome these challenges. By transferring echo skills and knowledge into a simulated echo environment and with the variety of HeartWorks pathologists that are available, doctors competencies can be greatly enhanced.”

PATIENT SAFETY

Laerdal and Synensis Partner Laerdal Medical and Synensis have joined forces to help improve patient safety and satisfaction by incorporating two Synensis products/services into Laerdal's portfolio: the Synensis Safety Culture Debrief and StoryCare® . Safety Culture Debrief is an assessment tool that analyzes hospital patientsafety culture data (required by the Joint Commission) and tells hospitals where to focus their simulation and improvement efforts. The Joint Commission is an independent organization that accredits and certifies more than 20,500 health care organizations and programs in the US. 34

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A team of surgeons from Jichi Medical University’s Department of Surgery in Japan have developed an interactive, patient-specific, surgical simulator for hepatectomy and pancreatectomy using preoperative imaging data. With their interactive simulator and a three-dimensional tactile mouse, they created a virtual 3D model using patient imaging data and established the feasibility of using it in a real clinical environment – applying it to navigation surgery, medical education and patient communication. In an article published in Journal of Computational Surgery (2014, Volume 10), the surgeons said preoperative simulation can greatly facilitate the safe and effective conduct of surgical procedures, and a computer simulation system can assist surgeons in preoperatively evaluating an operation and sharing of information among the operative staff. However, they had issues with their existing simulation systems, so they developed a new system using a patient’s own, anatomical imaging information that allows interactive control, similar to what a surgeon does in a real operation. A surgeon can intuitively control the system using a three-dimensional tactile mouse and change the translucency of objects, making it easier to understand complex anatomical relationships.

StoryCare is a cognitive simulation that helps clinicians learn and change behavior using audio stories that address patient safety issues such as poor communications, poor adherence to protocol and other human factors known to put patients at risk. Laerdal and Synensis say Safety Culture Debrief and StoryCare are solutions that can lead to improvement of patient safety culture and the patient experience – important, considering The Health Foundation article published in 2011 that says experts agree the root cause of poor patient safety in healthcare is related to culture.

Advanced Surgical Technology and Education Center Inova health care system has opened a new 6,900 square-foot simulation lab at Inova Fairfax Medical Campus in Falls Church, Virginia. Inova says the new Advanced Surgical Technology and Education Center (ASTEC) is a firstof-its-kind surgical teams training and education center to promote patient safety and is designed to accommodate a comprehensive, multidisciplinary simulation and training curriculum focused on improving surgical teamwork and technical skills.

NEW PRODUCTS & DEVELOPMENTS

PATIENT SAFETY

Birthing Simulators

Inova Fairfax Medical Center Using Qstream

Gaumard Scientific has completed the first US installations of its new Victoria birthing simulator at Adena Health System’s PACCAR Medical Education Center in Chillicothe, Ohio; Carolinas HealthCare System’s Carolinas Simulation Center in Charlotte, North Carolina; and Billings Clinic’s Simulation and Experiential Learning Lab (SELL) in Billings, Montana. Introduced earlier this year, Victoria is the latest addition to the family of NOELLE® maternal and neonatal care simulators. The company says its patented, precision, lifelike delivery and birthing mechanism births a life-like, full-term baby with sophisticated monitoring capabilities. The Victoria system includes comprehensive clinical scenarios, including shoulder dystocia and postpartum hemorrhage.

Inova Fairfax Medical Center (IFMC) and its Advanced Surgical Technology and Education Center (ASTEC) are using Qstream's mobile, game-based platform to improve patient safety and clinical knowledge among an interdisciplinary operating room (OR) team. IFMC’s Level 1 trauma center deployed four Qstream programs as part of ASTEC's initiatives to improve patient safety through technology with surgeons, nurses, anesthetists and surgical residents. These include Qstream programs that keep staff knowledge current in critical OR safety domains – including universal protocols, OR fire safety and other programs that help surgical residents perform better on the national SCORE curriculum and the companion ABSITE surgical skills exam. Qstream also has programs in development that cover methicillin-related staphylococcus aureus (MRSA) infection control and fundamental surgical knowledge required for simulation.

Send us your news on simulation and training! In January we will launch a new online information service on healthcare training and education. We invite you to send us your news, articles and white papers to be included. We especially welcome experience of real world applications of simulation in training, assessment or education to improve efficiency or safety.

Send your news to Fiona Greenyer at fiona@halldale.com and watch this space for more announcements!

From the publishers of:

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World News & Analysis NEW PRODUCTS & DEVELOPMENTS

ACADEMIC

Integration Opportunities

Affiliate Partnership

3D Systems has acquired Simbionix, a provider of 3D virtual reality surgical simulation and training, for $120 million. Simbionix will continue to be led by Gary Zamler, Simbionix’ CEO, who is now vice president and general manager of Simbionix Products for 3DS. 3DS’ recent acquisition of Medical Modeling gave it clinical capabilities in Virtual Surgical Planning (VSP®), guiding and instrumenting of complex personalized surgical procedures, production of 3D printed implants, and delivery of 3D printed patient-specific medical devices. 3DS says the combination of its clinical capabilities in planning and instrumenting for complex personalized surgical procedures, its 3D printed implants, and its patient-specific medical devices with Simbionix's 3D surgical simulation and training tools will accelerate the creation of a personalized healthcare platform that extends from the training room to the operating room. 3DS plans to pursue synergistic integration opportunities leveraging the combined resources and expertise to advance its healthcare portfolio. It also plans to incorporate its cloud-based Bespoke Modeling™ service into its Simbionix simulators. Bespoke Modeling lets medical professionals create, view, share and print full-color 3D anatomical models

directly from DICOM data. When used with Simbionix simulators, it helps medical professionals diagnose and communicate more effectively, simplify medical imaging and improve medical learning and training. Soon after the acquisition, 3DS introduced the Simbionix RobotiX Mentor™ robotic surgery skills and procedural training simulator, saying it is the only robotic training simulator that offers a truly interactive environment that lets surgeons and residents experience partial and entire robotic clinical procedures. The simulator is integrated into 3DS’ online curricula management system, MentorLearn™, to help programs incorporate the simulator and procedure modules into their robotic curricula. The MentorLearn system provides technical skills reporting and assessment and customization of curriculum, benchmarks and scores. 3DS also launched a Simbionix ultrasound training module for the practice of transvaginal ultrasound exams (GYN TVS), commonly used exams in many Obstetrics and Gynecology practices. Unlike external ultrasound exams, practicing pelvic ultrasound is more challenging to learners and educators – and the ability to perform and interpret these ultrasounds is an important part of clinical training programs.

RESEARCH

Learning to Break the Bad News Simulation in Healthcare, the Journal of the Society for Simulation in Healthcare, published two papers in August that explore studies about real life teaching approaches to improve the communications skills necessary in breaking bad news. In “Evaluation of the Impact of a Simulation-Enhanced Breaking Bad News Workshop in Pediatrics,” authors Kathleen Tobler, MD; Estee Grant, MD; and Cecile Marczinkski, PhD of Alberta Children’s Hospital reported on simulation-based training that produced a 100 percent improvement in communications skills, according to the ratings of participating families. Most importantly, when evaluating the residents’ post-workshop skills, parents who had previously received “bad news” and the physician and bereavement social worker doing the assessments reported improvement in 14 of 17 of the communications skills measured. The second article, "Teaching Communications Skills – Using Action Methods to Enhance Role-Play in Problem-Based Learning,” illustrates the use of structured techniques from psychodrama and sociodrama. Authors Walter Baile, MD and Adam Blatner, MD at the University of Texas MD Anderson Cancer Center in Houston found such methods as role-creation, role-reversal, and group-processing can substantially enhance the effectiveness of role-play in teaching communication skills for challenging conversations. 36

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Mater Education, part of Mater Health Services in Brisbane, Australia, and the Center for Medical Simulation (CMS) in Boston, USA have signed an Affiliate partnership where Mater will deliver certain CMS classes and in return will have access to a team of Harvard Medical School faculty. Mater Education has hosted the CMS’s Simulation Instructor training course, Simulation as a Teaching Tool since 2013 and will also deliver CMS’s Advanced Debriefing Course from 2015. As a CMS Affiliate, Mater Education will have an exclusive level of access to the resources, skills, advice and experience of the Harvard Medical School faculty simulation team that will help it further develop across Queensland and Australia. NEW PRODUCTS & DEVELOPMENTS

3D Printed Anatomy A research team at Monash University in Melbourne, Australia has created a kit of 3D-printed anatomical body parts that it says will revolutionize medical education and training, especially in countries where cadaver use is problematic. The team believes its “3D Printed Anatomy Series” is the first commercially available resource of its kind. The kit contains no human tissue, but provides all the major parts of the body required to teach anatomy of the limbs, chest, abdomen, head and neck. Professor Paul McMenamin, director of the University’s Centre for Human Anatomy Education, said the simple and cost-effective anatomical kit could dramatically improve trainee doctors’ and other health professionals’ knowledge and contribute to the development of new surgical treatments. Cadavers are often in short supply, McMenamin said, but “without the ability to look inside the body and see the muscles, tendons, ligaments, and blood vessels, it’s incredibly hard for students to understand human anatomy. We believe our version, which looks just like the real thing, will make a huge difference.” The kit is set to go on sale later this year and could have particular impact in developing countries where cadavers aren’t readily available or are prohibited for cultural or religious reasons.

PATIENT SAFETY

Urging More Simulation in India Union Health Minister of India, Dr Harsh Vardhan, appealed to the country’s faculty of medical colleges to include simulation as a training method in his keynote address to the country’s 5th Annual Conference of the Society of Cardiac-Anaesthesiology. He said hospital patients are concerned that student and resident doctors may be practicing on them, while students feel they are inadequately trained in history training, physical examination, diagnosis and management. Vardhan said the effectiveness of simulation as a bridge between ‘didactic’ medical teaching through lectures, tutorials, laboratory work and problem-based learning is being increasingly acknowledged the world over. “We don’t want an outdated medical curriculum framework. Our doctors have been world leaders throughout the 20th century. To keep our place there, our medical education planners should change with the times,” Vardhan said, congratulating the cardio-anaesthesiologist community for launching the “World Simulation Society” in India. ACADEMIC

Surgical Research Wayne State University School of Medicine’s surgery department received an $8.5 million grant from Mike and Marian Ilitch to develop innovative surgery technologies at the school in Detroit, Michigan. The grant will be used to create the Ilitch Chair for Surgical Innovation and fund research such as the patient-specific surgical simulator the department is currently developing. This simulation platform will let surgeons practice procedures on 3D replicas constructed from patient CT scans, decide the best approach for treatment and identify potential problems before making an incision. It could also be used to design and test virtual models of medical devices that could be 3D printed as physical prototypes. The department’s work is done in affiliation with the school’s Center for Smart Sensors and Integrated Microsystems, including a “robotic finger with eyes” that will work inside a patient’s abdomen and send what it “sees” and “feels” directly to the surgeon’s finger.

ACADEMIC CENTER BRIEFS SSH Accredits UH Manoa Nursing Simulation Center The University of Hawai‘i Translational Health Science Simulation Center (UH THSSC), part of University of Hawai‘i at Manoa Nursing (UH Manoa Nursing), was accredited by the Society for Simulation in Healthcare for three years, verifying the center’s internal operations and teaching and educational programs meet stringent standards. University of the Sunshine Coast Opens Nursing Center The University of the Sunshine Coast (USC) in Queensland, Australia has opened a new $25 million Learning and Teaching Hub for nursing education that is a joint initiative of USC, the Commonwealth Government's Structural Adjustment Fund and TAFE (Technical And Further Education) Queensland East Coast. The building will be used by students at both schools and includes simulation learning facilities, interactive teaching spaces and tutorial rooms. UW-Madison Opens New Nursing Facility The University of Wisconsin – Madison has opened a $52.8 million, 166,348-square-foot home for its School of Nursing. It includes an Active Learning Classroom to help students develop the skills necessary to work effectively in teams and analyze, discuss and solve complex, real-life challenges in health care; interactive student tables; and a simulated hospital suite with fully equipped hospital rooms and patient simulators that will stand in for patients at different stages of life. Lockheed Donates Simulation Equipment to UCF Nursing School Lockheed Martin has donated simulation equipment to the University of Central Florida’s College of Nursing in Orlando, Florida. Three high-fidelity mannequins, consumable medical supplies, an IV catheter trainer and other equipment will let students practice physical exams, history-taking, diagnostic skills and communication skills in a safe environment. Bangalore to Get New Clinical Skill Lab St. John’s Medical College in Bangalore, India, is planning to establish a Clinical Skill Laboratory early next year that will have dedicated simulation facilities and a goal of allowing the college to increase admissions and help students and faculty enhance their skills in complex surgical and medical procedures. Helping Improve Medical Education in Iraq The University of North Carolina at Chapel Hill (UNC) School of Medicine is collaborating with the University of Baghdad and its College of Medicine to help build a better medical education system in Iraq. The collaboration is funded through the International Medical Corps (IMC) and aims to enhance the curricula in the 23 medical schools throughout Iraq. UA – Phoenix Triples Size of Clinical Simulation Center The University of Arizona College of Medicine – Phoenix tripled the size of its Center for Simulation and Innovation to help the university accommodate growing class sizes and expand training partnerships with the community. The 33,000-square-foot center offers experiential, innovative and immersive simulation education and training to medical students and physician residents from UA Phoenix; physical therapy and physician assistant students from Northern Arizona University; nursing students from the University of Arizona, health professionals from Phoenix Children’s Hospital and AirEvac – Phi Air Medical Services, and others. University of Johannesburg Opens New Medical Simulation Lab The University of Johannesburg (UJ) has partnered with Philips Healthcare Africa Region to build a $1.86 million medical simulation lab with an ambulance simulation room, an emergency department representing casualty simulation, a general ward and an intensive care unit equipped with high-fidelity patient simulators. Philips is providing training for the trainers and to academic employees and clinicians, and the South African Department of Higher Education and Training awarded UJ a clinical training grant to help get the simulation lab up and running and improve the clinical competencies of graduates. M EDSI M M A G A Z I N E 5 . 2 0 1 4

World News & Analysis ACADEMIC

HOSPITAL

NEW PRODUCTS & DEVELOPMENTS

New Sim Center

Life-Saving Care

Elmhurst College and Elmhurst Memorial Hospital in Illinois have collaborated to build a new simulation center in the hospital for nursing students, hospital staff, first responders and other health care providers from around the region. The 4,600-square-foot Elmhurst College Simulation Center at Elmhurst Memorial Hospital has health care environments built and equipped like inpatient, outpatient and community settings; a homecare lab that lets students practice conducting a well-baby visit or adapting a home for someone learning to live with a disability; and cameras that let students watch simulation exercises in an observation room or remotely in class rooms or on their mobile devices.

A new program by Texas Children's Hospital Simulation Center will help reassure and prepare parents whose babies are being discharged from the hospital's neonatal intensive care unit (NICU) on ventilators with tracheostomies. The pilot program, currently in a study phase, lets parents practice reallife airway emergency scenarios on a mannequin that can occur when a baby on a ventilator with a tracheostomy is released from the NICU to be cared for at home. The goal is to educate parents how to respond to a variety of emergency scenarios and reduce readmissions to the hospital and/or accidental death. All families receive training on how to care for their baby's tracheostomy and ventilator, but simulation is the only way to really give them practice handling an emergency, said Dr. Jennifer Arnold, medical director of Texas Children's Simulation Center. She and her colleagues hope the program will be involved in a multi-center trial so other hospitals across the country can use it.

Ultrasound Simulation Technology

Calendar 7-11 November 2014 Learn Serve Lead 2014: The AAMC Annual Meeting Chicago, Illinois, USA www.aamc.org 11-13 November 2014 ASPiH Annual Conference 2014 Nottingham, UK www.aspih.org.uk/events 17-21 November 2014 43rd AAGL Global Congress on Minimally Invasive Gynecology Vancouver, British Columbia, Canada www.aagl.org/globalcongress/ 1-4 December 2014 I/ITSEC 2014 Orlando, Florida, USA www.iitsec.org 7-10 December 2014 IHI National Forum on Quality Improvement in Health Care Orlando, Florida, USA www.ihi.org/education/conferences 8-11 December 2014 2014 Special Operations Medical Association Scientific Assembly (SOMSA) Tampa, Florida, USA www.specialoperationsmedicine.org

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NEW PRODUCTS & DEVELOPMENTS

Training Solution CAE Healthcare is delivering a simulation-based training solution to Abiomed, a provider of heart support technologies, for its ImpellaÂŽ heart pump education programs. The training solution integrates a custom ultrasound simulator that lets physicians practice the placement of Abiomed's Impella device in the left ventricle in real-time under fluoroscopy and transesophageal echo, as well as transthoracic echo for monitoring. ACADEMIC

Improving Nurse Education in Thailand A Thailand Ministry of Public Health delegation made up of 90 nurse educators and students from colleges visited Northumbria University, in Newcastle, UK, to see how the University uses simulated patient mannequins to educate its nurses, and share what they learned when they returned to their country.

SonoSim LiveScanâ&#x201E;˘, the first ultrasound simulation technology to transform volunteers and standard mannequins into high-fidelity ultrasound training tools that was introduced early this year is now available for purchase. The company says it uses a combination of motionsensor technology and real-patient ultrasound data to provide medical educators with a true-to-life and cost-effective resource to train healthcare providers in bedside ultrasonography.

Index of Ads B-Line Medical www.blinemedical.com 5 CAE Healthcare www.caefidelis.com OBC IngMar Medical www.ingmarmed.com 7 KbPort www.kbport.com 13 Laerdal Medical www.laerdal.com IBC Limbs & Things www.limbsandthings.com 17 MEdSim Magazine www.halldale.com/medsim 27 & 29 Mimic Technologies www.mimicsimulation.com 9 NASCO www.enasco.com/healthcare 11 SESAM Belfast 2015 www.sesambelfast2015.com 15 Simbionix www.simbionix.com IFC The Society for Simulation in Healthcare www.simcertification.com 20 & 21 VCU School of Allied Health Professions wakingpatientsafetyreal.vcu.edu 25

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Take the “LLEAP” Introducing Laerdal Learning Application Are you looking to enhance your simulation training and increase the efficiency and efficacy of learning? Laerdal simulation products paired with our new Laerdal Learning Application (LLEAP) bring simplicity to running simulation training and efficiencies to the management and development of scenarios.

Be an early adopter, migrate to the LLEAP platform January 2015 through December 2015 for FREE! Visit us at laerdal.com/LLEAP to learn more. ©2014 Laerdal Medical. All rights reserved. Printed in USA. #14-14436

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Shoulder dystocia

Scenario after scenario, you can count on Lucina to deliver. As the first birthing simulator on the market that doubles as a standard female patient, Lucina offers the same true-to-life quality and bedrock reliability that you’ve come to expect from CAE Healthcare – along with the functionality and value of a fully wireless, high-fidelity patient simulator. Now, learners can practice everything from advanced CPR to postpartum hemorrhage – building confidence and competence. We’re delivering more, so you can deliver better.

The Way Healthcare Learns.

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