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Clinical Simulation in Alaska: More than Mannequins, More than Centers

Developing a Collaborative Model

Report to Dan Julius

University of Alaska Vice-President of Academic Affairs

Funded by University of Alaska Office of Workforce Development

University of Alaska Office of Associate Vice-President Karen Perdue

Submitted by Alaska Center for Rural Health – Alaska’s AHEC, UAA

March 2008

Project Planners

Karen Perdue, Associate Vice-President for Health Programs, University of Alaska Jan Harris, Associate Dean, UAA College of Health & Social Welfare Mia Oxley, Project Manager, UAA Health Programs Jackie Pflaum, Associate Director, UAA School of Nursing Suzanne Tryck, Director Regional Programs of Alaska, Washington School of Medicine Janice Troyer, Program Manager, UAA Alaska Center for Rural Health-Alaska’s AHEC Beth Landon, Director, UAA Alaska Center for Rural Health-Alaska’s AHEC

Alaska Clinical Simulation Taskforce

Alaska Division of Public Health - Public Health Nursing Jerry Troshynski, Staff Develop Coord Alaska Family Medicine Residency

Barbara Doty, MD, Associate Director of Rural Affairs Harold Johnston, Program Director

Alaska Native Tribal Health Consortium Tom East, Chief Information Officer

Alaska Nurse’s Association Debbie Thompson, President

Alaska Regional Hospital Dona Townsend, Chief Nursing Officer

Alaska State Hospital & Nursing Association Megan Wilmoth, Director of Programs

Bartlett Regional Hospital Justine Muench, Staff Develop. Coord.

Bassett Army Comm Hospital, Ft. Wainwright Lt. Col. Lisa Ingulli, Chief of Hosp Edu

Elmendorf AFB-3rd Medical Group Maj. Marlene Kerchenski, Director, Group Education & Training Lt. Col. Ryan Shercliffe, Chief of Emergency Services

Fairbanks Memorial Hospital Liz Woodyard, Associate Administrator Corlis Taylor, Education Dept Manager

Interior Region EMS Council, Inc. Dan Johnson, Executive Director

Maniilaq Health Center Wilma Goodwin, Director of Nursing

Providence Medical Services Roy Davis, Chief Medical Officer Shara Sutherlin, Chief Nurse Executive Carrie Doyle, Directorof Nursing Practice

UAA Allied Health Sally Mead, Division Director

UAA College of Health & Social Welfare Cheryl Easley, Dean

UAA Kenai Peninsula College Paul Perry, Paramedic Coordinator/Instru

Lynn Senette, Term Asst Professor UAA Health Sciences Department

John Riley, PA Program Coordinator UAA Mat-Su College Campus

Karen Carpenter, Term Asst Professor UAA School of Nursing

Marianne Johnstone-Petty, NRC/Lab/Distance Coordinator

Maureen O'Malley, Assistant Professor UAF Medical Services & Paramedic Program

Chuck Kuhns, Coordinator VA Healthcare System

Linda Boyle, Assoc Director of Nursing Andrea Neuerburg, Infecton Control Dennis Viloria, Assoc. Chief of Nursing

WWAMI Biomedical Program Dennis Valenzeno, Director and Associate Dean, UAA College of Arts & Sciences

Clinical Simulations in Alaska: More than Mannequins, More than Centers

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Table of Contents Table of Contents ........................................................................................................................... i

Executive Summary ...................................................................................................................... ii

I. Introduction ............................................................................................................................ 1

A. Background ...................................................................................................................... 1 B. Purpose .............................................................................................................................. 4

II. Findings .................................................................................................................................. 5

A. Use of Simulation Technology ......................................................................................... 5 1. Use and Interest in Alaska ............................................................................................ 5 2. Current Uses of Simulation Technology and Perspectives of Potential Users ............. 5

B. Key Findings from Statewide Taskforce ........................................................................ 6 1. November 27th, 2007 .................................................................................................... 6 2. January 24, 2008 ........................................................................................................... 8 3. Summary of Key Small Group Findings ...................................................................... 8 4. Summary of Large Group Discussion .......................................................................... 9

B. Experience from Continental United States and Canada........................................... 10 C. Potential Uses in Postsecondary and Continuing Education ..................................... 13

III. Discussion ............................................................................................................................ 14

A. Plan Ahead! .................................................................................................................... 14 B. Preliminary Outcomes ................................................................................................... 14 C. Clinical simulation is more than skill-building ........................................................... 15 D. Curriculum Development and Training ...................................................................... 15 E. Partner Collaboration .................................................................................................... 15 F. Sustainability .................................................................................................................. 16 G. Delivery Models and Governance Structures ............................................................. 16

IV. Conclusion ........................................................................................................................... 17

Appendix A: Project Methodology ........................................................................................... 19

Appendix B: Simulators, Distillation of Advantages and Challenges, Bibliography .......... 21

Appendix C: Use of Human Simulation Technology in Alaska (A Snapshot) ...................... 26

Appendix D: November 27, 2007 Alaska Clinical Simulation Taskforce Meeting .............. 36

Appendix E: January 24, 2008 Alaska Clinical Simulation Taskforce Meeting .................. 50

Appendix F: A Sampling of Clinical Simulation Delivery Models ........................................ 68

Appendix G: Alaska Clinical Simulation Taskforce Training Topics ................................... 73


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Executive Summary Clinical simulation appears to be the newest technological innovation to enter the clinical education environment. Far past the days of Resusci® Anne, clinical simulation embodies advanced technology, and a new way of thinking about education. Simulations of real clinical events generally employ learning tools which can range from practicing injections on oranges to very sophisticated high technology computers. In the postsecondary and continuing education of health care professionals, clinical simulation is increasingly recognized as a teaching resource to possibly reduce pressure on limited access to live clinical exposures, increase confidence of trainees, possibly improve patient safety and add rigor to the credentialing and precepting process. In September 2007, with resources from the University of Alaska’s Workforce Development Office as well as the UA Associate Vice-President for Health’s Office; the Alaska Center for Rural Health – Alaska’s AHEC (ACRH) at UAA was invited to determine the potential uses of clinical simulation technology for postsecondary and continuing education. Tasks included:

1) Form and convene a Statewide Taskforce 2) Conduct an inventory of clinical simulation purchases in Alaska and lessons learned 3) Review experience at the national level with clinical simulation 4) Determine potential uses in postsecondary and continuing education

Based on lessons learned from clinical simulation purchases in Alaska and experience at the national level, the following advantages and challenges of using human simulation technology were identified. Advantages

• This technology can provide realistic clinical experiences without risk to patients and learners; essentially, learners have “permission to fail” and learn from such failure in a way that would be unthinkable in a clinical setting

• Students can be exposed to clinical experiences they would rarely see and rare life-threatening events can be scripted and practiced using simulators for experienced residents and practitioners

• Scenarios can be designed with increasing complexity and introduced in a controlled way • Skills can be practiced repeatedly, tailored to individual needs • Practicing teamwork skills in simulated crisis situations can improve a team’s ability to

function effectively • Simulation-based learning can help students bridge the gap between classroom and

clinical settings and support their ability to apply what they have learned • Learning is interactive and includes immediate feedback • Sessions can be videotaped for subsequent review and discussion, fostering reflective

learning • Several learners can benefit from a session and learn from each other’s successes and

mistakes


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Challenges

• Equipment and associated costs for maintaining, troubleshooting and repairing it can be expensive

• Space is needed to house equipment, and location is important • Faculty development must be considered • Technical support is needed to maintain and run equipment • There is a need for more research to validate simulation as a teaching-learning strategy or

assessment/evaluation method that makes a difference in student learning and positive patient outcomes

Throughout this project, the task force members heard from a number of experts and pioneers in the employment of simulation in teaching situations. The net effect was to broaden our collective appreciation of the tools and uses of simulation and to counter the tendency to equate simulation technology with the most recently developed, high tech simulation tools. The task force learned not to equate simulation with the technology. The following conclusions are a synthesis of the Taskforce’s shared wisdom.

1. Needs Assessment/Curriculum Development: Technology is not an end in itself. The outcome sought should drive the simulation acquisition. This requires developing very specific outcomes, identifying curriculum needs, developing curricula, and understanding what curricula can be better/best served with this technology.

2. Collaboration: There are benefits in collaboration at every level of clinical simulation

development, including but not limited to: governance and management, curriculum development, acquisition, training, use, maintenance, sharing ideas, needs and experiences, sharing resources, and benefits.

3. Student Outcomes: While the technology may not generally reduce demand for clinical

training space or enable the training of more students, several realistic education outcomes were identified and include: improved clinical competency, improved critical thinking skills, improved communication among professionals, and integration of theory and practice placed in a practice context. It would also improve clinical exposure in rural, low patient volume settings.

4. Professional Outcomes: There is no evidence that the technology would decrease costs, but several promising education outcomes were identified and include: competency demonstration, cross-training, reduced orientation time, specialty training, standardization of training, improved team training, and training in chronic disease management.

5. Sustainability: Costs of operation and maintenance should be known and sustainable funding sources identified before acquisition of high fidelity simulation technology. This should include the cost of technicians, simulation specialists, faculty, maintenance, obsolescence of equipment, space demands, and upgrades.


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6. UA could, if funding could be identified and secured, do any of the following:

• Serve as a clearinghouse of curriculum for simulation training • Coordinate communication amongst interested Alaskan parties on resources,

outcomes data, and examples in the United States • Provide curriculum development leadership and serve as a resource by developing

curriculum templates and best practice standards for using simulation in education and by disseminating in Alaska

• Offer (or broker) simulation training for student educators and practitioners • Provide technical assistance • Conduct needs assessments for individual organizations or collaborative efforts • Collect data on the use of simulation in clinical education to document local

outcomes • Conduct research on some of the many unverified assumptions about use of

simulation in clinical education. A couple examples are: Is there a time (in any given discipline) when simulation experience is better than live clinical experience? Do we think simulation can substitute for clinical experience? Under what circumstances is this true? If so, what percent of live clinical experience could be met by simulation experience?

• Explore hosting a Simulation Center, and/or other collaborative endeavors

7. Pilot Projects: Pilot projects should be encouraged and the results disseminated as a means for expanding experience and expertise within Alaska. Some modest, community-based endeavors would enable Alaskans to test hypothesized outcomes as well as develop some comfort with the entire process and collaboration in this arena. Pre-hospital and hospital-based simulation was of particular interest to Taskforce members.

8. Increase Awareness: Taskforce members should introduce the subject of clinical simulation in various arenas and venues across Alaska, such as: Alaska Health Summit, ASHNHA conferences, University of Alaska meetings, EMS Conferences, etc.

9. Delivery and Governance: This project only “scratched the surface” of available governance and delivery structures. Myriad options exist and a collaborative model should be customized to fit with each program’s intended purpose.


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I. Introduction A. Background Clinical simulation appears to be the newest technological innovation to enter the clinical education environment. In the postsecondary and continuing education of health care professionals, clinical simulation is increasingly recognized as a resource to reduce pressure on limited clinical exposures, increase confidence of trainees, possibly improve patient safety and add rigor to the credentialing and precepting process. Clinical simulation is defined as “an attempt to replicate some or nearly all of the essential aspects of a clinical situation so that the situation may be more readily understood and managed when it occurs for real in clinical practice”1. Given the breadth of the definition, a nomenclature for organizing the universe of simulation is needed. For the purposes of this report, the following description from a book by Dr. Jeffries is used.

“Simulations are described along a continuum – from low-fidelity to high-fidelity – regarding the degree to which they approach reality. On the low-fidelity end of the simulation spectrum are experiences such as using case studies to educate students about patient situations or using role-play to immerse students in a particular clinical situation. Farther along the continuum are partial task trainers, such as IV cannulation arms or low-technology mannequins, that [sic] are used to help students practice specific psychomotor skills that are integral to patient care. More technologically sophisticated are computer-based simulations in which the participant relies on a two-dimensional focused experience to problem solve, perform a skill, and/or make decisions during the clinical scenario. Finally, full-scale, high-fidelity patient simulators are extremely realistic and sophisticated and provide a high level of interactivity and realism for the learner.”2

1 Morton, P.G. (1995). Creating a laboratory that simulates the critical care environment. Critical Care Nurse, 16(6), 76-81. 2 Jeffries, Pam. (2007). Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing.


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Table 1. Types of Simulators and Simulations

Type Description Examples Task Trainers Part of mannequin designed for specific

psychomotor skill Ear model, central/PICC line dressing model, Leopold palpation model

Mannequin Passive full body mannequin with exchangeable parts (e.g., wounds)

Resusci®Annie, age-specific mannequins (baby, geriatric)

Basic simulator Full body simulator with installed human qualities (breath sounds, childbirth)

VitalSim™ child and infant, Nursing Anne, Noelle™ birthing simulator

Patient simulator Full body simulator that can be programmed to respond to affective and psychomotor changes

SimMan®, Human Patient Simulator™

Computer Assisted Instruction (CAI)

Passive and interactive programmable software Fetal monitoring, ABG interpretation

Virtual Reality Complete simulated environment that includes audio, visual, tactile, hardware, electronics, and software

Virtual hospital/nursing home, IV simulator, robotics, data gloves

Standardized Patient (SP)

Individual who is trained to portray a patient or teach students using the SP as a teaching model

Scenarios related to invasive and non-invasive physical examination, interview, patient education, and discharge planning

Web-based simulation

Multimedia and interactive information accessed from around the world

Access via hyperlinks to virtual clinical environments in action (e.g., time lapse demonstration of the development of a pressure sore)

Blended Simulation

Use of multiple types of simulation to provide a comprehensive learning experience

SP: interview, simulator: physical examination and intervention, SP: education and discharge planning

Jeffries, P.R. (2007). Simulation in Nursing Education: from Conceptualization to Evaluation. (page 113). New York: National League of Nursing.


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The following diagram intends to clarify the range of fidelity and technology in simulation. Fidelity – how well the simulator mimics or reproduces experience with a living patient Technology – how intricate the simulator is, usually electronically or mechanically


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B. Purpose In September 2007, with resources from the University of Alaska’s SB-137 Workforce Development Office as well as the UA Associate Vice-President for Health’s Office, the Alaska Center for Rural Health – Alaska’s AHEC (ACRH) at UAA was invited to determine the potential uses of clinical simulation technology for postsecondary and continuing education. The initially identified activities included:

1. Form and convene a Statewide Taskforce 2. Inventory clinical simulation purchases in Alaska and lessons learned to date 3. Review experience at the national level with clinical simulation 4. Determine potential uses in postsecondary and continuing education

As with all projects entering uncharted territory, there were modifications. The Taskforce’s enthusiasm and insights, fueled in part by the caliber of participating national experts, supported a longer and broader view of the opportunities to consider and quagmires to avoid. This report moves quickly past a listing of potential technological uses and attempts to paint a framework for deliberate progress, a realistic role for the university, and realistic expectations for anyone considering an investment in moderate to high-fidelity clinical simulation technology.


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II. Findings This section provides aggregated data, with some analysis, for each of the project’s four sections. The integration of those sections occurs in the subsequent Discussion section. A description of the method is provided as Appendix A. In the course of this project, ACRH identified information and resources for potential users including types of simulators, a distilled listing of advantages and challenges of using human simulation technology, and a bibliography. That document is provided at the end of this report as Appendix B. A. Use of Simulation Technology 1. Use and Interest in Alaska ACRH interviewed 22 of Alaska’s 25 hospitals, ten UA programs, the Alaska Family Medicine Residency, four Fire Dept/EMS units, Guardian Flight in Fairbanks, the Alaska Department of Health and Social Services Section on Public Health Nursing, and the Community Health Aide/Practitioner Program at the Alaska Native Tribal Health Consortium. Of that group, many reported investments in mid-fidelity to high-fidelity clinical simulation equipment, including six hospitals, four UA programs, four Fire Department/EMS units and Guardian Flight in Fairbanks. Of the remainder, 11 hospitals and three UA programs expressed an interest in using simulation technology. Another four hospitals and three UA programs indicated they were “not sure.” All respondents saying “yes” or “not sure” were able to list potential users and uses. The most frequently cited barrier to purchase was cost. The tables of interview data are provided as Appendix C. Several themes emerged from the interviews. It is interesting to note that many of these concepts have been articulated throughout the project, both by Alaskans and by Continental United States users. 2. Current Uses of Simulation Technology and Perspectives of Potential Users Lessons Learned and Advice

• Rather than just purchasing the latest and most expensive technology it is critical to think through the users and the uses, and invest accordingly

• It is important to have someone responsible for managing and maintaining equipment. It is equally important to train more than one person for using/maintaining equipment in case the first person leaves

• High tech mannequins, such as SimMan, cannot be easily used outside for training (i.e. EMS) • Stick to reality for the scenarios employed and remember that debriefings are important


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Comments and Perceptions from Those who are Interested in Using Simulation Technology:

• Technology could cut down on overcrowding and overburdening of teaching facilities, especially in Anchorage

• Technology could free up faculty time, and get more students through the scenarios • Hiring standardized patients is expensive and they cannot reproduce pathology such as an

irregular pulse. And sometimes it is difficult to find someone to be a consistent patient • It is expensive and logistically problematic to get staff to urban Alaska for training • There are not enough patients for training in rural Alaska which makes for longer preceptorships

for new nurses/grads and harder to maintain skills for staff • Equipment is too expensive for a single rural facility to buy; many people in rural Alaska have

expressed interest in sharing or borrowing equipment • Some like the idea of having technology that is more realistic for Trauma Nurse Core Course and

ALS training • With less access to real patients for training because of confidentiality and liability issues;

simulators may be a way to address the need for access to patients • Current patient acuity is often too high for students to be able to practice on patients; this is a

mechanism for students to practice their skills before working on patients. Mannequins would be a mechanism to practice using equipment before using equipment on patients

• The technology could help people learn to cope with crisis situations 3. Advantages of Using Simulation Technology Comments from those who have used the equipment:

• Students and staff in rural Alaska do not get the same amount of exposure to multi-traumas or invasive procedures as those in urban Alaska, so working with mannequins can help verify skills and ensure skills are maintained

• Patients do not like to be practiced on, and there are fewer opportunities to practice skills in low volume hospitals

• The technology adds a step of realism to trainings (i.e. can alter vital signs), and teaches students to assess patients

• You can re-run scenarios as many times as necessary 4. Other Comments and Thoughts About Simulation Technology • It takes time and effort to develop scenarios and practice to keep up your skills (this comment

was made the most by those who have used the equipment) • “It’s the wave of the future.” “It’s where we are going.”

B. Key Findings from Statewide Taskforce 1. November 27th, 2007 During the November 27th meeting, Dr. Brian Ross provided an overview to the ISIS Center and provided insights to guide the Alaska Taskforce’s thinking.


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• ISIS has approximately 15 departments involved in simulation training. This has enabled them to standardize curriculum across those departments. They have also developed a peer-review process for developing curriculum. That has helped motivate clinical educators to work for them in developing curriculum, as it can become part of their portfolio. Curriculum development is an important piece of ISIS. They have a formal template for their curriculum with 12 essential elements. This enables them to more easily share curriculum with partners.

• Dr. Ross noted that medicine has, for the most part, used a silo approach to training and delivery of care, such as OB, Anesthesia, Internal Medicine, and Surgery using a “see one, do one, teach one” method. He talked about public demand for training “not on me for the first time.” Simulation allows students to become proficient in skills before ever working on a patient. It also allows for cross-discipline training.

• Dr. Ross reviewed different types of simulation equipment and uses. There is an impressing diversity of equipment available.

• It was noted that he has seen a lot of simulation centers that have different rooms for different disciplines, but many sit empty for large parts of the day. He believes it is more efficient and a wiser use of space to have a more open model that can be used for multiple disciplines. Dr. Ross mentioned a national study that noted that Simulation Center rooms are only used 18% of the time. Dr. Ross repeatedly advised that “there is no reason to buy something if someone is not taking intellectual responsibility for it and will make sure it is going to be used.” “You need to do a formal needs assessment, and then develop curriculum. The curriculum must start with how the patient presents and the entire process for moving the patient through the system.” Dr. Ross also talked about high fidelity simulators that contain modern functionality. “If you aren’t going to use all of the functions, it may not be the smartest purchase. The purchasing decisions should be driven by curriculum needs. Don’t get talked into equipment you don’t need!”

• Dr. Ross recommended that a consortium have a mission statement or list their primary goals. ISIS has three goals: provide leadership in use of simulation technology, improve quality of health care education, and improve patient safety and outcomes.

Janice Troyer presented an overview of data collected on the current use of clinical simulation in Alaska. This is described in Appendix C. In the closing comments for the November 27th meeting, several members commented that their eyes had been opened to the broad scope of simulations and technology and the possibilities for clinical education. Many noted they had a very narrow view of simulation previously. Members also noted they were beginning to see the value of collaborating with other disciplines and the need for team development training. A decision was made at the end of the meeting for each taskforce member to submit their top five to ten training needs to ACRH staff before the next meeting to help continue the process of determining the potential use of clinical simulation in Alaska. A complete set of the minutes from the November 27th meeting are provided as Appendix D.


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2. January 24, 2008 This meeting opened with a series of video-conference presentations from simulation projects outside of Alaska. A synthesis of those projects is provided in Appendix F. The taskforce participated in a series of discussions throughout the afternoon. They worked in three small groups: University of Alaska, Hospital/Providers, and Development and Delivery. The discussion then continued in the larger group setting. The University of Alaska group was asked to consider to what extent the use of simulation technology could impact delivery of classroom education and clinical training. They were also asked whether simulation technology would enable UA to train more students and what would be realistic expectations for training outcomes. The Hospital/Provider group was asked to consider to what extent the use of simulation technology could impact delivery of continuing education and CME training. They were also asked to identify realistic expectations for training outcomes and improving patient outcomes. The Development and Delivery group was asked to think about development, delivery, and organization of clinical simulation in Alaska. The groups were also asked to comment on any preliminary conclusions that could be drawn from the results of the Training Topics survey and to identify any important key concepts that should be included in the final report. 3. Summary of Key Small Group Findings The University of Alaska small group discussion members noted they would like to see documented evidence for positive outcomes in the use of simulation technology. They brainstormed both positive and negative impacts of using simulation technology as part of curriculum. Some of the benefits cited included the opportunity for interdisciplinary training, competency-based training, and increased skill development in professional communication. Members agreed simulations expose students to the reality of practice and also pointed out that students may soon demand technology and in that way lead the change. The challenge of incorporating simulation technology into the curriculum is that faculty development will need to be instrumental and additional personnel will be needed in terms of technology support staff and simulation specialists. Overall the group did not believe simulation technology would necessarily allow the training of more students, but would be a significant impact on clinical competence and confidence of new graduates. It was also believed that the use of simulation technology could take a load off clinical sites which are currently stretched to the limit. Clinical sites/hospitals would benefit as students come better prepared and patient safety is increased. The group summarized a list of realistic expectations for training outcomes which included: competency based improvement, confidence building in critical thinking skills, communication


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between professionals, quality of learning experience improved, integration of theory and practice placed in a practice context. The group concluded that they would like to see the University be a clearinghouse of information even if they do not own simulation equipment. This information, including curriculum, could be housed at UA for industry to access. The hospital/provider small group brainstormed both positive and negative impacts of incorporating simulation technology into their facilities. On the positive side, they noted the use of clinical simulation could be a way for staff to demonstrate competency, to cross-train with other staff, to be trained in specialty areas, to help standardize training, to improve team training and as a means for working with staff in the area of patient complaints and also in dealing with patients living with chronic diseases. The latter use was noted to be particularly important in rural areas where the remote clinician has limited experience with a particular condition. When thinking about negative impacts, the group expressed concern about the support needed for using simulation technology and whether it would add to staff workload or divert money from other areas. Other potential negative impacts included the space demands for technology and the potential problem of equipment quickly becoming outdated. The group concluded it will be important to initially identify a subset of needs that could be used for early successes such as skills training for new graduates and orientation for new staff. Team-based training would also be a good early focus. In order to spearhead the effort and keep the momentum going, dedicated staff need to be identified as the early “champions” (or as Dr. Brian Ross said the “intellectual owners”) and there needs to be a clearinghouse to broker the information on technology, curriculum and expertise. The development/delivery group noted that while many of the collected training topics were skill based, the value of clinical simulation is that it allows learning of these skills to be enriched with communication skills during a stressful event and helps learners develop and practice critical thinking skills in appropriate contexts. In terms of thinking about the delivering of clinical simulation in Alaska, the group noted it is important to consider the following: you cannot assume the same level of availability of technology across the state, we need to explore the mobility of equipment and the use of distance learning technology and there needs to be a clearinghouse of information such as an Alaska user group for sharing curriculum scenarios and data. This group also noted that training is almost more important than equipment in terms of resources and rural community members need to be engaged in this training. In thinking past this taskforce, this group could see the usefulness of developing subcommittees to address different areas of simulation utilization. 4. Summary of Large Group Discussion Once the large group came together, the discussion continued. There was general agreement that people liked the idea of working together and continuing to collaborate. The advantages of this are the networking aspect where partners can share best practices and avoid redundancy and an investment strategy that brings more credibility to funders when more partners are involved. There was some discussion about the need for a good business plan and sustainability model. And prior to these items, a needs assessment would need to be conducted to help inform the


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business plan. Participants made several comments regarding a needs assessment. The needs assessment would need to define simulation; questions would need to be asked carefully, so it is unbiased, and the assessment should be conducted at the administrator and training manager level. The need for a clearinghouse of information and Alaska user group (that included all the disciplines) was mentioned several times. It was suggested that the University of Alaska might play a role in this function to gather information about equipment and provide a resource library of scenarios. A complete set of the minutes from the January 24th meeting are provided as Appendix E. B. Experience from Continental United States and Canada The following section gives a brief overview of a sample of Continental U.S. and Canadian simulation programs reviewed by ACRH staff. They include:

• University of Washington’s ISIS Center – a university program with an expansive mission to serve the entire WWAMI region in providing leadership in the use of simulation technology, improving quality of health education and improving patient safety and outcomes.

• STARS – a mobile Canadian EMS-based training program within a larger organization that is completely community and foundation-funded

• Oregon Simulation Alliance (OSA) – A government-sponsored collaboration for the purpose of developing simulation capacity statewide

• ASTEC – Housed at the University of Arizona and more strictly focused in student education is exploring the use of telemedicine equipment to provide education in remote sites

• Wells Center – A nonprofit serving a collection of nursing schools through a hub and spoke model that is looking at the potential uses of combining datacasting with simulation technology

More details about each of these organizations can be found in Appendix F or in their respective websites listed in this section. The ISIS Simulation Center, located within the University of Washington Medical Center, contains a skills lab area with a variety of laparoscopic simulators and a mock hospital room with a high-fidelity mannequin. The mission of ISIS is to provide skills development and interdisciplinary training to residents, medical and nursing students, and medical faculty. They also serve as a simulation resource library and provide leadership in the area of simulation technology, particularly in the WWAMI region. ISIS has a Governing Board and an Executive Committee. The Executive Committee runs ISIS and develops the initiatives. Under this committee there are three major committees: Faculty experts, Education, and Research and Development. Website: http://www.isis.washington.edu/ The STARS Mobile Simulation Program uses two motor homes and a suburban to provide simulation training to healthcare providers in rural facilities across Alberta. The motor homes are


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each equipped with a permanently installed high-fidelity mannequin, while the suburban has mannequins housed in mobile cases/bags. The STARS mobile program works with individual healthcare facilities to determine their training needs. They conduct four simulation trainings a month focused on critical care, emergency medicine and interdisciplinary team training. STARS is a non-profit charitable organization. The STARS Foundation is the fundraising arm of the organization. About 70% of the funds are raised through philanthropic donations and 30% are raised through government partners. Facilities do not have to pay for training. STARS has two boards: one is a foundation board which oversees all fundraising and the other is a society board that helps make decisions about how money is spent. Website: http://www.stars.ca/bins/index.asp (see What We Do, Education & Research, Mobile Simulation Program) OSA is a collaborative statewide group formed in 2003 to develop and expand simulation capacity in all regions of the state for multi-disciplinary and interdisciplinary use for healthcare workforce development. OSA is comprised of multi-disciplinary regional coalitions each with a different model on how they use simulation and deliver training. Over 40 sites within OSA have purchased their own equipment. There are over 20 simulation centers and some coalitions within OSA are using a mobile delivery model. Initially OSA was funded through state, federal and private grants. They are currently in the process of finding ways to make OSA sustainable. OSA is coordinated by the Governor’s Office and serves both as an advisory group and provides oversight. The Simulation Alliance Governing Council has representation from Oregon community colleges, universities, healthcare provider organizations and other simulation users. Much of OSA’s focus has been on providing trainings to their partners including a three day Simulation Technician Training and a two day Foundations for Simulation Education Workshop. Website: http://www.oregonsim.org/index.php Two programs that have used and/or are planning to use simulation technology in conjunction with distance education are the WELLS Center in Colorado and the ASTEC in Arizona. Both have simulation centers, but deliver their simulation education with different methods. ASTEC, housed with the University of Arizona Medical School, does a majority of its training within the simulation center and primarily serves medical students and residents, though it does provide some training to physicians, nursing and other allied health students. ASTEC is part of the Dean’s Initiative with the Vice Dean overseeing staff. ASTEC hopes to use its telemedicine equipment to provide education in remote sites. For example, doctors in rural areas have used the equipment to observe scenarios done in the ASTEC simulation lab using one of the high fidelity baby mannequins. The doctors in the rural sites observed the performed scenario and were able to participate in the debriefing. Website: http://www.astec.arizona.edu/ The WELLS Center in Colorado is a non-profit currently housed within Colorado Center for Nursing Excellence. Using a hub and spoke model, staff provides training in both their simulation center and also travel to other sites for training. The WELLS Center partners with 26 nursing schools across the state and provides competency training for nurses in hospitals across the state as well. They focus on simulation training, faculty development and information dissemination. The WELLS Center has an Advisory Committee composed of statewide members, as well as an Executive group, which oversees policies and procedures. Recently WELLS has partnered with their local public broadcasting company to deliver high-speed


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datacasting via satellites. This approach allows remote participation for observing and debriefing. The datacasting allows large files to be sent to individual computers via satellites so users can receive images without an Internet connection, an advantage to some of their rural sites that only have access to dial-up. Live training events at the simulation center can be seen in real time. The Center is about to begin a pilot program to look at potential uses for this technology in conjunction with simulation technology. Website: http://www.coloradonursingcenter.org/CurrentProjects/WellsCenter.html More insight comes not from existing simulation projects, but from colleagues at the national level. The two specific to this project are Dr. Jeffries, a consultant assisting in planning for the UAA Health Sciences building, and Dr. Allen from the WWAMI Idaho office. Dr. Pam Jeffries, author of Simulation in Nursing Education: From Conceptualization to Evaluation, provided an overview of the current state of simulation from a nursing perspective at the January 24th meeting. She began by identifying some of the current challenges in nursing education such as faculty and clinical site shortages, pedagogical challenges and the demand on health care providers for more complexity in the workplace. Dr. Jeffries outlined the purpose of simulations and gave examples of how simulations are used as a teaching strategy, an assessment method, and for practice. In addition she discussed some advantages and challenges/barriers for using simulation as a teaching method. In looking towards the future Dr. Jeffries predicts that clinical simulations will be incorporated into all core curriculum courses. She sees the use of simulation, as a way to challenge students to problem-solve, to make decisions and to provide a unique and critical experience students may not be able to get on a clinical unit. Dr. Jeffries also foresees more interdisciplinary simulation centers in the future where nursing and medical students are able to work and practice together in an education setting before performing procedures and caring for real patients. The last half of Dr. Jeffries’ talk focused on thinking about and planning for Clinical Simulation centers. ACRH staff also spoke with Dr. Suzanne Allen of the WWAMI Idaho office. Idaho has a statewide coalition-planning group that started about two years ago. She noted that many Idaho groups have simulation technology, but are missing scenarios. That was one impetus for putting the planning group together. The Northwest Physicians Insurance Company has taken the lead for this group and paid for the teleconference and meetings. The coalition includes hospitals, EMS and academic groups. Dr. Allen noted it took one and a half years of meetings to make sure they had the right players at the table and to decide how to structure a coalition. The plan was for the coalition to be temporarily housed under the Idaho Hospital Association. It may eventually become its own entity. They have developed a steering committee to provide oversight and are currently in the process of forming work groups, which may include: curriculum development, equipment/scheduling, academics, hospitals and possibly EMS. All of these programs shared lessons learned and advice. These lessons revolved around several themes: planning ahead before buying equipment, thinking through which delivery models and governance structure make the most sense for a region, advantages of collaborations, the importance of both curriculum development and training and focusing on sustainability from the beginning.


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C. Potential Uses in Postsecondary and Continuing Education Seventeen taskforce members submitted a list of training and education topics that had potential for the use of simulation. The topics covered a wide range from very broad to very specific. Though the original intent was to find a handful of common topics, this became impossible as over 150 training topics were submitted. An attempt was made to sort these into major categories including:

• Emergency airway management and cardiac life support • Disaster management/emergency scenarios away from the hospital • Codes/emergencies in the hospital • Physical exams • Technical skills • Deliveries/neonates/pediatrics • Communication • Health promotion/management

Examples of topics for each of these categories are included in Appendix G. In some cases, instead of listing specific topics, members listed the types of learners that could potentially benefit from the use of simulation technology. These included: ETT, EMTs, Paramedic, CHAP, RN, PA, NP, MD, Resident, Medic, new staff, faculty and new graduates. Types of training were also listed including:

• Skills training for EMS providers • Continuing education • Re-credentialing • Continuing medical education • Deployment training and re-deployment training • Skills and procedure competency screening for students, new hires, interims, locums, travelers,

emergency responders • Faculty development • Training new staff for specialty areas

Taskforce members were invited to make comments about their satisfaction level of the current training they provide and to make any additional comments regarding simulation technology. A wealth of comments was provided and can be viewed in the individual charts in Appendix G.


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III. Discussion A. Plan Ahead! Dr. Brian Ross, the Executive Director of ISIS, stresses the importance of doing a needs assessment before buying simulation equipment. Curriculum should drive the training needs and these needs will drive the type of simulation equipment and/or center you create. Dr. Ross suggests identifying essential elements of a curriculum and then figuring out which components could have value added by simulation. Shirley Anderson, Executive Director of OSA, noted they were in the process of conducting a series of site assessments designed to capture the state of “readiness” for simulation in different locations in Oregon. Unfortunately OSA received grant funds before this process was completed and they had a limited timeframe from which to disburse funds. In retrospect they wish they could have completed that process before awarding grants to the coalitions. Shirley Anderson also suggests that workforce issues should define the needs for simulation, not the universities. Mike Lamaccia, Director of the STARS Mobile Simulation Program, noted that it was a needs assessment done with physicians in rural Alberta that drove the need for bringing the training to the facilities. Physicians complained about not being able to come in for training because they did not feel they could leave their communities. He also suggests discouraging individual facilities from going out and buying their own simulation equipment before determining their needs. Mike notes the “honeymoon” will be over quick when these same facilities realize the time it takes to maintain and program the equipment. B. Preliminary Outcomes None of these experts could point to peer-reviewed outcomes data for clinical simulation, and all mentioned the need for it. The three most common outcomes sought are: education that improves patient safety, decreased demand for clinical training sites and a method to shorten orientation time for new hires. Nevertheless, the contagious enthusiasm to develop this educational modality continues to secure significant funding. Data are starting to emerge, with two examples provided here. A. Dr. Ross described a small, unpublished study done by ISIS that compared the training time

needed for eight students using the old resident training model (see one, do one, teach one) with a group of eight students using simulation in their training. They found that the simulation cohort was far advanced early on, but by the end of the training both were groups were about the same level. He said the advantage of this is that you may be able to add more skills training without increasing the amount of time covering the curriculum to include simulation. He also noted he wanted to repeat the experiment the following year, but none of the faculty was willing to go back to the old training method-they all wanted to continue with the simulation training.

B. Dr. Jeffries shared a nursing study she had conducted that evaluated three different educational methods using simulation from low fidelity to high fidelity. They looked at learning outcomes for each of the “roles” across educational methods. They did not find a significant difference in learning outcomes across roles. That means those who play the role


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of “observer” in a simulation are learning as much as the other participants. Pam Jeffries was surprised at this finding, but also encouraged by the ramifications.

C. Clinical simulation is more than skill-building People can learn algorithms of skills via rote memorization from a textbook, a classroom lecture, practice on a classmate, observation via videoconference or mid to high fidelity simulation. The value of mid to high fidelity simulation, in addition to being ideal for experiential learners, is that it also enables the development of communication skills in a stressful environment and critical reasoning skills. The communication and critical reasoning are not afforded by the other teaching modalities. Several invited speakers and Taskforce members articulated the importance of “hand-off” skills and interdisciplinary communication, and that they are both inadequate in the current educational environment. This is a significant niche that mid to high-fidelity clinical simulation can serve. D. Curriculum Development and Training Dr. Ross emphasized the importance of curriculum development with simulation technology. He commented that it takes a tremendous amount of work to write the curriculum for simulations. ISIS is working towards standardizing their curriculum. They have developed a standardized curriculum template, which all faculty are required to use. This has enabled ISIS to share their curriculum with other partners. By sharing curriculum, training costs go down and patient safety goes up. One example he used to illustrate this process is that ISIS worked with multiple disciplines to develop a standardized way to do central line removal. All residents must be certified at ISIS before performing this function on a real patient. Dr. Ross also noted that it is important not to try and do too many things at once or be all things to all users. Shirley Anderson noted that much of the work that OSA did revolved around providing workshops for coalition partners on how to use simulation technology and develop curriculum. Alyson Knapp, Coordinator of ASTEC, suggests that Alaska not limit its imagination on how simulation can be incorporated into teaching. There are things she is teaching with simulation now that she never would have guessed she would be doing a year ago. E. Partner Collaboration The examples provided in this report demonstrate the wide variety of collaborations that exist even within this small representative sample of simulation programs, from partners within a university to a network of rural facilities to regional coalitions. Shirley Anderson noted that the most successful coalitions within OSA are those that had existing partnerships on other projects and expanded to include clinical simulation. The OSA collaborations have evolved over time. In areas with bigger populations, sometimes the larger collaborations have split into smaller coalitions because there is not enough equipment to support the entire group. Several organizations are breaking out of coalitions and merging with organizations geographically closer to them. Jana Berryman, Director of the WELLS Center, also gives advice regarding collaborating partners. She notes they work hard to not be seen as a


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competitor with their partners. They strive to be transparent in what they do and look for funding sources that will benefit their partners. They also encourage the participation of new partners. Dr. Ross also encouraged the Alaska Taskforce to be as inclusive as possible when thinking about partners in the planning stages. Dr. Allen sees advantages of coalitions to be: a) the ability to buy equipment at a reduced rate, b) sharing equipment, and c) help with scenario building and curriculum development. F. Sustainability Shirley Anderson noted that it is extremely important to develop a plan for sustainability of funding and a succession plan for leadership. OSA has been grant-funded to date and they are now looking at ways to sustain the Alliance. She noted in her presentation that OSA members received free grant funded training and are now reluctant to pay for that training. Jana Berryman of the WELLS Center also noted that they have primarily been grant funded and are now looking at the issue of sustainability. They have recently started a fee for service. They hope this fee will provide 30-60% of their funding in the future. Dr. Allen noted their recently formed Idaho coalition is in the process of outlining a structure for how to pay for the simulation technology so that it is self-sustaining. G. Delivery Models and Governance Structures As can be seen from the Continental United States and Canadian examples, delivery of simulation education varies widely from simulation centers where learners come to the simulation center to receive training to mobile units that deliver training to the local healthcare facilities to the incorporation of distance technology into simulation training. Dr. Ross is a firm believer in taking simulation technology to where the training needs are. He suggests a “footprint” is needed in each partner facility. Each facility has very different kinds of patients and needs and so by providing simulation training at the sites, the staff is able to use their own equipment in a simulation, which ensures the training is as close as possible to what will really happen. The examples also demonstrate an array of governance structures. Shirley Anderson notes that if you are going to form a similar alliance, it is important to have an Executive Director or someone that is responsible for the day-to-day operations such as training and grant oversight. She also suggests a succession plan for leadership as some of the early leaders in a planning process may burn out.


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IV. Conclusion Clinical Simulation is here. Independent of what happens to the Taskforce or its members, clinical simulation has arrived in Alaska. Many investments have been identified and more are inevitably on the horizon. The following conclusions are a synthesis of the Taskforce’s shared wisdom. 1. Needs Assessment/Curriculum Development: Technology is not an end in itself. The

outcome sought should drive the simulation acquisition. This requires developing very specific outcomes, identifying curriculum needs, developing curricula, and understanding what curricula can be better/best served with this technology.

2. Collaboration: There are benefits in collaboration at every level of clinical simulation development, including but not limited to: governance and management, curriculum development, acquisition, training, use, maintenance, sharing ideas, needs and experiences, sharing resources, and benefits.

3. Student Outcomes: While the technology may not generally reduce demand for clinical training space or enable the training of more students, several realistic education outcomes were identified and include: improved clinical competency, improved critical thinking skills, improved communication among professionals, and integration of theory and practice placed in a practice context. It would also improve clinical exposure in rural, low patient volume settings.

4. Professional Outcomes: There is no evidence that the technology would decrease costs, but several promising education outcomes were identified and include: competency demonstration, cross-training, reduced orientation time, specialty training, standardization of training, improved team training, and training in chronic disease management.

5. Sustainability: Costs of operation and maintenance should be known and sustainable funding sources identified before acquisition of high fidelity simulation technology. This should include the cost of technicians, simulation specialists, faculty, maintenance, obsolescence of equipment, space demands, and upgrades.

6. UA could, if funding could be identified and secured, do any of the following:

• Serve as a clearinghouse of curriculum for simulation training • Coordinate communication amongst interested Alaskan parties on resources, outcomes

data, and examples in the United States • Provide curriculum development leadership and serve as a resource by developing

curriculum templates and best practice standards for using simulation in education and by disseminating in Alaska

• Offer (or broker) simulation training for student educators and practitioners • Provide technical assistance • Conduct needs assessments for individual organizations or collaborative efforts


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• Collect data on the use of simulation in clinical education to document local outcomes • Conduct research on some of the many unverified assumptions about use of simulation in

clinical education. A couple examples are: Is there a time (in any given discipline) when simulation experience is better than live clinical experience? Do we think simulation can substitute for clinical experience? Under what circumstances is this true? If so, what % of live clinical experience could be met by simulation experience?

• Explore hosting a Simulation Center, and/or other collaborative endeavors 7. Pilot Projects: Pilot projects should be encouraged and the results disseminated as a means

for expanding experience and expertise within Alaska. Some modest, community-based endeavors would enable Alaskans to test hypothesized outcomes as well as develop some comfort with the entire process and collaboration in this arena. Pre-hospital and hospital-based simulation was of particular interest to Taskforce members.

8. Increase Awareness: Taskforce members should introduce the subject of clinical simulation in various arenas and venues across Alaska, such as: Alaska Health Summit, ASHNHA conferences, University of Alaska meetings, EMS Conferences, etc.

10. Delivery and Governance: This project only “scratched the surface” of available governance and delivery structures. Myriad options exist and a collaborative model should be customized to fit with each program’s intended purpose.

Appendices

Clinical Simulations in Alaska Appendix A: Project Methodology

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Appendix A: Project Methodology The following describes specific activities which occurred in the course of this project. Form and Convene a Statewide Taskforce ACRH and the Project Planners developed a Clinical Simulation Taskforce with representatives from the University of Alaska and interested industry partners. Industry partners primarily included hospitals and EMS departments, both of which are recognized as relatively heavy users of clinical simulation technology in the Continental United States. Some members were identified through the October phone interviews of Alaskan users. The Alaska Department of Health and Social Services selected a representative from Public Health Nursing and the Alaska State Hospital & Nursing Home Association also sent a representative. The Taskforce convened in-person, in Anchorage, on November 27th and January 24th. The final meeting occurred via videoconference on March 5th. In the November meeting, two important data sources were presented. First were the aggregate findings from interviews of users and potential users across Alaska. These data had not been collected previously and provided a useful perspective to inform potential new users or larger scale investments. Second, Dr. Brian Ross from the University of Washington’s Institute for Surgical and Interventional Simulation (ISIS) attended in-person to give a presentation on ISIS and share wisdom on the thoughtful selection and structured use of clinical simulation technology. In the January 24th meeting, ACRH presented the aggregated training topics information from Taskforce members. In addition, approximately half of the meeting was dedicated to video presentations of significant clinical simulation projects in Oregon, Indiana, and Alberta (Canada). In addition to providing an overview to their design, governance and simulation capacity; each presenter shared wisdom and lessons learned. The remainder of the meeting focused on discussion of information learned to date and the development of “key concepts” as well as suggestions for the future of clinical simulation in Alaska. The March 5th meeting occurred via videoconference and focused on discussion of the final report’s content and suggestions for improvement. Assessment of Use and Interest in Alaska Between mid-October and November 21st, ACRH conducted a series of telephone interviews to determine the current use of human simulation technology in Alaska. The Project Planners developed the questions and assisted in the aggregation of resultant data. Specifically, ACRH successfully interviewed 22 of Alaska’s 25 hospitals, ten UA programs, the Alaska Family Medicine Residency, four Fire Dept/EMS units, Guardian Flight in Fairbanks, the Alaska Department of Health and Social Services Section on Public Health Nursing and the Community Health Aide/Practitioner Program at the Alaska Native Tribal Health Consortium.

Clinical Simulations in Alaska Appendix A: Project Methodology

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While a census of users was not feasible or appropriate, responses were sufficient to provide a representative sample and snapshot of human simulation technology in Alaska. For those facilities or UA programs who own moderate to high fidelity equipment, questions were asked regarding the: • type of training the equipment is used for • who the primary users are • whether equipment is ever transported out of the main facility for training • maintenance issues to date • lessons learned about using this type of technology For those facilities that did not own any moderate to high fidelity simulation equipment, questions were asked about: • interest in using simulation technology for training in their facility • how they would envision using simulation technology • perceived advantages of using simulation technology Select Examples and Experts from Lower 48 Members of the Clinical Simulation Steering Committee identified two initial resources from the Continental United States: Dr. Brian Ross and Dr. Pam Jeffries. Based on communications with those individuals, and recommendations from Taskforce members, ACRH identified a short list of agencies to interview. Due to time and resource constraints, only a few programs were interviewed. At best, they are a representative sample. Nevertheless, each has proven valuable in informing the Taskforce’s dialogue on the diversity of delivery modalities and governance structures feasible, as well as providing insights to Alaska’s planning. Potential Uses in Postsecondary and Continuing Education At the close of the November meeting, Taskforce members agreed to engage in a cursory brainstorm of potential training topics of benefit to their organization that could be served by this technology. Specifically, they agreed to identify their top training topics, to reflect on whether the topic is currently addressed to their satisfaction, and to consider whether they see potential for simulation technology use. This information would reflect the diversity of identified training needs as well as the overlap. Shared training topics could be used by members in the development of collaborations, either technology use or curriculum development. That information was submitted to ACRH in mid-January for aggregation in advance of the January 24th meeting.

Clinical Simulations in Alaska Appendix B: Simulators, Distillation of Advantages and Challenges, Bibliography

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Appendix B: Simulators, Distillation of Advantages and Challenges, Bibliography The information in the following chart was taken from the website of the Penn State College of Medicine Simulation Lab. More details can be found about the different simulation technology on their website: http://www.hmc.psu.edu/simulation/available/mds.htm Type Description Examples Model-driven simulators (high fidelity simulators)

A mannequin body or part of body to physically represent the patient, and have physiologic and pharmacologic models that direct real time autonomous reactions to interventions and therapies; these types of simulators generally integrate multiple system models to produce a realistic patient response; simulator usually sold separate from monitors and ancillary equipment needed to provide realistic setting

BabySim, Emergency Care Simulator, Human Patient Simulator (HPS), PediaSim, PediaSimECS, Sydney Perfusion Simulator

Instructor-driven simulators (intermediate fidelity simulators)

Partial or full body mannequin as a physical presence on which to practice interventions. The simulators may interact with the user in limited ways, but the bulk of responses are created by the instructor. They often use real interventional equipment (probes, IV lines, ventilators, etc.) and may or may not use real monitoring equipment. The output signals to their displays are consistent with the patient anatomy and condition being presented and are changed by the instructor to reflect real-time changes in patient condition.

Airman, Baby Hal, Code Blue III Interactive System for ACLS Instruction, HAL, Noelle Obstetric Simulator, PatSim-1, SIMA, SimMan

Virtual Reality Simulators Use computer modeling and complex programs to cause the user to believe that they are interacting with a patient, when in reality, they are interacting only with the imagination of the computer. The simulator has some type of physical representation with sensing instruments that inform the computer of the user’s movements. The program then computes the changes that should take place within the model and projects the correct response onto the screen. Systems may include some sort of 3D imaging to make the environment more realistic and intuitive

AccuTouch Endoscopy Simulator, AccuTouch Endovascular Simulator, Angio Mentor, CathSim Intravenous Training System, Endotower, GI Mentor, Uro Mentor and so on-more listed on website

Computer Based Simulators

Most contain an interactive patient vital sign screen which responds to user interventions. Physical skills and tasks cannot be taught on them. Educational content is mainly focused on learning facts, using the info learned to make treatment decisions, and evaluating the effectiveness of that treatment.

A few examples: ACLS Simulator, Anesthesia Simulator, Cardiac Arrest, Critical Care Simulator, Gas Man, Sedation Simulator

Task Specific Models

Designed to teach a specific task, procedure, or anatomic region. They often resemble anatomic sections of the body, but this is not necessary. Some are automated, but there is no adjustment based on the user’s actions.

Website lists all the manufacturers


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The following list of advantages and challenges was distilled from notes taken from some of the articles and books listed in the Sources section. It is not intended to be comprehensive, but to give the reader a sense of what is being discussed in the literature. Compiled by Janice Troyer of the Alaska Center for Rural Health-Alaska’s AHEC. Advantages of Using Human Simulation Technology • This technology can provide realistic clinical experiences without risk to patients and learners • Tasks/scenarios can be created on demand; the instructor controls the clinical situation, events, and

timing of learning • Students can be exposed to clinical experiences they would rarely see; rare life-threatening events can

be scripted and practiced using simulators for experienced residents and practitioners. • Tasks/scenarios can be designed with increasing complexity and introduced in a controlled way. • Skills can be practiced repeatedly, tailoring to individual needs. • Replaying scenarios allows several approaches to the same situation or event. • There is an opportunity for interactive, interdisciplinary health care team learning and team

performance assessment to practice important clinical, communication, leadership and interpersonal skills.

• Practicing teamwork skills in simulated crisis situations can improve a team’s ability to function effectively.

• Research shows students involved in active learning retain knowledge longer. • Learners have “permission to fail” and to learn from such failure in a way that would be unthinkable

in a clinical setting. It gives students an opportunity to explore limits of each technique rather than having to remain within the zone of clinical safety.

• Instructors do not have to take over as often as they would in a clinical unit when students are having difficulty or mishandling a situation.

• A training agenda can be determined by the needs of the learner, not the patient; learners can focus on whole procedures or specific components, practicing these as often as necessary.

• Simulation-based learning can help students bridge the gap between classroom and clinical settings and support their ability to apply what they have learned.

• Learning is interactive and includes immediate feedback. • Action can be paused for reflection and correction. • Sessions can be videotaped for subsequent review and discussion, fostering reflective learning. • Standards against which to evaluate student performance and diagnose educational needs are

enhanced. • Students accustomed to simulation experiences report decreased level of performance anxiety and

increased self-confidence in their psychomotor skills and critical thinking abilities. • Several learners can benefit from a session and learn form each other’s successes and mistakes. • Clinical teaching time can be decreased.

Challenges of Using Human Simulation Technology • Equipment and associated costs for maintaining, troubleshooting and repairing it can be expensive. • There is the potential cost of a simulation center coordinator and technical support personnel. • There are space needs to house equipment (including a control area where simulation is staged,

storage space for life-size simulator(s) and supporting equipment as well as a remote area to debrief). • Faculty development must be considered when implementing an education curriculum using human

patient simulation-they must learn new instructional skills and techniques. • Technical support is needed to maintain and run equipment.


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Sources BOOKS Jeffries, P.R. (2007). Simulation in Nursing Education: from Conceptualization to Evaluation. New York: National League of Nursing. (Note: this book has been ordered by the UAA Consortium Library) Dunn, W.F. (Ed.) (2004) Simulators in Critical Care and Beyond. Des Plaines: Society of Critical Care Medicine. (Note: a request has been put into the UAA Consortium Library to order this book.) ARTICLES Binstadt, E.S., Walls, R.M., White, B.A., Nadel, E.S., Takeyesu, J.K., Barker, T.D., et al. (2007). A comprehensive medical simulation education curriculum for emergency medicine residents. Annals of Emergency Medicine, 49(4), 495-504. (Describes a complete curriculum redesign to fully implement a medical simulation model using adult learning principles, medical simulation learning theory, and standardized national curriculum requirements for an emergency medicine residency curriculum.) Buchanan, J.A. (2001). Use of Simulation Technology in Dental Education. Journal of Dental Education, 65 (11), 115-1231.(Discusses the potential use of simulation technology in dental education and gives an overview for virtual-reality based simulation products-with a few photos and discusses potential uses for virtual reality simulators.) Good, M.L. (2003).Patient simulation for training basic and advanced clinical skills. Medical Education, 37 (Suppl 1), 14-21. (Includes a brief history of human patient simulator development, features of contemporary simulators, as well as benefits, limitations and effectiveness of this learning modality.) Harlow, K.C. and Sportsman, S. (2007) An Economic Analysis of Patient Simulators for Clinical Training in Nursing Education. Nursing Economics, 25 (1), 24-29 (Evaluated the difference between three stand-alone versus one regional center in terms of facility, equipment and faculty costs-study done in Texas.) Issenberg, S.B., McGaghie, W.C., Petrusa, E.R., Gordon, D.L. & Scalese, R.J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher, 27(1), 10-28. (A literature review of articles from1969-2003 whose objective was to answer the following question: What are the features and uses of high-fidelity medical simulations that lead to most effective learning?) Jeffries, P.R. (2005). A Framework for Designing, Implementing, and Evaluating Simulations Used as Teaching Strategies in Nursing. Nursing Education Perspectives, 26(2), 96-103. (A good overview of using simulations as a teaching strategy in nursing.) Kneebone, R. (2003) Simulation in surgical training: educational issues and practical implications. Medical Education, 37, 267-277. (Good background information on different kinds of simulators.) Lathrop, A., Winningham, B., VandVusse, L. (2007). Simulation-Based Learning for Midwives: Background and Pilot Implementation. Journal of Midwivery & Women’s Health, 52 (5), 492-498.


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(Includes some good background information on the use of simulations-very little of the article is about midwivery specifically.) Maran, N.J. and Galvan, R.J. (2003). Low-to high-fidelity simulation – a continuum of medical education? Medical Education, 37 (Suppl 1), 22-28.(Gives a good overview of types of simulation equipment available) Morgan, P.J. and Cleave-Hogg, D. (2005). Simulation Technology in training students, residents and faculty. Anaesthesiology,18, 199-203 (An overview of the developments in medical education and assessment using high-fidelity simulation-included descriptive and research papers) Peteani, L.A. (2004) Enhancing Clinical Practice and Education With High-fidelity Human Patient Simulators. Nurse Educator, 29 (1), 25-30. (Includes an idea for developing a business plan to outsource SimMan to others for a charge to help with costs of buying equipment.) Rauen, C.A. (2004). Simulation as a Teaching Strategy for Nursing Education and Orientation in Cardiac Surgery. Critical Care Nurse, 24 (3), 46-51. (Great list of advantages and challenges of using simulation as a teaching strategy-in Table 2) Seropian, M.A., Brown, K., Gavelanes, J.S., & Driggers, B. (2004, April) An Approach to Simulation Program Development. Journal of Nursing Education, 43 (4), 170-174. (Talks about components in developing a simulation program-good concise article.) WEBSITES-GENERAL Society for Simulation in Healthcare: http://www.ssih.org/public/ (This society, established in 2004, was formed “to represent the rapidly growing group of educators and researchers who utilize a variety of simulation techniques for education, testing, and research in health care. The membership, now over 1,500, is united by its desire to improve performance and reduce errors in patient care using all types of simulation including task trainers, human patient simulators, virtual reality, and standardized patients.”) UW-ISIS (University of Washington’s Institute of Surgical and Interventional Simulation): http://www.isis.washington.edu/ Seattle University’s Nursing Clinical Performance Lab: http://www.seattleu.edu/nurs/lab.asp WISER (The Peter M. Winter Institute for Simulation Education and Research) at the University of Pittsburg: http://www.wiser.pitt.edu/ (includes a list of all the courses offered through the simulation center.) Oregon Simulation Alliance: http://www.oregonsim.org/ STARS: http://www.stars.ca/bins/index.asp (This Canadian organization has a Mobile Simulation Program (using motor homes)) Penn State: College of Medicine: Simulation Development and Cognitive Science Lab: http://www.hmc.psu.edu/simulation/ (includes a list of what is available equipment wise)


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VIDEO LINKS TO DEMONSTRATION OF SIMULATORS Pediatric Human Patient Simulator: http://www.cincinnatichildrens.org/ed/cme/ems/human-simulator.htm Nursing Anne Simulator: http://www.uwec.edu/nurs/simulationlab/index.htm PRODUCT WEBSITES Laerdal: http://www.laerdal.com/Navigation.asp?nodeid=5736689 METI: http://www.meti.com/in_index.html Gaumard: http://www.gaumard.com/customer/home.php

Clinical Simulations in Alaska Appendix C: Use of Human Simulation Technology in Alaska

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Appendix C: Use of Human Simulation Technology in Alaska (A Snapshot) Background to the Method ACRH conducted a series of telephone interviews between mid-October and November 21st to determine the current use of human simulation technology in Alaska. An attempt was made to contact: • Hospitals in the state • UA health programs known to use human simulation technology and/or who are involved in clinical

education • EMS/fire departments across the state While a census of users was not feasible or appropriate, responses were sufficient to provide a representative sample and snapshot of human simulation technology in Alaska. For those who own moderate to high fidelity equipment, questions were asked about the: • type of training the equipment is used for • who the primary users are • whether equipment is ever transported out of the main facility for training • maintenance issues to date • lessons learned about using this type of technology For those facilities that did not own any moderate to high fidelity simulation equipment, questions were asked about their: • interest in using simulation technology for training in their facility • how they would envision using simulation technology • perceived advantages of using simulation technology Of the following tables, Table A lists those facilities/programs who currently own moderate to high-fidelity simulation equipment. Table B lists those who do not. Following these tables is a thematic organization of respondent comments regarding lessons learned, advantages of using simulation technology and why people are interested in simulation technology.


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Use of Human Simulation Technology in Alaska (a Snapshot) Table A: Facilities that currently own moderate-to high-fidelity simulation equipment Facility/UA Dept. Contact Position or Dept.

Type of simulation equipment own

When equipment was purchased (if known)

Uses of Simulation Technology (current and/or planned)

Is equipment ever transported out & used away from the facility? If so, where?

Equipment maintenance issues

UNIVERSITY OF ALASKA PROGRAMS Kachemak Bay Campus in Homer Carol Klamser UAA nursing faculty

SimMan Spring of 2007

Plans to use with nursing classes, CNA classes & possibly with an EMT class

Probably not-too cumbersome to do this

No maintenance issues to date; plans to use IT department if problems occur

Chukchi College in Kotzebue Dara Whalen UAA nursing faculty

Nursing Anne (from Laerdal)

Summer of 2006

Used to date with nursing students to practice fundamentals (i.e. BP, pulse, bowel sounds); Med-Surg-catheters, IV intravenous, Peds/Ob-fetal heart tones; hopes to eventually use as part of Trauma Nursing Core Curriculum (TNCC) and for CEs with CNAs

NO

No maintenance issues to date with the electronics; had to fix some of the joints herself

Kenai Peninsula College Paramedic Program Paul Perry Faculty

Two SimMans; one a newer generation

First one purchased 2 years ago, second SimMan purchased one year ago

We build our paramedic and EMT programs around the use of SimMan for cardiac assessments mostly. On average we use SimMan about 8 hours a week. I have also used it do ACLS scenarios with the physicians at Central Peninsula Hospital; to practice the more invasive skills with the Nikiski and Kenai Fire Depts., and once with Central Emergency Services who used SimMan to run scenarios for those employees who were interested in becoming paramedics; we have also shared SimMan with associate nursing students at our college to do basic airway management

YES, see previous cell for examples of sharing equipment at other sites.

I do my own maintenance. Maintenance can be potentially expensive, but I keep a close eye on the equipment and make sure it’s used properly. (Paul attended 2 days of SimMan training which included maintenance.)

Tanana Valley College Paramedic Program in Fairbanks Chuck Kuhns Faculty

One SimMan and two ALS mannequins from Laerdal

Have owned Sim Man for about 2 years and the ALS mannequins for about 1 year

These mannequins are primarily used with ALS students-EMT level. I use it primarily to simulate scenarios for my students. For example a respiratory patient can improve or decline depending on how the student interacts with the mannequin. I have also used mannequins for procedures or skills training, though I usually fall back on the lower-fidelity mannequins for this.

No, it would be too hard to haul all the pieces needed. I think SimMan works best in a lab setting, rather than being hauled around.

I maintain the equipment. We chose not to carry the warranty because of the expense ($5000/yr) I get help from the rep when they are up or call local people to help when needed.


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Facility/Contact Equipment When bought? Uses of Simulation Equipment Transported out? Maintenance Prince William Sound Community College in Valdez Julie Fronzuto Faculty

Have heard that PWS recently bought a SimMan

Summer of 2007?

Was unable to complete this interview

HOSPITALS OR AFFILIATE PROGRAMS Maniilaq in Kotzebue Brian Reiselbara Chief Flight Paramedic

A METI-Emergency Care Simulator

Owned for about a year

We are the regional training center for EMT and ETT classes. We have used METI for ACLS trauma and other trauma training. We have also done mock codes at the hospital with the staff there: physicians, nurses, EMTs, and also the local fire department.

We plan to take it out to villages to train the CHAPs, but are waiting on money to fund those flights. Last year we took it to one of the CHAP symposiums to help in ALS training.

No maintenance issues to date. All our EMS staff went through 3 days of METI training which included maintenance.

Norton Sound Health Corporation in Nome Peter Pierson Training Department

A METI man Owned less than a year

We have only used it once with an ACLS class; because we have been so short-staffed since spring, we have not really had the opportunity to fully use it yet, but plan to soon. (Peter noted they had a company rep come up for 2 days of training, but because they were so short-staffed at the time & busy with calls, most of the staff were unable to attend.) I envision the mannequin will be used mostly for the more invasive ACLS and BLS procedures and for advanced assessments. With the METI mannequin, we will be able to run scenarios where meds are pushed and the mannequin responds appropriately.

Not sure yet if the equipment will ever be transported out

Because the equipment is so new, this has not yet been an issue.

Ketchikan General Hospital Val’ee Gray Education Department

VitaSimKelly & VitaSimKid

Received one week before interview

Plans to use for ACLS and PALS training No, equipment will stay in hospital, we don’t want to risk damaging it; we plan to invite local fire dept & others in outlying areas to come in for training

No maintenance issues to date, anticipates having to replace arms and sections of skin from time to time.


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Facility/Contact Equipment When bought? Uses of Simulation Equipment Transported out? Maintenance Basset Hospital at Ft. Wainwright; Lt Col Lisa Ungulli Head of Hospital Education

They have an older version of SimMan & plan to put in request for a SimBaby & Noelle (birthing simulator)

Not sure how long they have had the SimMan; hopes to get new equipment within 2 years

1) Pre-deployment training for the soldiers going to Iraq and Afghanistan-to train them for scenarios they might see

2) Maintenance training 3) Post-deployment training-for example an

OBGYN physician coming back from Iraq may need practice on a birthing simulator if they have spent the past year working as a general physician

I don’t envision using this equipment in the field, but I could see taking it to other facilities such as Ft. Rich or inviting them here.

No particular maintenance problems to date; plans to have Laerdal come up when they get the new equipment.

Yukon Kuskokwim Health Corporation Glen Jorgensen Former Clinical Nurse Educator, now in OR

One SimMan,

Bought Summer 2007; haven’t started using it yet-just found a designated area to keep it

Glen envisions using it for the high-risk/low volume cases such as chest tubes and mock codes. He says they plan to use SimMan for training of the fire department, nursing program, providers and nurses, as well as the upper levels of the CHA/P program.

SimMan will probably stay in the hospital and people wanting training will come here.

No maintenance issues to date-equipment brand new.

Providence Lifeguard Air Ambulance Charles Darnelle Education Coordinator

Have one SimMan and one SimBaby

Have had this equipment about 3 years

Use for training paramedics, the higher level EMS courses and CE courses for difficult airway management for nurses and residents

We have both driven it to communities and flown it on ERA. For example we have gone to Barrow and Cordova. We have a portable air compressor that allows us to use the equipment in remote locations.

Normally we have had no maintenance problems, but recently our SimMan was damaged while left unattended at a conference and so we will have to spend quite a bit sending it in to have it repaired.

Providence Children’s Hospital Cindy Alkire Asst Chief Nurse Executive

Have a Noelle Interactive Childbirth Simulator with a fetal and neonatal PEDI mannequin

Used for childbirth/delivery instruction, breech extraction, shoulder dystocia drills, vacuum assisted delivery, emergency c-section drills, mock codes (advanced life support), neonatal advanced life support and post partum hemorrhage management. Noelle used to train nurses, physicians, residents and EMTs all over Alaska

Noelle has been used for instruction of emergency deliveries by Providence Seward, Providence Valdez, Central Peninsula EMS, Willow EMS and Palmer EMS (Note: it has to be transported by vehicle because of size)


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Facility/Contact Equipment When bought? Uses of Simulation Equipment Transported out? Maintenance FIRE DEPARTMENTS/EMS SERVICESHomer Volunteer Fire Dept. Bob Painter, Chief

One SimMan and one ALS training mannequin

Have had SimMan for 3 years, first in the state to buy one

Used mostly for training with the EMTII and EMT III and ACLS classes. Have also used it in EMT I classes since you can modify the vital signs.

It’s not very portable, but we have taken it to Anchor Point. Seldovia would love to use it, but we haven’t figure out a way to fly it over. The model we have is not wireless which means it’s tied to cables.

We haven’t had any maintenance issues to date. Occasionally I have had to do some cleaning and replacing pieces/cover openings.

Central Peninsula EMS John Evans Training Officer

Have a METI man not currently being used, would like to buy a SimMan; have a Crash Kelly for fieldwork

Was purchased about 5 or 6 years ago

We have a METI that we do not use anymore. We found the software and equipment so complex that we would have to hold up our simulations to accommodate the software. The model we got was one of the first models off the shelf. If we had a SimMan, we would use it for ALS training (we have about 40 paramedics-the biggest EMS service on the peninsula)

If we had a SimMan I would only consider transporting it to other communities on a limited basis since it would involve moving a lot of equipment, but it would be nice to be able to take it to Cooper Landing

Our MetiMan was very expensive to maintain which is one of the reasons we don’t use it anymore. Also it used Apple software and was very finicky.

Anchorage Fire Dept Dave Wallace

SimMan (Initially we got a METI but it was more high tech, expensive and difficult to program so we traded it in for the SimMan)

Have had the SimMan for about 2 years

We use it to do ALS scenarios- used for higher level EMT classes.

SimMan left our building once, he can be put into a car, but he has to be on a battery and you have to take a compressor so it’s not a particularly easy process.

Pat Vincent, who is in charge of all our training does all the maintenance.

Juneau Fire Dept Charlie Blattner EMS Training Officer

One SimMan and a VitalSim (another SimMan was sent to Ketchikan)

Bought Summer of 2007

I use SimMan to do skill reinforcement of lectures I give, to reinforce problems or weaknesses. We are able to reproduce scenarios that match a call we have just done; we are also able to do airway management from intubation to surgical cricothorotomy-we can make the mannequin spasm

Yes, we have two fire departments here, so we plan to use SimMan with both of them for training.

No problems too date. I plan to call Laerdal if anything comes up, we have had good support from them to date.


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Facility/Contact Equipment When bought? Uses of Simulation Equipment Transported out? Maintenance OTHER ORGANIZATIONS Guardian Flight in Fairbanks Don Wells Training Director

2 SimMan 1 SimBaby

Have had one SimMan for 3 yrs; recently purchased other equipment at an auction Oct 2007

We do mostly pre-hospital and critical care training like chest tubes, surgical criocs, airway management I train my staff, nurses, and paramedics If we are doing a pre-hospital scene, paramedics take the lead; for a hospital to hospital scenario (i.e. ICU to Seattle), the nurses take the lead in the scenario

Yes, we have shipped SimMan out all over the state. We bring an air compressor and he runs off a laptop. We have 5 bases across Alaska and do training in Fairbanks, Anchorage, Sitka, Ketchikan & Unalaska

Forgot to ask


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Table B: Facilities that do not currently own moderate to high-fidelity simulation equipment Facility/UA Dept Contact Position

Would you be interested in using simulation technology?

Potential uses for simulation technology at your facility

Would you envision ever transporting equipment for use away from your facility?

UNIVERSITY OF ALASKA PROGRAMS Kenai Peninsula College Lynn Senette UAA nursing faculty

YES, we applied for funding to purchase SimMan, but did not get it

To use in training BS/AAS nursing students in Kenai and/or Anchorage; to run clinical scenarios

Probably not

UAA main campus Marianne Johnstone-Petty UAA nursing faculty

Not sure; though the equipment, such as SimMan, is nice, getting instructor buy-in and the instructors up to speed might be too much work.

I could see running different case studies/scenarios. I don’t see doing code situations, but doing the day-to-day patient assessments. I don’t see it replacing what we do now, but giving students more practice time with their skills.

No, I would envision SimMan having a home and the students coming to it.

UAA main campus Dennis Valenzeno AK WWAMI Director

We have talked about it from time to time. In terms of 1st yr students we have not embraced the technology. We use cadavers and I don’t see giving that up.

I could envision using the simulations as a way to bring the first and 3rd year medical students together to work on team approaches. Perhaps the 3rd/4th year students could take on the role of the physician while 1st year students play the role of a resident or intern and then you could bring in nursing students as well.

That would depend on what equipment we ended up with and our capacity. I could envision bringing the equipment, if it was portable, over to the Residency perhaps.

UAA Main Campus John Riley PA Program, Director

YES

I could imagine using simulation technology for many of the same things medical or NP students would use it for: procedures, exams, emergency procedures, anything where you can’t have a standardized patient (actor). I envision using it mostly during the student’s didactic year.

I’m not sure where the program will be housed, but I imagine it would make more sense to have students go to a center rather than duplicating space/equipment.

UAA Allied Health Sally Mead, Director and staff

YES

The Rad Tech and Dental Hygiene program could envision having their students participate in crisis scenarios with other providers for teamwork training and to provide an opportunity for students to respond to a crisis. They see using the equipment on a limited basis each semester (ideally sharing equipment with other programs). Medical Assisting could use it for practicing taking blood pressures, pulses and temperatures. Note: A planned paramedic program may also have a need for this equipment.

With many students enrolled in allied health distance programs across Alaska, staff wonder if there are any virtual tools that are being considered for basic science course like chemical labs and anatomy/physiology classes.

Mat-Su Campus Not sure

We could possibly use it for the nursing and EMT programs. I believe they are also trying to establish a paramedic program here. It might also be used for a vet-tech class-though I think the classes here only introductory.

Perhaps simulation could also be used to do community outreach, for example with the Red Cross. Maybe we could share equipment with Mat-Su Regional Hospital


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Facility Interest? Potential uses of Simulation Equipment Transported out? HOSPITALS and AFFILIATE OrganizationsPetersburg Medical Center Sandy Tackett Director of Nursing

YES, We would love to have more lifelike mannequins

ACLS and PALS classes and on-going training with the nurses; we are also hoping to be approved for distance education for nursing, so I could see using the equipment for those students

NO

Wrangell Medical Center Janet Buness Director of Nursing

NO

I don’t really see any need for this type of equipment at our center. (They currently have an ACLS CPR doll that has different cardiac rhythms that is used by the ER nurses and physicians for continuing education)

Cordova Community Medical Center Gretchen Zollden Director of Nursing

YES

Practicing trauma, cardiac issues and CodeBlue situations

The EMTs at our local fire department and the community college, which may be starting a nursing program, may have use for the equipment as well.

Bartlett Regional Hospital Justine Muench Staff Development Director

YES, all we currently have is a low-fidelity CPR mannequin

-For new nurses and new graduates -For continuing education for our staff -Patient education We also have long-term care facilities-I’m not sure if they would have a need.

Not sure. We might consider sharing equipment with UAS. It would depend on how portable the equipment was and who has ownership to see how it could be shared.

South Peninsula Hospital Laurin Painter & Ann Marie Bailey Former/Current Education Directors

Yes, but we don’t have the money to purchase equipment.

Simulation technology would be useful for doing advanced life support training of physicians and allied health practitioners, though the higher fidelity equipment is not needed for BLS training

No, the equipment is expensive and I don’t see lending it out. It is not that easy to move around.

Central Peninsula Hospital Susan Shumaker Staff Development

Not sure For physicians to practice chest tube placement and intubation; For RNs to practice IVs, foleys, central line placements, ACLS, assessment issues, ostomies & wound care.

Likes the idea of a collaborative venture between university & facilities where staff & maintenance costs could be shared; possibly a “mobile classroom”

ANMC Tom East, Chief Information Officer

Not sure at this time Potentially for training and CMEs

Sitka Community Hospital Tom Marthaller JoAnn Clyde Director of Nursing

The staff are interested in using simulation equipment, but we can’t afford it

We could use for practicing more invasive procedures and advanced trauma like compressing pneumothorax.

Our community has 2 hospitals, a fire dept and air transport, so the potential for sharing a resource is there.

Providence Kodiak Island Medical Center Darla Merrett Education Department

Yes, but we can’t afford to buy this equipment ourselves, we’re too small

We have been able to borrow a SimMan from the Coast Guard base and from the city fire dept to use for PALS and ACLS training. I could also see using it for airway management, TNCC, working on newborns for intubation and so on.

I could envision using equipment for staff at our senior center, the assisted living facility, and the area Native association.


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Facility Interest? Potential uses of Simulation Equipment Transported out? BBAHC -Kanakanak Hospital in Dillingham, Starla Fox, Deputy Nurse Director Dave Milligan with EMS Dept.

Yes, we are very interested in simulation technology, but we haven’t looked seriously at buying any yet, because we don’t have the money

The EMS Dept does all the training for the CHA/Ps and EMTs in the region (we serve 32 villages); we have a PALS, ACLS and pre-natal instructor here. Starla also noted that hospital staff use the EMS Dept for CE training like ACLS and PALS training

The health aides come into Dillingham for training and we also have a 2-year rotation where we go to each village for a 2-week training; simulation equipment could be used in both of these instances.

Providence Valdez Julie Silkett, OR supervisor & Lois Platt, Nursing Manager

Our local college is getting a SimMan and I am sure we will be able to borrow it; we have a good relationship with them.

ACLS and TNCC training Possibly for CNA training as well.

NO

Providence Seward Alexis Klapproth Associate Director of Nursing

We don’t have the money for the more expensive mannequins (we currently only have CPR mannequins and an IV arm)

I could see using the fancier mannequins for the Trauma Nurse Core Competencies and ALS training.

No, we don’t loan out our equipment, but I could see if we borrowed simulation equipment that it could be shared with our local fire department.

SEARHC Mike Motti EMS Dept

Yes, our regional EMS Coordinator’s Group has been discussing simulation technology

We have clinics all over Southeast and training needs to be provided for health aides, mid-levels, and physicians.

Yes, I would travel to all the clinics to do the trainings.

Fairbanks Memorial Hospital Corlis Taylor Education Department

We have no high-fidelity simulator, but have a Computer Based Simulator (ACLS Simulator)-students interact with people on the computer

I could see using the technology for new nursing graduates who need to go through a core nursing skills course that lasts 8 weeks; we have talked about sharing equipment with the local paramedic program. We also have WWAMI medical students and other medical students that do an OB rotation that could use the equipment.

I would think the equipment would stay in the hospital

Alaska Family Residency Harold Johnston Program Director

Providence has been researching the possibility of putting in a simulation center, modeling it after one in Pennsylvania

We would like to use it for training for obstetric emergencies, starting central lines, intubation, resuscitation, chest tubes, advanced trauma life support, simulations of thorasentesis, parasentesis, venus cut-down, acute emergency management.

No, we would not need to transport equipment anywhere.

Alaska Regional Hospital Dona Townsend Chief Nursing Officer

I am not aware of any simulation technology here or any research currently being done here for obtaining equipment.

I could see using it for training students, advanced training of staff and maybe some BLS type training for community education.

Probably not. We have affiliations with Cordova, so potentially we might take equipment to be shared out there. We don’t have many outreach programs here.


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Facility Interest? Potential uses of Simulation Equipment Transported out? VA Hospital Andrea Neuerburg RN & Infections Control Nurse

YES We have a lots of student nurses that affiliate with us in the BS program. The VA has a program where student nurses can work with us under a tech status. We also have students in ambulatory surgery, medical assisting and practical nursing, so I see simulation technology as a way for them to practice their clinical skills before they start working on patients. Also when we get new equipment in, it would be nice to be able to demonstrate on a mannequin before they start using the equipment on patients.

No, I don’t see a need for transporting equipment out of our facility.

OTHER ORGS CHA/P (Community Health Aide/Practitioner) Program Torie Heart

Has never considered it.

Our training sessions are 3-4 weeks long and already jam packed, so it would be hard to add to the curriculum. Also much of the training happens in the field. It is very difficult to get CHA/Ps together for training as they are often the sole providers in their villages; There might be a potential for doing lung assessments or blood pressures with the mannequins.

Alaska Dept of Health and Social Services Jerry Troshnyski Staff Develop Coordinator with Public Health Nursing Section

Haven’t really thought about it; our focus is more population based.

We don’t really have need for the mannequins. Our staff does CPR training and a few immunizations. What I think might be more effective for us are some type of computer simulation; something like the SimCity Societies program that kids use.

Clinical Simulations in Alaska Appendix D: November 27, 2007 Alaska Clinical Simulation Taskforce Meeting

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Appendix D: November 27, 2007 Alaska Clinical Simulation Taskforce Meeting 10:30 am to 3:30 pm

Attendees: Taskforce Members:

X Karen Perdue X Andrea Neuerburg*** X Cheryl Easley X Jan Harris X Dona Townsend X Harold Johnston X Maureen O’Malley * X Karen Carpenter X Chuck Kuhns X Dan Johnson X Suzanne Tryck X Dennis Valenzeno X Corlis Taylor** X Roy Davis X Justine Muench X Lynn Senette X Paul Perry X Jerry Troshynski X Jackie Pflaum X Debbie Thompson X Sally Mead X John Riley X Tom East

Staff: X Beth Landon X Mia Oxley X Janice Troyer X Jennifer Risse X Lori Ehrhart

*Maureen O’Malley sat in for Marianne Johnstone-Petty from the UAA School of Nursing **Corlis Taylor sat in for Liz Woodyard from Fairbanks Memorial Hospital ***Andrea Neuerberg sat in for Linda Boyle of the VA Healthcare system Also in attendance for part of the morning: Mike Driscoll, UAA Provost and JoAnn Gonzalez-Major of Division of Allied Health at UAA Guest Speaker: Dr. Brian Ross, Executive Director of ISIS (Institute of Surgical and Interventional Simulation) I. Introductions/Scope of Work Karen Perdue opened the meeting at 10:40am. She gave an overview of the purpose of the group. “The purpose of this taskforce is to learn from each other’s experience with the technology, learn what the technology can and cannot do for us, and finally develop a large-scale view the technology’s potential for Alaska. The taskforce is not charged with making commitments or investments regarding this technology.” People in attendance introduced themselves. Karen Perdue reviewed the Scope of Work and “key questions” to be answered by the Taskforce over the course of three meetings. She noted there has been an increase in the use of simulation technology, as well as an increase in the sophistication of the technology and part of the purpose of today’s meeting was to find out what is going on in the state. She also noted that we have invited Brian Ross to give us an overview of simulation and what is happening at the national level. (Karen Perdue noted that within the Scope of the Work there is mention of a subset of Taskforce members traveling to Simulation Centers in the Continental United States (we will not be doing this, but we will be bringing experts up from the Continental United States to talk about Simulation Centers.)


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Karen Perdue says that the taskforce needs to look at what simulation can do and not do in terms of education, continuing education and residency programs. The final outcome of the taskforce meeting will not be recommendations about vendors or equipment endorsement, but rather to create a picture of the potential for using simulation in our programs and to look at, for example, whether or not we should develop some kind of system, such as a consortium, to find ways to work together on incorporating simulation within our programs. Karen Perdue also described some of the parallel processes that are revolving around the topic of simulation. UA is in the mode of expanding its health education programs. We are making investments in equipment, in buildings (including a $46M Health Science Building), etc. One question that has arisen is whether we should have a Simulation Center in the new UAA health building. Karen Perdue then invited questions from the Taskforce. Harold Johnston asked who the “decision makers” are that will be using this report. The report will advise the UA President, but Karen Perdue also anticipates it will inform other decision-makers including hospitals and EMS agencies. Dr. Roy Davis explained that Providence is very interested in this technology for physician education and physician credentialing. Justine Muench asked about the ability, over the three meetings, to assess the value of this technology for rural Alaska/non-road system sites. Karen Perdue agreed that this is an outcome. Karen Perdue explained that this project is a partnership between the University of Alaska, the Alaska Center for Rural Health-Alaska’s AHEC, and the University of Washington (Suzanne Tryck). Karen Perdue introduced guest speaker Dr. Brian Ross, Ph.D., M.D. (see bio below) from the University of Washington’s ISIS center. Dr. Ross is a member of the attending staff in the department of Anesthesiology at the University of Washington. Since 2003, he has held the rank of full professor of Anesthesiology, and in 2005, was named by the dean of the University of Washington School of Medicine to serve as the first Executive Director of ISIS (Institute for Surgical and Interventional Simulation). In 1975, he received his Ph.D. in physiology/pharmacology from the University of North Dakota and went on to complete postdoctoral research in the area of respiratory disease at the University of Washington. He received his M.D. in 1983 from the University of Washington School of Medicine. In 1986 he completed a fellowship in Obstetrical Anesthesia from the University of California at San Francisco, before returning to the University of Washington to complete a residency in anesthesiology. Dr. Ross’s interest and involvement in medical simulation has been apparent since 1996, when he developed the initial curriculum for the Department of Anesthesiology at the University of Washington. Since that time, he has been responsible for the development of over 20 simulation-based courses for medical students, residents and nurses. Through community outreach and the


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continuous development of simulation curriculum, the ISIS program, under the direction of Dr. Ross, has become an educational cornerstone for the university, community, region (including the five-state WWAMI area-Washington, Wyoming, Alaska, Montana, and Idaho) and the medical simulation industry. Dr. Ross noted that he would like to see the name of his center (ISIS) changed eventually. He noted they have struggled to get other UW partners involved because others assume their center is focused on surgery, which it is not. Dr. Ross advises if a group is formed, it is critical to be as inclusive as possible and the name should reflect that. If there is someone missing from the room, it needs to be recognized and they should be invited to subsequent meetings. People should be included independent of the size of the organization or department they represent. Every partner should have an equal seat at the table. This is very important. ISIS came into being about five years ago. They recently moved into the University of Washington Medical Center in July. Dr. Ross then played an introductory video clip generated for their opening. (See the following website to view that clip: http://www.isis.washington.edu/ -see introductory video). ISIS has approximately 15 departments involved in simulation training. This has enabled them to standardize curriculum across those departments. Dr. Ross noted that a recent national report (source not provided) indicated over 100,000 hospital deaths were due to mistakes, most attributed to poor communication. ISIS can simulate an emergency and train on communication as well as clinical responses. ISIS does the whole spectrum of clinical simulation from low-fidelity to high-fidelity. One of Dr. Ross’ passions is “third world medicine.” He believes simulation can be used to reach out to people beyond the road system. He plans to use WWAMI as a model for the third world and distance education. Dr. Ross recommended that a consortium have a mission statement or list their primary goals. ISIS has three goals: provide leadership in use of simulation technology, improve quality of health care education and improve patient safety and outcomes. The Dean’s mandate is to provide simulation training (cognitive, OSCE, skills and high fidelity) throughout the WWAMI region. He also advises that finding the capital for the technology is difficult. It is even harder to find support for training and staff to maintain and coordinate use of the equipment. Dr. Ross noted that medicine has for the most part used a silo approach to training and delivery of care, such as OB, Anesthesia, Internal Medicine, and Surgery using a “see one, do one, teach one” method. He talked about public demand for training “not on me for the first time.” Simulation allows students to become proficient in skills before ever working on a patient. It also allows for cross-discipline training. Dr. Ross talked about how inefficient the earlier simulation system was for UW staff, with more time invested in set-up and take down than in the time it took to do the actual simulation. By having a common simulation center that serves multiple needs and shared staffing, it is a much more efficient system. Everything is set up and ready to go for the instructor – it only needs to be scheduled in advance. They have also developed a peer-review process for developing curriculum. That has helped motivate clinical educators to work for them in developing curriculum, as it can become part of their portfolio.


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Development of curriculum has been an important piece of ISIS and one of the first people that Dr. Ross hired for ISIS was Dr. Sarah Kim, a curriculum director. Dr. Kim has created a formal template for their curriculum with 12 essential elements. This enables them to more easily share curriculum with partners like Oregon Health and Sciences University and the University of B.C. UW plans to partner with five other sites within the Seattle area and each will have a “footprint” for simulation equipment. These sites have very different kinds of patients and needs. Because of this Dr. Ross feels it is important to do the simulation training at the sites. He also feels it is important for staff to use their own equipment in a simulation, as it ensures the training is as close as possible to what will really happen. Dr. Ross explained the new ISIS center, which they just moved into in July, sits directly below the OR at the UW Medical Center. They had the option of having a larger space across the street, but decided to go with a smaller space (about 2,000 sq feet), so they could be closer to the residents and faculty that would be using the simulation center the most. It is too difficult for residents and faculty to take the time to cross the street to use the simulation center so this was an important consideration. They may eventually build another simulation center in another part of campus to serve nurses and pharmacists and so on. He noted that he has seen a lot of simulation centers that have lots of different rooms for different disciplines, but many sit empty for large parts of the day. He believes it is more efficient and a wiser use of space to have a more open model that can be used for multiple disciplines. Dr. Ross noted a national study noted that Simulation Center rooms are only used 18% of the time (source not provided). Besides the simulation center, ISIS also serves as a resource library, including curriculum. Simulators are currently used by a myriad of industries, including health care. An important question is whether or not simulation can substitute for real patients. There is also the need to be trained in rare but complicated situations such as a family medicine doctor dealing with shoulder dystocia. Dr. Ross noted that good clinical judgment comes from bad clinical decisions made earlier. “You don’t want residents making mistakes on live patients – simulation can play a role here.” Dr. Ross described a study done by ISIS that compared the training time needed for eight students using the old resident training model (see one, do one, teach one) with a group of eight students using simulation in their training. They found that the simulation cohort was far advanced early on, but by the end of the training both were groups were about the same level. He said the advantage of this is that you may be able to add more skills training without increasing the amount of time covering the curriculum to include simulation. He also noted he wanted to repeat the experiment the following year, but none of the faculty were willing to go back to the old training method; they all wanted to continue with the simulation training. Dr. Ross reviewed reasons to do Simulation Training:

• Patient safety • Changes in medical education • Changes in healthcare economics • Increasing necessity of sophisticated skills


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• Technology maturation • Change in curricula and need for validation studies • Regulatory requirements Currently ISIS uses their simulation with nursing students, residents, visiting physicians, medical students and with community outreach activities including tours for elementary and high school students. Dr. Ross reviewed different types of simulation equipment and uses. He emphasized that learners should get exposed to the cognitive content before engaging in the simulation because it is more resource efficient. There is an impressing diversity of equipment available. He went into some depth on birthing simulators and laprascopic surgery simulators. “There is no reason to buy something if someone is not taking intellectual responsibility for it and will make sure it is going to be used.” “You need to do a formal needs assessment, and then curriculum development. The curriculum must start with how the patient presents and the entire process for moving the patient through the system.” Dr. Ross talked about high fidelity simulators that have all the bells and whistles. “If you aren’t going to use all of the functions, it may not be the smartest purchase. The purchasing decisions should be driven by curriculum needs.” “Don’t get talked into equipment you don’t need!” Regarding rural access and distance delivery of simulation, Dr. Ross is exploring the idea of using Xbox technology as a way of delivering distance simulation. He says it has better video graphics than many telehealth-specific equipment. It also has the same interface all the time. He considers web-based education a failure because every program is different and learners have to learn each new program. He has met with the developer at Microsoft to develop some problem-based learning across WWAMI with that system using the Xbox technology. He sees value in delivering health care with it as well someday. Dr. Ross noted there is a Society for Simulation in Health Care (SSH) (www.ssih.org), which has an annual meeting every year. He will be presenting on faculty development this year. Dr. Ross advised again that the need and function should define the space and the equipment. He gave examples of small centers which focus on only one discipline, and noted there are only five to six centers in the country that are multi-disciplinary. He also noted JCAHO and ACGME are strongly endorsing simulation. The group broke for a short lunch and then Dr. Ross entertained questions for a few minutes. Dr. Ross asked Chuck Kuhns what works best for getting simulation into rural areas. Chuck said he is not entirely impressed with the distance education courses available. Simulation is more hands-on and better than books. He said you need a mannequin that is easy to transport, and he does not find the SimMan they have to be. Flying students in for training is not really an option because of the expense. They are practicing with students now using Laerdal’s computer-based Sim Hospital.


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Dr. Ross’ big question is how you get this technology to remote areas, and standardize that exposure in small areas. Jerry Troshynski asked if there was any kind of software like Sim Public Health. Dr. Ross does not think that exists, but did suggest some related software that may be of interest. Paul Perry noted he had invested $1,500 in a fancy suitcase for Sim Man, but it takes over two hours to disassemble the equipment to put in the suitcase. Now they send him on a gurney. It is much faster and easier. He also has a checklist of things to pack with the equipment. Dr. Ross talked about the need for a toolkit that you pack whenever taking simulation technology away from the main facility. Suzanne Tryck asked about how the simulation works after you get everything out there. Do students really learn, or are they just having fun with a new toy? Paul Perry said that students enjoy it, that it is fun, but there is a lot of learning. They have a series of scenarios and criteria. Students must learn things on a checklist. If they do not learn, they have to start over at the beginning of the scenario. The simulation equipment is incorporated into their learning. Chuck Kuhns talked about the mannequin as an instructor. “I can be behind the scenes with the remote control. The students are focused on the mannequin, not me.” He also videotapes the students so they can review how they performed from another angle. Dr. Ross talked about the advantages of having a group of some sort working together on curriculum and sharing ideas for how to use the equipment Justine Muench spoke from a non-road system perspective. “If the simulation can’t be put on a plane easily or packaged in a transportable manner, you cut out a 1/3 of our state using the equipment.” Dr. Ross said we have to be able to do this. He noted “if we can put people on the moon we should be able to do this – it’s just packing and transport. We should be able to move the simulation equipment some way.” Janice Muench shared how a Canadian group has converted a motor home to be ½ ER recess room and half computer control room. Corliss talked about an ACLS class that Harborview Medical Center of Seattle provided in Fairbanks. They sent up five hard side giant suitcases via UPS. They arrived a week before the class. They also sent a five page list of equipment and supplies. Dr. Ross noted there are companies that rent equipment, so you do not necessarily have to spend $23K on a Simulation Lab when you can rent equipment two to three times a year for a lower price. Tom East asked about virtual reality for training. Dr. Ross gave examples of virtual simulation equipment being considerably more expensive than simulator alternatives. The technology


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continues to improve and the landscape will change. Right now, the extra cost is not justified in his experience. There was discussion about the military’s investment in simulation. Tom East referenced the Alaska Federal Health Care Partnership (AFHCP). Andrea Neuerburg from the VA also commented on the opportunity for partnership as well. The National Guard needs flight missions. Chuck Kuhns talked about Bassett Hospital (Army) outside of Fairbanks having equipment that they are not using. Dr. Ross echoed earlier comments about the need for someone who has intellectual ownership of the investment; who will make sure the equipment is used. Dan Johnson talked about rural training and the need for a technical specialist that knows the equipment and travels with it. Dan Johnson also mentioned another military facility separate from Bassett Hospital in Fairbanks that has a significant investment in simulation. Janice Troyer then presented her findings of what is happening across Alaska currently with simulation technology. She contacted all the hospitals, including tribal health corporations; many of the fire/EMS departments, air ambulances and any UA programs she had heard use the technology or potentially could use the technology. Though a complete census of users was not feasible, she feels she got a good representative sample and snapshot of what is happening with simulation technology in Alaska. Janice Troyer asked organizations that had equipment how it was being used, the advantages of using the equipment, how it filled a need in their training, how long they had the equipment, whether the equipment was ever used outside of the facility and if there had been any maintenance issues. For those facilities that did not have equipment, she asked whether they would be interested in using simulation, what some of the potential uses could be and whether they ever envisioned using the equipment away from their main facility. Janice Troyer reported that in general the EMS/Paramedic programs seem to be the most numerous users; using them for ACLS training, airway management, chest tubes, surgical criocothorotomy and ALS scenarios. A few hospitals have used simulation equipment for CE courses for nurses and residents in airway management, ACLS and PALS training. At least one nursing training program was using a moderate-fidelity mannequin for giving students a chance to practice fundamentals (BP, pulse, bowel sounds and catheters), IVs and fetal heart tones. Janice Troyer also noted the military used simulation for pre-deployment training for soldiers headed to Iraq and Afghanistan, maintenance training and post-deployment training. She gave an example of an OB-GYN doctor spending a year in Iraq practicing as a general physician and then needing practice on a birthing simulator when they came back. SimMan seemed to be the most common piece of equipment in the state. For those she called who did not have equipment, but were interested in simulation, several training ideas were suggested and include: day-to-day assessments and running clinical scenarios for nursing students; procedures, exams and emergency procedures where you can’t use


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standardized patients for NPs, PAs and medical students; and using for teamwork training across disciplines. Hospitals were interested in using it for CE training such as ACLS, PALS and TNCC classes; allowing staff to practice the more invasive maneuvers such as chest tube placement and intubation and also for demonstrating new equipment on mannequins before trying on patients. This last item was mentioned for both staff and patients or family members. Janice Troyer then referred everyone to the table of Alaska information in the binders she collected that contains details of the type of equipment each facility has, how long they have had the equipment, how it is being used, any maintenance issues and whether the equipment was ever transported out for use. See Table A for those facilities with equipment and Table B for those without. Janice Troyer noted she collected five pages of comments during the conversations. These were lumped into themes and distilled into a one-page document located directly after tables A and B. Janice Troyer reviewed these comments including the lessons learned and advice from those who use the equipment as well as the reported advantages of using simulation technology for those who had equipment and the perceptions of advantages for those who did not. One of the themes that came out is that it is important to have more than one person trained to use equipment. Dr. Ross echoed this important point. Others in the group noted that many organizations have recently made investments in simulation technology, but do not know how to use the equipment, or do not necessarily have someone overseeing its use. Janice Troyer mentioned she had been told that Laerdal does provide two days of training to use SimMan. Paul Perry noted he had a professional video team come in and tape Laerdal’s two day training, so he can share it with new staff. Janice Troyer noted that many of the rural facilities mentioned that students and staff do not get the same amount of exposure to multi-traumas or invasive procedures as those in urban Alaska, so working with mannequins can help verify skills and ensure skills are maintained. The added step of realism and being able to rerun scenarios was also noted as a definite advantage to using simulation equipment. Janice Troyer noted some had a perception that simulators would free up faculty time. Dr. Ross noted that is not necessarily true. An instructor needs to run the scenario. You do not just turn it on and leave the room. The logistics and expense of leaving the community for training could be avoided if the equipment could be made available locally. Small sites cannot make an independent equipment investment. Sharing in the purchase and use of equipment makes more sense to them. Janice Troyer commented that it seemed the simulation equipment was being used primarily for skills training in Alaska. Dr. Ross noted that it is also very useful for interdisciplinary training and communication skills.


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Dr. Ross commended Janice Troyer and others for doing such a thorough analysis of equipment and its use in Alaska before starting the process of discussion of where do we go from here. Justine Muench asked whether there had been any studies on using simulation equipment with Native populations. Cheryl Easley talked about the value of using simulation to run culturally appropriate scenarios. She noted HRSA’s Division of Nursing might have some resources. Brian Ross started his next Powerpoint presentation on Developing Simulation Projects He noted that working in silos is inefficient and costly. Seven steps to developing a successful simulation program:

• Needs assessment • Curriculum development • Identification of curriculum components which lend themselves to simulation (and where

simulation could add value) • Identification of simulators that support the curriculum • Development of assessment tools • Allotment of dedicated non-clinical time for training-someone “owning” the simulator

intellectually • Rapid clinical assimilation “For the Needs assessment, consider what do you need to teach? What’s the low-hanging fruit? (for us it was patient handover in the hospitals). Ask risk managers, departments, insurance companies, employees, faculty, regulatory agencies and so on.” A comment that Dr. Ross reiterated throughout the day: “Do not buy a simulator and then develop the curriculum, buy the simulator based on the curriculum.” Dr. Ross noted that at ISIS they have developed a standardized curriculum template that all faculty have to follow. The following table outlines the components:

Standard Curriculum Template

Goals Real life relevance Anatomy Material, media, tools, instruments, supplies Steps of the procedure 1st, 2nd, 3rd Cognitive Lecture, description, error recognition Cognitive test Skill training Specific criteria to meet Test skills performance Validation


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Curriculum Outline • Instructor contact info • Target trainees • Description of curriculum • Goals and objectives • Instructor notes • Prerequisite knowledge and skills • Common errors and prevention strategies • Cognitive training • Simulator set-up • Skill training • Assessment methods • Appendices

Dr. Ross gave an overview of the types of validity: Training and Testing • Face validity (looks like the task) • Content validity (detailed exam by content experts) • Construct validity (can identify novice versus experts) • Concurrent validity-scores on curriculum match other gold standard scores • Discriminate validity-factors that should correlate actually do –all R’s look like R’s • Clinical Outcome • Predictive validity-can curriculum predictive performance in the real world. (All these strategies have merit; however, predictive validity is the one most likely to provide clinically meaningful assessment.) Jerry Troshynski talked about the cost of not doing simulation. Dr. Ross suggested the group that has the most to gain from simulation is the insurance companies. He approached the Insurance Commissioner in Washington State. He then spoke with an insurance company, that did not want to contribute/make an investment when the other companies were not doing the same. Harold Johnston talked about hospitals becoming more accountable for outcomes from their payers, and that being a driver. There is an argument that the state should be interested in training consistency to improve health overall. The Taskforce took a planned break and Mia Oxley reconvened the group to facilitate a discussion based on the following key questions:


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SIMULATION RELATED 1. Who are the potential Alaskan users of simulation technology? (By discipline? By

geography? By organizational type – post-secondary education or provider?) 2. What Alaskan training needs could we address using simulation technology? 3. To what extent could simulation technology impact delivery of classroom education and

clinical training? 4. To what extent could simulation technology impact the delivery of continuing education and

CME? 5. To what extent will this technology enable UA to train more students? 6. What would be the anticipated training outcomes? 7. To what extent would the use of simulation technology improve patient outcomes? DELIVERY STRUCTURE RELATED 1. What value might a collaboration or partnership add to the use of simulation technology? 2. Under what circumstances? 3. How should our recommendations prioritize among the potential users and needs? 4. What is (are) the recommended delivery system structure(s)? 5. What structure is recommended for management and maintenance? Mia Oxley proposed we focus on the simulation-related questions for this meeting and save the delivery-related questions for Meeting 2 – focusing on the value of simulation to taskforce members and their organizations. Dennis Valenzeno pointed out that they have 8 cadavers for student training that are occasionally used by area physicians for practicing pacemaker insertion, etc. In terms of the overall problem, many of our issues could be resolved with lower tech solutions. This raised a question of how to approach the topic, given the breadth of constituents in the room. Roy Davis recommended keeping it pretty broad, but narrowing down the actual uses. He expressed concern that health care is a team sport – health care professionals need to be able to work as a team. Harold recommended going back to the principle of need. Simulation equipment is only a subset of the education universe. He also suggested that this group, or whatever succeeds it, should very much embrace the importance of communication. Dr. Ross agreed that we need to start with a basic list of training needs. Mia Oxley suggested everyone do an abbreviated needs assessment for clinical simulation training opportunities in their organization and bring it to the next meeting. Debbie Thompson pointed out that nurses generally need six months between finishing school and being really ready to work with patients in a hospital. She asked how much simulation will add to or take away from that training investment.


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Roy Davis echoed that example with his own examples of preparing physicians for working with patients. There was some discussion about the difference between Janice’s assessment of investments and use compared to the next step of organizational needs assessments. As it was discussed in more depth, the level of questioning and analysis required was daunting at the least. Karen Perdue suggested we focus on a nucleus of partners to conduct the in-depth needs assessment, and others could possibly branch out from there. She recommended the University, Providence, and the Residency as a good start. Roy Davis added the State as a possibility. Maureen O’Malley spoke about a culture that has drifted away from skill development. Andrea Neuerburg said that if Janice Troyer called her again she would answer the question about training needs much differently, and in greater depth. Debbie Thompson suggested that the hospitals could ask their Risk Managers and get a wealth of useful information on training needs. Dr. Ross described a simulation done at the ISIS center. They will run one with five residents – usually one senior, one midlevel, and 3 junior residents. Students start with a Pre-Op form which has missing information that they need to glean from the patient when they are taking a history. At some point, a midlevel resident comes in and relieves a junior resident, thus practicing handover. Then an event is triggered, with the attending physician out of the room for a donut. After the event is completed, they do a structured debriefing. Two of the junior residents observe the entire process with the checklist in hand. Dr. Ross noted that the observers often learn the most. Dr. Ross also noted when they do a “code” for team training, after the debriefing they will repeat the scenario with blindfolds. This forces them to be more aware of verbal communication during the event. Harold suggested we do an inventory of communication training needs alone. There are likely to be commonalities across facilities. Tom East suggested that ANTHC’s training department has a laundry list of training needs. He wonders if giving people a general list from which to choose items would be more efficient. Dr. Ross didn’t think so. He suggested that his list may be different from Tom’s. It is more appropriate to get site-specific ideas. He suggested asking people for their top 5-10 needs. Harold suggested that after this taskforce completes its three meetings, one of the recommendations may be to conduct a more thorough needs assessment in the facilities. Mia Oxley proposed the next meeting be on January 24th, and that people send their training ideas to Janice Troyer by the middle of January. Janice Troyer would then have time to organize the information for sharing on the 24th.


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Karen Perdue suggested having two reporting categories: education and clinical training. We discussed categories and how we organize information. There was some discussion of breadth of training needs, with a strong argument for focusing on skill development. It is possible that Pam Jeffries could participate in our next meeting. Meeting dates • Karen Perdue recommended that people tentatively hold January 24th, January 30th, or

February 5th for the second meeting.

• Also, Karen Perdue proposed that we hold the 3rd meeting on March 5th or 18th. Closing comments Mia Oxley invited everyone to share what they will take away from this meeting. What follows are the closing comments. • Dr. Ross wanted to follow up with rural Alaskans and their needs/opportunities.

• Tom East said ANTHC was interested in this technology and appreciated this discussion.

• Dan Johnson was interested to see where this goes for EMS.

• Corliss Taylor said this was quite interesting and was surprised at how much was already going on around the state. FMH shared some of the issues voiced by other hospitals in terms of students and new hires. She also thought the ongoing CE/CME had applications.

• Lynn Senette stressed that if we were going to succeed, we needed to have a common vision. Unless we have that vision from the balcony, we won’t be as successful.

• Jackie echoed earlier comments. She thanked Dr. Ross for coming and being the very best presenter they could have for the first meeting. It was also daunting to think about what the SON needs to do now.

• Justine Muench echoed the comments about Dr. Ross. And if we have the common vision, Lynn mentioned, we will have an easier time.

• Cheryl Easley talked about visiting China and their simulation centers – and the Chinese asking Cheryl Easley what she had in her country. Cheryl Easley sees collaboration as key to going forward. The more people we have working on it, the better.

• Harold said he has learned a tremendous amount and is impressed at the resources available. The most important thing Harold can see is that we are approaching it methodically and thoughtfully, and that it is a measured approach.

• Andrea Neuerburg admitted she came in today with a stovepipe view for nursing. She now sees value for collaborating with many other disciplines. The discussion opened her eyes about approach, resources, and collaboration.

• Dona Townsend also came in with tunnel vision. She has gleaned a lot of information, including and especially the need for team development in training.


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• John Riley said this is another reminder of how great it is to be in Alaska and work together. We all share the goal of having high quality providers. We learned who are the “haves” and the “have-nots” and how to share those resources.

• Karen Carpenter agrees with what has been said. It has been great to see so many people together.

• Suzanne Tryck appreciated all of the useful comments and looked forward to moving forward.

• Roy Davis was impressed with attendance and believed it spoke to interest and our capacity to be successful.

• Paul Perry uses simulation. As he looks to the next 20 years and our patient needs, and evolving curricula, we will need innovative ways to teach those skills. Simulation is the answer in his neck of the woods on EMS. He had no idea that it was so far-reaching.

• Debbie Thompson came in with a narrow nursing vision. After listening to the other comments, she saw simulation as a wide open door. The question she thought we needed to address by the 3rd meeting was sustainability. She didn’t just mean the real estate. She meant having the people to teach in that area, funding to support that instruction, access for everyone – and we would be remiss if we only went part way. If we didn’t sustain it, we would go backwards.

• Jerry Troshynski comes from a public health background. It was gratifying to see horizons broadened. One of the ten responsibilities of public health is assuring a competent workforce. Also, when he talks to hiring managers, he joked he asks for a copy of their kindergarten transcript that says “plays well with others.” He saw simulation as training us on technical competencies, but also as a safe and reinforcing model for communication.

• Dennis Valenzeno echoed the breadth of the discussion. His thoughts were crystallized in two areas: one was more aligned with education, a center with higher end equipment, and the other aspect was the technical skills training needed in the workforce. The Center would assist with coordination. And communications training is cross-cutting.

• Janice Troyer appreciated everyone thinking about the rural stakeholders and was glad that was being recognized in this forum.

• Mia Oxley talked about planning with Dr. Ross for this meeting. And his theme about creating a prototype for the third world.

• Karen Perdue thought it was a good meeting. She learned a lot. She agreed with Debbie’s comments. It is important to think through how to resource this initiative for sustainability. She also learned a lot about clinical quality and honing skills in specialized areas, especially for hospitals in a highly regulated environment.

• The meeting was concluded at 3:30 pm. Taskforce members were told they would be notified by the end of the week when Meeting 2 will take place.

Clinical Simulations in Alaska Appendix E: January 24, 2008 Alaska Clinical Simulation Taskforce Meeting

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Appendix E: January 24, 2008 Alaska Clinical Simulation Taskforce Meeting 9:30 am to 4:30 pm

Attendees: Taskforce Members: X Karen Perdue X Dennis Viloria** Cheryl Easley X Jan Harris Dona Townsend X Barbara Doty**** X Maureen O’Malley X Karen Carpenter X Chuck Kuhns X Dan Johnson am Suzanne Tryck X Dennis Valenzeno X Corlis Taylor* Roy Davis X Justine Muench X Lynn Senette X Paul Perry X Jerry Troshynski X Jackie Pflaum X Debbie Thompson X Sally Mead

pm John Riley X Tom East X Megan Wilmoth X Wilma Goodwin X Lt. Col. Ryan Shercliffe*** X Carrie Doyle***** X Marianne Johnstone-Petty

Staff: X Beth Landon X Mia Oxley X Janice Troyer X Jennifer Risse X

*Corlis Taylor sat in for Liz Woodyard from Fairbanks Memorial Hospital **Dennis Viloria sat in for Linda Boyle of the VA Healthcare system ***Lt. Col. Ryan Shercliffe sat in for Major Marlene Kerchenski from Elmendorf ****Barbara Doty sat in for Harold Johnston from Alaska Family Medicine Residency *****Carrie Doyle sat in for Shara Sutherlin of Providence Health System Also in attendance for part of the morning: JoAnn Gonzalez Major, UAA Instructional Designer Guest Speakers: Shirley Anderson, Executive Director of the Oregon Simulation Alliance; Mike Lamacchia, Director and Flight Paramedic with The STARS Centre in Alberta; and Pam Jeffries, Author of Simulation in Nursing Education. I. Introductions/Agenda Review Karen Perdue provided a synopsis of progress on this project since the November meeting, gave an overview to today’s meeting, outlined the deliverables for today’s meeting, and reviewed what is anticipated in the final product. After everyone introduced themselves, Janice Troyer provided an overview of the guest speakers who would be participating via videoconference. She described the organizations they represent, gave a snapshot of their structure, and gave an introduction of the information they were invited to present to us. Janice Troyer also oriented people to their packets. The majority of attendees had reviewed the Oregon Simulation Alliance article emailed out prior to the meeting. Janice Troyer pointed out the Simulation Delivery Models handout that provides an organized synopsis of the phone


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interviews conducted over the past couple of months with facilities and programs outside of Alaska. II. Oregon Simulation Alliance (OSA) First guest speaker: Shirley Anderson, Executive Director of OSA. Shirley Anderson explained that, to date, OSA has secured $1.6M in funding. Most of that is from their Workforce Investment Board, focusing on improving competence and capacity. While OSA cannot claim all credit for improving training capacity with clinical simulation (there are other factors), it is understood that clinical simulation facilitates a portion of it. Currently, 45 organizations use clinical simulation, and about 20 have Simulation Centers. OSA is currently conducting surveys to collect information to guide their next steps. At this point, their grants are done and they are now looking at sustainability more closely. Sustainability is challenging. Because OSA has not charged their members any fees for training, members have come to expect these services for free and are balking at having to pay the $750 membership fee. Shirley Anderson noted that Idaho is in the process of forming a coalition of partners and has outlined a structure for how to pay for simulation technology and training through membership fees. She sees this as an advantage to charge for services in the very beginning. The most successful coalitions within OSA are those that had existing partnerships on other projects, and then expanded those partnerships to include clinical simulation. The new coalitions that had not been functioning as a group were not as successful. One example of a coalition that has worked well is a physician’s group that trains interns and residents in Portland on laproscopic procedures. That is going well and they are now developing a mobile unit to train rural physicians. Another example is a coalition that has a mobile van that travels to rural areas and trains nurses and others in the region. In areas with bigger populations, sometimes the larger coalitions have split into smaller coalitions because there is not enough equipment to support the entire group. 60% of the coalitions originally formed continue to collaborate, but some of those ways of collaborating have changed over time. Several organizations are breaking out of coalitions and merging with organizations geographically closer to them. Networks and partnerships have been formed through people meeting within the OSA sponsored clinical simulation training workshops. Team training, communication, sentinel event training, and new employee and nursing orientation are common uses of clinical simulation. Surveys show it has decreased overall orientation time. They can use clinical simulation to assess skills quickly. Twelve hospitals reported that they provided over 3,000 mannequin-based trainings in the past year – a six fold increase over the prior year. Nursing was the highest user and the first adopter of the use of clinical simulation. They have physicians, PTAs, dental hygienists, and assistants that are increasing their use as well. Dental folks use it to train for medical emergencies in outpatient settings. EMS has been the most difficult group to engage. They have been using simulation technology the longest and it is hard to get them to think past a mass casualty circumstance. Shirley Anderson shared OSA’s lessons learned and provided the following suggestions for Alaska:


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• What market is ready? Conduct an assessment—the momentum is in who is ready (Shirley Anderson noted that OSA did site visits to assess readiness and some of their need).

• Conduct a needs assessment so you know where to put your energy (Training was the biggest need and OSA responded with a great deal of training).

• Start where you have the biggest bang for the buck; early successes will carry the project. • Talent is what moves you forward: identify the early adopters and develop them so they can

work to develop others. • Your motto needs to be “We can make it successful,” NOT “ I can make it successful.” • Develop your own identity and product. Find what pieces do and do not fit with “Alaska” and

create what will work for you. (The OSA model may not be the best for Alaska.) • Openness and transparency are important; you don’t want to give the impression it is a clique. • Not all groups will collaborate in the same way. There are forms and each fit with different

people/groups. Some examples include: 1. Networking (little communication; all decisions made independently) 2. Cooperative (Provide information to each other; all decisions are made independently) 3. Coordination (Share information and resources; some shared decision making) 4. Coalition (Frequent and prioritized communication; members vote in decision making) 5. Collaboration (Frequent communication and mutual trust; consensus decisions) (OSA has examples of all of these and there are no set standards. The local areas have to decide what would work best for them.)

• Must be discipline agnostic: be inclusive and leave your specific profession and institutional hat at the door (everyone works toward the common goal, even when sometimes it is not in the best interests of your institution!). Make sure no one profession dominates the council.

• We found many coalitions were on paper coalitions only! Many people will buy into the idea of simulation without realizing how difficult it is to acquire the funding. This is why we acquired grants in order to “jump-start” the purchase of equipment and with training—what we found is extremely important.

• Recruit a cadre of volunteers and keep them engaged; the governing board will burn out without assistance from others.

• Be sure to manage expectations—yours and others. • Develop partnerships with others you have not partnered with in the past (provide

opportunities for sharing and networking so you don’t reinvent the wheel). • Be inclusive in creating your board/governing council/task force, and make sure there is

representation from all stakeholders…even if they are not currently ready to start simulation. • Join Society for Simulation in Healthcare (SSIH)—excellent resource for information and to

learn what others are doing. • Provide frequent opportunities for sharing and networking. • Do not have the organization which is the “elephant in the middle of the table” be the leader

of the initiative. We found it was imperative to have the initiative brought forward by the hospitals and academic institutions at the same time.

• Make sure the organization’s/institution’s decision makers are brought in very early into the discussion (they control the funding and determine priorities).

• Keep your legislative and congressional delegations informed of your activities, in case an opportunity for funding occurs.

• Don’t move too rapidly.


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• The mantra must be increasing competence and confidence and patient safety. Sally Mead asked Shirley Anderson how they were able to form a governing council in equal fashion. Many people were investing in simulation equipment in Oregon, but it was not coordinated and there was limited communication. The Governor’s office stepped in to encourage formation of a group. The call went out loud and clear for people to attend the planning meeting. It was nearly a year later that they had a day-long retreat. They did not want to call it a “board” because of the authoritative tone that conveys. They wanted an inclusive and representative group. That day-long strategizing retreat resulted in identifying who would be impacted by simulation, who were the key decision-makers necessary to be represented, and how to keep this on the Governor’s radar. Beth Landon asked if there had been any demonstrated outcomes. Shirley Anderson said she knows that nursing education capacity has improved, but it is not entirely clear how much is due to the use of clinical simulation. Shirley Anderson did note that clinical simulation had decreased demand on clinical sites; some clinical time is being done by simulation. She recommended looking at the Board of Nursing rules for didactic/clinical training requirements and figure out how much we can move from the facilities/clinical time to simulation (some are up to 20%). Faculty needs to be engaged–some have a philosophical issue with clinical simulation supplanting clinical time. Rural areas are using clinical simulation for conditions/situations they don’t see enough locally (e.g., OB, emergencies, etc.). In terms of shortening employee orientation time, it is a gut feeling for outcomes. One OSA member says one employer has reduced orientation time by two shifts. They are working on developing better data collection instruments which takes time. Marianne Johnstone-Petty asked Shirley Anderson if, in hindsight, she wished they had developed data collection systems early. Shirley Anderson said, yes, in an ideal world, she would have. But everything takes time and you can’t put too much on people’s plates. Many people were overwhelmed with acquiring equipment, finding a space for it, and getting people trained to use it. Barbara Doty asked if there were resources for shared curriculum nationally. Shirley Anderson said, no, they were the first “out of the box” and joked that being on the cutting edge often felt like the “bleeding edge.” Shirley Anderson put out an RFP for a two-day clinical simulation training course. She talked to Mayo, Stanford, and other prestigious universities. They did not want to come to our state to do the training and they (furthermore) did not have a curriculum in place. OSA developed their own foundation curriculum and then worked on a clinical simulation apprenticeship, and finally a clinical simulation technology curriculum. OSA found that the faculty members were burning out (two exceptional faculty had quit). In response, OSA trained “clinical simulation techs” to do a big chunk of the work previously done by faculty. The college in Springfield provided the training and now plan to offer that curriculum to other states. Mia Oxley asked what criteria was used for their needs assessment to determine “readiness.” Shirley Anderson suggested contacting Dr. Michael Seropian to get his proprietary tool. Shirley


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Anderson noted that some of the examples she might include on an assessment tool would look at the level of buy-in and follow-through commitment, finding out if an organization had space for the equipment, asking how they would envision using higher fidelity equipment differently than lower fidelity equipment, and finding out if they realized how much energy it was going to take to develop a simulation program. Shirley Anderson gave an example of someone who would have failed a readiness assessment, and how poorly the resources were subsequently deployed. Beth Landon asked about the clinical simulation needs assessments. Shirley Anderson felt these were overlooked in the race to secure and spend the money. People put together proposals before thinking through how the suggested equipment would fill local needs. This was partly due to the fact that OSA got their grant money too early in the assessment process. She encouraged people to think through this process before being awarded resources. This hole in the planning compromised efficacy for some of the coalitions. Karen Perdue asked how the Workforce Investment Board had been involved. Shirley Anderson noted that the Oregon WIB had been looking at workforce shortages and capacity. Healthcare had been a target area. The other funder was the federal Department of Labor. They found two things: it was easier to get funding for programs than for equipment or infrastructure. OWIB funded OSA to work on marketing, sustainability, and fund development. Shirley Anderson suggested we think about the niches this equipment will fill, and sell the concept to funders. Justine Muench asked if the local coalitions did separate fund-raising as well. Shirley Anderson said one coalition was successful with a foundation in their county. The bulk of the coalitions have survived with in-kind donations from member organizations. In their recent survey, OSA asked about in-kind donations. Respondents documented about $1M in in-kind contributions. The equipment was primarily supported with federal funds and in-kind support from hospitals and colleges. People were now adding different simulators and broadening what they want. III. STARS Mobile Simulation Program Mike Lamacchia is a paramedic and the Director of the STARS Mobile Simulation Program, located in Alberta. Mike Lamacchia outlined the topics of his presentation: program justification, examples and challenges of a mobile simulation program, their curriculum and audience, program administration and costs, lessons learned, and critical success factors. Mike Lamacchia noted a physician’s survey conducted in ’97 pointed to a need for more community-based training. People were going to conferences separately and there were limited opportunities for people to train with those they worked with. STARS, an air-ambulance company, has developed a mobile simulation program. The simulation training they provide is free and allows for “practice as you practice” training. The STARS budget is $21M for all bases and includes their helicopters, etc. They receive 70% through private support, underlining the importance for a public relations tool. Mike Lamacchia noted that you can’t build a centralized simulation center and assume people will come to it for training. People want and need to be able to be trained locally. They are able to conduct the training while people are at work, and thus


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employees don’t have to take time away from work (reduces time away from family, coverage issues, and travel expenditures). Mike Lamacchia noted that there are considerations and challenges to providing mobile simulation training. There are essentially two methods: one in which you have equipment installed in something such as a motor home and the other in which you are packaging up equipment and transporting it to a facility to use within the building. Set-up time needs to be considered, especially in the latter. Both of these methods have merit depending on the audience and location. STARS currently operates 2 motor homes with installed simulation equipment, and uses a Suburban and transport simulation equipment for the more remote areas. (Mike Lamacchia noted that there is a program in Ontario that uses a 28 foot trailer.) Environmental factors (hot, cold, rain, wind, snow) need to be considered; the equipment must be robust. Power is also an important consideration (Mike Lamacchia recommends a diesel generator for fixed installed mobile units). If you blow a hospital’s breakers, that creates issues. You need a dedicated AC power source and UPS units with adequate batteries. Physical space is a consideration, as well as AV equipment (Mike Lamacchia notes that security cameras are inexpensive compared to other systems). You also need to think about back-up equipment; if you drive 5 hours to a community and your AV doesn’t work, that’s a problem. Another challenge is to consider the entire clinical simulation training costs. For example, $500,000 bought the motor home and the simulator – that’s it. You have to think beyond the capital expenditures to set-up and delivery (and sustainability and maintenance). STARS received its funding from philanthropic organizations. Also, mobile equipment must be used by small groups rather than by large groups. Mike Lamacchia explained that a bare bones motor home is over $200K alone. STARS also purchased a Suburban. Set-up on site with the Suburban takes an hour, while setup with the mobile home is about 20 minutes. The Suburban approach is tiring. You can burn your staff out with the set-up and take-down time (Mike Lamacchia showed pictures of the motor home interior). STARS had to build the environment in which the crews work within this motor home. This is a real benefit to the learners. Mike Lamacchia shared suggestions for developing curriculum & working with your audience. He strongly recommended having local champions to get people to sign up for trainings. He also noted there is value in identifying cases out of past experiences in that community to help develop the curriculum. It takes more planning, but is worth it. There is value in sending out an orientation package beforehand as it saves time (Harvard has an excellent one that can be adapted to any program). Rich multimedia improves buy-in. Looking at real labs, EKGs, and real digital radiography is also beneficial. Simulators are important, but so are all other aspects of the learning environment. Mike Lamacchia gave an example of how simulation has been incorporated into four CME modules created for family medicine doctors in Alberta. Four multimedia CME modules were created that include a pre-test, the module, a human patient simulator (HPS) session, and a post-test. STARS travels to the clinics with their mobile simulation unit to provide the HPS session and post-test. MDs love it. The session and post-test occur during clinical time, so they do not


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have to leave their facility to complete their CME. This program was developed in conjunction with RPAP of Alberta. (The Alberta Rural Physician Action Plan) Mike Lamacchia noted that with a mobile simulation program you must have dedicated administrative support. One person must have the skills and responsibility to oversee the program. Mike Lamacchia does this for STARS. STARS has a dedicated team of individuals for teaching with at least 4 or 5 facilitators of all types (RN, EMT-P, MD). He notes that burn-out rate is high due to the travel requirements. STARS operates 9 months of the year. They have 3 bases, 2 motor homes and 1 suburban, 6 FTEs, 12 training mobile events per month, and a similar number of base events. Their yearly budget is about $600K. Mike Lamacchia suggested four critical success factors:

• Develop of a rigorous, long-term business plan. • Dedicate staff members at the outset. • Establish financial autonomy through industry partnerships and aggressive pursuit of

grant/donations • Secure institutional buy-in and support from top down.

Barbara Doty asked if Mike Lamacchia did any work with training in communities that were off the road system. Mike Lamacchia said he did not and was not familiar with any programs that did. Barbara Doty asked about outcomes for RPAP. Mike Lamacchia noted a study was completed three years ago that did reflect favorably on mobile simulation training being brought. He offered to forward that study. In terms of industry outcomes, Mike Lamacchia said little research has been done to demonstrate the benefit of using simulation. Most of what they have is subjective and “feel good.” Barbara Doty asked if Australia uses simulation in non road-based systems. Jackie Pflaum responded that she had heard at the Simulation conference she recently attended in San Diego, that yes they were using mobile simulation training in rural, off road areas. Dan Johnson asked if the equipment they transported via the Suburban could be easily carried in and out of the vehicle. Mike Lamacchia responded that one case is 60 lbs, but everything else is lighter. So yes, everything is in cases on wheels or with nice handles. The total weight is 350 lbs dispersed over 4 bags/cases. Justine Muench asked about competency demonstration and related paperwork, and who was in charge of that. In the MD world, Mike Lamacchia noted they have the RPAP model. With nurses, it is not yet that formal. STARS knows when a community has a case that has gone bad (they get called), and their training is designed in response to that experience. National competencies are under development.


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IV. Simulation Technology in Nursing Education Pam Jeffries gave about an hour long presentation titled “Simulations: Concepts, Challenges, and Simulation Center Considerations.” See power point presentation slide handout for details. Mia Oxley asked how clinical simulation reduces the demand for clinical training sites. Pam Jeffries explained that data are not yet available. She knows there is demand for education reform, and clinical simulation may fill that demand. Pam Jeffries shared a nursing study she had conducted that evaluated three different educational methods using simulation from low fidelity to high fidelity. They looked at learning outcomes for each of the “roles” across educational methods. They did not find a significant difference in learning outcomes across roles. That means those who play the role of “observer” in a simulation are learning as much as the other participants. Pam Jeffries was surprised at this finding, but also encouraged by the ramifications. Mia Oxley asked if the observer’s learning improves if they are given more structure. For example, Brian Ross had noted they give their observers a checklist to complete while observing. Pam Jeffries responded that she was not aware of any studies that demonstrated a value in using this type of structure, but supported the idea. Jackie Pflaum asked a question about skills development. Pam Jeffries talked about OSCEs (Objective Structured Clinical Examinations), and gave an example of a student that needed to hang an IV piggyback. An actor played the role of patient. After 3-5 minutes, the student came running out of the station in tears. The student said “the patient is talking to me.” Prior training did not include the factor of human interaction and the need to be able to talk to the patient, or family members, etc. It is more than the specific skills; the complexity of the real environment is important. There was some discussion about the use of dedicated space versus “flex space.” Both are important considerations in a simulation center. Pam Jeffries noted that METI and LAERDAL are cross-platform. One runs on Apple and the other runs on a PC. Pam Jeffries suggested we think about this before making the investment. Jackie Pflaum asked if the integrated interdisciplinary lab which is being built at the Indiana University where Pam Jeffries works will replace other existing labs. Pam Jeffries responded that they plan to keep their nursing lab due to issues in orchestrating use of the new center. (The interdisciplinary simulation center will be used by many different disciplines and user groups.) Dan Johnson asked if Pam Jeffries has any plans for community outreach with the interdisciplinary center, working with other disciplines – for both normal training and mass casualty training. Pam Jeffries said, yes, absolutely. You want 100% use in your center because of the enormity of the investment. It can be used when students are not there too (weekends, holidays, etc.)


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Sally Mead asked about involvement of allied health students in use of the simulation center. Pam Jeffries explained that allied health was not “at the table” much in the beginning or since for their particular project. Pam Jeffries wants them there so it is interdisciplinary training, but that has not happened yet. Justine Muench asked about the “virtual technology” with outlying hospitals or schools – is it separate or part of the Simulation Center? Pam Jeffries gave some examples. Virtual technology is a piece of equipment. Another is the EICU that they have at the hospital. They want students trained at the EICU. It doesn’t take much space but it is remote. Pam Jeffries says telehealth is an area they want to enter. V. Training Topics and other handouts Janice Troyer gave a brief overview of the Alaska Clinical Simulation Taskforce Training Topics handout included in the information packet. Sixteen facilities/programs completed a chart. She noted the charts were filled out in many different ways—some topics were very specific while others were very broad. It was not possible with over 150 topics listed to come up with a handful of common topics. Instead, Janice Troyer did the best she could to sort the topics into some general categories. These are listed in Appendix G and include the following: emergency airway management and cardiac life support; disaster management-emergency scenarios (away from hospital); codes/emergencies (in hospital); physical exams; technical skills; deliveries/neonates/peds; communication; and health promotion/management. Examples of topics were listed for each category. In addition to the more specific topics, some people listed types of learners and types of training on the charts. These are listed in Appendix G. Janice Troyer said they decided to include each individual chart in the handout since the chart contained so many insightful comments. The Steering Committee felt it would be useful information to all participants in the taskforce when thinking about the future of incorporating simulation into training. VI. Small Groups For the next hour, the larger group was divided into three smaller groups and given a set of questions to begin answering. These groups included: University of Alaska, Hospitals/Providers, and Development/Delivery. All groups were asked to: 1) discuss the questions posed for the group, 2) list key concepts for the final report, 3) identify any lingering information needs that need to be addressed now or eventually, and 4) if relevant, pose additional related questions. Groups were facilitated by Sally Mead, Mia Oxley, and Beth Landon. Once the groups came back together, each group presented the highlights of their discussion to the larger group. Below is a list of the questions posed and a summary of discussion highlights for each group.


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University of Alaska Group Questions posed: 1. To what extent could use of simulation technology impact delivery of classroom education,

either positively or negatively? What are any requisite conditions to encourage desirable impacts?

2. To what extent could use of simulation technology impact clinical training, either positively or negatively? What are any requisite conditions to encourage desirable impacts?

3. Could simulation technology enable UA to train more students? What factors would affect this?

4. What are realistic expectations for training outcomes? 5. What preliminary conclusions could we draw from the results of Training Topics survey of

Task Force Members? In looking at the use of clinical simulation to impact delivery of classroom education, the UA group asked what evidence there was for changing classroom methods towards the use of simulation. Due to limited experiences, it is unknown if changing methods is best. They would like to see more hybrid approaches for using simulation. There is the ideal and then there is the real. Rebuilding coursework for simulation by older faculty is a challenge. The current curriculum process has a set structure (chair time learning). In looking at the use of simulation technology to impact clinical training, it was noted that in the EMS system clinical and classroom is all intertwined. As a positive, students will demand technology and may lead the change. Some positive benefits include interdisciplinary training, the opportunity for competency-based training, and increased skill development in professional communication. Simulations expose students to the reality of clinical practice. Negative impacts include teachers not having the skills to use simulation in either the classroom or clinical sites. Faculty development will be instrumental. Additional staff will be needed: technology support staff and simulation specialists. In answering the question about whether simulation technology will allow more students to be trained, the group did not necessarily think more students could be trained, but that there would be a significant impact on clinical competence and confidence. The larger group agreed with that comment, though Jan Harris noted they might be able to get a few more advanced level students trained with simulation technology. Justine Muench said you could possibly increase the number of students trained in the distance sites. The group thought that simulation could take a load off clinical sites which are currently stretched to the max. Clinical sites/hospitals will benefit since students will be better prepared. Simulation technology could improve team training which can improve patient safety. The reality is the number of students is tied to the number of faculty even with simulation. If clinical simulation enabled the training of more students, it would be necessary to consider adding faculty for those students. Student expansion is most needed at the advanced professional levels.


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The following were listed for realistic expectations for training outcomes: competency based improvement, confidence building in critical thinking skills, communication between professionals, quality of learning experience improved, and integration of theory and practice placed in a practice context. Preliminary conclusions from the training topics survey included:

• There was too much to digest—lots of possibilities • Many topics involve high intensity events • Huge learning curve for faculty • Raises huge questions if there are simulation curricula that we can use rather than

creating them from scratch • Everyone is excited about the idea

In conclusion, the group noted we need to remember our critical focus in training outcomes. The UA should/could be a clearinghouse of info, even if it doesn’t have equipment. The curriculum could be housed at UA for industry to access. Hospital/Provider Group Questions posed: 1. To what extent could the use of simulation technology impact the delivery of continuing

education and CME, either positively or negatively? What are any requisite conditions to encourage desirable impacts?

2. What are realistic expectations for training outcomes? 3. What are realistic expectations for improving patient outcomes? 4. What preliminary conclusions could we draw from the results of Training Topics survey of

Task Force Members? Generally speaking, the impact on CE/CME and team development is that it can be a means for staff to demonstrate competency. It can be used for staff cross-training, for mandated specialty training (MD credentialing or competence for nursing staff), as a means for working with staff in the area of patient complaints (hospitals feeling pressure for patient satisfaction), to better standardize training, for more team-training, and to better prepare families as caregivers of patients living with chronic conditions. (This is especially important in rural areas where the remote clinician has limited experience with that particular condition). Simulation offers learning and practice with rare but life threatening events. HR professionals would see simulation as a means for advanced qualification demonstration and during orientation. The group also noted the potential use for career exploration with the AHECs and for optimizing the use of telemedicine infrastructure in rural Alaska. When thinking about negative impacts, the group asked who is going to support/staff this added function? Hospital education departments will have to develop the skills for clinical simulation. There may be reluctant learners. Also, for those 45+ years, the concept of an annual skills assessment via clinical simulation could be difficult. Money may have to be diverted from other areas to be directed toward simulation. Since technology changes constantly, obsolescence of


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equipment needs to be a consideration. There are competing space demands. The validity of learning is not documented in the literature. Expertise is needed to run simulations. What to conclude about positives and negatives? We need to focus in on some needs. For example, skills training for new graduates and orientation for new staff could be key for early focuses. Then team-based training (hand-off communication, emergency care) would be a good start to feel success before other forays. There must be dedicated staff to make sure it all happens; there need to be “champions” to help spearhead the effort and keep the momentum going. There really needs to be a clearinghouse function, someone to broker the information who knows the different models and places to get the curricula and expertise. In terms of thinking about outcomes, simulation is not a replacement of clinical experience. But outcomes can include increased patient safety, improved customer satisfaction, increased learner confidence, possibly shorter periods for staff orientation, and possibly decreased turnover through greater satisfaction which would improve retention. Preliminary Conclusions? There will be revenue needs for on-going administration. It is easy to find money for equipment, but not for programming. Mandates could be used as incentives to leverage funding. Lack of research to document outcomes is a recurring concern. Alaska needs an investment strategy, networks, a resource clearing house, a plan for collecting outcome date, and some super-users. To move ahead we might ask: What can we do now so that development/use of simulation is better for all of us? Justine Muench added that she really likes the OSA model. She can see forming local coalitions and looking at simulation needs in regional areas and forming partnerships based on those needs. Jackie Pflaum noted she could see a role of AHEC to support career exploration, to support coordination, and to support delivery of CE/CME. Development/Delivery Group Questions posed:

1. What preliminary conclusions could we draw from the results of Training Topics survey of Task Force Members?

2. What thoughts do you have at this point about the overall development/delivery/organization of simulation training in Alaska?

3. Important concepts that should be included in final report? The majority of the topics fall neatly into developing skills according to an algorithm with clean steps. This is often taught in a classroom structure, with straightforward memorization. The value of clinical simulation is that it allows the learning to be enriched with communication skills during a stressful event and helps in developing and practicing critical thinking skills. Chuck Kuhns gave an example of teaching a student the skills for rapid sequence intubation and then providing that student with a simulation scenario (e.g., snowmachine accident where throat is


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hurt) so the student needed to use critical thinking skills on whether that intubation was appropriate in that situation. Chuck Kuhns noted that while learning skills was important, it was also very important to put those skills into contexts where critical thinking skills were used. The following are some of the thoughts the group discussed about developing and delivering simulation training in Alaska:

We can’t assume the same level of availability of technology across the state.

There seems to be a lack of peer-reviewed outcomes research.

Training is almost more important than equipment in terms of resources-we need to have training to alleviate burnout. Rural community members need to be engaged in this training.

We should explore mobility of equipment and the use of distance learning technology. (There was some discussion about the high data casting technology used by the WELLS Center in Colorado.)

Some members liked the philanthropic aspect of STARS and the mobility aspect of that program.

Interdisciplinary training in a team-building environment serves multiple purposes.

It was thought it would be good to have a clearinghouse of information. It was also suggested that it would be good to develop an Alaska user group for sharing curriculum scenarios and data. You could develop a standardized curriculum template that could be shared more easily.

One key concept the group thought would be good to include in the report included the idea that simulation is more than just mannequins or a simulation center.

When thinking about what would happen after March 5th, the group could see a use for continuing some sort of taskforce, but possibly morphing it and developing subcommittees to address different areas.

VII. Large Group Continuing Discussion After the small group facilitators finished giving their presentations, a larger group discussion ensued, which was facilitated by Mia Oxley. She noted that one overarching theme was the idea of people wanting to work together. Sally Mead pointed out Oregon’s example of working together and the need for a sophisticated structure. “If we move in that direction, we need to be careful about the words we use to develop a structure.” Chuck Kuhns pointed out if there was a one-time funding he would like to see a user group with all of the disciplines represented; it could be a resource library of scenarios. Karen Perdue pointed out that we need an investment strategy. How do we tell our funders that we have a plan?


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Beth Landon reiterated there are two reasons for a larger partnership/collaboration:

1. Networking (avoid redundancy, share best practices, learn from each other) 2. Investment strategy – more credibility with funders

Karen Perdue said the whole state doesn’t necessarily need an investment strategy, but UA certainly needs one. Barbara Doty suggests we can learn from the electronic records experience. They identified super-users who became the “go to” people. Dan Johnson noted that, historically, it is easy to fund equipment, but harder to find funding for planning. Simulation technology won’t be used unless it meets a need for people; it needs to meet existing needs. If a need can best be met by using simulation, people will find the money. Tom East noted if we are going to have a shared governance it needs to have lots of structure. Tom East and Karen Perdue agreed that it was nice to talk about working together, but when it was time to put their own money on the table, the dialogue can become very different. Promising funding and providing funding are two very different things. Distance education is a recent example. An organization was funded to develop a clearinghouse for distance education and vet proposals for funding. Now all the distance education funding is gone and users are not willing to pay for clearinghouse functions. The business model to pull all this together is very tough, and the process has to move slowly. Tom East suggested we figure out a good business plan and sustainability model. Beth Landon asked if their would be any use in doing a needs assessment to inform the business plan. There was some agreement on that. Maureen O’Malley said that today she had heard nothing about cost savings. Karen Perdue said data did not seem to be in about outcomes. Barbara Doty pointed out that a needs assessment must be well done and questions needed to be asked carefully. Dan Johnson pointed out that a needs assessment must be unbiased, and might even suggest there was insufficient need for simulation. Debbie Thompson suggested that we need to define simulation and include this in a needs assessment. Megan Wilmoth said that the needs assessment should be conducted at the administrator and training manager level. The CEO’s perceptions are relevant, even if they are misinformed. Beth Landon suggested the final report should not be a wet blanket, but should be cautionary.


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Mia Oxley said we need to get more precise about what “this” is. Lynn suggested better defining the potential for using simulation and what potential needs it would address in Alaska. Then, if there was a windfall of resources in the future, it would be easier to determine the type of investment to occur. Mia Oxley asked how we can prioritize the needs. Do we identify low hanging fruit? Or do we look for universal needs? Tom East said if you were going to prioritize the needs, you needed to know who you were targeting for dollars. If the investors were foundations, the approach would be different than asking hospitals to invest in a program. Barbara Doty pondered that if the AHEC were successful and had statewide coverage in five years with all its centers, the AHEC could be pods of resource that broker information. She felt a lot of this was information management, more than nuts and bolts. Marianne Johnstone-Petty suggested focusing on the customer – the patient. That should be our primary focus: patient safety. Mia Oxley asked the group, if we went home today and didn’t come back, what are we still missing? Dennis Viloria suggested each facility needs to name its most important needs. Megan Wilmoth said facilities weren’t necessarily willing to pay for what they needed. She suggested taking the training topics a step further. Prioritizing training topics was not the same as determining what someone will pay for and what they are willing to suffer with. Corlis Taylor reminded the group that we all represent different entities. Five years from now we will all be doing clinical simulation no matter what. We need to think about what we can do now as we move towards simulation, so it is more organized, constructive, and collaborative the way we do it. I wasn’t looking at this group for money. I was asking how can what we do leverage with what others are doing in the state? Debbie Thompson observed that Janice’s work was more comprehensive than anything done to date. The value of the data collected, aggregated, and disseminated to date was invaluable. Creating a clearinghouse to continue this, and possibly also doing follow-up and communication, would be great. Maureen O’Malley asked what a little group could do with the clearinghouse function to keep tabs on or identify what is affordable and useful. Pam Jeffries is already a consultant to UAA. So it would be a smaller group that took this to the next level.


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Karen Perdue pointed out that we have considerably more information than we anticipated having. Our report will reflect that information, and may have a few recommendations, but the UA is not responsible for continuing the group at this time. Our purpose was to jump start the conversations. Karen Perdue asked if the group felt it needed to convene for a third meeting. Justine Muench spoke to the need for a final product. Karen Perdue clarified there will be a written report. Barbara Doty suggested that the final report lay out scenarios for both UA and for industry. She suggested we survey people a year later to find out what people did with the information. Tom, despite his earlier cautionary tone, was still a believer in utopia. Given that there will be multiple investments in clinical simulation, there is value in some level of coordination. And then we are talking about some kind of governing body. Chuck Kuhns agreed that we don’t need another meeting, we have accomplished a lot, but he also did not want to see people lost out there with equipment sitting in boxes. The only way this state will grow is if we work together. Megan Wilmoth would like to see a concrete business plan, pick low-hanging fruit that ties back to community benefit, perhaps a small pilot program. Sally Mead thought the university may be in a position to try something like that on a small scale in the form of interdisciplinary training for sake of patient safety—increasing communication skills. Karen Perdue suggested having an employer partner. Sally Mead suggested maybe having five interested faculty that are appropriately compensated for working on the curriculum. VIII. Participant Closing Comments Paul Perry said this was going to go forward. Simulation is coming. We can step up to the plate or let it go past us. Tom East thought this had been good and educational. He would like to see the effort move forward. Lynn said simulation was out there and not going away. She appreciated Corlis Taylor’s comments and felt they helped focus their thoughts. Marianne Johnstone-Petty thought it was a great experience and anticipated seeing us again. Debbie Thompson thought it was a good experience and had opened her eyes to what was happening now. She saw the need for coordination.


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Carrie Doyle mirrored the comments. The organization and structure for long-term viability will be important. Chuck Kuhns commended the organizers on how informative this had been, and how exciting it all was. He said it made you want to go further. Sally Mead resonated with the OSA model and felt there were qualities to that structure that fit here. Starting with some pieces, like a pilot, can be informative and help us move forward without an expensive leap. We are not ready for that leap yet. Janice Troyer had a lot of fun on the project, enjoyed meeting everyone, and appreciated the learning experience. Megan Wilmoth agrees with Sally Mead. She would like to see it progress slowly and doesn’t want us to feel hampered because we don’t have $10M. Dennis Valenzeno thought we were coming to a consensus on what simulation meant and what could be done. Jan Harris enjoyed getting a sense of the potential. Dan Johnson appreciated hearing what was happening in other states. It was also been valuable to get a perspective on the issues of classroom programs. We will find common ground. Corlis Taylor appreciated the opportunity to meet with a wide variety of people on simulation issues. This summer the FMH CEO asked her about simulation and was very excited about it. Shortly after, Corlis Taylor got a letter about this meeting. She felt like she was finally on the cutting edge of something.

Dennis Viloria originally thought simulation meant you plug into a mannequin and the scenario runs. Now I’m realizing it is more than just mannequins. I like the collaboration and look forward to more training and sharing of resources. Karen Carpenter found this fascinating. She had no idea simulation training technology was so organized in some places. It will be interesting to see what happens and see if people work together and cross political barriers. Justine Muench learned a lot, met a lot of people, and hoped this moves forward with a pilot project. The Oregon model really resonated with her. John Riley said the discussion had been very amorphous and was now getting somewhere. UA has some resource and a need to develop something like a pilot project. Barbara Doty thought it was interesting when she interviewed faculty about needs at the Residency that they listed equipment. That was not what she got here. She spoke to the


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possibility of clinical simulation improving retention in rural communities. She saw a role for the AHEC. Karen Perdue found this very “simulating.” She thanked Janice Troyer, Beth Landon, and Mia Oxley. Karen Perdue noted, we went faster than we anticipated due to planning and organization of this process. The meeting was adjourned about 4:30 pm. The next and final meeting was tentatively scheduled for 9 am to 12 pm on March 5th. (It will likely be done via videoconference for those taskforce members outside of Anchorage.

Clinical Simulations in Alaska Appendix F: A Sampling of Clinical Simulation Delivery Models

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Appendix F: A Sampling of Clinical Simulation Delivery Models

Facility Contact Who are the learners?

Simulation Training Topics

Delivery Model Governance Structure

Funding Sources Notes

Oregon Simulation Alliance (OSA) Formed in 2003 Contact: Shirley Anderson Executive Director of OSA Some information from article written in Journal Simulation in Healthcare (Vol 1, Num 1, Spring 2006) and the OSA website.

Note OSA is comprised of multi-disciplinary regional coalitions so learners vary with each coalition. The journal article lists the following: 1) Nursing schools 2) Allied Health 3) Hospital systems

(nursing) 4) Hospital systems

(residents) 5) Medical schools 6) Practicing

physicians

Note: training topics used with simulation vary within each coalition OSA’s overall goal is to develop & expand simulation capacity in all regions of the state for multidisciplinary & interdisciplinary use for healthcare workforce development, including pre- and post-service, career-ladder, and re-entry/refresher programs. Some of the training OSA has provided to their partners include: • 3-day Simulation

Technician Training • Foundations for

Simulation Education

See website for descriptions.

Delivery models vary. OSA has over 20 simulation centers where groups come in to use equipment. Some sites transport simulation equipment to sites. One coalition is in the process of buying a van to travel throughout their region to deliver training. Over 40 sites have purchased their own equipment.

OSA is a collaborative statewide group, coordinated by the Governor’s Office. OSA is both an advisory group and an oversight committee. The Simulation Alliance Governing Council has representation from states’ community colleges, universities, healthcare provider orgs, and simulation users. They are a corporate non-profit. Currently they contract out to have an executive director who is about half-time.

Funding was obtained from the Oregon Workforce Investment Board, the Federal Dept. of Labor, the Oregon Dept. of Public Health, and the Northwest Health Foundation (a private granting agency). Each org was approached separately with separate proposals. Total funding for yr 2004 was $1,050,000, and considered seed money for the overall process. They are currently in the planning process for finding ways to make OSA sustainable.

The statewide simulation process included visits to communities to do assessments; simulation specialist education, faculty development, and a mechanism for allocation and distribution of funds.

Site assessments were designed to capture the state of “readiness” for simulation at different locations in Oregon.

OSA did not prescribe regional coalitions, but let “local define local.”

OSA asked OHSU to develop simulation training curriculum & program; OSA provided funding for individuals to attend training who were selected by OSA committee.

Used RFP process to distribute money for equipment and faculty development.

Advice: In journal article, the following were things they wished they had done differently: 1) they would have disbursed their funds after the site visits rather than concurrently (they had very little time to distribute funds), 2) they had held awardees more accountable for their use of the equipment while not being viewed as a governing body (no clear process established to deal with an institution not meeting general expectations), and 3) hire a permanent director for the alliance (initially council members offered services on a volunteer basis). Other words of advice from the Governing Council: a) have workforce issues define the needs, not the universities; b) develop a plan for sustainability; c) have a succession plan for leadership; and d) coalitions may be important to a community when first starting simulation, but after maturation, member organizations my no longer be part of the coalition, but remain viable and strong associates of the coalition. Website: http://www.oregonsim.org/index.php


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STARS Mobile Simulation Program Based out of Alberta, Canada Michael Lamacchia, HPS Program/Outreach Manager Started first official training in September 1999.

Healthcare providers in rural facilities.

Used to train for critical care and emergency medicine (e.g., toxicology, cardiac emergencies, traumatic brain emergencies). Also used for interdisciplinary team training. Work with facilities to determine their training needs; do about 4 simulation trainings a month.

Use 2 motorhomes equipped with a high-fidelity mannequin. Each motorhome has 2 rooms--one is a mock up ER code room and one a control room. 2 full-time technicians and 18 part-time staff work with mobile units (physicians, nurses, and paramedics); part time staff work as air ambulance crew when not providing training.

The STARS program has 2 boards: one is a foundation board which oversees all fundraising and the other is a society board that makes decisions about how the money is spent. Both boards are voluntary and composed of CEOs, CFOs, oil and gas folks, and community members. The STARS program has a president and CEO who have direct control over funds. Below them are the VP and directors. Mike directs and manages educational activities in Alberta, including the mobile program.

STARS is a non-profit, charitable organization. The STARS Foundation is the fundraising arm of the organization. Its primary purpose is to raise the funds to support and enhance patient care and transport program, educational programs, and research projects. Funds are also provided by the health regions and Alberta Health and Wellness. The majority of gifts to the Foundation come from individual contributions; each community served also contributes with fundraising events (70% of funding raised through philanthropic donations and 30% raised through government partners).

Initially did a needs assessment of physicians in rural Alberta. All complained about not being able to come in for training because they didn’t feel they could leave their communities. Originally they planned to use a suburban to transport simulation equipment to facilities for training in some of the smaller facilities, but found if they had a patient in a room, there was no place to do the training, so that is how they came up with the idea of setting up a motor home. Note: Training does not cost anything for facilities as they use foundation funds to cover training costs.

Advice: It is important to get people together to talk about ways to collaborate. Try to discourage people from going out and buying their own equipment. The “honeymoon” will be over quickly when people realize what it takes to maintain and program the equipment. Even now we still have people wanting to buy their own equipment. Website: http://www.stars.ca/bins/index.asp Go to What We do, Education & Research, Mobile Simulation Program.


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University of Arizona, Tucson ASTEC (Arizona Simulation Technology and Education Center) Contact: Alyson Knapp, Coordinator and Curriculum Development ASTEC opened in the Summer of 2005.

Mostly serve medical students and residents. EMT, paramedic, flight nurses and fire dept, and medical faculty. They work to a small degree with College of Nursing. And to small degree with Allied Health Students (rad techs, med techs, med assts, phlebotomists, pharmacy).

About half training is procedures and about half scenarios; ASTEC staff work with faculty to determine learning objectives. Teamwork training is the focus. To Practice their skills (example given a surgeon using surgical trainer to practice for a surgery the next day).

They have an acute care NP program. Each class comes to center 2X during program to run through scenarios--done in between ACLS lectures. Have had radiology students practice low frequency/high risk event such as a bad contrast reaction--run through a scenario. Other allied health students have practiced doing triage, taking histories, doing BPs and IVs, and so on. Pharmacy students do mostly team training.

800 sq ft simulation center housed in the hospital. They have 2 adult and 1 baby high-fidelity mannequins and surgical trainers and task trainers. 99% of the time students come to the center to train. Training is done either by ASTEC staff or by University faculty. All scheduling is done by Alyson.

ASTEC is part of the University of Arizona Medical School. They are part of the Dean’s initiative. ASTEC staff are overseen by the Vice Dean. The director is a tenured professor. A simulation committee is made up of faculty, engineers, and telemedicine folks. They meet every month or two to help with planning. The Center has a lot of autonomy with their budget.

Salaries & appointments are made by the Dean of the College of Medicine. An initial budget paid for the mannequins. EMS personnel pay to use the Simulation Center. Industry partners provide some funding; they are a Center of Excellence for STORTZ. They received a 3-year grant of educational/research monies. They do testing of new equipment as part of this grant.

ASTEC also uses telemedicine equipment. They have 2 flat screen plasmas in their center and terminals in the lab, control room, engineering, and various medical offices. One of the surgeons is connected to smaller hospitals in Arizona and ambulances through video. They use this equipment to provide healthcare. ASTEC is hoping to use this equipment in the future to provide education in remote sites. An example of what they have done with this technique is: Doctors in rural areas have used the telemedicine equipment to observe scenarios done in the lab at ASTEC using the baby mannequin. They observe and then participate in a debriefing.

Advice: Get as much space as you can. We struggle with our lack of space all the time. What mistakes should we not make? Don’t put your blinders on. Don’t limit your imagination on how simulation can be incorporated into teaching. There are things I’m teaching with simulation now, I never would have guessed I would be doing a year ago. Website: http://www.astec.arizona.edu/


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Work, Education, and Lifelong Learning Simulation (WELLS) Center Housed within the Colorado Center for Nursing Excellence on the Colorado Bioscience Campus. Jana Berryman, ND, CNS, RN Project Director

Nursing students, medical students, paramedic students. Continuing education for practicing nurses and physicians. High school students. Faculty of both academic and educational settings. They aspire to serve more disciplines in the future.

The WELLS Center focuses on both simulation training, faculty development, and information dissemination. The center develops specific scenarios for low occurrence/high risk scenarios as needed by their hospitals. The center provides full day workshops on how to develop simulations, how to facilitate simulations, and technical programming. In addition, they have developed a template for developing a scenario. The Center hosts a listserv and bimonthly meetings to cover a variety of simulation topics.

They have a 5000 sq. foot simulation center. They call it a hub-and-spoke model. They deliver training within their own center and travel to other sites. Besides partnering with 26 nursing schools across the state, they provide competency training for nurses in hospitals across the state. Staffing at the center includes one fulltime director, 2 simulation coordinators (master prepared RNs); 2 simulation technical coordinators, a part-time curriculum coordinator and grant writer, and 1 fulltime admin asst

The WELLS Center is a non profit currently housed within the Center of Excellence and has an Advisory/Project committee. This group is composed of statewide members from nursing education--both academic and practice, medicine, EMS, high school, and the community. There is also an executive group which oversees policies and procedures.

Currently they are primarily grant funded with a grant from the Colorado Dept. of Labor and Employment. They have a building lease in partnership with the Colorado Hospital. They received a 1.1 million dollar equipment grant. They are now beginning to look at sustainability and recently started a fee for service. As the government funds decrease over the next 5 years, they envision the fee for service will provide 30-60% of the funds with grants making up the rest. Note: The current budget is about $400,000.

Recently the WELLS Center has partnered with their local public broadcasting company to deliver high-speed data casting via satellites. This approach allows remote participation for observing and debriefing. The data casting allows large files to be sent to individual computers via satellites so users can receive images without internet connection. Live training events at the simulation center can be seen in real time. The Center is about to begin a pilot program to look at potential uses for this technology in conjunction with simulation technology. The Wells Center is also developing a library of simulation scenarios.

Advice: Jana noted that they work hard to not be seen as a competitor with their partners. “We try to be transparent in what we do and look for funding sources that will benefit our partners. Our doors are also always open to new partners.” Website: http://www.coloradonursingcenter.org/CurrentProjects/WellsCenter.html


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Facility Contact

Who are the learners?


Delivery Model Governance Structure Funding Sources Notes

University of Washington ISIS Center (Institute for Surgical and Interventional Simulation) Contact: Dr. Brian Ross, Director

Residents, medical students, nursing students, visiting physicians, community outreach with K-12 students.

Team training with multiple disciplines. Some of the areas in which ISIS provides training using simulation technology include: general surgery, obstetrics, otolaryngology, internal medicine, and anesthesiology ISIS also serves as a simulation resource library center and has developed a standard curriculum template for their faculty.

ISIS has a simulation center housed within the University Medical Center. It is an open space (less than 2000 sq ft) that can be reconfigured as needed. It includes a skills lab area and a high fidelity mannequin. ISIS partners with 19 different medical departments, nursing, dental, and to some degree bio-engineering and mechanical engineering. They also partner with Children’s Hospital and Madigan Army Medical Center.

ISIS has a Governing Board and an Executive Committee. The Executive Committee runs ISIS and develops the initiatives. Under this committee there are 3 major committees: Faculty/Experts Group, an Education/ Curriculum Committee and a Research and Development Committee.

The ISIS mission is to provide skills development, serve as a simulation resource library, and to provide leadership in the area of simulation technology, particularly in the WWAMI region. Note: Brian Ross was our guest speaker for the first taskforce meeting on Nov 27, 2007. He spoke about the use of simulation technology on the national scene, including its historical development, as well a the activities of ISIS.

Advice: It is important to do a needs assessment before buying equipment. The curriculum should drive the training needs and these needs will determine the type of simulation equipment/center you need. Do not buy the simulator and then develop the curriculum; buy the simulator based on the curriculum needs! Figure out the essential elements of the curriculum and then identify those components which can have value added to them by simulation. Simulation technology needs to be taken to where the training needs are. A “footprint” is needed in each partner facility. There needs to be a common administrative thread and standardized curriculum. During the planning stages, it is important to be as inclusive as you can. Website: http://www.isis.washington.edu/

Clinical Simulations in Alaska Appendix G: Alaska Clinical Simulation Taskforce Training Topics

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Appendix G: Alaska Clinical Simulation Taskforce Training Topics

Organization Page(s) Alaska Family Medicine Residency 3 Alaska Native Tribal Health Consortium 4-6 Bartlett Hospital 7 Bassett Army Community Hospital 8 Central Peninsula Hospital 9 Cordova Community Medical Center 10 Elmendorf AFB-3rd Medical Group 11 Fairbanks Memorial Hospital 12 Interior Region EMS Council 13 Providence Alaska Medical Center (2) 14 State of Alaska Public Health Nursing 15 TVC Paramedic Academy 16 UAA BSHS MEDEX PA Program 17 UAA School of Nursing 18 UAA Allied Health Program 19-20 UAA WWAMI Program 21 VA Primary Care Clinic and Homeless Veterans Service 22-23

Compiled by Janice Troyer of the Alaska Center for Rural Health-Alaska’s AHEC on 1/22/08.


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SIMULATION TRAINING TOPICS - An overview The categories below demonstrate the broad range of topics listed in the charts of this document with examples for each: • Emergency Airway Management and Cardiac Life Support (e.g. rapid sequence intubation, ventilator management, ACLS,

PALS, BLS)

• Disaster Management-Emergency Scenarios (away from hospital) (e.g. scenarios of multiple trauma, critical care transport, medical readiness training)

• Codes/Emergencies (in hospital) (e.g. code and crash cart training, anesthesia crisis intervention, rapid response team, ATLS procedures, emergency treatment of stroke patient, code response for respiratory or cardiac arrest, ED triage skills)

• Physical Exams (e.g. exams such as thyroid and abdomen exams showing normal and abnormal finding, lung exams with normal and pathology, diabetic foot exam)

• Technical skills (e.g. wound care, suturing, IVs, chest tubes, blood draws, injections, catheters, complex line placement, splinting lab, orthopedic skill, lumbar puncture, conscious sedation, virtual colonoscopy, joint aspiration, glycemic management, administration of high-alert medication, medication reconciliation)

• Deliveries/neonates/peds (e.g. fetal monitoring, emergency childbirth, crash C-section, neonatal resuscitation, pediatric emergencies (not PALS))

• Communication (e.g. team decision making/communication; communication with patients/family, physician; motivational interviewing; interviewing skills-family assessment; patient handoff)

• Health Promotion/Management (e.g. teaching for infectious diseases; health promotion-chronic condition)

• Types of Learners listed in charts: ETT, EMTs, Paramedic, CHAP, RN, PA, NP, MD, Resident, Medic, new staff, faculty, new grads

• Types of Training listed in charts: Basic 1st responder; skills training for EMS providers; resident training; continuing education; re-credentialing; CME; deployment training and redeployment training; skills and procedure competency screening for students, new hires, interims, locums, travelers, emergency responders; faculty development; and training new staff for specialty areas.


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ORGANIZATION _Alaska Family Medicine Residency Date __Jan 15 2007 CONTACT re this form Barbara Doty M.D. Phone 907 354-0460 e-mail [email protected]_

TRAINING/EDUCATION TOPIC

STATUS Comment Is this topic currently addressed to your organization’s satisfaction? Or do you aspire to improve the quantity or effectiveness of this training? Feel free to elaborate after indicating:

SATISFIED / NOT SATISFIED

SIMULATION POTENTIAL Comment Do you see any potential for simulation technology in addressing this topic? Feel free to elaborate.

YES / NO / UNSURE Rapid Sequence Intubation, Adult and Pediatric

Need CALS type training with hands on tips and tricks. Airway management is critical for bush Emergencies

Yes. See CALS Program info

ATLS Procedures: Chest Tube, Central Line, Cutdown, Intraosseous Arterial Line, Paracentesis Cricothyrotomy Thoracentesis Demonstrate cardiac arrythmias in mock code model

ATLS courses are q4 years, hard to access. No skill review resource is currently available in between Rare but needed skill set for all hospital and Emergency staff

Well done with SIM Man

Obstetrical malposition, Gyn Procedures including D/C, Shoulder Dystocia, Post Partum Hemmorage, IUPC/Scalp electrode, Perineal tear repairs

Emergency Childbirth by inexperienced staff are common; OB care requires a lot of “touch” training as assessment is usually manual

OB training models are available- see CALS Company in Woodstock makes

Ventilator Management including Peds and Neonate

Critical for bush settings when weathered in. Rare events Could have vent machine set-up with ability to modulate settings, etc

Virtual Colonoscopy, Flex Sig, EGD Colon CA is the #1 cancer in Alaska and access to trained professionals who can do diagnostic tests is limited

Many virtual colonoscopy tools available Good one at ANMC but not enough access to others needing training

Conscious Sedation Specific training required for hospital credentials. No sim system currently available

Could do with Sim Man

Neonatal resuscitation including Airway placement, Umbilical Catheter, IV start

Available in many hospitals already Many models available

Suturing including tendon and complicated laceration repair

Not formally available. Usually use pig feet models Models available

Joint Injection, Fracture Reduction closed or partly open

Not currently available Models available for joint injection

Lumbar Puncture for adults and kids Not in Alaska Many models available coupled with podcast ipod training video clips


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ORGANIZATION _______Alaska Native Tribal Health Consortium ____ Date __1/15/08______ CONTACT re this form __Thomas D. East, Ph.D._______________ Phone __729-1986 e-mail [email protected]_





YES / NO / UNSURE

Skills and procedure competency screening for students, new hire, interims, locums, travelers, emergency responders

Using simulators would not subject patients to clinical staff who do not know the basic skill or procedure. Pre-screening would reduce negative patient experience.

Yes

Re-accreditation and CEU: Simulators are useful in training key courses such as PALS and ACLS where our clinical staff require certification

Not Satisfied Yes potential with existing simulators

Experience acceleration… training on high risk, low incidence situations

Not Satisfied, limited or no experience in handling unusual cases for clinical staff who have been recently educated, or who are moving into different skill areas

Yes- a simulator could be used to accelerate experience defibrillator, management of cardiac arrest, trauma, patients showing signs of decline ("crumping") and in need of a Rapid Response Team (breathing, heart rate, pulse, etc)

Models that allow for physical exam skills to be demonstrated and practiced with normal and abnormal findings. That may not exist yet, as it is so basic.

Not satisfied… particularly for remote CHAP training Yes- Physical Simulation Model

Models for IV/blood draw that are more realistic than the arms we have now. But we have been using simulated arms for years.


Models for IM/SQ injection: we have static models for now; they practice on classmates before real people; still works


Emergency scenarios of multiple trauma: this is in great need. However the level of intervention is not ACLS: no meds


Treatment skills models: eye and ear drops, eye exams & treatments, nasal packing, aseptic ointment on burn dressings


Orthopedic injuries for assessment & splints Not satisfied… particularly for remote CHAP training Yes- Physical Simulation Model

Suturing, other wound care Not satisfied… particularly for remote CHAP training Yes- Physical Simulation Model


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Oxygen administration: only with use of BVM, cannula, and nebulizer. No intubation


Emergency childbirth Not satisfied… particularly for remote CHAP training Yes- Physical Simulation Model

Visual pt that can go through steps in treatment.

Not satisfied… particularly for remote CHAP training Yes- Virtual Simulation Model

Small portable disposable simulation kits would be great for wound care practice, perhaps other exam skills like thyroid exam, abdomen exam, maybe others I cannot think of right now.


Models with abnormal general appearance and simulated physical findings,


Simulated history paths and exam paths, outcomes of any treatments. Esp. for very sick adults and kids.


Be great if there was an online visual simulation of how the CHAP manual is supposed to be used.


Disaster management training Desktop training and disaster drills are OK but take a fair amount of resources… would be nice if a virtual world could be used to run the entire disaster sim using avatars for key players

Yes- Virtual Simulation Model

Equipment failure simulation with biomed intervention

Not satisfied… some equipment failures are in the middle of essential medical procedures and require biomedical technician intervention

Yes


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Additional Comments: (Feel free to attach) The distance ed students are so wide spread that it is impractical to have bulky and expensive simulation models in all possible remote locations. From the looks of these models and associated equipment, they are not very portable on small planes! Upkeep and updating would be a definite issue, regardless of where it is used. This would be one of our biggest concerns: day to day care and feeding of simulation equipment to keep it healthy and ready to work! This would be investment in big ticket items that need a workforce dedicated and training it is assembly, use, storage, and maintenance. There would have to be a recurring budget for just those things. And we would need a clear jurisdictional path to iron out where these things would be housed & maintained. Comments from Herb Sivitz, Alaska Clinical Engineering Services (ACES) Director: I would like an opportunity to provide a proposal for ACES services for equipment planning, room and facility design, implementation, and on-going medical equipment management and support. In the Task Force SOW outline #5 under The final report will summarize findings from the assessments and answer the following: What is the recommended Management and Maintenance Structure (sustainability)? I believe this focuses how to have it pay for itself, but all of the medical equipment needs to be maintained. I would include the actual simulator as well, but would expect training on any potential simulator system. I have both the Biomed techs and Medical Network Administrators that can cover the entire system and the entire facility. If required, I could generate a support service proposal for the final report. It would help if there was some kind of typical equipment list for simulation rooms, but we could generate something close for budgeting purposes. Let me know if I can assist somehow in the final report, even if it is to review an existing proposal for maintenance. From the Task Force minutes; “Karen [Perdue] also described some of the parallel processes that are revolving around the topic of simulation. UA is in the mode of expanding its health education programs. We are making investments in equipment, in buildings (including a $46M Health Science Bldg), etc. One question that has arisen is whether we should have a Simulation Center in the new health building. “ I have not approached UAA about medical equipment support if there is any, but this would be a good opportunity to provide a proposal as mentioned before to provide planning, implementation, and support services. I am sure they have Biological Safety Cabinets and hoods for chemistry class.


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ORGANIZATION _______Bartlett Hospital ____ Date __1/15/08______ CONTACT re this form __Justine Muench, Staff Development Coordinator Phone __796-8912 e-mail [email protected]_

Training/Education Topic Status Comment Simulation Potential Satisfied/Not Satisfied

ACLS satisfied; could be better with more advanced simulation but adequate Yes; Sim Man

Fetal Monitoring not satisfied yes Difficult Birth not satisfied yes Pediatric emergencies (not PALS) not satisfied yes ED Triage Skills not satisfied yes Emergency treatment of stroke patient not satisfied yes

Coordinated and Timely DC or Transfer not satisfied unsure; the hands-off communication piece could have simulation potential

Transcutaneous Pacer Insertion not satisfied yes Pulmonary Artery Catheter Insertion and care not satisfied yes


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ORGANIZATION ______Bassett Army Community Hospital Date __15 January 2008_____________ CONTACT re this form ____LTC Lisa A. Ingulli___ Phone : 907-978-6836 e-mail [email protected] or [email protected]


STATUS Comment Is this topic currently addressed to your organization’s satisfaction? Or do you aspire to improve the quantity or effectiveness of this training? Feel free to elaborate after indicating: SATISFIED / NOT SATISFIED


YES / NO / UNSURE

ACLS Yes, but would like to improve it Yes, using a sim man for a mega code training PALS Yes, but would like to improve it Yes, using a more advanced sim baby TNCC/ENPC This is not taught at BACH, would like to have an

instructor that would do more hands on skills not just talk through it.

Yes, use sim man for training instead of just stating what people would do

Medic Training Yes, but would like to enhance it with a mini sim lab Yes, there is a MSTC (Sim Lab is a separated building on post that is not part of the hospital) on post for medic training, but if there was something that the hospital could do at our level then we would not have to compete with others on post to use the lab and we could make scenarios that are for the field medic as well as for CSHs (military tent hospital)

Deployment Training No, trying to make a mini sim lab here at BACH geared for docs and nurses as well as medics for combat skills.

Yes, would like to see a lab where nurses and docs could practice skills that they would use in combat that they normally do not do in their normal jobs such as work with vents, art line, mascal injuries such as amputations, massive head injuries, etc. General skills that nurses and docs normally do not get here in Alaska are loading and unloading a stretcher, putting a person on a backboard, KED, putting in and trouble shooting chest tubes, giving massive infusions of blood using an infuser, using PSAG trousers, starting largebore IVs, using nasopharyngeal and oral pharyngeal airways, practice using critical thinking skills for actions that are taken to look for a reaction and what to do during the reaction. Medics could learn not just hands on skills but what is needed to be documented especially in a deployed ER

Redeployment Training No, trying to make a mini lab here at BACH geared for docs and nurses as well as medics

Yes, would like to see sim equip for docs and nurses to train on skills that they may not have used in combat. Such as doc’s when they come back from deployment they could train on using a scope sim equip to remove a gallbladder or a nurse could practice ob deliveries and using an EFM monitor or a ER nurse practice peds skills such as the Braslow Bag/cart/tape, inserting peds IVs and oral airways.

Code and crash cart training Yes, but would like to improve it. Use a sim man for mega code training and Cardioversion training NRP, EFM Yes, but would like to improve it Yes, would like to get a NOEL, a birthing dummy since OB is a big part of

BACH.


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ORGANIZATION __________Central Peninsula Hospital___________ Date _12/21/07______________ CONTACT re this form _____Lynn Senette______ Phone __ 262-0333 ____ _ e-mail [email protected]__





YES / NO / UNSURE

National Patient Safety Goals We address this in our education process. However, audits indicate that ongoing education is necessary.

Unsure.

ACLS/BLS/TNCC etc. This is part of educational offering. Yes. Annual safety update Our process is currently cumbersome and needs some streamlining. Unsure.

Clinical skills training We provide training on selected topics for new skills, high risk/low volume skills etc.

Yes.

Infection control Need additional education. Yes. Credentialing Yes, but would need to know more about logistics

and cost Demonstrating proficiency Have recently used a SIM man for demonstrating competency in intubations Yes, but same as above

CMEs Yes, but same as above


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ORGANIZATION ______Cordova Community Medical Center__ Date _1/9/08______ CONTACT re this form ___Gretchen Zolldan, RN/DON_______ Phone __907-424-8246 e-mail [email protected]___





YES / NO / UNSURE

PALS Satisfied-bring trainer from Anchorage every year to train nursing staff unsure

ACLS Satisfied-bring trainer from Anchorage every hear to train nursing staff unsure

TNCC Not Satisfied-I need to find funding/grant for the facility to be able to afford the class for nursing staff

unsure

Wound Care Not Satisfied-I need to find funding/grant for the facility to be able to afford several nurses to attend

Yes/unsure

BLS Not Satisfied-I need to find staff member to volunteer to become a certified instructor

Unsure

Corporate Compliance Not Satisfied-our previous trainer left the facility some time ago and the program has “floundered” since then

yes

Additional Comments: (Feel free to attach) I have focused more on nursing/health care staff for the education/training topics. I know there is some work going on with ASHPIN to assist facilities in obtaining video conferencing capabilities. Not sure where Cordova is on that list.


83

ORGANIZATION : 3rd Medical Group Elmendorf AFB Date: 14 Jan 2008 CONTACT re this form: Major Marlene Kerchenski Phone: 907-580-5548 e-mail: [email protected]



SIMULATION POTENTIAL Comment Do you see any potential for simulation technology in addressing this topic? Feel free to elaborate. YES / NO / UNSURE

Medical Readiness Training Not optimal. As relevant as this subject is to the GWOT, it would benefit military and civilian communities to provide simulated technology to merge thoughts, products and training to ensure training is coherent and meets standard of care; Goal: training is consistent for providers which leads to optimal delivery of care for patients. “Hands on” or simulated technology is always the best teachers and motivates its learners to participate by thinking critically.

I hope that this is something that could become a reality for our facility.

TeamSTEPPS (to teach junior staff to effectively communicate to senior staff without fear)

The topic is presented to departments upon request or suggestion by the Pt. Safety Manager if the department is having communication issues that have been voiced. It helps just in time, but once there is staff turnover, which occurs frequently, the teams have to regroup and new members haven't had the benefit of the training. Simulation would help to get everyone comfortable with the tools and techniques from TeamSTEPPS and encourage staff to watch each other's back.

Simulation technology would be a great addition to the TeamSTEPPS program. It is currently being used at Travis AFB hospital to continually promote the skills that are learned in the 4-hour course. It would provide real-life scenarios in which the participants would benefit from.

ACLS Satisfied. Could improve team effectiveness Yes PALS Satisfied. Could improve team effectiveness Yes TNCC Satisfied. Could improve team effectiveness Yes Rapid Sequence Intubation Not Yes Ventilators Not Yes Emergency Blood Admin Not Yes Precipitous Delivery Not Yes Crash C-section Not Yes Rapid Response Teams Not Yes Training related to meeting Joint Commission standards and readiness medical skills for each function. (IV starts, catheter, triage, etc.)

Yes, they are being addressed currently. Readiness medical skills training could be improved.

Ways to use simulation technology for code blue drills, triage and nursing/tech skills. Could even be used for military exercises with the EMEDS to train in casualty care.

Facial trauma/jaw fracture (from dental point of view)

NO Unaware of this type of simulator exists but this is a definite war type wound as well as MVA.

Pediatric ventilator management NO Could be a possibility with the hi fidelity pediatric mannequins.

Additional Comments: In our ER setting the greatest anticipated benefit would be enhanced/improved team dynamics and effectiveness. This could be accomplished in a simulation lab or in situ.


84

ORGANIZATION ____Fairbanks Memorial Hospital______________________ Date __1/15/2008_____________ CONTACT re this form ___Corlis Taylor_________ Phone __ 458-5580 ___ e-mail [email protected]





YES / NO / UNSURE

Core Skills for New Grad RN We currently offer a core skills set of 6 classes for New Grad RN’s on topics such as IV Therapy, crash cart/mock code, chest tubes, physical assessment and lab values

Yes, simulation would help tremendously and would be a better assessment of competency

Chest Tubes We currently offer during a skills fair to staff on the surgical unit – Yes, I think a simulation lab would be an improvement on the watermelon that we currently use

Cardiac catheters Not satisfied – we just opened a cardiac cath lab Yes, simulation offers a tremendous opportunity for continuing education and training in this area

Training new staff for specialty areas such as Emergency Department or ICU

Not satisfied Computer simulation for specific areas such as ICU or the ED would help tremendously in assessing skills on an ongoing basis for competency and also staff wanting to learn new skills to work in another area


85

ORGANIZATION ___Interior Region EMS Council ____ Date __1-15-08_______ CONTACT re this form __Dan Johnson__ Phone __907 456 3978 _ e-mail [email protected]___





YES / NO / UNSURE

Basic (initial) training in “First Responder” (AKA ETT), or EMT in rural areas

Not satisfied. We are able to do this training, but it currently requires face to face, traditional training and is expensive and logistically difficult to deliver this to rural locations.

Better computer-based and other distance methodologies for delivering knowledge content. Better simulation technologies for delivering skills training.

Continuing education in skills for first responders and EMTs (all levels) in rural areas

Not satisfied. This is getting done, generally using local resources. But, the availability of actual patient experience or realistic skills training can be scant. It is generally not practical to send out experienced instructors for this.

Better simulation technologies for delivering continuing education in skills, especially from a distance.

Continuing education in knowledge/content (as opposed to skills)

Satisfied. Materials are available and easy to access. Better computer-based and other distance methodologies for delivering knowledge content, especially from a distance.

Initial Training in advanced EMT (EMT 2 and 3)


Better computer-based and other distance methodologies for delivering content. Better simulation technologies for delivering skills training.

Continuing education in advanced emergency procedures/skills for rural RN, PA, NP, MD


Better computer-based and other distance methodologies for delivering knowledge content, especially from a distance.

Skills training for urban-based pre-clinical EMS providers of all levels

Not satisfied - It is difficult to find clinical time in Fairbanks. Lack of clinical training resources could possibly be mitigated through the use of better “whole patient” simulators (as opposed to specific skills simulators).

Advanced EMS skills training for urban RN, PA, NP, MD

Not satisfied – it is often difficult to find the human (patient) and other resources (e.g. “dog labs”, etc.) necessary to conduct this training.

Better simulation technologies for delivering continuing education in skills to supplement available instructor and clinical/patient resources.

Hands on experience for urban and rural pre-clinical EMS providers.

Not Satisfied - Many, if not most rural and urban pre-hospital EMS providers get very little experience in caring for true emergency patients.

The reality is that rural and semi-rural (urban outskirts) EMS services do not have a lot of patient volume. The availability of better “whole patient” simulators could improve realistic skills training as a substitute for real experience.


86

ORGANIZATION: Providence Alaska Medical Center DATE: December 17, 2007 CONTACT re this form: Dr. Roy Davis, Chief Medical Officer PHONE: 261-6020 EMAIL: [email protected]

TRAINING/EDUCTION TOPIC

STATUS SIMULATION POTENTIAL

Code Blue Response Training addressed by ALS & ATLS – not hands on Yes – Team Training Physician Re-credentialing CME and case load – very subjective Yes – Hands on Training On-going Peer Performance Primarily addressed by case load outcomes Yes – Specific Assessment Team Communication Poorly addressed Yes – Hand-off Simulation Rapid Response Team On-going education – communication skills Yes – Reproduce Case Presentations Patient Safety Variable attempts at addressing Yes – SBAR Training Resident Training Residency Program Yes – Supplementary Anesthesia Crisis Intervention CME and on-going training Yes – Case Specific


87

ORGANIZATION Providence Alaska Medical Center Date 1/8/08 CONTACT re this form Carrie Doyle Phone (907) 261-6005 e-mail [email protected]



SIMULATION POTENTIAL Comment Do you see any potential for simulation technology in addressing this topic? Feel free to elaborate. YES / NO / UNSURE

Code Response – Finding and running a patient who is having some form of respiratory or cardiac arrest.

No, this topic is not currently addressed to our organization’s satisfaction. There are many methods of running a code smoothly and systematically but none are practiced well. Also, many staff members have not had to deal with a code unexpectedly and then when they are faced with a code they tend towards “panic.”

Yes

Total Care of Patient I do not believe this concept has been addressed by our organization. I have seen this concept done in other SIM labs. Basically the student is given a patient to include all orders, etc. They must then take off orders, complete care of patient, etc

Yes

Care of the cardiac patient No Yes – This topic could include gathering an accurate history of all pertinent questions, doing a focused exam of the cardiac system and then prioritizing care according to problem.

Care of respiratory patient No Yes – This topic could include gathering an accurate history of all pertinent questions, doing a focused exam of the respiratory system and then prioritizing care according to problem.

Splinting lab Not Satisfied – This has been done to a certain extent but with nothing formalized. This would benefit techs, nurses, and residents.

Unsure


88

ORGANIZATION ______State of Alaska Section of Public Health Nursing ____ Date ___January 8___ CONTACT re this form __Jerry Troshynski______ Phone __ 334-2399_ e-mail [email protected]______





YES / NO / UNSURE

CPR Certification/Recertification

Required training for all of our PHNs. Often we depend on community partners (usually local EMS) for training and sim models. Not satisfied with current efforts, statewide, to maintain 100% current certification.

If the sim technology is portable and available to communities and partners, it could be useful to us.

Administering PPD skin tests Currently new PHNs to our system either are already assumed to have this skill, or practice on other staff or clients. We do require this skill to be checked off in the orientation process, but have no real way to “practice” other than the live “victim.” So, not satisfied with the current method

If the sim model is portable and available, it would be useful.

Administering IM and SQ immunizations

Again, currently, new PHNs or community partners (EMTs) who need to be training as part of orientation, or as part of a mass vaccination exercise train and practice on each other. Not satisfied with current method.

If sim model is portable and available, would be useful.

Venipuncture PHNs are not required, often, to perform venipuncture. However, there are times when venipuncture is required. Currently the only training/refresher options we have are to practice on each other. So, not satisfied.

If sim model is, again, portable and available, would be useful.

Naso-pharyngal smears Obtaining this type of culture, applied through the nasal passages to the very back of the throat, is required to test for pertussis (whooping cough) and other communicable diseases. Though we rarely need to do these, we need to have the ability to do. Right now we have no training program for this.

Portable and available


89

ORGANIZATION __TVC Paramedic Academy________________________ ____ Date 1/13/2008 ___________ CONTACT re this form _Chuck Kuhns ___________________ Phone _455-2895 ____ _ e-mail [email protected]______





YES / NO / UNSURE

Critical Care Transport Course Not satisfied – the course is in the planning stages to train paramedics and nurses

Yes – if there was the ability to rent trauma manikins for simulation during the course from within the state

Continuing Education classes Not satisfied – conflict between local courses using the simulation manikins and taking simulation manikins to the villages by plane

Yes – if there was the ability to rent simulation manikins from within the state

Paramedic Training Satisfied – the program relies on simulation manikins throughout the course to create realistic scenarios for the students.

No


90

ORGANIZATION __UAA BSHS MEDEX PA Program________________________ Date 1/15/08 CONTACT re this form _____John Riley___________________________ Phone __ 786-6570 ____ e-mail AFJOR________________





YES / NO / UNSURE

Technical skills (see below) NOT SATISFIED, aspire to improve the quantity YES ,need new clinical space and equipment for this

Basic Clinical Skills Exams: Ear, eye, cardiac, lung, GU, GYN, with NL and PATH

SATISFIED, aspire to improve the quantity YES, need new clinical space and equipment for this

Recorded exam room activities: H&P, OSCS

SATISFIED, aspire to improve the quantity YES, need new clinical space and equipment for this

Emergency airway management and intubation

NOT SATISFIED, aspire to improve the quantity YES, can be difficult to get this experience with patients

Joint aspiration


Complex line placement


Skin excision and punch biopsy NOT SATISFIED, aspire to improve the quantity YES, can be difficult to get this experience with patients Team decision making NOT SATISFIED, aspire to improve the quantity YES, with interdisciplinary simulation Error prevention NOT SATISFIED, aspire to improve the quantity YES

Standardized patients SATISFIED, aspire to improve the quantity Need new clinical space for this

Technical skills:

Phlebotomy IV placement CBC interpretation Urinalysis interpretation EKG reading Rhythm strip reading Traumatic eye exam

Slit lamp exam Suturing Knot tying Surgery gown and glove Would irrigation, debridement Incision and draining


91

ORGANIZATION ___UAA School of Nursing__________ ____ Date _______________ CONTACT re this form ___Maureen O’Malley______________ Phone __ 786-4584 _ e-mail: [email protected]


We address many topics in undergraduate nursing education. The topics below are those we feel could be improved upon.



SIMULATION POTENTIAL Comment

Do you see any potential for simulation technology in addressing this topic? Feel free to elaborate.

YES / NO / UNSURE Glycemic Management We already cover all of these items. We feel

simulation would enhance all. I indicate two items as high that come from our graduate surveys.

Yes – could include skills with glucometer, IV management.

Communication (with patients, families, physicians) High Yes Administration of High-Alert Medications Yes Teaching – Health Promotion Unsure Patient Hand-off /SBAR Unsure Medication Reconciliation Unsure Psychomotor skills, IVs, tube feedings, chest tubes Yes Skills – pediatric and newborn Yes Interviewing skills – family assessment Unsure Organization and prioritization, managing a group of patients Yes Airway management, tracheostomy Yes Faculty Development Yes Central Line Management and medication administration Yes Wound Care & sterile technique Yes Management/Teaching for Infectious Diseases – TB Unsure Maternal Child Health-New mom with baby Yes Health Promotion-Chronic Condition, Arthritis, DM, community resources Unsure Venipuncture Yes High Intensity Situations-Code, hemorrhage, emergency surgery, etc. High


92

ORGANIZATION ____________UAA Allied Health Sciences__ ____ Date ____January, 2008_________ CONTACT re this form ___Sally Mead___________________ Phone __786-6930___ _ e-mail [email protected]__ TRAINING/EDUCATION

TOPIC STATUS Comment

Is this topic currently addressed to your organization’s satisfaction? Or do you aspire to improve the quantity or effectiveness of this training? Feel free to elaborate after indicating:



YES / NO / UNSURE

1. Enhance Existing Simulations in AHS programs

Not Satisfied: Programs like Rad Tech use a small room with x-ray equipment for students to practice using each other. Need trained “actors” for the doctor role or real patient who knows the experience for feedback in session debriefing.

-Need new facility/simulation space for UAA -Need LIS software to increase simulation’s relevance to real practice -Rad tech 2nd year students need Trauma Room simulation

2. Demonstrate interdisciplinary simulations

Not Satisfied: All AHS programs/students need to work with other health care providers as a replication of real time practice. It is not really occurring at this time.

-Create case-based scripts across AHS, nursing, physician training. This would be labor intensive and have fiscal implications. - Ideal to have Health Information system software in place, LIS, RIS, PhIS and all HIPAA compliant -Develop assessment process to benefit patient, student and faculty. Did it simulate the real environment? -Interface the telehealth network with this type of interdisciplinary for consult/simulation for our rural students -Could use pneumatic tube system for transporting x-rays, specimens, paperwork between “practices” within the training facility to better simulate the practice setting.


93

ORGANIZATION _UAA_CTC , Allied Health Division, Medical Laboratory Technology Department_ Date: 1-19-08 CONTACT re this form Heidi Mannion Phone 786-6924 e-mail [email protected]





YES / NO / UNSURE

Multitasking NOT SATISFIED Due to the current design of our student lab and the need for oversight during clinical practicums, students have little opportunity to multitask which is an important skill for clinical laboratory professionals.

YES Creating a core lab within the student lab would provide opportunities for the students to multitask allowing them to use several analyzers and perform multiple tests during simulations.

Health care team interactions

NOT SATISFIED Students do not have an opportunity to interact with other health care professionals until they go to clinical practicum. During practicum their interactions are limited. Graduates have said that they felt unprepared for their interactions with the rest of the health care team.

YES Creating simulations where medical, nursing, radiology and clinical laboratory students interact would provide students an opportunity to learn the best approach for handling difficult situations.

Shift change NOT SATISFIED We provide several opportunities for students to learn the importance of documentation and communication in microbiology and transfusion medicine to allow a smooth transition and maintain quality of care. Providing the same opportunity in a core lab and among other health care professionals would enhance student learning.

YES Creating a core lab within the student lab would provide additional opportunities to simulate the need for documentation and communication within the lab and with other health care professionals

Medical Informatics NOT SATISFIED We have the software for a physician office laboratory information system which has limited capabilities. Use of the laboratory information systems during clinical training varies depending on hospital policy.

YES Having a laboratory/hospital information system with electronic medical records and simulating how each health care professional uses the system would provide students in all programs equivalent training in medical informatics.


94

ORGANIZATION Alaska WWAMI Biomedical Program at UAA Date 6 December 2007 CONTACT re this form Dennis Valenzeno Phone (907) 786-4789 e-mail [email protected]





YES / NO / UNSURE

Integrative Case Conferences Under development Yes

Physical exam Addressed well, but briefly Yes

Team training Not adequate Yes

Horizontal class integration (bring together 1st yr, 3rd yr, etc.)

Addressed, but needs improvement Yes

Techniques training Addressed as enrichment Yes

Anatomy Currently addressed with simulators called cadavers! Yes


95

ORGANIZATION: Alaska VA Healthcare System: Primary Care Clinic Date 15 Jan 08 CONTACT re this form DViloria





YES / NO / UNSURE

Electrocardiogram, 12 leads Satisfied although there are areas needing improvement

Yes. Would show exact lead locations for best diagnostic result. Trouble shooting, show readings of inaccurate placement of leads, patient movements, etc

Diabetic Foot Exam Varied techniques Yes. Standardize technique, correct areas to check, what deformities, symptoms, signs, etc. to note. Programmable patient reactions, foot conditions, nails, etc

Checking in patients on initial appointment

Satisfied although not enough time to accomplish all clinical reminders

Yes. Obtaining vital signs, standardize script in obtaining patient data. Programmable patient personalities and characteristics such as PTSD, drug seekers, complex health conditions, etc.

Use of Peak Flow Meter Yes. How to instruct patient on proper procedure. Effects of pulmonary conditions on the measurement.

Room Set Up and preparation of patient for Women’s Health Clinic

Not Satisfied. Many nursing staffs are unfamiliar with the clinic and apprehensive when assigned due to infrequent exposure.

Yes. Standardize Lay out of room, required supplies and equipment, patient preparation, questions to ask patient, positioning, assisting provider, etc

Medication Reconciliation The same medication with different names, patients don’t know their medications

Yes. Explain procedure to patient, identification of medications, colors and shape, effects, contraindications, interaction with other meds and foods

Home Oxygen Evaluation Need improvement Yes. Proper technique, different phases, de-saturation, titrating flow of O2 when at rest and ambulation. When to stop the evaluation.

Peripherally Inserted Central Catheter (PICC Line) Management

Rare occurrence, hard to maintain proficiency Yes. Dressing change, flushing, obtain blood sample. Different types, Different technique: Groshong, Hickmann, Port-a-Cath.

Nursing Alert /code Satisfied Yes. How to respond, what supplies and equipment bring, assessing patient, different scenarios such as chest pain, dyspnea, medication reaction, syncope, vaso-vagal

BLS and ACLS ACLS not offered to non-OR nursing staff. Yes. Cardiac rhythm identification, Mega Code, algorhythm for various cardiac conditions

How to respond to Fire Satisfied Yes. RACE, different types of fire Operation of Fire Extinguishers

No Training Yes. Different extinguishers for different type of fire. PASS

Parenteral injection On the job training Yes. Proper techniques in doing intramuscular, Subcutaneous, intradermal injections, to include administration of Goserelin (Zoladex)

Physical Assessment (Providers)

Yes. Systemic Assessment of patient on Circulatory, pulmonary, neurological, muscular, skeletal, and all the other systems. Programmable signs and symptoms, and varying severity of ailments, and complications.


96

ORGANIZATION _Homeless Veterans Service, Alaska VA Healthcare System and Regional Office ____ Date __Jan. 15, 2008 CONTACT re this form _James M. Fitterling, Ph.D.___ Phone __273-4078 ____ _ e-mail [email protected]_




YES / NO / UNSURE

Motivational Interviewing Not satisfied. Client ambivalence is a ubiquitous and foundational problem/issue in every area of healthcare. Motivational interviewing is an evidence-based practice that effectively addresses this. There are a lot of training consultants and programs that claim to be "motivational interviewing" that aren't. Training should be provided by a certified MI trainer (http://www.motivationalinterview.org/). This training needs to be in-depth that focuses on developing criterion level of knowledge and skills; simply warming a seat in a workshop will not develop this.

Yes. Even though the primary focus of simulation technology is in primary medical care, sim tech can also have potential applications in behavioral health. Video presentation of a trained clinician posing as a client following a scripted clinical presentation with alternate scripted responses based on the trainee's interactions could serve as a training tool for clinicians to develop this clinical skill. A video of motivational Interviewing developer, William R. Miller, Ph.D. can be found at: http://psychotherapy.net/video/miller_motivational_interviewing?gclid=CLTEzsHr-JACFQUgkgodrBVx3w

(NOTE: Since the focus is on primary medical applications and not behavioral health, I restrict my suggestions to motivational interviewing which has broad applications in health care.)

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