simulation and the family medicine physician: current and future applications for technical skills...
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Simulation and the Family Medicine Physician: Current and future applications for technical skills training Annual International Family Practice Congress
November 5, 2015
Deborah Rooney PhD
MEDICAL SCHOOL UNIVERSITY OF MICHIGAN
Copyright 2015. All Rights Reserved.
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Disclosures and conflicts of interest
• None (yok)
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My Background
• Medical education since 1991
• Nine years in surgical education
• PhD in Educational Psychology
• Director of Education and Research, Clinical Simulation Center, University of Michigan (UMCSC)
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UM Clinical Simulation Center (UMCSC)
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2315 2314 2305
UMCSC Spaces
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UMCSC Utilization
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Today’s talk: Simulation-based education
o Brief history of developments that influenced simulation
Simülasyonu etkileyen gelişmelerin kısa bir tarihçesi
o Examples of simulation-based training for technical skills targeted toward Family Medicine
Teknik beceriler için gerekli olan güncel simülasyon bazlı eğitim
o Projected trends in simulation-based training for the family medicine physician
Simülasyon temelli eğitimde öngörülen akımlar
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Simulation-based education is not new
Sushruta, 2600 years ago Used specific simulation models for procedural simulation;
• Gourds, fruit, clay pots, leather pouch full of “slime,” mud, or water, bamboo, wax on wood
• Included full size patient simulator for splinting and ligature • Suture training on the stem of a lotus lily, or cloth
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Simulation-based education is not new
Simulasyon bazlı eğitim yeni değil
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n = 2
n = 690
History of Simulation-based Education
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1973 Dr. Gordon introduces “Harvey”
History of Simulation-based Education
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1970s Standardized Pts
History of Simulation-based Education 1973 “Harvey”
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1980-90s Computers
History of Simulation-based Education 1973 “Harvey”
1970s Std Pts
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1990s Virtual Reality
History of Simulation-based Education 1973 “Harvey”
1970s Std Pts
1980s Computers
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1973 “Harvey”
1970s Std Pts
History of Simulation-based Education
1980s Computers
1990s VR
1998 Standards
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2000 Error
1973 “Harvey”
1970s Std Pts
History of Simulation-based Education
1980s Computers
1990s VR
1998 Standards
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Development & refinement of best practices • Invention and proof of concept of specific
simulators, skills curricula
• Development of practical tools to support learning and assessment in complex settings
• Application of educational theories
History of SBE* for technical skills: 2000 to present
*SBE= Simulation-based Education
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Educational Theory and Technical Skills: Bloom
Bloom, based on Dave, R. (1967). Psychomotor domain. Berlin: International Conference of Educational Testing.
Higher order psychomotor skills
Lower order psychomotor skills
Watch instructor and repeat (copy)
Complete task with verbal instruction
Combine learned skills to meet novel requirements
Apply automatic strategies
Perform with expertise without assistance
Naturalization
Articulation
Precision
Manipulation
Imitation
GOAL
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Freq
uenc
y
Urgency (risk)
urgency frequency
urgency frequency
(CVC, critical care)
Current Trends: technical skills training
( PE, IV)
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Address Gap
Impact Pt Care
Value ?
Current Trends: technical skills training
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• M2 (second year medical students), n=12
• Technical skills training prior to clinical experience; ü Central line (CVC) placements ü Thoracentesis ü Lumbar puncture
Kelley S, et al. Impacts of Electives in Family Medicine on Preclinical Medical Students. Society of Teachers of Family Medicine 2015 Conference on Medical Student Education.
Addressing gaps: SBE preclinical training
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Training • 3 x 2-hour sessions
• Lecture followed by hands-on practice
• 2-3 preceptors acted as coaches Assessment
• Before, after, and 6-month follow-up • Knowledge
• Attitudes related to Family Medicine
• Skills test after course and 6-month follow-up Kelley S, et al. Impacts of Electives in Family Medicine on Preclinical Medical Students. Society of Teachers of Family Medicine 2015 Conference on Medical Student Education.
Addressing gaps: SBE preclinical training
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Knowledge Test • 9 item • MCQ
Topics • Contra/inidicatations • Anatomy
Preclinical training: assessment
Kelley S, et al. Impacts of Electives in Family Medicine on Preclinical Medical Students. Society of Teachers of Family Medicine 2015 Conference on Medical Student Education.
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SBE preclinical training: improves knowledge
Knowledge Knowledge Mean Difference
P (two-tailed)
Pre-course Post-course 1.18 0.007
Pre-course Follow-up 1.17 0.012 Post-
course Follow-up 0.18 0.34 Kelley S, et al. Impacts of Electives in Family Medicine on Preclinical Medical Students. Society of Teachers of Family Medicine 2015 Conference on Medical Student Education.
Change in knowledge test scores
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Skills Test • Time • Needle redirects (pokes) • Ordered steps
Preclinical training: assessment
Kelley S, et al. Impacts of Electives in Family Medicine on Preclinical Medical Students. Society of Teachers of Family Medicine 2015 Conference on Medical Student Education.
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Steps = Insert spinal needle with stylet in place -> Check opening pressure -> Obtain spinal fluid in tube -> Replace stylet -> Remove needle
Example Skills Test: Lumbar puncture
SBE preclinical training: skills assessment
Kelley S, et al. Impacts of Electives in Family Medicine on Preclinical Medical Students. Society of Teachers of Family Medicine 2015 Conference on Medical Student Education.
1 2 3 4 5
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SBE preclinical training: improves skills
Kelley S, et al. Impacts of Electives in Family Medicine on Preclinical Medical Students. Society of Teachers of Family Medicine 2015 Conference on Medical Student Education.
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Performing the skills-based and hands-on procedures as part of the course improved my; knowledge Mean 8.29 (SD 1.32)
confidence Mean 8.09 (SD 1.58)
skill Mean 8.23 (SD 1.50)
(1=strongly disagree, 10=strongly agree)
SBE Preclinical training: improves attitudes
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The course improved my perception of family medicine ü Post mean 7.23 (SD 1.48) ü Follow-up mean 7.37 (SD 1.66) ü p=0.62
The course has led me to reconsider (or has reinforced my interest in) family medicine as possible career option
ü Post mean 5.54 (SD 1.66) ü Follow-up mean 5.94 (SD 1.96) ü p=0.22
(1=strongly disagree, 10=strongly agree)
SBE Preclinical training: improves attitudes
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Simulation to attract students to family medicine
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What about impact to patient care?
Ya hastaya etkisi?
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∅
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Improves patient outcomes: Central Venous Catheter (CVC) placement in MICU
Sim-based, mastery training central line placement skills in Medical ICU (MICU);
• Presentation with contra/indications for CVC • Video demonstration of CVC IJ placement • One-on-one instructor & trainee practice with
feedback • Pre-post training assessment
Barsuk JH, McGaghie WC, Cohen ER, O'Leary KJ, Wayne DB. Simulation based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. Crit Care Med. 2009 Oct;37(10):2697-701.
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SBE improves patient outcomes: Central Venous Catheter (CVC) placement
Sim-based, mastery training central line placement skills in Medical ICU (MICU);
• Fewer needle passes • Fewer arterial punctures • Fewer catheter adjustments
Barsuk JH, McGaghie WC, Cohen ER, O'Leary KJ, Wayne DB. Simulation based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. Crit Care Med. 2009 Oct;37(10):2697-701.
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Cohen ER, Feinglass J, Barsuk JH, et al. Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical intensive care unit. Simul Healthc. 2010 Apr;5(2):98-102.
Follow-up research compared pre-post Catheter-Related Bloodstream Infections (CRBSI) and potential cost-savings for the hospital
-Cohen and colleagues
CVC placement in Medical Intensive Care Unit (MICU)
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Cohen ER, Feinglass J, Barsuk JH, et al. Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical intensive care unit. Simul Healthc. 2010 Apr;5(2):98-102.
4.2/100 MICU CVC CRBSI/adm.
0.42/100 MICU CVC CRBSI/ adm.
SBE CVC training improved infection rates
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• Training cost ~US$110,000 ( 319,000)
• Approximately 9.95 CRBSIs were prevented in MICU patients/ CVCs in the year after intervention
• Each translated to US$82,000 ( 240,000) and 14 added hospital days
Cohen ER, Feinglass J, Barsuk JH, et al. Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical intensive care unit. Simul Healthc. 2010 Apr;5(2):98-102.
2M
SBE CVC training reduced costs
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What about the future?
Gelecekte neler olabilir?
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Simulation
System-based Trng & Assmnt
Streamlined Trng & Assmnt
Non-technical
Skills Trng & Assmnt
Projections
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Simulation
System-based Trng & Assmnt
Streamlined Trng & Assmnt
Shared
Projections
• Increased incentives for system-level patient-safety initiatives
• Hospital safety officials interested in incorporating simulation in quality control cycles
• Interprofessional training is preferred
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• Prepare for new EHR
• SBE sessions targeted provider/nurse pairs practicing delivery of maternity care
• Triageà labor à complicationà postpartumà discharge
• Supplement to classroom/online
Systems-based training: EHR & Maternity Care
193 individuals 64, 2-hr sessions x 4 weeks
Smith R, Hammoud M, Marzano D. (2014) University of Michigan
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Results
• 100% participation
• Reduced anxiety toward EHR
• Operationalized knowledge
• Fostered teamwork
• Increased interest in SBE
36
25
23
12 5
92
OB Faculty
OB Residents
Midwives
Family Med Faculty Family Med Residents Nurses
Smith R., Hammoud M., Marzano D. (2014) University of Michigan
Systems-based training: EHR & Maternity Care
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Simulation
Streamlined Trng & Assmnt
Non-technical
skills
Authentic Trng & Assmnt
Projections
Costs associated with dedicated simulation resources
• Space
• Expertise
• Time
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• Using available web-based curriculum on computer
• Self-directed training and assessment
• Addresses knowledge, skills, attitude
Future Training: Streamlining technical skills training with technology
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Future training targeting technical skills: retinal exam
• Originally developed for residents, soon to be adapted by medical students (n=170)
• 3 weeks to teach retinal exam skills
• 30 minutes/session = 85 teaching hours
• Teaching commitment = 0
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Future training targeting technical skills: endoscopy
Residents; • Family medicine • IM-Gastroenterology • Surgery
ü Self-directed learning
ü 24 hour access
ü Built-in assessment
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Simulation
Non-technical
skills
Streamlined Trng & Assmnt
Systems-based Trng. & Assmnt
Projections
• “Overlooked” domains
• More complex skills (decision-making)
• Communication and professionalism
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End-of-Life (Palliative) Care
Targeted Trainees: • 2nd and 3rd year Family Medicine residents (n=30)
Learning Goals: • Improve residents’ knowledge about symptoms
associated with dying process • Improve residents’ ability to treat symptoms • Improve residents’ communication skills with patient/
families
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End-of-Life Care Program: logistics
Intervention • Presentation • Clinical simulation • 10 x 2 hour sessions
Pre-post assessment • Knowledge • Communication (social worker acting as family member)
• Comfort
Chiang C, Kelley S, & Petersen, K. Teaching End-of-Life Care to Resident Physicians Using Clinical Simulation. Healthcare Professional education Day, University of Michigan, 2015
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Communication Skills: third-year medical students in Turkey
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Final thoughts