simulation in medical education professor harry owen
TRANSCRIPT
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SIMULATION IN MEDICAL SIMULATION IN MEDICAL EDUCATIONEDUCATION
Professor Harry Owen
and
Val Follows
Flinders University School of Medicine
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Simulation in Medical Education• Simulation technologies used in Medical
Education in Australia, the US and Europe
• Setting up the Flinders University Medical School Clinical Skills and Simulation Unit
• Fundamentals of high-fidelity simulation
• Where do we go from here? Some observations on the future of simulation
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Who’s who in medical education
• Basic medical education– Medical students
• Pre-vocational medical education– Interns, RMOs, PGY 1&2
• Specialist training (discipline-based)– Registrars/Senior registrars/Fellows
• Specialists and GPs (life-long learning)– CME, MOPS, IRM, etc
• Teachers and trainers
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AdelaideSouth Australia
1111
22
11
(1)(1)
(1)(1)
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Source: Jones A (BMSC)
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Simulation centres
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209
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25
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Publications on ‘patient simulation’ in clinical care
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'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02
Papers
Year
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Simulation technologies used in medical education
• Computer-based simulations (micro-worlds, micro-simulation)
• Virtual environments +/- haptics
• Part-task trainers
• Low-fidelity simulators/manikins
• Simulated or standardised patients
• Hybrid simulations
• High-fidelity (full mission) simulation
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Knowledge/Skills/Attitudes
• Individual psychomotor skills
• Appropriate application of skills
• Communication / Team performance / Leadership skills (CRM)
• Supervision/teaching
• Assessment
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Knowledge/Skills/Attitudes
• Teaching best practice– learner centred– appropriate use of technology
• Assessment best practice– Valid and reliable– Reproducible
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The Flinders Clinical Skills and Simulation Unit
• Grew from a project to improve airway management teaching to medical students
• Value to teaching other health professionals and other skills recognised
• Funding generated from teaching outside the medical school
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Endotracheal intubation
• Learnt on patients under anaesthesia
• No special consent• Duty of care to protect
patient from harm• Increased risk when
performed by a student or trainee
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Endotracheal intubation
• ETI needed by many health professionals, including anesthesiologists, paramedics/EMTs, rural GPs, emergency physicians, ICU staff, respiratory therapists, etc.
• Competence requires practise
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• Animals– Small, e.g. cats– Large, e.g. dogs or
monkeys
• Unconscious patients– In the OR– In ICU
• Newly dead/recently deceased
• Cadavers• Simulators
When and how should ETI be taught?
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The learning environmentThe learning environment
• Quiet, few Quiet, few distractorsdistractors
• Clinical equipmentClinical equipment• Expert tutorsExpert tutors• Realistic modelsRealistic models• Many different Many different
modelsmodels– Easy Easy difficult difficult
very difficult very difficult
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CPR Prompt ®
(Compliant)Actar D-Fib® (Armstrong)
Little Anne™ (Laerdal)
CPR Pal® (Ambu)
Basic Buddy™ (Lifeform)
Economy Saniman ®
(Nasco)
Adult A-A Female ®
(Nasco)
Fat Old Fred ®
(Lifeform)David/Adam ®
(Nasco)
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The Flinders Clinical Skills and Simulation Unit
• Computer-based Teaching – ResusSim– CathSim– PA simulator– ECG– Local anaesthesia
• Part-task trainers– BLS & ALS– IVI & CVC– Trauma– Adult– Gynae & Obstetric– Neonatal– Premature (28wks)– Paediatric (age
range)
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The Flinders Clinical Skills and Simulation Unit
• Several whole body manikins including:– ResusciBaby– ALS baby– ResusciAnne with
SkillReporter– Mr Hurt– Nursing Anne– Megacode Kid– etc
• SimMan UPS– Postoperative care
modules– Trauma modules– Severe Trauma
modules– Local produced
dental trauma modules
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Anatomy of a simulation (1)
Components• Student/trainee/
health professional • Procedure/task/skill/test/
treatment or equipment• Patient and/or disease
process• Trainer/supervisor
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Anatomy of a simulation (2)
Function of components• Passive
– Enhance setting for realism
• Active– Change in a programmed way
• Interactive– Responds to action or event
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Trainees learning cricothyrotomy on a part-task trainer
(Note educational aids in background)
Trainee performing an emergency cricothyrotomy in a full-mission simulation.
(Note more realistic setting)
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High fidelity simulation (1)
• Determine educational needs and choose most efficient and effective
• Need to balance resource availability and student demand
• May need to ‘promote’ low-tech solutions
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High fidelity simulation (2)
• Confirm teaching goals can be achieved using simulation
• Develop scenario, acquire equipment needed and prepare associated materials
• Test and validate the simulation
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Options for running simulations• Free-form
– Easy but poor learning
• ‘On the fly’– Scripted but intensive for the ‘controller’ and
some variables may appear discontinuous
• Programmed trends– More sophisticated simulations possible
• Trends and event handlers– Facilitates high-fidelity simulation with most
realistic response to interventions
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Resources needed
• Equipment:– Simulators, monitors, defibrillator, trolleys, etc
• Disposables:– Appropriate for scenario, setting and
participants, re-use w/o compromising fidelity
• Faculty:– Trained, available, practised
• Support staff:– Technician/bio-medical engineer essential!
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Before and after simulations...
• Set-up scenario– eg. make blood, set up area, X-rays, notes, etc
• Load simulation program • Check everything works
– Cameras, VCR, communicators
Afterwards...• Check simulator (replace or repair parts)• Clean everything used and put away• Replace/reorder all used items
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High fidelity simulation (3)
• Allow time for briefing and familiarisation with the patient simulator and equipment
• Brief participants on:– Broad objectives– The scenario– How to get help
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High fidelity simulation (4)
Always follow the script but...
…have alternative outcomes planned and rehearsedSimulation control room
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High fidelity simulation (5)Using simulation situations
can be re-run to explore outcome with different treatments
Mission critical tasks can be performed by learners without putting patients at risk
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High fidelity simulation (6)
Facilitated debriefing with an expert practitioner. Participants reflect on their own performance and discuss this with the group
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How we use the SimMan UPS• Anaesthesia• Emergency medicine• Family Medicine/GP• CCU/ICU• Trauma/retrievals• Paramedics/EMT• Specialist nurses• Medical Imaging• Paediatrics• Rural health workers
• Sim Centre settings– OR, PACU, ER,
Imaging suite, post-op ward, clinic, aircraft, ambulance, home, roadside, terrorist incident, etc
• Outreach settings– Regional hospitals,
rural settings, etc
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Medicine: A High-Risk Industry• Harvard Medical Practice Study (1991)
identified a ‘serious error’ rate of 3.7%– (serious error leads to prolonged hospital
stay or disability)
• Vincent (2001) NHS ~11% error rate with 50% preventable– ~50,000 patients pa die from medical error
or accident. Litigation cost £44billion
• Australian data - adverse event rate of ~17%
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Successful strategies for crisis management:
• Use of written checklists to help prevent crises
Use of established procedures in responding to crises
Training in decision making and resource co-ordination
• Systematic practise in handling crises including part-task trainers and full-mission realistic simulation
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The future of simulation...• Skills training tool for all disciplines
– Acute care– Try new techniques and/or equipment– Patient safety initiatives– Retraining
• Multi-disciplinary training– inter-professional communication– team performance
• Training in decision-making/resource co-ordination
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Simulation technologies used in medical education
• Computer-based simulations (micro-worlds, micro-simulation)
• Virtual environments +/- haptics
• Part-task trainers
• Low-fidelity simulators/manikins
• Simulated or standardised patients
• Hybrid simulations
• High-fidelity (full mission) simulation
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Simulation research must address healthcare training needs
• Improved outcomes– Fewer adverse events, fewer preventable
incidents, fewer ‘near miss’ events
• Increased efficiency of training– Improved outcomes in same or (preferably)
less training time
• Improved use of resources– Fewer failures, more efficient training,
quicker performance