A case for Funding Large Scale Simulations in Australian Healthcare

Marcus Watson PhD

Senior Director Queensland Health Skills Development CentreSchool of Medicine, The University of Queensland

Does size matter?

Does size matter?

California Queensland

Area 163,696 sq mi 668,207 sq mi

Population 36,500,000+

(234.4/sq mi)

4,100,000+

(6.3 /sq mi)

Cairns Cairns

Townsville Townsville

Mackay Mackay

BundabergBundaberg

Hervey BayHervey Bay

RockhamptonRockhampton

Toowoomba Toowoomba (not an official centre)(not an official centre)

RomaRoma

QH SDCQH SDC

Skills Development Centre

Skills Development Centre

28. Fundamentals of Laparoscopic Surgery29. Minimally Invasive Surgical Techniques30. Introduction to Laparoscopic Surgery31. National Endoscopic Training Initiative32. Operative Laparoscopy Workshop for O&Gs33. Perioperative Advanced Laparoscopic Skills

Surgical and Psychomotor Skills

Intensive Care and Anaesthetics

7. Intensive Care Crisis Event Management8. Anaesthetic Crisis Resource Management9. Anaesthetic Crisis Resource Management for GPs10. Paediatric Anaesthetic Crisis Resource

Management11. Recovery Room Crisis Resource Management12. Basic Assessment & Support in Intensive Care13. Effective Management of Anaesthetic Crises14. Advanced Paediatric Intensive Care Critical Skills15. Physiotherapy and Critical Care Management16. Introduction to Physiotherapy Cardiorespiratory

Management

Emergency and Rural

19. Advanced Life Support – Interns20. Advanced Cardiac Life Support21. Clinical Rural Skills Enhancement22. Emergency Events Management23. Emergency Crisis Resource Management24. Emergency Technical Skills Course for

Doctors25. Acute and Critical Medical Emergencies26. Pre-Hospital Trauma Life Support27. Paediatric Emergency Crisis Resource

Management

Communication Skills5. Frontline Communications6. Friday Night in the ER

34. Emergo Train

Disaster Medicine

Courses Delivered by the SDC

Medical Radiations

35. Introduction to Vascular Ultrasound36. Basic Skills in O&G Ultrasound37. Practitioner Initiated X-ray

17. Maternity Crisis Resource Management

18. Newborn Crisis Recourse Management

Maternity and Newborn

Faculty Training

1. Simulation With Integrated Mannequins2. Crisis Resource Management Train the

Trainer3. Difficult Debriefing Training4. Grad Dip Health Simulations

Changing the face of healthcare

What healthcare needs is clinical training on an industrial scale with simulation efficiently integrated into clinical practice along with other educational methods.

Identifying the Critical Motivation

Training Systems

Technical skills

Non-Technical skills

Interdisciplinary learning

Specialty skills

Human Factors

Organisations design

Equipment design

Technology integration

Pre-employment skills Process design

Workload assessment

Performance assessment

Workplace orientation

Competency assessment

Safety

Quality

Quantity

Efficiency

Identifying the Critical Motivation

Training Systems

Technical skills

Non-Technical skills

Interdisciplinary learning

Specialty skills

Human Factors

Organisations design

Equipment design

Technology integration

Pre-employment skills Process design

Workload assessment

Performance assessment

Workplace orientation

Competency assessment

Safety

Quality

Quantity

Efficiency

Identifying the Critical Motivation

Training

Safety

Quality

Quantity

Efficiency

Quantity of Quality argument

• We have a clinical skills shortage • Increasing the number of students increase the burden

on already overs stretched clinical mentor• We can provide more simulation experience but we

cannot guarantee more experience on clinical placements

• We can control the quality of simulations experience

Quantity of Quality argument

• The opportunity for clinicians to develop clinical skills is often haphazard and there are examples of clinicians graduating without having been assessed or in some cases performing crucial clinical skills.

Wall, Bolshaw, & Carolan, 2006, Medical TeacherFox, Ingham Clark, Scotland, & Dacre, 2000, Medical Education

Remmen, et. al., 2001, Medical Education

• In the 1960s medical students received 75% of their teaching at the bedside, in the late 1970s this dropped to 16% and since then it has decreased further.

Ahmed, & El Bagir, 2002, Medical Education

• The acquisition of basic clinical skills suffered when there is limited supervised hands-on experience, skill levels in health are likely to drop unless alternate training methods are used.

Remmen, et. al., 2004, Medical EducationSeabrook, 2004, Medical Education

Learning methods

Learning Method

Non-Technical Skill

Situation Awareness Communications

Decision-making Teamwork

Leadership

Didactic learning

Poor Poor Poor Poor Poor

Video examples

Fair Fair Strong Fair Fair

Discussion forum

Poor Poor Fair Poor Poor

Decision games

Fair Fair Strong Strong Strong

Virtual reality

Fair Fair Strong Fair Poor

Immersive learning

Strong Strong Strong Strong Strong

Debrief learning

Strong Strong Strong Strong Strong

How we learn now

Strong = High quality, Broad scope and Readily available Moderate = Limited quality or Limited scope or Limited availability

Lim ited = Limited quality or Limited scope and Limited availability OR Limited quality and Limited scope or Limited availability

Evaluation & research

Immersive learning

Virtual reality

Decision games

Video examples

Didactic learning

Discussion forum

E-learning Lectures series

Simulations Clinical practice

Debrief learning

Workshops & seminars

State standards

National standards

International standards

How we should be learning in 2015

E-learning Lectures Simulations Clinical practice

Workshops & seminars

Immersive learning

Virtual reality

Decision games

Video examples

Didactic teaching

Discussion forum

Debriefing

Change of focus from Limited quality and Readily available to High quality and Limited availability by increasing preparing through e-learning and simulations and increasing debriefing

Evaluation & research

State standards

National standards

International standards

Reduced reliance on didactic learning due to the availability of stronger training methods

Strong = High quality, Broad scope and Readily available Moderate = Limited quality or Limited scope or Limited availability

Lim ited = Limited quality or Limited scope and Limited availability OR Limited quality and Limited scope or Limited availability

How we should be learning in 2025

E-learning Lectures Simulations Clinical practice

Workshops & seminars

Immersive learning

Virtual reality

Decision games

Video examples

Didactic teaching

Discussion forum

Debriefing

Limited scope and availability due to development of more engaging methods of learning Evaluation

& research

State standards

National standards

International standards

Strong = High quality, Broad scope and Readily available Moderate = Limited quality or Limited scope or Limited availability

Lim ited = Limited quality or Limited scope and Limited availability OR Limited quality and Limited scope or Limited availability

Safety and Efficiency argument

• Patient error is estimated to have a direct cost in Australia of $2 billion a year

• Patient are treated by ‘teams’ of clinicians not by a clinician

• Patient safety reports indicated that non-technical skills are involved in the majority of adverse events reported that cause harm

Wilson, Runiman, Gibberd, Harrison, Newby, & Hamilton, (1995) Medical Journal of Australia

• Other industries have become safer by a combination of standards, regulations and appropriate preventative

• Healthcare needs to provide the right training

Team training Crisis Resource Management

Tertiary Hospital 2007• Births ~ 4,800

• Annual mandatory fire drills• Fires = 0

• Annual mandatory basic life support• Cardiac emergencies = 0

• Maternity emergencies that occurred in 2007• Cord prolapse = 22

• Placental abruptions = 41

• Shoulder dystocia = 71

• Maternity Crisis Resource Management MaCRM• 2 day multidisciplinary workshop including

scenarios and structured debriefing

Training – when, where and how

• Multidisciplinary training in healthcare is starting to occur in hospital systems with varied levels of success. Most issues arrive when clinicians undergo concurrent training rather than training as a team.

El Ansari, Russell & Willsc (2003) Public Health

• Australia has simulation centres that provide excellent immersive learning for technical and non-technical skills. • The training capacity of most centres is not limited by the

number of simulators or rooms but rather by the number of instructors and the support staff available to deliver training

• An analogy is cottage industries that provide high quality products to a small proportion of the population.

Training – when, where and how

1. Tertiary Skills Development Centres– Inter-disciplinary training – Specialty training– Technical hub – Supports University training – Conducts major research– Staff 10-50 FTE, – 100-200 PT instructors

2. Affiliated Skills Development Centres– Inter-disciplinary training – Supports University training – Conducts major research– Staff 3-9 FTE, 10-50 PT

instructors

3. Portable Simulations– Inter-disciplinary training– Specialty training– Opportunistic training– Supports University training– Staff 2-3 FTE, 2-100 PT

instructors

4. Departmental ‘Pocket’ Simulations– Department training– Inter-disciplinary training– Opportunistic training– Rehearsals– Research– 1-2 FTE, 3-20 PT instructors

How quickly can we grow?

Based on 2007 Queensland Healthclinical population - Actual trainingDays required will increase

How many people will it take?

Per participants training day in Instructors

Simulation Coordinators

Administration and Logistics

Support2008- current ratio 0.27 0.42 0.142015- estimated economy of scale

0.27 0.36 0.13

Queensland Health

30,000 training days 37-43 58-67 19-20

120,000 training days 148-172 230-265 77-80

Six Critical Training Issues

1. The right blended learning environments,

2. Emphasis on the knowledge and skills likely to prevent harm,

3. Standardisation of curriculum and reliable assessment,

4. Training as teams not just as individuals,

5. The use of skilled instructors,

6. Dedicated support staff to provide efficient and accountable education.

What Australia has to do

Rank Priority Description

1Curriculum exchange program

Centrally funded core curriculum to meet graduate and new clinicians training requirements (PGY 1-3 for all disciplines) with a focus on non-technical skills

Validate and mandate one or more methods of assessing non-technical skills Curriculum that supports a continuity throughout a clinician’s career across

disciplines and facilities

2

The development of immersive learning capability

The rapid development of skilled simulation coordinators and instructors Formal training and recognition of their educational and technical skills Significant administration and logistic support to minimise clinicians’ time away

from clinical service

3

The development of administrative hubs for simulation

Dedicated management and governance to ensure quality and appropriate coverage of simulations training integrated into clinical placements

Dedicated staff to provide the coordination and logistic support for course delivery in each state to ensure a continuum of interdisciplinary training across facilities for all clinical staff

4

The development of equipment and infrastructure for simulations

A review of existing simulation equipment to increase use through better access, regular maintenance by skilled instructors and simulation coordinators

The development of affordable portable audio visual systems to improve learning through effective debriefing

The expansion of simulation equipment to meet the needs of the expanding training capacity

Questions1. We can do things in simulation we cannot or

should not do with ‘real’ patients

2. We can apply simulation systematically and opportunistically to develop a leaner and safer healthcare system

3. We can develop more simulation-based training but we cannot rely on more quality clinical training opportunities