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Practical Simulation: Key Principles & Methodologies: “—making the rubber meet the road” by John J. Schaefer, III, MD, Professor Anesthesia and Perioperative Medicine Assistant Dean MUSC College of Medicine, Lewis Blackman Endowed Chair

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Practical simulation key principles methodologies making the rubber meet the road

Practical Simulation: Key Principles & Methodologies:

“—making the rubber meet the road”

by John J. Schaefer, III, MD,

Professor Anesthesia and Perioperative MedicineAssistant Dean MUSC College of Medicine,

Lewis Blackman Endowed Chair

South Director: HealthCare Simulation of South Carolinaemail: [email protected]


Charleston sc and the medical university of south carolina

Charleston, SC and the Medical University of South Carolina


Practical simulation key principles methodologies making the rubber meet the road

  • Established 1824

  • Colleges Medicine, Nursing, Dentistry, Pharmacy, Health Professions

  • MUSC Medical Center is comprised of four separate hospitals (the University Hospital, the Institute of Psychiatry, the Children's Hospital, and the Ashley River Tower).

  • The Medical Center includes centers for specialized care (Heart Center, Transplantation Center, Hollings Cancer Center, Digestive Diseases Center).


Objectives practical simulation methods in healthcare education

Objectives:“Practical Simulation Methods in HealthCare Education”

  • Practical Simulation Defined

  • Why “Practical Simulation” is critical to your success

  • The operational concept to achieve it

  • Practical Simulation Demonstrations across range of “Simulation types”

    • Task training: NG tube objective assessment (interactive demo)

    • Task Training: Orthopedic Surgery (video demo)

    • Student run multi-simulator, single instructor interactive demo

    • Individual assessment----Nursing student med administration (video demo)

    • Individual assessment----Pediatric Resident NRP Individual assessment (video demo)

    • Team Training:

      • Team Leader Focus: Pediatric ER emergencies (video demo)

      • Interdisciplinary Focus: SIRE (video demo)

      • Specialty Team Focus: Neonatal LBW Team (video demo)

    • Research using Simulation

  • Summary


Objectives practical simulation methods in healthcare education1

Objectives:“Practical Simulation Methods in HealthCare Education”

  • Practical Simulation Defined

  • Why “Practical Simulation” is critical to your success

  • The operational concept to achieve it

  • Practical Simulation Demonstrations across range of “Simulation types”

    • Task training: NG tube objective assessment (interactive demo)

    • Task Training: Orthopedic Surgery (video demo)

    • Student run multi-simulator, single instructor interactive demo

    • Individual assessment----Nursing student med administration (video demo)

    • Individual assessment----Pediatric Resident NRP Individual assessment (video demo)

    • Team Training:

      • Team Leader Focus: Pediatric ER emergencies (video demo)

      • Interdisciplinary Focus: SIRE (video demo)

      • Specialty Team Focus: Neonatal LBW Team (video demo)

  • Summary


Practical simulation pyramid of success

Communicate Value

Establish Value

Create/Deliver Quality Courses

Create a Functional Center/Lab

Practical Simulation Pyramid of Success

Focus will be on simulation methodology critical to achieving success!

Develop a Realistic Plan


What is meant by practical simulation in healthcare

What is meant by “practical” simulation in Healthcare?

  • Simulation as a teaching methodology that takes advantage of simulator tools where diverse and large numbers of Healthcare students and practitioners have individual and group access to training.

  • Healthcare teachers with reasonable training can adopt simulation training methodologies rapidly.

  • The “value” of using simulation justifies the capital, operating and indirect costs associated with it.


Objectives practical simulation methods in healthcare education2

Objectives:“Practical Simulation Methods in HealthCare Education”

  • Practical Simulation Defined

  • Why “Practical Simulation” is critical to your success

  • The operational concept to achieve it

  • Practical Simulation Demonstrations across range of “Simulation types”

    • Task training: NG tube objective assessment (interactive demo)

    • Task Training: Orthopedic Surgery (video demo)

    • Student run multi-simulator, single instructor interactive demo

    • Individual assessment----Nursing student med administration (video demo)

    • Individual assessment----Pediatric Resident NRP Individual assessment (video demo)

    • Team Training:

      • Team Leader Focus: Pediatric ER emergencies (video demo)

      • Interdisciplinary Focus: SIRE (video demo)

      • Specialty Team Focus: Neonatal LBW Team (video demo)

    • Research using Simulation

  • Summary


Musc healthcare simulation center

MUSC Healthcare Simulation Center

  • 11,000 sq ft training space, 15 available training rms.

  • Stake holders: All Colleges & Medical Center

  • Opened June 2008

  • Activities 2008-09:

    • 70 course

    • 9,000 student encounters

    • 6,000 full scale simulations

    • 2,000 task trainer simulations

    • 70 faculty involved in simulation

Focus will be on simulation methodology critical to achieving success!


Simulation center capital costs example

Simulation Center Capital Costs Example:

Large Center:

Size: 11,000 sq ft facility

Capital Costs:

Renovation ~ $1,566,353

Simulation equip.~ $810,000

AV equipment ~ $300,638

Computers ~ $206,500

Other~ $25,000

Total: ~ $2,908,491

Average capital cost / sq. ft ~ $250


Simulation center costs yr examples

Simulation Center Costs/yr. Examples:

Large Center:

Staff: 30% Med. Director, 2 Admin., 2 Sim., Spec., 1 IT

Operational Costs:

Salaries ~ $303,027

Rent~ $208,847

Other~ $61,250

subtotal: ~ $573,124

Recapitalization Costs:~$117,250

Total Costs per year:~$690,374


Typical busy week s schedule

Typical busy week’s schedule

Focus will be on simulation methodology critical to achieving success!


Advocacy vs value based funding

Advocacy based funding:

“The concept seems valuable-- so I’ll pay”

Generates “enthusiasm” but is harder to translate into $

Difficult to sustain

“Fickle/Vulnerable” to change

Value based funding:

“The results of training—are valuable--- so I’ll pay”

“The training cost $ you save us is worth what we pay you--- so I’ll pay”

“The malpractice cost $ you save us is worth what we pay you--- so I’ll pay”

Advocacy vs. Value based funding:

Focus will be on simulation methodology critical to achieving value!


Value model which is the basis of what a stakeholder is paying for

Value Model (which is the basis of what a stakeholder is paying for):

Value from the viewpoint of those funding medical simulation commonly falls into at least four forms:

  • Utilization:

    • # students trained

    • # courses delivered

    • # faculty involved

  • Measured Educational Value:

    • Subjective evaluations

    • Objective evaluations

    • Peer reviewed publications

    • Non-peer reviewed publications

    • Grant dollars generated

  • Financial Educational Value:

    • Indirect dollar savings (Malpractice Costs)

    • Direct dollar generation or savings (Save direct training dollars)

  • Public Relations Value:

    • Recruitment

    • Referrals to Health System

    • Fund Raisers

    • Others


Communicate value to stakeholders

Communicate Value (to Stakeholders)


Objectives practical simulation methods in healthcare education3

Objectives:“Practical Simulation Methods in HealthCare Education”

  • Practical Simulation Defined

  • Why “Practical Simulation” is critical to your success

  • The operational concept to achieve it

  • Practical Simulation Demonstrations across range of “Simulation types”

    • Task training: NG tube objective assessment (interactive demo)

    • Task Training: Orthopedic Surgery (video demo)

    • Student run multi-simulator, single instructor interactive demo

    • Individual assessment----Nursing student med administration (video demo)

    • Individual assessment----Pediatric Resident NRP Individual assessment (video demo)

    • Team Training:

      • Team Leader Focus: Pediatric ER emergencies (video demo)

      • Interdisciplinary Focus: SIRE (video demo)

      • Specialty Team Focus: Neonatal LBW Team (video demo)

    • Research using Simulation

  • Summary


Practical simulation key principles methodologies making the rubber meet the road

Competent Facilitator

(runs own simulator)

Lower cost per student

Student self training

or 1 facilitator with

multiple sim. activities

Low cost

Range of HealthCare Simulation Operational Use:

This is what we have been doing since 2002---

Most Users are here---

We do some of this now too--

Expert Instructor,

Expert Simulator Operator

High Costs per student

Complexity of operating simulator & Teaching

Utilization of Simulation-based Education Methods


Practical simulation key principles methodologies making the rubber meet the road

Current “Expert” Instructor/Sim Operator approach

Expert Curriculum/Scenario, Competent Facilitator Model

Expert Instructor

Expert Sim. Operator

Competent Facilitator

Competent Facilitator

Competent Facilitator

Practical Simulation

  • Simulator predominantly in manual mode or scenario (3G) is modified on the fly

  • Limited “Objective” educational outcomes

  • Utilization is severely limited by limited # of “Expert” Instructors and “Expert” simulator operators

  • Simulator only running a scenario with a specific set of objectives with grading and feedback

  • Extensive “Objective” educational outcomes

  • Utilization is significantly increased because competent Facilitator training threshold is lowered

Small grp. exercises


And in some cases

And in some cases

Competent Supervisor

  • Simulator only running a scenario with a specific set of objectives with grading and feedback and operated by trainees

  • Extensive “Objective” educational outcomes

  • Utilization is maximized because complexity of operation threshold is lowered to the point that trainees can learn to run a scenario in minutes.

Student independent learning

Student independent learning

Student independent learning

Student independent learning

Note: until this level is achieved, using simulation requires more “Instructors” than traditional educational methods though many believe simulation decreases the need.


What does not work well

What does not work well--

  • Manually adjusting the simulator “on the fly” to create a case that tracks with training objectives can only be done by a highly trained operator (even with a script).

  • Simultaneous paper and pencil or electronic evaluation with some type of evaluation form while you are also running a simulator (this requires concentration) is generally impractical.

  • “Non-structured Debriefing”. While some people have been formally trained as educators, most Healthcare providers that teach are not.


Practical simulation key principles methodologies making the rubber meet the road

With “manual” operation of the simulator, you have to teach a teacher to competently run this GUI with enough expertise to create “Human Reactions” in real time while watching the trainees:


What does work pretty well

What does work pretty well--

  • Pre-course participant preparation through studying online curricula based on “adult learning” principles.

  • With just about any simulation training exercise, the facilitator has immediately available well designed curricula to support standardization (usually web-based) with less time in training of the trainer.

  • The simulation exercise uses a well designed, pre-programmed simulation scenario run by the facilitator (teacher). This scenario incorporates semi-automated evaluation of key educational objectives embedded in the scenario that are automatically flagged for focused feedback specific to the individual or group’s performance and additionally supports standardization of the whole evaluation/feedback process.

  • The facilitator then uses this debriefing file as a preliminary educational diagnosis that when coupled with a standardized “reflection” process leads to a focused, standardized (yet individually specific) learning encounter with the student.


With a well programmed scenario a teacher or student only has to accurately run this

With a well programmed scenario, a teacher (or student) only has to accurately run this-

Bag-Mask competency skill scenario

BP assessment practice skill scenario

Nursing Critical Care Assessment Training scenario

Anesthesia Difficult Airway Management Competency scenario

LMA skill competency scenario

Nursing Med Surg Training scenario

Trauma Assessment Demo scenario


Practical simulation key principles methodologies making the rubber meet the road

With a well programmed scenario, physiology, pathophysiology, pharmacodynamics, seizures, airway obstruction, etc. are pre-programmed

With selection of “Standard induction of general anesthesia”, apnea, airway obstruction, hypoxic physiology automatically occur


Multimedia can be embedded in a programmed scenario to

Multimedia can be embedded in a programmed scenario to:

  • Present simulation “case stem”


Multimedia can be embedded in a programmed scenario to1

Multimedia can be embedded in a programmed scenario to:

  • Diagnostic information: labs, EKGs, X-rays, videos—ECHO, ultrasounds

Choosing a menu item here returns a set of Physician orders on the monitor


Multimedia can be embedded in a programmed scenario to2

Multimedia can be embedded in a programmed scenario to:

  • Clinical signs & symptoms (as a picture, sound, movie or document that is presented on the monitor) that the actual simulator can’t otherwise emulate.


Multimedia can be embedded in a programmed scenario to3

Multimedia can be embedded in a programmed scenario to:

  • Standardized debriefing cues during the simulation that automatically appear on the monitor.


Multimedia can be embedded in a programmed scenario to4

Multimedia can be embedded in a programmed scenario to:

  • Scenario support info.: i.e. equipment list, equipment layout & QA, instructions, etc.


Practical simulation key principles methodologies making the rubber meet the road

Nursing Aspiration Prevention & Rx”Semi-Automated, Standardized Guide for“Diagnostic Educational Objectives based Reflection”


Practical simulation key principles methodologies making the rubber meet the road

Well designed/programmed scenarios that are simple to run coupled with“Semi-Automated Objective Driven Reflection Process”


Objectives practical simulation methods in healthcare education4

Objectives:“Practical Simulation Methods in HealthCare Education”

  • Practical Simulation Defined

  • Why “Practical Simulation” is critical to your success

  • The operational concept to achieve it

  • Practical Simulation Demonstrations across range of “Simulation types”

    • Task training: NG tube objective assessment (interactive demo)

    • Task Training: Orthopedic Surgery (video demo)

    • Student run multi-simulator, single instructor interactive demo

    • Individual assessment----Nursing student med administration (video demo)

    • Individual assessment----Pediatric Resident NRP Individual assessment (video demo)

    • Team Training:

      • Team Leader Focus: Pediatric ER emergencies (video demo)

      • Interdisciplinary Focus: SIRE (video demo)

      • Specialty Team Focus: Neonatal LBW Team (video demo)

    • Research using Simulation

  • Summary


Task training ng tube objective assessment interactive demo

Task training: NG tube objective assessment (interactive demo)


Good theater does not equal learning

Good “Theater” does not equal “Learning”!

=


Task training ng tube objective assessment interactive demo1

Task training: NG tube objective assessment (interactive demo)


Task training ng tube objective assessment interactive demo2

Task training: NG tube objective assessment (interactive demo)

  • Key Points to observe:

    • Using SimMan or SimBaby or VitalSim Advanced software with a “dumb” task trainer to enhance simulation

    • Specific educational objectives driven

    • Simplified menus

    • Use of multimedia to support standardization

    • Debriefing log documents performance of specific educational objectives

    • Performance is automatically scored!


Lets do it

Lets do it---

  • Need a volunteer to run scenario (familiar with a nasogastric tube)

  • Minimal experience with SimMan

  • NOTE: I will be the


Vital signs training

Vital Signs Training

Competent Supervisor

Student independent learning

Student independent learning

Student independent learning

Student independent learning


Vital signs training1

Vital Signs Training

  • ALS (Vital Sim Advanced) & SimMan Simulators

  • 1 student runs simulator, 1 student measures RR, 1 student measures HR, 1 student measures BP then switch & practice again, & again---etc.

  • Call facilitator for help as needed, when confident take summative version.


Student run multi simulator single instructor interactive demo

Student run multi-simulator, single instructor interactive demo

Competent Supervisor

  • Simulator only running a scenario with a specific set of objectives with grading and feedback and operated by trainees

  • Extensive “Objective” educational outcomes

  • Utilization is maximized because complexity of operation threshold is lowered to the point that trainees can learn to run a scenario in minutes.

Student independent learning

Student independent learning

Student independent learning

Student independent learning

Note: until this level is achieved, using simulation requires more “Instructors” than traditional educational methods though many believe simulation decreases the need.


Student run multi simulator single instructor interactive demo1

Student run multi-simulator, single instructor interactive demo

  • Key Points

    • Specific educational objectives driven

    • Simplified menus

    • Use of multimedia to support standardization

    • Performance is automatically scored and shows on monitor!

    • Debriefing log documents performance of specific educational objectives


Lets do it1

Lets do it---

  • Need 8 volunteers to run scenario (familiar with measuring HR, BP, RR)

  • Minimal experience with SimMan


Practical model used in following examples

Practical Model used in following examples:

Expert Curriculum/Scenario, Competent Facilitator Model

Competent Facilitator

  • Simulator only running a scenario with a specific set of objectives with grading and feedback

  • Extensive “Objective” educational outcomes

  • Utilization is significantly increased because competent Facilitator training threshold is lowered


Team leader focus pediatric er emergencies video demo

Team Leader Focus: Pediatric ER emergencies (video demo)


Individual assessment nursing student med administration video demo

Individual assessment----Nursing student med administration (video demo)


Interdisciplinary focus sire video demo

Interdisciplinary Focus: SIRE (video demo)


Research using simulation

Research using Simulation


Individual assessment pediatric resident nrp individual assessment video demo

Individual assessment----Pediatric Resident NRP Individual assessment (video demo)


Specialty team focus neonatal lbw team video demo

Specialty Team Focus: Neonatal LBW Team (video demo)


Task training orthopedic surgery video demo

Task Training: Orthopedic Surgery (video demo)


Objectives practical simulation methods in healthcare education5

Objectives:“Practical Simulation Methods in HealthCare Education”

  • Practical Simulation Defined

  • Why “Practical Simulation” is critical to your success

  • The operational concept to achieve it

  • Practical Simulation Demonstrations across range of “Simulation types”

    • Task training: NG tube objective assessment (interactive demo)

    • Task Training: Orthopedic Surgery (video demo)

    • Student run multi-simulator, single instructor interactive demo

    • Individual assessment----Nursing student med administration (video demo)

    • Individual assessment----Pediatric Resident NRP Individual assessment (video demo)

    • Team Training:

      • Team Leader Focus: Pediatric ER emergencies (video demo)

      • Interdisciplinary Focus: SIRE (video demo)

      • Specialty Team Focus: Neonatal LBW Team (video demo)

    • Research using Simulation

  • Summary


Practical simulation key principles methodologies making the rubber meet the road

Competent Facilitator

(runs own simulator)

Lower cost per student

Student self training

or 1 facilitator with

multiple sim. activities

Low cost

Range of HealthCare Simulation Operational Use:

Focus on the methods to work in towards this quadrant

Expert Instructor,

Expert Simulator Operator

High Costs per student

Complexity of operating simulator & Teaching

Utilization of Simulation-based Education Methods


Specific focus areas

Specific Focus Areas:

  • Focus on complex scenarios that run simply

  • Take advantage of multimedia fx. to support simplification & standardization

  • Whatever grading paradigm you prefer, maximize the opportunity for simplification & value through automation

  • Focus on designing intuitive menus

  • It’s all about removing barriers & creating value statements at the individual & stakeholder level


Hope this was inspiring

Hope this was inspiring---


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