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Applications of Simulation in Anesthesiology David M. Gaba, M.D. Director, Patient Safety Center of Inquiry at VA Palo Alto HCS Professor of Anesthesia, Stanford University School of Medicine Why Use Patient Simulation? Regardless of the application, there is never a risk to a patient

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Applications of Simulation in Anesthesiology


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applications of simulation in anesthesiology
Applications of Simulation in Anesthesiology
  • David M. Gaba, M.D.
    • Director, Patient Safety Center of Inquiry at VA Palo Alto HCS
    • Professor of Anesthesia, Stanford University School of Medicine
why use patient simulation
Why Use Patient Simulation?
  • Regardless of the application, there is nevera risk to a patient
  • Simulators allow the presentation at will of a wide variety of scenarios, including uncommon but critical events
  • The underlying (medical) causes of each situation are known
why use patient simulation3
Why Use Patient Simulation?
  • The same events can be presented to different clinicians or teams
  • Errors can be allowed to occur and play-out that in a real patient would require immediate intervention by the investigator/instructor
why use patient simulation4
Why Use Patient Simulation?
  • Clinicians can be required to interact with actual medical equipment and a variety of clinical personnel (and personalities)
  • Intensive and archival recording of clinician performance is facilitated, e.g.
    • Multiple video views and audio
    • ECG, EEG
diverse applications of patient simulation in anesthesiology
Diverse Applications of Patient Simulation in Anesthesiology
  • Education
  • Training
  • Research
  • Risk management and public relations
  • Performance Assessment (covered later)
distinction between education and training
Distinction Between “Education” and “Training”
  • Education
    • The goal is to improve knowledge and conceptual understanding
  • Training
    • The goal is to improve the performance of tasks or functions
applications of simulators in anesthesiology education
Applications of Simulators in AnesthesiologyEDUCATION
  • Example Target Groups:
    • University students
    • Pre-clinical medical students
  • Example Target Curriculum:
    • Applied physiology or pharmacology
applications of simulators in anesthesiology education8
Applications of Simulators in AnesthesiologyEDUCATION
  • Example Target Group:
    • 2nd year medical students in “Preparation for Clinical Medicine” Course
  • Example Target Curriculum:
    • “Introduction to the Integrated Management of the Ill Patient”
      • Interleaving of Dx, Monitoring, Rx
applications of simulators in anesthesiology education9
Applications of Simulators in AnesthesiologyEDUCATION
  • Example Target Group:
    • 2nd year medical students in basic anesthesiology classroom course
  • Example Target Curriculum:
    • Early exposure to clinical anesthesia
applications of simulators in anesthesiology education10
Applications of Simulators in AnesthesiologyEDUCATION
  • Example Target Group:
    • Anesthesiology clerkship students
  • Example Target Curriculum:
    • Introduction to anesthesiology
      • Complements OR experience
applications of simulators in anesthesiology education11
Applications of Simulators in AnesthesiologyEDUCATION
  • Example Target Group:
    • Pharmaceutical or device manufacturer representatives or executives
  • Example Target Curricula:
    • Introduction to clinical environments
    • “Anesthesia for Amateurs” (Boston CMS)
applications of simulators training
Applications of SimulatorsTRAINING
  • Training is targeted at specific professional groups
  • Training curricula focus on skills & behaviors required for tasks on the job
applications of simulators training13
Applications of SimulatorsTRAINING
  • Example target group
    • Novice anesthesia residents
  • Example training curricula
    • Basic airway management skills
    • Techniques for induction of anesthesia
    • Managing routine abnormalities during anesthesia; calling for help
applications of simulators training14
Applications of SimulatorsTRAINING
  • Example target group
    • Experienced anesthesia residents
  • Example training curricula
    • Preparation for anesthesia specialty rotations
    • Advanced airway management skills
    • Anesthesia Crisis Resource Management (ACRM)
applications of simulators training15
Applications of SimulatorsTRAINING
  • Target Population:
    • Experienced Anesthesia Personnel
  • Example training curriculum:
    • Hands-on experience with the use of a new pharmaceutical agent (e.g. remifentanil):
      • Familiarity:Mixing, dosing, infusion set-up
      • Safety:Recognition of and response to side-effects and complications
applications of simulators training16
Applications of SimulatorsTRAINING
  • Example target group
    • Non-anesthesia physicians and nurses
  • Example training curriculum:
    • Principles and practice of safe conscious sedation
      • Credentialing requirement in some institutions
applications of simulators training17
Applications of SimulatorsTRAINING
  • Example target group
    • Experienced anesthesiologists (CME)
  • Example training curricula
    • Advanced airway management skills
    • Use of new techniques or technologies (e.g. drugs, monitors)
    • Anesthesia Crisis Resource Management (ACRM)
many centers run anesthesia crisis resource management acrm why
Many Centers Run “Anesthesia Crisis Resource Management - ACRM” -- Why?
  • Crises or challenging situations occur frequently
  • Major gaps exist in training and performance concerning decision making and teamwork
  • Patient safety may be improved by targeting these issues more than medical/technical issues
slide19

Crisis management behaviors have been studied extensively in aviation

Resulting in special training:

Crew Resource Management (CRM)

crisis management
Crisis Management
  • Successful crisis management requires BOTH:
    • Sound technical skills of individuals
    • Sound crisis management behaviors and teamwork
principles of dynamic decision making and teamwork
Principles of Dynamic Decision Making and Teamwork
  • Cognitive Components:
    • Know the Environment
    • Anticipate and Plan
    • Use All Available Information & Cross Check
    • Prevent/Manage Fixation Errors
    • Use Cognitive Aids
principles of dynamic decision making and teamwork22
Principles of Dynamic Decision Making and Teamwork
  • Team Management Components:
    • Leadership & followership
    • Communication
    • Distributing the workload
    • Calling for help early
approach of anesthesia crisis resource management acrm its derivatives
Approach of Anesthesia Crisis Resource Management (ACRM) & Its Derivatives
  • Training “Philosophy”:
    • Single-Discipline, Discipline-Specific: “Training Crews to Work in Teams”
      • Example: Training anesthesiologists to work with with each other & in teams
      • Ideally to be complemented with multidisciplinary combined team training
approach of anesthesia crisis resource management acrm derivatives
Approach of Anesthesia Crisis Resource Management (ACRM) & Derivatives
  • Training “Philosophy”:
    • Primary emphasis on decision making and teamwork behaviors but embedded within technically challenging situations
      • Typically aim for > 60% emphasis on these behaviors, <40% on medical/technical details
approach of anesthesia crisis resource management acrm derivatives25
Approach of Anesthesia Crisis Resource Management (ACRM) & Derivatives
  • Training “Philosophy”:
    • Full-day simulation-based course
    • Highly interactive, with high instructor-participant ratio
    • Detailed debriefings after each simulation
acrm simulation scenarios
ACRM Simulation Scenarios
  • High-fidelity (x surgery), typically 4 per session @ 30-45 min, participants rotate roles
    • Spectrum of challenging clinical situations
      • Equipment & environment failures
      • Clinical crises
      • “Stat” or “Crash” cases
    • Spectrum of challenging interpersonal situations (surgeon, nurse, patient, family)
slide30

Debriefings with video allows discussion of alternatives and pros & cons of CRM behaviors & technical choices

beyond acrm expansion within without
Beyond ACRM: Expansion “Within” & “Without”
  • ACRM derivatives for other specialties
  • Instructor training
  • Progressive curriculum
  • Clinical catastrophe
  • Combined team training
  • Multiple patient simulations
  • Simulation for executive level
crew resource management crm training applies to many medical domains
Crew Resource Management (CRM) Training Applies to Many Medical Domains
  • OR - ICU
  • Emergency Dept. - Cardiac arrest teams
  • Delivery room - Cath lab / radiology
  • Field responders - Military medicine
  • Non-code patient emergencies (IMPES)
  • Interns - Medical students (intro)
  • Etc.
applications of simulators research
Applications of SimulatorsRESEARCH
  • A wide variety of research on human performance in health care requires simulation

*“Educational research” & performance assessment

* Clinical techniques (e.g. pediatric sedation)

* Human machine interaction

* Decision making * AI in ICU

* Telementoring * Stress * Fatigue

applications of simulators research34
Applications of SimulatorsRESEARCH
  • Simulation is a key research tool in human performance because it provides:
      • Reproducibility
      • Controllability
      • Criticality
    • All in a confidential environment with no risk to patients
applications of simulators research35
Applications of SimulatorsRESEARCH
  • Research extends well beyond anesthesiology and health care and well beyond medical investigators, e.g.
    • Cognitive or social psychology
    • Biomedical engineering
  • At several centers PhDs have been awarded based on experiments using a simulator
applications of simulators risk management
Applications of SimulatorsRISK MANAGEMENT
  • Appropriate simulation training may REDUCE:
    • The frequency of adverse clinical events
    • The impact of clinical events that do occur
    • The likelihood of litigation after an event
    • A jury’s perception that the institution did not take patient safety seriously
applications of simulators public relations
Applications of SimulatorsPUBLIC RELATIONS
  • Ongoing training & research activities attract considerable media attention
    • Highly visual & dynamic
  • Outreach programs are feasible, including
    • Schools - Youth groups
    • Museums - Politicians
video link with hm queen elizabeth ii
Video-link with HM, Queen Elizabeth II

The video-conferencing set-up

Dr. Donovan introduces Dr. Gaba to Her Majesty

Dr. Gaba addresses Her Majesty

key challenges ahead for simulation in anesthesiology and health care
Key Challenges Ahead for Simulation in Anesthesiology and Health Care
  • Pedagogical Challenges
    • Integrating different types of simulation-based education & training
      • On-screen & mannequin;
      • Principles, technical skills, & behavioral skills
    • Integrating simulation-based training with clinical training
key challenges ahead for simulation in anesthesiology and health care40
Key Challenges Ahead for Simulation in Anesthesiology and Health Care
  • Challenges of the Clinical Environment
    • Principles of patient safety taught in the simulator must be a part of the real clinical environment
    • They must be constantlyreinforced or the training will be vitiated
unanswered questions about simulation training and or crm
Unanswered Questions About Simulation Training and/or CRM

Each can be the topic of a multi-day seminar

  • Does it work?

How effective is it? Is it “cost-effective”

Who should get it and how often?

  • Can you assess performance using the simulator,i.e. for certification & recertification

Covered in later talk

does it work
Does It Work?
  • High face validity for this belief
  • We do not currently know for sure
  • We may well never know for sure
    • Suggestive data from many sources
    • Definitive experiments may be impossible due to logistics and cost
obstacles to investigating the impact of simulator training on performance
Obstacles to Investigating the Impact of Simulator Training on Performance
  • No gold standard for measuring performance
    • Need to use simulation to test simulation
  • High inter- and intra- individual variability will require large cohorts of subjects
slide44

3x

Prototypical Experimental Design

Chopra, et al; others

a definitive impact on performance experiment will be very expensive
A Definitive “Impact on Performance Experiment” Will Be Very Expensive
  • The number of simulations required is very high:
      • Familiarization sessions
      • Training sessions
      • Testing sessions
  • Expert evaluation of performance is expensive
slide46

500

450

400

Required N per Cohort

350

300

250

200

150

100

50

0

0

0.25

0.5

0.75

1

1.25

1.5

Minimum Detectable Difference / Std. Dev

How Large Must the Cohorts Be?

at MDD/SD = 0.1, N=1944

Estimate of Required N (per cohort) for 80% power, a = 0.05

unanswered questions regarding investigations of impact on performance
Unanswered Questions Regarding Investigations of Impact on Performance
  • After how many simulation sessions can or should the impact be measured?
    • After 1 session only?
      • Naive to think that a single course can have a profound impact
      • In commercial aviation simulation (and CRM) is a career-long endeavor
should we attempt to perform definitive studies of simulation impact
Should We Attempt to Perform Definitive Studies of Simulation Impact?
  • Goal: To convince the skeptics
  • Answer: Maybe -- if the resources are there
  • BUT… Beware of being sucked into:
    • Under-powered studies with high risk of Type II error
    • Studies of “one-off” simulation sessions rather than integrated long-term use of simulation
bottom line
Bottom Line
  • ...no industry in which human lives depend on the skilled performance of responsible operators has waited for unequivocal proof of the benefits of simulation before embracing it… Neither should anesthesiology .

(Gaba, Anesthesiology 76:491-494, 1992)