Applications of Simulation in Anesthesiology

1. 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

2. 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

3. 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

4. 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

5. Diverse Applications of Patient Simulation in Anesthesiology • Education • Training • Research • Risk management and public relations • Performance Assessment (covered later)

6. 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

7. Applications of Simulators in AnesthesiologyEDUCATION • Example Target Groups: • University students • Pre-clinical medical students • Example Target Curriculum: • Applied physiology or pharmacology

8. 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

9. 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

10. Applications of Simulators in AnesthesiologyEDUCATION • Example Target Group: • Anesthesiology clerkship students • Example Target Curriculum: • Introduction to anesthesiology • Complements OR experience

11. 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)

12. Applications of SimulatorsTRAINING • Training is targeted at specific professional groups • Training curricula focus on skills & behaviors required for tasks on the job

13. 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

14. 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)

15. 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

16. 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

17. 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)

18. 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

19. Crisis management behaviors have been studied extensively in aviation Resulting in special training: Crew Resource Management (CRM)

20. Crisis Management • Successful crisis management requires BOTH: • Sound technical skills of individuals • Sound crisis management behaviors and teamwork

21. 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

22. Principles of Dynamic Decision Making and Teamwork • Team Management Components: • Leadership & followership • Communication • Distributing the workload • Calling for help early

23. 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

24. 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

25. 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

26. 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)

27. Simulation Room -- VA Palo Alto

28. Scenarios are challenging medically, technically, and in terms of teamwork

29. A Picture of “Face Validity”

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

31. 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

32. 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.

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 3x Prototypical Experimental Design Chopra, et al; others

45. 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

46. 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

47. 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

48. 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

49. 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)

50. The End