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MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY. Professor Harry Owen Director, Clinical Skills and Simulation Unit Flinders University Adelaide, South Australia harry.owen@flinders.edu.au. MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY. Background to simulation

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medical simulation in improving patient safety

MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY

Professor Harry Owen

Director, Clinical Skills and Simulation Unit

Flinders University

Adelaide, South Australia

harry.owen@flinders.edu.au

medical simulation in improving patient safety1
MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY
  • Background to simulation
  • Simulation technologies used in Medical Education in Australia, the US and Europe
  • Fundamentals of high-fidelity simulation
  • How simulation can improve patient safety
  • Emerging trends in simulation
why simulation
Why simulation?
  • Simulation is valuable when ‘on-the-job’ training is expensive or risky
  • Simulation has been adopted for training where consequences of error expose many people to risk or the cost of error is high, for example:
    • Aerospace
    • Military
    • Nuclear power plants
medicine a high risk industry
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%
how simulation can improve patient safety
How simulation can improve patient safety
  • Fewer errors
  • Better error trapping
  • Improved recognition of error and/or consequences of error
  • Develop capacity to manage consequences of error
advantages of simulation
Advantages of Simulation
  • Structured learning
  • Guaranteed and scheduled opportunities for teaching learning
    • Uncommon situations can be presented
    • Teacher can model process, give feedback, repeat process, modify process
  • Repetition as often as needed
successful strategies for crisis management
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
who s who in medical education
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
simulation technologies used in medical education
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
cost and benefit in simulation
Cost and benefit in simulation

Full mission simulation

Manikin training

$$$$$

Part-task trainers

CBT

Increasing level of fidelity and exclusivity

medical education includes knowledge skills attitudes
Medical Education includesKnowledge/Skills/Attitudes
  • Individual psychomotor skills
  • Appropriate application of skills
  • Communication / Team performance / Leadership skills (CRM)
  • Supervision/teaching
  • Assessment
knowledge skills attitudes
Knowledge/Skills/Attitudes
  • Teaching best practice
    • integrated
    • learner centred
    • appropriate use of technology
  • Assessment best practice
    • valid and reliable
    • reproducible
the flinders clinical skills and simulation unit
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 quickly recognised
  • Now involved in teaching across disciplines and outside the medical school
endotracheal intubation
Endotracheal intubation
  • Learnt on patients under anaesthesia
  • No special consent

but

  • Duty of care to protect patient from harm
  • Increased risk when performed by a student or trainee
endotracheal intubation1
ETI needed by many health professionals, including anesthesiologists, paramedics/EMTs, rural GPs, emergency physicians, ICU staff, respiratory therapists, etc.

Competence requires practise

Endotracheal intubation
when and how should eti be taught
When and how should ETI be taught?
  • Animals
    • Small, e.g. cats
    • Large, e.g. dogs or monkeys
  • Unconscious patients
    • In the OR
    • In ICU
  • Newly dead/recently deceased
  • Cadavers
  • Simulators
the learning environment
The learning environment
  • Quiet, few distractors
  • Clinical equipment
  • Expert tutors
  • Realistic models
  • Many different models
    • Easy  difficult very difficult
outcomes of the eti program
Outcomes of the ETI program
  • Goal of reducing patient risk of trauma has been achieved
  • Improved confidence of students and trainees
  • Trainees receive more teaching
  • Improved trainer satisfaction
the flinders clinical skills and simulation unit1
CBT

ResusSim

CathSim

PA simulator

ECG

Local anaesthesia

Part-task trainers

BLS & ALS

IVI & CVC

Trauma

Adult

Gynae & Obstetric

Neonatal

Premature (28wks)

Paediatric (age range)

The Flinders Clinical Skills and Simulation Unit
slide20

Actar D-Fib®

(Armstrong)

Adult A-A Female ®

(Nasco)

CPR Prompt ®

(Compliant)

Fat Old Fred ®

(Lifeform)

David/Adam ®

(Nasco)

Little Anne™

(Laerdal)

CPR Pal®

(Ambu)

Economy Saniman®

(Nasco)

Basic Buddy™

(Lifeform)

the flinders clinical skills and simulation unit2
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

The Flinders Clinical Skills and Simulation Unit
anatomy of a simulation 1
Components

Student/trainee/health professional

Procedure/task/skill/test/treatment or equipment

Patient and/or disease process

Trainer/supervisor

Anatomy of a simulation (1)
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

Anatomy of a simulation (2)
slide24
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)

high fidelity simulation 1
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
high fidelity simulation 2
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
resources
Resources
  • 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
    • Bio-medical technician essential! Also clerical.
before and after simulations
Before and after simulations...
  • Set-up scenario
    • eg. make blood, set up OR, X-rays, etc
  • Load up simulation program
  • Check everything works
    • Cameras, VCR, communicators

Afterwards...

  • Check simulator
  • Clean everything used and put away
  • Replace/reorder all used items
high fidelity simulation 3
High fidelity simulation (3)
  • Allow time for familiarisation with the simulator & equipment
  • Brief participants on:
    • The scenario
    • Educational objectives
    • How to get help
high fidelity simulation 4
High fidelity simulation (4)

Always follow the script but...

…have alternative outcomes planned and rehearsed

Simulation control room

high fidelity simulation 5
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

high fidelity simulation 6
High fidelity simulation (6)

Facilitated debriefing with an expert practitioner. Participants reflect on their own performance and discuss this with the group

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

How we use the SimMan UPS
simulation centres
Simulation centres

May 2003

11

9

10

20

195

25

2

10

6

5

2

2

Flinders Uni

research needed on simulation in healthcare training
Research needed on simulationin healthcare training
  • 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
simulation technologies used in medical education1
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
the future of simulation
The future of simulation...
  • Skills training tool for all disciplines
    • Acute care
    • New techniques and/or equipment
    • Managing complications
    • Retraining
  • Multi-disciplinary training
    • inter-professional communication
    • team performance
  • Training in decision-making/resource co-ordination