Transcript Practical Simulation | John J. Schaefer, MUSC College of

Practical Simulation: Key Principles & Methodologies:
“—making the rubber meet the road”
by John J. Schaefer, III, MD,
South
Professor Anesthesia and Perioperative Medicine
Assistant Dean MUSC College of Medicine,
Lewis Blackman Endowed Chair
Director: HealthCare Simulation of South Carolina
email: [email protected]
Charleston, SC and the
Medical University of South Carolina
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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”
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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”
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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 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
Focus will be on simulation methodology critical to achieving success!
Communicate
Value
Establish Value
Create/Deliver Quality Courses
Create a Functional Center/Lab
Develop a Realistic Plan
What is meant by “practical” simulation in Healthcare?
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2.
3.
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 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
• 11,000 sq ft training space, 15
available training rms.
• Stake holders: All Colleges & Medical
Center
• Opened June 2008
• Activities 2008-09:
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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:
Large Center:
Size: 11,000 sq ft facility
Capital Costs:
Renovation
Simulation equip.
AV equipment
Computers
Other
Total:
~ $1,566,353
~ $810,000
~ $300,638
~ $206,500
~ $25,000
~ $2,908,491
Average capital cost / sq. ft ~ $250
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
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”
Focus will be on simulation methodology critical to achieving value!
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:
1.
2.
3.
4.
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Utilization:
# students trained
# courses delivered
# faculty involved
Measured Educational Value:
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Subjective evaluations
Objective evaluations
Peer reviewed publications
Non-peer reviewed publications
Grant dollars generated
Financial Educational Value:
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Indirect dollar savings (Malpractice Costs)
Direct dollar generation or savings (Save direct training dollars)
Public Relations Value:
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Recruitment
Referrals to Health System
Fund Raisers
Others
Communicate Value (to Stakeholders)
Results
% Tasks Completed Successfully
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
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2
Session
3
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
Range of HealthCare Simulation Operational Use:
Complexity of operating simulator & Teaching
Most Users are
here--This is what we
have been doing
since 2002---
Expert Instructor,
Expert Simulator Operator
High Costs per student
Competent Facilitator
(runs own simulator)
Lower cost per student
We do some of
this now too--
Student self training
or 1 facilitator with
multiple sim. activities
Low cost
Utilization of Simulation-based Education Methods
Current “Expert” Instructor/Sim
Operator approach
Expert Curriculum/Scenario,
Competent Facilitator Model
Competent
Facilitator
Expert
Instructor
Expert Sim.
Operator
Practical Simulation
Competent
Facilitator
Small grp.
exercises
•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
Competent
Facilitator
And in some cases
Competent
Supervisor
Student
independent
learning
Student
independent
learning
•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
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-• 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.
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-1. Pre-course participant preparation through studying online curricula
based on “adult learning” principles.
2. 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.
3. The simulation exercise uses a well designed, pre-programmed simulation
scenario run by the facilitator (teacher). This scenario incorporates semiautomated 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.
4. 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-
Anesthesia
Bag-Mask
LMA
skill
BP
Difficult
Nursing
assessment
Critical
Airway
competency
Care
practice
Management
Assessment
skill
skill
scenario
scenario
Nursing
Med
Training
Competency
scenario
scenario
Surg
Training
scenario
scenario
Trauma
Assessment
Demo scenario
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:
• Present simulation “case stem”
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 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 to:
• Standardized debriefing cues during the simulation that
automatically appear on the monitor.
Multimedia can be embedded in a programmed scenario to:
• Scenario support info.: i.e. equipment list, equipment layout & QA,
instructions, etc.
Nursing Aspiration Prevention & Rx
”Semi-Automated, Standardized Guide for
“Diagnostic Educational Objectives based Reflection”
Well designed/programmed scenarios that are simple to run coupled with
“Semi-Automated Objective Driven Reflection Process”
⁺
₌
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)
Good “Theater” does not equal
“Learning”!
=
Task training: NG tube objective assessment (interactive demo)
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--• Need a volunteer to run scenario (familiar
with a nasogastric tube)
• Minimal experience with SimMan
• NOTE: I will be the
Vital Signs Training
Competent
Supervisor
Student
independent
learning
Student
independent
learning
Student
independent
learning
Student
independent
learning
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
Competent
Supervisor
Student
independent
learning
Student
independent
learning
•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
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 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 it--• Need 8 volunteers to run scenario (familiar
with measuring HR, BP, RR)
• Minimal experience with SimMan
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)
Individual assessment----Nursing student med administration (video demo)
Interdisciplinary Focus: SIRE (video demo)
Research using Simulation
Individual assessment----Pediatric Resident NRP Individual assessment (video
demo)
Specialty Team Focus: Neonatal LBW Team (video demo)
Task Training: Orthopedic Surgery (video demo)
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
Range of HealthCare Simulation Operational Use:
Complexity of operating simulator & Teaching
Focus on the methods to
work in towards this
quadrant
Expert Instructor,
Expert Simulator Operator
High Costs per student
Competent Facilitator
(runs own simulator)
Lower cost per student
Student self training
or 1 facilitator with
multiple sim. activities
Low cost
Utilization of Simulation-based Education Methods
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---