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

• 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).

“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 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?
1.
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.
2.
Healthcare teachers with reasonable training can adopt simulation training methodologies rapidly.
3.
The “value” of using simulation justifies the capital, operating and indirect costs associated with it.

“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

• 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:
Large Center:
Size: 11,000 sq ft facility
Capital Costs:
Renovation
Simulation equip.
AV equipment
Computers
Other
Total:
Average capital cost / sq. ft ~ $250
~ $1,566,353
~ $810,000
~ $300,638
~ $206,500
~ $25,000
~ $2,908,491

Simulation Center
Costs/yr. Examples:
Large Center:
Staff: 30% Med. Director, 2 Admin., 2 Sim., Spec., 1 IT
Operational Costs:
Salaries ~ $303,027
Rent
Other
~ $208,847
~ $61,250 subtotal: ~ $573,124
Recapitalization Costs: ~$117,250
Total Costs per year: ~$690,374

Focus will be on simulation methodology critical to achieving success!

•
•
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.
Utilization:



# students trained
# courses delivered
# faculty involved
2.
Measured Educational Value:
 Subjective evaluations
 Objective evaluations
 Peer reviewed publications
 Non-peer reviewed publications
 Grant dollars generated
3.
Financial Educational Value:
 Indirect dollar savings (Malpractice Costs)
 Direct dollar generation or savings (Save direct training dollars)
4.
Public Relations Value:
 Recruitment
 Referrals to Health System
 Fund Raisers
 Others

Communicate Value (to Stakeholders)
Results
50%
40%
30%
20%
10%
0%
100%
90%
80%
70%
60%
1 2
Session
3

“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:
Expert Instructor,
Expert Simulator Operator
High Costs per student
Most Users are here---
Competent Facilitator
(runs own simulator)
Lower cost per student
This is what we have been doing since 2002---
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
Instructor
Expert Sim.
Operator
Practical Simulation
Expert Curriculum/Scenario,
Competent Facilitator Model
Competent
Facilitator
Competent
Facilitator
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

And in some cases
Student independent learning
Student independent learning 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
Note: until this level is achieved, using simulation requires more “Instructors” than traditional educational methods though many believe simulation decreases the need.

• 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:

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
Nursing Critical practice skill 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

• 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”
⁺
₌

“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)

• 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!

• Need a volunteer to run scenario (familiar with a nasogastric tube)
• Minimal experience with SimMan
• NOTE: I will be the

Competent
Supervisor
Student independent learning
Student independent learning
Student independent learning
Student independent learning

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

• 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

• 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)

“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:
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

• 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