“Bringing It Home”
Bringing Simulation Home:
From the Simulation Laboratory to In Situ Simulation
“Simulation changes what we teach, how we teach
and when [and where?] we teach.”
Jeff Riley, Mayo Clinic, Rochester MN USA
Disclosure:
• Create
a simple low fidelity perfusion simulator
I have advised, or managed grants or clinical trials to Mayo Clinic in
the areas
of simulation
and perfusion
technology
with scenarios
the following
• Work
with
colleagues
to produce
simple
groups:
that address training needs at the participant’s
Sorin USA
Specialty Care
place of
work
Medtronic
Maquet Getinge Group
Global Blood Resources
Terumo Cardiovascular
The last time I heard Riley talk at a
meeting, I _________.
1.
2.
3.
4.
5.
left the room
was underwhelmed
had heard it before
learned something
went home and
changed something
Status: In Situ Perfusion Simulation
•
First In Situ Perf Sim June 2009 at The American Society of Extracorporeal
Technology (ICEBP/AmSECT) Safety & Best Practices Meeting in NOLA
– Collaboration between academia, industry and your professional organizations
has been successful
•
Feasible: The human factor interface between the perfusionist, the cardiac
surgical team, the complex equipment and the patient lends itself well to
simulation exercises
– The centerpiece technology that makes a high-fidelity OR education
suite more feasible is the Orpheus Perfusion Simulator from ULCO
•
There have been several publications focusing on perfusion simulation in
recent years
– Most of these publications have focused on teaching thoracic surgical
residents at boot camps
•
A recent PubMed search (August 21, 2011) of “In Situ simulation” yielded 21
publications going back to 2008.
– In Situ perfusion simulation has and will occur at numerous meetings in
2011 and 2012
Have you participated in a perfusion
simulation in the last 12 months?
1. No
2. Where would I
find a perfusion
simulation center?
3. Yes
From Wikipedia, the free encyclopedia
“Medical simulation is a branch of simulation technology related to
education and training in medical fields of various industries. It can
involve simulated human patients, educational documents with detailed
simulated animations, casualty assessment in homeland security and
military situations, and emergency response. Its main purpose is to train
medical professionals to reduce accidents during surgery, prescription,
and general practice.
Many medical professionals are skeptical about simulation, saying that
medicine, surgery, and general healing skills are too complex to
simulate accurately. But technological advances in the past two
decades have made it possible to simulate practices from yearly family
doctor visits to complex operations such as heart surgery.”
At home, are you involved with In
Situ simulation?
1. Frequently
2. One or two times
per year
3. Rarely
4. What is In Situ
simulation?
AmSECT
ICEBP
Academia
Industry
AmSECT’s ICEBP Community Simulation Project:
An Observational Feasibility Study
Produced by the AmSECT’s ICEBP Perfusion Simulation Collaboration
New Orleans LA USA: June 24, 2009
Have you participated in an AmSECT /
ICEBP simulation at ______?
1.
2.
3.
4.
5.
6.
7.
BP NOLA 2009
BP Toronto 2010
Intl Conf NOLA 2011
1&2
1&3
2&3
All three
Jun 2009: New Orleans
Medtronic
Terumo
SUNY University
Midwestern University
Sorin Room 412
Terumo Room 414
Medtronic Room 409
Maquet Room 419
Oct 2010 Toronto
•
•
•
•
Sim centers are expensive
In Situ simulation is feasible
Evaluation is possible
Participants value the experience
“Simulation has several attributes of value to adult education, relevant to the
cardiac surgical situation (19). It allows learners to be actively engaged in the
educational process, in solving real life problems, and in gaining relevant (albeit
simulated) clinical experience, and it provides opportunities for practice, for
feedback, and for reflection (27). Simulation has been used to impart knowledge
and teach skills in many medical disciplines.”
What is different about adult education and learners?
Human Factors and the Cardiac
Surgical Multidisciplinary Team
• HF contribution to cardiac surgery is becoming obvious
• Given the scientific gains in cardiac surgery – the
greatest opportunity for future improvement lies in
improving human performance
• Implies the evaluation of clinicians and of equipment and
the interaction between the two
• A large part of the HF science involves improving
aspects of teamwork to reduce errors
Merry AF. Human factors and the cardiac surgical team: A role for simulation. J ExtraCorpor Technol. 2007;39:264-6.
Eason MP. Simulation devices in cardiothoracic and vascular anesthesia. Semin
Cardiothorac Vasc Anesth. 2005;9(4):309-23.
http://www.surveymonkey.com/s/perfusion-simulation
AmSECT’s Taskforce on Perfusion Simulation
ELSO’s Simulation Taskforce
Mayo Clinic
Multidisciplinary
Simulation Center
http://www.simcentral.com.au/
In Situ
Simulation
Error Reporting Identify Problem
Design Scenario
Around Problem
Run Scenario
Am J Manag Care. 2010;16(6):e145-e150)
Debrief and
Pronovost P, Freischlag J. Improving teamwork to reduce surgical mortality. JAMA. 2010
Evaluate
2010;;304:1721-1722.
Neilly J, Mills P, Xu Y, Carney B. Association between implementation of a medical team training
program and surgical mortality. JAMA. 2010;304:1693-1700.
Does your perfusion group participate
in a prospective perfusion errorreporting system?
1. No
2. Would like to
design one to use
3. Occasionally
4. Yes
If you could benchmark with other groups,
would you contribute to an AmSECT / ICEBP
/ international voluntary error-reporting
system?
1. No
2. Occasionally
3. Yes
Extra-Corporeal Life Support
ECLS, ECMO and Simulation
Simulation activities are a central element for our
institutional continuous cycle of ECLS systematic
improvement to meet the ELSO requirements for an
ECLS Center of Excellence
– Clinical case CQI event reports guide scenarios
• Basic individual and team competency training
• Safety Drills in simulation center
– hypertension, hypotension, hypovolemia
– venous air and arterial thrombus embolism
• Team and Specialist performance assessment
1.
2.
3.
4.
Weinstock PH, et al. Pediatr Crit Care Med. 2005;6:635-641.
Anderson JM, et al.Simul Healthcare. 2006;1:220-227.
Fleming GM, et al. Pediatr Crit Care Med. 2009;10:439-444.
Nishisaki A, et al. Anesthesiology Clin. 2007;25:225-236.
In Situ Sim is Simple
•
First: Identify key perfusionist and team behaviors to practice and confirm
by simulation.16
– High reliability organizations know and practice the key behaviors and skills
required during high-risk critical events.17, 18
– HRO error-reporting identifies team learning opportunities
•
Second: select and outline a realistic high risk, high frequency scenario
based on the interaction between the clinician, a piece of equipment and a
patient situation.
– The scenario should be realistic and have scientific and clinical merit (written
procedures and references).
– The scenario should be integral to a clinical procedure guideline and include
practitioner behaviors and skills that are measurable.
•
Third: the scenario should be presented in an organized fashion such as the
brief-simulate-measure-debrief-evaluate model.
– Debrief / Reflection is important and where the learning takes place
•
The simulation ends with the completion of two simple, written evaluation
instruments that give the facilitator and the learner the opportunity to
evaluate the learning scenario.
The Eight Steps of Scenario Design
McLaughlin, et al. Simul Healthc. 2006;1:18–21
1.
2.
3.
4.
5.
6.
7.
8.
OBJECTIVES: Create learning ⁄ assessment objectives.
LEARNERS: Incorporate background ⁄ needs of learners.
PATIENT: Create a patient vignette to meet objectives that also
must elicit the performance you want to observe.
FLOW: Develop flow of simulation scenario including initial
parameters, planned events ⁄ transitions, and response to
anticipated interventions.
ENVIRONMENT: Design room, props, and script and determine
simulator requirements.
ASSESSMENT: Develop assessment tools and methods.
DEBRIEFING: Determine debriefing issues and mislearning
opportunities.
DEBUGGING: Test the scenario, equipment, learner responses,
timing, assessment tools, and methods through extensive pilot
testing.
Begin
Simulation
On CPB: P2
Read Patient
Medical
Record
Recognize and
Treat
Hypotension
Set-Up HLM
and DMS
AMOD-03:___
Increase
Blood Flow?
No
Surgeon: "Aortic
cannula is in"
Orpheus: Clamp arterial line
AMOD-04:___
Yes
Admin
Alpha
Agonist?
Anesth: "What
is the cardiac
index?"
No
Anesth:
"Treating the
mABP?"
Perfusionist Communicates
Appropriately
AMOD-01:___
Perf Test
Art Line?
No
AMOD
0 = not able to perform task
1 = was guided through task
2 = requires some task assistance
3 = just able to perform task
4 = performs task promptly
AMOD-05:___
Orpheus: Set SVR = 25
Surgeon: "Drift to
32oC"
Perfusionist Tests
Art LIne, Discovers
Clamp
AMOD-06:___
Perfusionist Communicates
Appropriately
No
Surgeon: "Go on
bypass'
Perf
Response?
Yes
AMOD-07:___
Orpheus: Unclamp arterial line
Perf Changes
HE Water
Temp
Anesthesiologist: "Let me know
when you are up to full flow"
AMOD-02:___
Initiate
CPB per
MD VO
No
On CPB: P2
Orpheus: Set SVR = 7
Yes
On CPB: P2
No
How many In Situ simulation scenarios
have you or your team designed in the
last 2 years?
20% 20% 20% 20%
20%
1.
2.
3.
4.
5.
None
One or two
Three to five
More than five
Going back home
to give it a try
1
2
3
4
5
What is competency?
Acad Med. 2002;77:361–367
•
•
•
‘‘Competency’’ is a complex set of behaviors
built on the components of knowledge, skills,
attitudes (KSA)
‘‘Competence’’ is personal ability
Discrete measurable behaviors
1. competency identification
2. determination of competency components and
performance levels
3. competency evaluation, and
4. overall assessment of the process.
Kolb's
Learning
Styles
Active
Experimentation
Doing
Concrete Experience
Feeling
Accommodating
Diverging
(feel and do)
CE/AE
(feel and watch)
CE/RO
Perception
Continuum
Processing
Reflective
Observation
Watching
Continuum
how we
do things
how we think
about things
Converging
Assimilating
(think and do)
AC/AE
(think and watch)
AC/RO
Abstract
Conceptualization
Thinking
© concept david kolb, adaptation and design
alan chapman 2005-06, based on Kolb's learning
styles, 1984
What is your clinical learning style
preference?
1. Concrete experience
(feeling)
2. Reflective observation
(watching)
3. Abstract
conceptualization
(thinking)
4. Active experimentation
(doing)
Crisis (Crew) Resource Management
Seven Skills
•
•
•
•
•
•
•
Mission / Flight Analysis (briefing)
Assertiveness
Decision Making
Communication
Leadership
Adaptability and Flexibility
Situational Awareness
http://marinegouge.com/mediawiki-1.13.3/?title=Crew_resource_management
DAMCLAS / MCSALAD / SADCLAM
In a culture of safety sense, does your cardiac
surgery team participate in multi-disciplinary
“team training”?
20%
20%
20%
20%
3
4
20%
1. We probably never
will
2. Not right now
3. We do not need to
4. We are in planning
stages now
5. Yes we do
1
2
5
Summary
• You are performing In Situ simulation everyday. With a
little reading, planning, written organization and
adherence to a few educational and structural methods
you can formalize your simulation activities at your home
base
• Any type of simulation including In Situ is employed to
give highly-trained competent professionals the
opportunity to demonstrate their patient- and machinespecific skills in an evidence and clinical procedure
based activity
• Go home and (re-)energize your team
http://www.surveymonkey.com/s/perfusion-simulation