Simulation-based education in optimizing patient safety and outcomes: a local experience

PP Chen

Chief of Service

Department Anaesthesiology & Operating Services

Alice Ho Miu Ling Nethersole Hospital &

North District Hospital, Hong Kong

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Outline

� Is simulation-based medical education the right approach for us in HK?

� Local experience

To err is human �� (1999)

HA Sentinel Events 2009-2010

HA Q&S Report 2011

HA Q&S Report 2011

Common contribution factors to medical error

� Failure to check & detect

� Lack of training

� Ineffective communication

� Poor leadership

� Unclear role delineation

� Poor decision making

Reason J. BMJ 2000.

Simulation-based medical education

� Effective learning through active learner engagement

� Hands-on experience in a �real-life� setting

� Reflective learning � immediate debrief � Errors can be allowed to occur and reach their

conclusion � Repetitive practices

� Ability to vary difficulty & complexity

� Allows training on teamwork, leadership, communication , situation awareness, decision making

Areas of simulation-based medical education

� Skills acquisition� Technical eg surgical techniques

� Non-technical eg communication

� Changing behaviour� Human factors

� Team dynamics

� Assessment/credentialling � undergraduate, professional, continuous professional development

What is the Evidence for Simulation-based medical training?

� Self-efficacy Taekman JM, et al. Anesth Analg 2004, Nishisaki A, et al. CritCare Med 2006

� Competence Sica GT et al. Am J Roentgenol 1999, DeVita MA et al. Qual Saf Health Care 2005, Wallin CL et al. Med Educ 2007

� Operational performance� Airway mx Mayo PH et al. Crit Care Med 2004

� Surgical procedures Chaer RA, et al. Ann Surg 2006

� Communication Berkenstadt HB, et al. Chest 2008

� Professional behaviour & attitude Weaver SJ , et al. J Quality Patient Safety 2010

� Patient outcomes difficult to measure

��.but is simulation-based medical education expensive?

Low-fidelity vs High-fidelity

� Role play

� Standardized patients (Actor)

� Task- trainers

� Computer-based programme eg virtual reality

� Full motion computer controlled simulator

Confucius551 BC � 479 BC

I hear and I forget,

I see and I remember,

I do and I understand

不聞不若聞之，

聞之不若見之，

見之不若知之，

知之不若行之;

學至於行之而止矣

First do no harmPrimum non nocere

1720�s1027

SBME is really a great approach for patient safety training! ......

especially for high-risk, low frequency (uncommon) medical

conditions

SBME in Hong Kong?

HK has come a long way ��

� Technical skill training � ACLS, ATLS, PALS, Airway management � Surgical skill training eg laparoscopy, endoscopy� Nursing education� Undergraduate teaching

� Non-technical skill� CRM eg ACRM, EMAC� Communication skill training� Team training

A&E Training Centre RTSKH

� Basic Life Support (BLS)

� Advanced Cardiovascular Life Support (ACLS)

� International Trauma Life Support (ITLS)

� Acute Stroke Life Support (ASLS)

� Simulated Accident & Vehicle Extrication (SAVE)

� Emergency Management of Severe Burns (EMSB)

� Public courses � BLS, Basic ITLS, Airway mgt, First Aid

CMC Resuscitation Training Centre

� AHA & National Safety Council Courses� BLS

� ACLS

� PALS

� Heartsave CPR

� First Aid

� Airway Mgt

� Emergency Response Team Course

� Public courses

HA Infectious Disease Simulation TrainingCentre (HAIDSTC) PMH

� Drills on infectious disease� Work in collaboration with AED, ICU, hospital

infection control teams & supporting services, CHP and DH

� Conduct simulation training program for newly qualified HA registered nurses � organized by IANS� Enhance essential core competencies in patient

assessment and proficiency in providing safe practice during medical emergency

� Train-the-trainer courses � Critical care nursing

Demonstrating how to perform NPA in a safe manner

Suspected avian influenza (H5N1) � Performing endotracheal intubation

A nurse is assisting the doctor in performing a high-risk procedure � lymph node aspiration on a patient suspected of plague

Ambulance Depot in the Hospital Authority Infectious Disease Centre - A woman with suspected avian influenza

HKEC Training Centre, PYNEH

Crew Resource ManagementPatient Safety

� Aim to enhance communication and cooperation of the hospital staff and medical teams to reduce hospital incidents and ensure patient safety

� Pilot in PYNEH, training of 1400 staff 2010-2011

� Using local cases for illustrations

� In the evaluation phase

PYNEH

� Simulator instructors course in March 2011, conducted by the Harvard�s Simulation Centre team

� Fully staff to provide training for HKEC�s & other HA healthcare professionals

� Minimal Access Surgery Training Centre� Spacious with advanced computer-controlled

surgical skill training simulators

� Surgical skill training

NTWC Clinical Skill Training Centre Tuen Mun Hospital

Multidisciplinary Simulation & Skill Centre, QEH

� Recently held a simulation instructor course conducted by the WISER group, University of Pittsburg in May 2011

� ATLS

� Resuscitation courses

� Endovascular surgical skill training

University Postgraduate Training Centres

� HKU JC Skill Development Centre QMH� ATLS, ACLS

� CUHK JC Minimally Invasive Surgical Skill Centre PWH

� CUHK Orthopaedic Skill Lab, PWH

NDH Institute of Clinical Simulation� Anaesthesiology-training course

� Effective Management of Anaesthesia Crisis (EMAC) 2004-

� Exposure to Anaesthesia Safety & Emergencies (EASE) for new trainees

� Crew resource management courses� Anaesthesia Crisis Resource Management (ACRM) 2001-

� Management of Anaesthesia Clinical Emergencies (MACE)

� Medical Intervention of Clinical Emergencies (MICE) for different medical specialties

� Nursing Intervention of Clinical Emergencies (NICE)

� Airway management courses� Advanced & Difficult Airway Management � Anaesthesiologist (ADAM-A)

� ADAM- N for nurses

� ADAM- D for doctors from all medical specialties

� Others � Safe sedation course for doctors and nurses from different medical specialties

� HA Junior Doctors� Essential Basic Clinical Skills Course

� Team-CPR workshop for different medical specialties

� Instructors courses & refreshers

Usual CRM course format

Medical Intervention of Clinical Emergencies Course 2009

94.6% 75.8% 70.8% 91.0% agree or strongly agree

MICE Evaluation from 56 participants

0

20

40

60

80

Rel

evan

ceof

trai

ning

Wor

k m

ore

safe

ly

Cha

nge

prac

tice

Rec

omm

end

othe

rs

Per

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e

Strongly disagree

Disagree

Undecided

Agree

Strongly agree

Mean scores + SD 4.2+0.5 3.9+0.7 3.9+0.7 4.1+0.7)

94.5% 75.8% 70.9% 91.0%

Subsequent Follow-up 2011 � n=65, response rate 54%

� 55 experienced one or more (median 3, range 0-7) medical emergencies after the course

� The most common types of event were

� shock (45), cardiac arrest (41), airway crisis (33).

� Forty seven (72.3%) perceived that lessons learned during the course were helpful in managing their clinical emergencies

� The respondents� attitude towards principles of crisis management showed significant improvement in all aspects (p<0.001)

Team-CPR course

� Participants agreed that� the course has achieved its

stated objective (5.28+0.46)

� the course content was practical for their workplace (5.44+0.51)

� their learning in the course was enhanced by the experiential education process (5.33+0.49 )

� they were satisfied with the course as a whole (5.33+0.49)

� Behavioural aspects, communication and team interaction issues and deficiencies in other non-technical areas were observed

Is SBME the answer?

� SBME is only just a tool to enhance learning & training

� In order to be effective it has to be implemented appropriately

� SBME trainers and raters have to be properly trained

� Organisational support and additional resources

� Outcome evaluation and course review

See one, do one, teach one

See one, practice many times on simulator, do one, teach one

��..and learn about communication, teamwork,

decision making

Asia Pacific Meeting on Simulation in Healthcare 2011

New Horizons Grand Hyatt, Hong Kong 19/05/11 - 22/05/11

We still have a long way to go in HK!

Summary

� Patient safety remains a major priority in HA

� There is a general shift of teaching approach toward high-fidelity SBME in HK healthcare

� SBME in healthcare is still relatively new to us

� Concern about cost-effectiveness

� What direction � single vs multiple centres

� Various centres need to work together to come up with a comprehensive programme for HA & HKAM

Thank you!chenpp@ha.org.hk

Acknowledgement

Dr Libby Lee, HAHO

Dr WK Ching, HAHO

Dr CC Lau, HKEC Training Centre, PYNEH

Dr CW Kam, NTWC Clinical Skill Training Centre, TMH

Ms OM Ho, HA Infectious Control Simulation &Training Centre, PMH