The Integrated Simulation Center:Lessons Learned

Tony Errichetti, Patty Myers, Tom Scandalis

American Association of Colleges of Osteopathic Medicine4th Annual Meeting – “Challenges and Opportunities”

Baltimore, MD - June 24, 2006

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Objectives

• Describe the state-of-the-art simulation center

• Discuss curricular, political and logistical issues in setting up a simulation center

What are the key issues, decisions?

• Review major simulations technologies, and their integration

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Simulation = reality substitution

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Increased use of simulations Increased use of simulations because….because….

Shrinking patient base, shorter staysShrinking patient base, shorter stays

COMLEX-PE, USMLE-CSCOMLEX-PE, USMLE-CS

DO School Sim Center Program SurveysDO School Sim Center Program Surveys - 2001 - SP Programs: 62%- 2001 - SP Programs: 62%

- No robotic sim programs - No robotic sim programs (JAOA)(JAOA) - 2006 - SP programs: 82%, 8% under development- 2006 - SP programs: 82%, 8% under development - Robotic sim programs: 57% - Robotic sim programs: 57%

(submitted to JAOA)(submitted to JAOA)

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Increased use of simulations Increased use of simulations because….because….

Simulation industrySimulation industry (SPs, patient simulators, (SPs, patient simulators, virtual reality)virtual reality)

High medical error rates, lawsuits and public High medical error rates, lawsuits and public demands for higher qualitydemands for higher quality - -

Patient safety!Patient safety!

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Classroom Work

How do simulations “work”?

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How do simulations “work”?• Practice / repetition in a patient- and trainee-

safe environment (sim center)

“Confidence builds competence”

• Arousal, increase of productive anxiety, “nightmare” scenarios

• Feedback / debriefing – the essential element

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Simulations ….Simulations ….

……solve training logistical problemssolve training logistical problems

““We prescribe illnesses”We prescribe illnesses”

……provide control of the clinical training provide control of the clinical training and skills assessmentand skills assessment

……do not harm or leave patients untreated do not harm or leave patients untreated as a bi-product of medical educationas a bi-product of medical education

Simulation Center Elements

Simulation TechnologiesSimulation Connectivity System

Simulation Technologies

Simulation Triad

Simulated and standardized patients: What’s the difference?

Simulated Standardized

More realistic More standardized

Less standardized Less realistic

Training Assessment

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Early Mechanical Simulator

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1700s“Venus Médica”

La Specola Collection, Firenze

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1700s“Venus Médica”

La Specola Collection, Firenze

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Gross Anatomy

Animal Models

e.g Suturing Practice

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Part-task / Part body trainersBasic conceptsPsychomotor skills training

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Patient simulators (manikins) Teamwork, procedures e.g. codes, ACLS

Procedure simulators Psychomotor skills, e.g.

laproscopic surgery

Virtual Reality and Computer-Based ProgramsPC/Mac – Patient “in the computer” (DxR)Haptic – Feel and touchFull immersion – Haptic plus virtual environment

Full-Immersion Virtual Reality

                                                                                                        

Diana – University of Florida

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Easy storageUsers (trainees, faculty) retrieve videos

through the webSP / Sim training / quality assuranceDebriefing / precepting / feedback – locally

and remotely

Digital AV

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Paperless PC / PDA data collection - ROI: saves time and human resourcesData analysis / scoring / score reportingEvaluation of trainees, facultyLongitudinal studies of competency acquisition

Data Collection

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Managing schedules (e.g. students, SPs) - ROI: saves time and human resourcesExam managementAutomated announcementsAutomated DV camera movements

Program Management

Planning / Financial Issues

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Training areas (rooms)

Permanent Mobile

Simulators, equipment (stuff)

Faculty Staff (people)

Curriculum SPs, trainers,techs, coordinators

$im Center Element$

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# 1 Problem

Building first, then planning

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Problems• Budgeting and

purchasing out of synch with planning and operations.

• Users aren’t consulted in design process.

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Lesson Learned

Planning =

Really good planning =

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# 2 Problem

Buying more manikin than what’s needed, and / or not budgeting for

other simulation equipment

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Lesson Learned

• Manikin just one of hundreds of pieces of equipment needed

• Develop a program first (planning again) before committing to a manikin

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Lesson LearnedSim Centers are expensive!

“We’re in a medical education arms race!”- Ken Veit, D.O. - PCOM

Collaborate when possible Establish regional sim centers

Sell your services

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# 3 Problem

Decentralized management of simulation services

Administrative Problem

Family Medicine

Surgery / ED

MIS

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Lesson Learned

Centralized management of all sim services, under a dean (vs. e.g. family medicine), to

maximize efficiency, and program integration

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Lesson Learned

Program director = an expert in performance test development (usually a Ph.D.) who can

work with and develop clinical faculty to: create formative and summative assessment

set pass-fail standards design research

Have a consultation line in your budget to bring in experts

How Simulations Are Changing Clinical Learning

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From Learning Silos…

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To integrated curriculum

Basic Sciences / Clinical

Knowledge / Skills

Because the work requires integration of knowledge, skills, attitudes

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…and integrated health care delivery

DOCTORS

NURSES, PAs

PTs

…because healthcare requires team work

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“Cardiology” Scenario

Students encounter a cardiology complaint (manikin) and discuss physiology /

pharmacology issues with a science teacher

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“Gross anatomy - SP” Scenario

Students in gross anatomy dissect the abdomen and then watch a video, in the lab, of a patient (SP) presenting with abdominal

complaints.

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“Suturing” Scenario

Students practice suturing (p/task trainer) attached to a “conscious patient” (SP)

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“Conscious - Comatose” Scenario

Students encounter a hospital patient (SP), then that same patient in a comatose state

(manikin)

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“Pre-Encounter” Scenario

Students prepare for a sim encounter by meeting a web-patient (PC-VR), then meet

the “actual patient” (manikin) in an ED setting, and / or live patient (SP)

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“Patient Management” Scenario

Students encounter a patient (SP), then that same patient in a acute state

(manikin), then manage the patient’s treatment post-discharge (PC-VR)

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“Simulator-Audience Response” Program

Students encounter a patient in an acute state (manikin), and through a live DV feed,

an audience participates via an audience response system

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“Death and dying” Scenario

Students encounter “dying patient”(manikin), then counsel “grieving family

member” (SP)

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Death and Dying Scenatio: Objectives

• Combine clinical training and behavioral medicine

• Verisimilitude: Using the manikin to get students (MS1) into the “death and dying” scenario, to practice couseling

• Integrate PA, DO and psychology faculty

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Steps

• Developed manikin case

• Developed 5 SP cases, i.e. 5 SPs representing 5 different grief reactions

• Trained SPs

• Ran the program

• Debriefed the students

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Videos

Summary:State-of-the-Art Sim Center

Integrates the Simulation TriadIntegrates knowledge and skills

Simulation connectivity system that integrates everything together

Plan before you build -

Consult the users! Faculty development – the hardest

job

For InformationTony Errichetti, Ph.D.

Chief of Virtual Medicine

Director, Institute For Clinical Competence

terriche@nyit.edu

516.686.3928