Practical Simulation: Key Principles & Methodologies:
“—making the rubber meet the road”
by John J. Schaefer, III, MD, Professor Anesthesia and Perioperative Medicine
Assistant Dean MUSC College of Medicine, Lewis Blackman Endowed Chair
South Director: HealthCare Simulation of South Carolinaemail: [email protected]
Charleston, SC and the Medical University of South Carolina
• 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”
• 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
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
Communicate Value
Establish Value
Create/Deliver Quality Courses
Create a Functional Center/Lab
Develop a Realistic Plan
Focus will be on simulation methodology critical to achieving success!
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.
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:
– 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 facilityCapital Costs:
Renovation ~ $1,566,353Simulation equip. ~ $810,000AV equipment ~ $300,638Computers ~ $206,500Other ~ $25,000
Total: ~ $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 ITOperational Costs:
Salaries ~ $303,027Rent ~ $208,847Other ~ $61,250
subtotal: ~ $573,124Recapitalization Costs: ~$117,250Total Costs per year: ~$690,374
Typical busy week’s scheduleFocus 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. 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
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3
Session
% T
asks
Com
plet
ed S
ucce
ssfu
lly
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
Com
plex
ity o
f ope
ratin
g sim
ulat
or &
Teac
hing
Expert Instructor,Expert Simulator OperatorHigh Costs per student
Competent Facilitator(runs own simulator)Lower cost per student
Student self trainingor 1 facilitator with multiple sim. activitiesLow cost
Utilization of Simulation-based Education Methods
Range of HealthCare Simulation Operational Use:
Most Users are here---
This is what we have been doing since 2002---
We do some of this now too--
•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
Expert Curriculum/Scenario, Competent Facilitator Model
Practical SimulationExpert Instructor
Small grp. exercises
Expert Sim. Operator
Current “Expert” Instructor/Sim Operator approach
Competent Facilitator
Competent Facilitator
Competent Facilitator
And in some cases
Competent Supervisor
Student independent learning
Student independent learning
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.
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 semi-automated 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-
Bag-Mask competency skill scenario
LMA skill competency
scenarioBP assessment
practice skill scenario
Nursing Critical Care Assessment Training scenario
Anesthesia Difficult Airway Management Competency
scenarioNursing Med Surg Training
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
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.
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
•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
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
Com
plex
ity o
f ope
ratin
g sim
ulat
or &
Teac
hing
Expert Instructor,Expert Simulator OperatorHigh Costs per student
Competent Facilitator(runs own simulator)Lower cost per student
Student self trainingor 1 facilitator with multiple sim. activitiesLow cost
Utilization of Simulation-based Education Methods
Range of HealthCare Simulation Operational Use:
Focus on the methods to work in towards this quadrant
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---
