John C. Messenger, MD, FACCJohn C. Messenger, MD, FACCAssociate Professor of MedicineAssociate Professor of Medicine
Division of CardiologyDivision of CardiologyDirector, Cardiac Catheterization LaboratoriesDirector, Cardiac Catheterization Laboratories
University of Colorado DenverUniversity of Colorado Denver
Simulation Training to Improve Heart Attack Care for Rural Hospitals
2008 AHRQ Annual Meeting
BackgroundBackground
Multiple therapies have been demonstrated to Multiple therapies have been demonstrated to improve survival in patients suffering a heart improve survival in patients suffering a heart attack--acute myocardial infarction (AMI).attack--acute myocardial infarction (AMI).
Published guidelines, endorsed by multiple Published guidelines, endorsed by multiple medical societies, are now update almost yearly.medical societies, are now update almost yearly.
Despite this, the rates of guideline-recommended Despite this, the rates of guideline-recommended treatment adherence for AMI care are suboptimal treatment adherence for AMI care are suboptimal in many healthcare settingsin many healthcare settings– Rates lower in rural hospitals versus urbanRates lower in rural hospitals versus urban
Effective dissemination and education of rural Effective dissemination and education of rural providers may play a role in this.providers may play a role in this.
BackgroundBackground
CRUSADE Registry DataCRUSADE Registry Data– Association between hospital Association between hospital
processes of care and outcomes processes of care and outcomes among patients with AMI among patients with AMI
Better adherence to guideline-Better adherence to guideline-based treatments for heart attack based treatments for heart attack patients patients Better Clinical Better Clinical outcomesoutcomes
Peterson ED et al. JAMA 2006; 295(16):1912-20.
Why a Rural Hospital Why a Rural Hospital Setting?Setting? Rural hospitals have not Rural hospitals have not
been specifically targeted been specifically targeted in recent national quality in recent national quality campaignscampaigns
No mandatory reporting No mandatory reporting requirements for AMI requirements for AMI quality measures quality measures
Care teams appear to Care teams appear to differ from urban differ from urban hospitalshospitals
Low volume AMI centersLow volume AMI centers
Rural Health Care and Rural Health Care and AMIAMI Acute Myocardial InfarctionAcute Myocardial Infarction
– Small Numbers=limited opportunities to Small Numbers=limited opportunities to care for these patientscare for these patients
3% of pts were discharged home from the ED 3% of pts were discharged home from the ED despite a final diagnosis of MI in rural hospitalsdespite a final diagnosis of MI in rural hospitals
No mandatory QI programs for AMI careNo mandatory QI programs for AMI care Unknown which quality improvement Unknown which quality improvement
methods work best for AMI care in the methods work best for AMI care in the rural settingrural setting
Unknown which educational programs Unknown which educational programs are effectiveare effective
Westfall JM et al. Ann Fam Med 2006;4:153-158
How do healthcare How do healthcare providers learn about providers learn about changes in care?changes in care?
Read journals with updated scientific Read journals with updated scientific statementsstatements
““Throw-away” magazines on medical topics Throw-away” magazines on medical topics Attend annual or semi-annual meetings of Attend annual or semi-annual meetings of
professional societies with didactic lecturesprofessional societies with didactic lectures E-mails sent with links to educational websitesE-mails sent with links to educational websites Local continuing education programsLocal continuing education programs
– Lunch or dinner programs with speakersLunch or dinner programs with speakers Word of mouth through practices/hospitalsWord of mouth through practices/hospitals
Human Learning: Level of Human Learning: Level of InteractivityInteractivity
Why Use Why Use Simulations?Simulations?
InteractionInteraction is associated with learning is associated with learning achievement and retention of achievement and retention of knowledgeknowledge
Participants Participants learned fasterlearned faster and had and had better attitudesbetter attitudes when they used an when they used an interactive instructional environmentinteractive instructional environment
Retention
Teach Others 90% Collaborative Simulations
Learn By Doing 75% Simulations
Discussion Groups 50% Web Seminars, IM, chat
Demonstration 30% Animation
Audio Visual 20% PowerPoint Slides
Lecture 5% Streaming mediaSource: Andersen Consulting
Retention
Teach Others 90% Collaborative Simulations
Learn By Doing 75% Simulations
Discussion Groups 50% Web Seminars, IM, chat
Demonstration 30% Animation
Audio Visual 20% PowerPoint Slides
Lecture 5% Streaming mediaSource: Andersen Consulting
Najjar, L. J. (1998). Principles of educational multimedia user interface design. Human Factors, 40(2), 311-323.
Pilot of a novel Pilot of a novel educational programeducational program
Use medical simulation as Use medical simulation as a platform for education a platform for education in rural hospitals:in rural hospitals:– Embed an up-to-date Embed an up-to-date
didactic curriculumdidactic curriculum– Create a ‘realistic’ setting Create a ‘realistic’ setting
Exposure to rare eventsExposure to rare events Team trainingTeam training Cover the spectrum of Cover the spectrum of
carecare– Create a safe environment Create a safe environment
to practice and teachto practice and teach– Take education to rural Take education to rural
hospitals hospitals
Medical SimulationMedical Simulation
Training tools developed to Training tools developed to imitate:imitate:– Anatomic regionsAnatomic regions– Clinical tasks Clinical tasks – Real patients Real patients – Real-life circumstances in which Real-life circumstances in which
medical care is renderedmedical care is rendered
Issenberg SB and Scalese RJ. Persp Biol Med, (51)1:31-46, 2008
Spectrum of Spectrum of Simulations Simulations
Lower Cost Higher Cost
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Recommendations Recommendations from IOMfrom IOM Use simulators to ensure that clinical training Use simulators to ensure that clinical training
is is safesafe for patients for patients Develop simulators for use in skills Develop simulators for use in skills
assessmentassessment Use simulation technology to improve Use simulation technology to improve
individualindividual and and team performanceteam performance through through interdisciplinary team traininginterdisciplinary team training
Use simulation for problem solving and Use simulation for problem solving and recovery from problems — “crisis recovery from problems — “crisis management”management”To Err is Human: Building a Safer Health
System, Institute of Medicine, Committee on Quality, National Academy Press, 1999
Features and Uses of Medical Features and Uses of Medical Simulations That Lead to Simulations That Lead to Most Effective LearningMost Effective Learning
FeedbackFeedback Repetitive PracticeRepetitive Practice Range of DifficultyRange of Difficulty Multiple learning Multiple learning
strategiesstrategies Clinical variationClinical variation
Controlled Controlled environmentenvironment
Individualized Individualized learninglearning
Defined outcomes Defined outcomes and benchmarksand benchmarks
Simulator validity Simulator validity and realismand realism
Curricular Curricular integrationintegrationBest Evidence Medical Education (BEME) Collaboration
Issenberg SB et al. Med Teach 27(1):10-28, 2005
Goal of Rural Hospital Goal of Rural Hospital Simulation Project Simulation Project
Implement a novel training program aimed at improving Implement a novel training program aimed at improving adherence rates to guideline-recommended treatment of adherence rates to guideline-recommended treatment of AMI in rural hospitals in order to improve clinical outcomes.AMI in rural hospitals in order to improve clinical outcomes.
– Incorporate most recent guidelinesIncorporate most recent guidelines– Directed at appropriate levels for EMS, Nursing, PhysiciansDirected at appropriate levels for EMS, Nursing, Physicians– Encourage team training as it really occurs in the management of AMIEncourage team training as it really occurs in the management of AMI– Provide for interaction and practiceProvide for interaction and practice– Incorporate immediate and summative feedback on performanceIncorporate immediate and summative feedback on performance– Take education and training to rural providers to maximize benefitTake education and training to rural providers to maximize benefit
Project ObjectivesProject Objectives
Evaluate acceptance and Evaluate acceptance and effectiveness of a simulation-based effectiveness of a simulation-based educational programeducational program– Focus on recognition and management Focus on recognition and management
of AMI patients presenting to rural of AMI patients presenting to rural hospitals hospitals
Assess the state of AMI care in rural Assess the state of AMI care in rural hospitals in Colorado before and hospitals in Colorado before and after simulation trainingafter simulation training
Our TeamOur Team
Multidisciplinary groupMultidisciplinary group– University of Colorado University of Colorado
DenverDenver CardiologistsCardiologists Family Medicine Family Medicine Rural Health NursingRural Health Nursing
– Colorado Foundation for Colorado Foundation for Medical CareMedical Care
– Medical Simulation Medical Simulation CorporationCorporation
Funded by AHRQ Funded by AHRQ
Target AudienceTarget Audience
Rural Healthcare ProvidersRural Healthcare Providers– PhysiciansPhysicians– Nurse practitionersNurse practitioners– Physician assistantsPhysician assistants– NursesNurses– ER techniciansER technicians– First responders/EMSFirst responders/EMS
Rural and Critical Rural and Critical Access Hospitals in Access Hospitals in ColoradoColorado
100 miles
Project OutlineProject Outline
Simulation-based trainingSimulation-based training– On-site training with physicians from UCDOn-site training with physicians from UCD– Formal didactic curricula using simulationFormal didactic curricula using simulation
Recognition of AMIRecognition of AMI Guideline-based treatment of AMIGuideline-based treatment of AMI Recognition of life-threatening complications of AMIRecognition of life-threatening complications of AMI Focus on core quality measures and “best practices”Focus on core quality measures and “best practices”
Pre and Post training assessment of AMI Pre and Post training assessment of AMI managementmanagement– Survey of participants regarding utility of Survey of participants regarding utility of
simulation trainingsimulation training– Retrospective and prospective chart review of Retrospective and prospective chart review of
AMI patients at participating hospitalsAMI patients at participating hospitals
Simulation TrainingSimulation Training
Use of SimManUse of SimMan™, with ™, with four AMI scenarios four AMI scenarios
Touch screen interface Touch screen interface with introduction to with introduction to the simulator by the the simulator by the proctorproctor
Proctor records Proctor records orders/instructionsorders/instructions
Team training with 3-5 Team training with 3-5 participants per groupparticipants per group– MD, RN, EMSMD, RN, EMS
Components of the Components of the ScenariosScenarios Brief introduction to each case on computerBrief introduction to each case on computer ““Patient” can be interviewed and examined Patient” can be interviewed and examined
by participantsby participants Continuous heart rhythm and vital sign Continuous heart rhythm and vital sign
monitoringmonitoring Labs, X-ray, EKG’s available for interpretation Labs, X-ray, EKG’s available for interpretation
by participantsby participants All treatments recorded, with pharmacology All treatments recorded, with pharmacology
algorithms built in to simulationalgorithms built in to simulation Simulated adverse events occur in each case Simulated adverse events occur in each case
requiring appropriate treatmentrequiring appropriate treatment
Example of Simulated Example of Simulated CaseCase
Simulation Simulation ImplementationImplementation
Components of the Components of the Simulation Training Simulation Training ProgramProgram Each scenario with 4-5 post-simulation Each scenario with 4-5 post-simulation
questionsquestions– guideline recommended careguideline recommended care– risk assessment and reperfusion therapyrisk assessment and reperfusion therapy
Expert feedback during simulations provided Expert feedback during simulations provided by faculty during and after each caseby faculty during and after each case
Following the simulation training, review of Following the simulation training, review of didactic curriculum on updated AMI didactic curriculum on updated AMI management guidelines for 2008 performedmanagement guidelines for 2008 performed
Post training assessment of the simulation Post training assessment of the simulation training program by participantstraining program by participants
Participants in Participants in Simulation Training Simulation Training ProgramProgram
18
54
4
122 5
Physicians
Nurses
NP/PA
EMT
Pharm
Other
95 healthcare professionals at 5 rural hospitals
Healthcare Provider Healthcare Provider Evaluation of Simulation Evaluation of Simulation TrainingTraining
Questions:Questions:
– Simulated cases realistic and Simulated cases realistic and engagingengaging
– Requires critical thinking Requires critical thinking skillsskills
– Using this system confidence Using this system confidence and skills can be improvedand skills can be improved
– Useful for on-site training of Useful for on-site training of healthcare providershealthcare providers
Proportion Proportion Strongly Agree Strongly Agree
or Agreeor Agree
98%98%
99%99%
98%98%
98%98%
Proportion Proportion Strongly Strongly Agree Agree
85%85%
86%86%
65%65%
87%87%
n=85 respondents
Performance on case-Performance on case-based questionsbased questions
Case 1Case 1
Case 2Case 2
Case 3Case 3
Case 4Case 4
9595
7979
9090
100100
Overall % correct
75-10075-100
40-10040-100
50-10050-100
100100
Range
*Scores from 18 groups at 5 hospitals
Variability in Variability in Performance on case-Performance on case-based questionsbased questions
*Scores from 18 groups at 5 hospitals
60
65
70
75
80
85
90
95
100
1 3 5 7 9 11 13 15 17
Groups
% C
orr
ect
Ongoing Research Ongoing Research EffortsEfforts Determination of quality of care for AMI Determination of quality of care for AMI
patients at the participating rural hospitals patients at the participating rural hospitals – Baseline: In the period from 1/2007 to 12/2007Baseline: In the period from 1/2007 to 12/2007– Following Simulation Training: From 7/2008-Following Simulation Training: From 7/2008-
6/2009.6/2009. Chart abstraction by CFMC into the ACTION Chart abstraction by CFMC into the ACTION
Registry (Duke Clinical Research Institute)Registry (Duke Clinical Research Institute)– Allow for benchmarking of AMI care compared to Allow for benchmarking of AMI care compared to
hospitals participating in ACTION. hospitals participating in ACTION.
Challenges Challenges EncounteredEncountered
Despite using a commercially available Despite using a commercially available simulator, development time was longer simulator, development time was longer than anticipated.than anticipated.
While many hospitals were eager to While many hospitals were eager to participate, the chart abstraction participate, the chart abstraction component of this project limited many component of this project limited many due to limited staffing resourcesdue to limited staffing resources
Tailoring the evidence based guidelines Tailoring the evidence based guidelines to all levels was more difficult than to all levels was more difficult than expected. expected.
Coordination of training at each hospital Coordination of training at each hospital took more effort than expected. took more effort than expected.
Lessons LearnedLessons Learned
The actual delivery of on-site rural healthcare The actual delivery of on-site rural healthcare training was easier than anticipatedtraining was easier than anticipated
Having on-site faculty to discuss AMI care Having on-site faculty to discuss AMI care was well received was well received
Partnering with CFMC (that had pre-existing Partnering with CFMC (that had pre-existing relationships with these hospitals) enabled relationships with these hospitals) enabled this project this project
Provision of CME and CEU credit hours Provision of CME and CEU credit hours resulted in significant participation at each resulted in significant participation at each sitesite
ConclusionConclusion Use of a novel simulation based training program Use of a novel simulation based training program
focusing on AMI care in rural hospitals was felt to:focusing on AMI care in rural hospitals was felt to:– Be realistic and engagingBe realistic and engaging– Require critical thinking skills for AMI careRequire critical thinking skills for AMI care– Improve confidence and skills in AMI careImprove confidence and skills in AMI care– Useful for on-site training Useful for on-site training
Education was easily delivered on-site to a large Education was easily delivered on-site to a large number of participantsnumber of participants– Accepted by physicians, nurses and EMS Accepted by physicians, nurses and EMS
Evaluation of the impact of simulation on Evaluation of the impact of simulation on guideline-based AMI care is ongoingguideline-based AMI care is ongoing
Collaborators on this Collaborators on this projectproject
University of Colorado University of Colorado DenverDenver– Jack Westfall MD, MPHJack Westfall MD, MPH– Andrew Klein MDAndrew Klein MD– John Rumsfeld MD, PhDJohn Rumsfeld MD, PhD– Fred Masoudi MD, MSPHFred Masoudi MD, MSPH– John Carroll MDJohn Carroll MD– Michael Kim, MDMichael Kim, MD– Cathy Jaynes RN, PhDCathy Jaynes RN, PhD
Medical Simulation Medical Simulation Co.Co.– Amy KetronAmy Ketron– Shannon GettingsShannon Gettings
Colorado Foundation Colorado Foundation for Medical Carefor Medical Care– Deb ChromikDeb Chromik– Niki HydeNiki Hyde– Nancy BorgstadtNancy Borgstadt
Questions/CommentsQuestions/Comments
