Tips for Increasing the Realism of Simulation Training

1
Tips for Increasing the Realism of Simulation
Training

• Richard Stair, MD, FACEP
• Residency Program Director
• Clinical Assistant Professor
• University of Florida, Gainesville

• Ernest Wang, MD, FACEP
• Academic Director, CSTAR
• Assistant Professor
• Feinberg School of Medicine
• NorthShore University HealthSystem

• CORD Academic Assembly
• March 7, 2009

2
Statement of Disclosure

• The speakers have no conflicts of
  interest/disclosures related to this topic.

3
Realism, Websters way

• true and faithful portrayal of nature and of
  people in art and literature

4
Realism, the simulation way

• Make the simulator reproduce how real patients
  look and sound
• Reproduce the environment to match an ED
• Reproduce the cases as accurately as possible
• Reproduce materials and equipment as close as
  possible
• Make the assessment and feedback similar to
  clinical environment

5
Psychological Fidelity

• Degree to which the trainee perceives the
  simulation to be a believable surrogate for the
  trained task or real patient encounter
• Allows learner to make conceptual sense of the
  scenario
• Generally considered to be the most essential
  requirement for team training

A Typology of simulation fidelity (adapted from
Rehmann et al, 1995) Beaubien, Baker. Quality
and Safety in Health Care, 2004.
6
Skillful blending of the three modes of thinking
about realism environmental, equipment, and
psychological will allow our trainees to
suspend disbelief, or to actively sign up for
the fiction contract that this is a situation
with real relevance for them.
Rudolph et al. Sim Healthcare. 2(3)161-163, Fall
2007.
7
Simulator as patient

• Appearance of high fidelity simulators mostly
  modeled after healthy males
• Patients seem to vary more
• Attempt to change the appearance of the simulator
  to match patient appearances

8
Tips to match appearance

• Use the most appropriate simulator
• The parts department
• Fractures
• Burns
• Wound
• Bleeders
• Instant sex change

9
Tips to match appearance

• Post-Halloween shopping spree
• Hair
• Clothes
• Patient gowns (yeah, all our patients are in
  gowns)
• Street clothes
• Makeup
• Jaundice
• Rashes
• Burns
• Abrasions and contusions
• Diaphoresis

10
Hybrid

• Kneebone et al. - Integrated Procedural
  Performance Instrument (IPPI)
• IV infusion
• Blood cultures
• IM injection
• SC injection explaining to patient
• Suturing a wound
• Performing an ECG
• Using a nebuliser measuring peak flow
• Urinary catheterisation

11
Kneebone et al. - Integrated Procedural
Performance Instrument (IPPI)
Used with permission Kneebone et al.
12
Tips to match sound

• Invest in good audio equipment
• Recruit different people to provide voices,
  preferably from remote location
• Live parent with child
• Performance art
• Dyspneic
• Garbled
• Choice expletives
• Whiskey and cigarettes

13
Environment reproduction

• Mimic patient rooms from your ED as much as
  possible
• Curtains
• Oxygen and suction supplies
• Crash carts
• Medical supplies
• Vary level of support
• Trauma rooms
• Fast track rooms

14
Developing cases

• Probably the most important, and time-consuming,
  portion of developing realistic cases
• Consistent approach to developing cases will
  probably result in better cases
• Multiple factors to consider in case development,
  but goal is to remain realistic from start to
  finish

15
Factors to consider

• Case complexity
• Ability to reproduce findings
• Time course of actual case vs. time constraints
  to run the case
• Time course of orders and results
• Critical actions vs. benign actions vs. dangerous
  actions
• Rewards and penalties for performance
• Involvement of team members, consultants, etc.
• Disposition

16
Real cases

• Advantages
• No doubt about the realism of the case
• Easier programming of the simulator
• Easy to reproduce data and images
• Easy to reproduce an expected time course
• Ability to expand from textbook cases to the
  atypical cases
• Disadvantages
• Complexity may be an issue
• Regional deficiencies

17
Created cases

• Advantages
• Can develop cases not seen in your ED
• Tailor to your resources and level of complexity
• Can develop to teach very specific points
• Disadvantages
• More effort to develop and program
• Supporting data and images must be sought and
  carefully matched

18
Match fidelity to the learning objectives

• What are the learning objectives?
• What are my learners baseline KSAs and is the
  simulation level-appropriate?
• Do a task analysis
• Is simulation the best technique for teaching
  this?
• Scerbo et al. 2006 - simulated limb better than
  VR for phlebotomy

19
Tips for realistic cases

• Use a reliable system that helps develop cases
  from beginning to end
• Determine the set of critical actions, and
  consider potential for incorrect actions
• Determine pathways for correct and incorrect
  management
• Develop a time course for information exchange,
  patient responses to interventions

20
Template to set up case

• BEGINNING SIMULATOR SETTINGS
• Monitor HR RR BP pOx
• ABCs Airway normal swollen occluded other not
  protected
•   Breathing normal decreased on right
  decreased on the left
  
  diminished bilaterally wheezes
  rales
•   Circulation normal no peripheral pulses
  no femoral pulseless
•   Disability normal right hemiplegia right
  hemiparesis unresponsive left
  hemiplegia left hemiparesis other_____________
  ____ GCS motor
  eyes verbal
•  Physical findings
• HEENT normal
• NECK normal
• CHEST normal
• CARDIAC normal
• ABDOMEN normal
• BACK normal
• EXTREMITIES normal
• RECTAL / GU normal

21
Template for expected actions

• First set of treatments or interventions
  minutes Performed
• 1. yes no
• 2. yes no
• 3. yes no
• 4. yes no
• 5. yes no
• 6. yes no
• 7. yes no
• 8. yes no
•  
• Second set of treatments or interventions
  minutes Performed
•  
• 1. yes no
• 2. yes no
• 3. yes no
• 4. yes no
• 5. yes no
• 6. yes no

22
Template for simulator responses

• SIMULATOR RESPONSES TO INTERVENTIONS AND
  TREATMENTS
• APPROPRIATE and TIMELY INAPPROPRIATE and/or
  DELAYED
•  
• 1 - treated correctly within minutes 1 -
  incorrect or after minutes
•  
• HR __________ HR __________
• RR __________ RR __________
• BP __________ BP __________
• pOx __________ pOx __________
• Changes Changes
• 2 - treated correctly within minutes 2 -
  incorrect or after minutes
•  
• HR __________ HR ___________
• RR __________ RR ___________
• BP __________ BP ___________

23
Tips for realistic scenarios

• Run multiple cases concurrently
• Its how we actually practice
• Better assessment of overall performance
• Medical knowledge
• Procedural skills
• Prioritization, multitasking and organization
• Vary the cases run
• Should not be intubating and shocking the
  mannequin every use
• Create realistic alternatives (ex CPAP)

24
Tips for realistic scenarios

• Include distraction
• Provide references that would be available in the
  ED
• Run cases that will need to be signed out to
  another provider
• Oversight of team members

25
Tips for realistic scenarios

• Provide data discretely
• Single lab sheets may provide information not
  requested
• If not ordered, then data is not received
• Provide data in time sensitive manner
• Tests like EKG and fingersticks should be
  provided quickly
• Blood work and CT scans take time
• Ensure the quality of images provided

26
Tips for realistic scenarios

• Run seasonal cases seasonally
• Bronchiolitis in January, not July
• Heatstroke in July, not January
• Run random cases (no assigned curriculum topic)

27
Tips for realistic scenarios

• Provide adequate instruction to both performers
  and evaluators
• Admit the limitations of simulation
• Establish the ground rules to address the
  limitations before running cases
• In general
• If simulator provides it accurately, find it
• If simulator does not provide it accurately, must
  be sought and represented verbally

28
Tips for realistic feedback

• Spend time on developing the expectations
• Knowledge base
• Critical actions
• Procedural performance
• Teamwork
• Teach and evaluate similar to clinical
  evaluations (competency-speak)

29
Make simulation a social endeavor

• Personal Relevance
• Engagement
• Draw people in
• Team interaction
• Supportive, concrete debriefing
• Evoking response

30
Summary

• Environmental reproduction
• Realistic case development
• Match fidelity to the learning objectives
• Maximize psychological fidelity
• Make simulation a social endeavor

31
A successful scenario is not based on the
realism of the simulation itself, but rather the
alchemy of participants stepping into their
roles, connecting with others in the scenario,
and actively linking to their previous social,
clinical, and psychological experience.
Rudolph et al. Sim Healthcare. 2(3)161-163, Fall
2007.
32
References

• Dieckmann P, Gaba D, Rall M. Deepening the
  Theoretical Foundations of Patient Simulation as
  Social Practice. Sim Healthcare 2183-193, 2007.
• Beaubien JM, Baker DP. The use of simulation for
  training teamwork skills in health care how low
  can you go? Qual. Saf. Health Care,
  200413i51-i56.
• Scerbo MW, Dawson S. High Fidelity, High
  Performance? Sim Healthcare 2224-230, 2007.
• Rudolph, Jenny W. PhD Simon, Robert EdD Raemer,
  Daniel B. PhD. Which Reality Matters? Questions
  on the Path to High Engagement in Healthcare
  Simulation. Simulation in Healthcare The Journal
  of the Society for Simulation in Healthcare.
  2(3)161-163, Fall 2007.
• Wang EE, Beaumont J, Kharasch M, Vozenilek JA.
  Resident Response to Integration of
  Simulation-based Education into Emergency
  Medicine Conference.Acad Emerg Med.
  2008,151207-1210.
• Nestel D, Cecchini M, Calandrini M, Chang L,
  Dutta R, Tierney T, Brown R, Kneebone R. Real
  patient involvement in role development
  evaluating patient focused resources for clinical
  procedural skills.Med Teach. 2008 Jun30(5)534-6.

33
References

• Salas E, Burke CS. Simulation for training is
  effective when ... Qual. Saf. Health Care,
  200211119-120.
• Kneebone R, Nestel D, Wetzel C, Black S, Jacklin
  R, Aggarwal R, Yadollahi F, Wolfe J, Vincent C,
  Darzi A. The human face of simulation
  patient-focused simulation training.Acad Med.
  2006 Oct81(10)919-24. Review.
• Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon
  D, Scalese RJ. Features and uses of high-fidelity
  medical simulations that lead to effective
  learning a BEME systematic review. Med Teach.
  2005 Jan27(1)10-28.
• Kneebone RL, Kidd J, Nestel D, Barnet A, Lo B,
  King R, Yang GZ, Brown R. Blurring the
  boundaries scenario-based simulation in a
  clinical setting.

34
Thank you!Questions?
35
Contact us

• Richard Stair -
• rwstair_at_ufl.edu
• Ernest Wang -
• ernestwangmd_at_yahoo.com
• www.cstarweb.com