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MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY

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Harvard Medical Practice Study (1991) identified a serious error' rate of 3.7 ... Test and validate the simulation. Resources. Equipment ... – PowerPoint PPT presentation

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Title: MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY


1
MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY
  • Professor Harry Owen
  • Director, Clinical Skills and Simulation Unit
  • Flinders University
  • Adelaide, South Australia
  • harry.owen_at_flinders.edu.au

2
MEDICAL SIMULATION IN IMPROVING PATIENT SAFETY
  • Background to simulation
  • Simulation technologies used in Medical Education
    in Australia, the US and Europe
  • Fundamentals of high-fidelity simulation
  • How simulation can improve patient safety
  • Emerging trends in simulation

3
Why simulation?
  • Simulation is valuable when on-the-job training
    is expensive or risky
  • Simulation has been adopted for training where
    consequences of error expose many people to risk
    or the cost of error is high, for example
  • Aerospace
  • Military
  • Nuclear power plants

4
Medicine A High-Risk Industry
  • Harvard Medical Practice Study (1991) identified
    a serious error rate of 3.7
  • (serious error leads to prolonged hospital stay
    or disability)
  • Vincent (2001) NHS 11 error rate with 50
    preventable
  • 50,000 patients pa die from medical error or
    accident. Litigation cost 44billion
  • Australian data - adverse event rate of 17

5
How simulation can improve patient safety
  • Fewer errors
  • Better error trapping
  • Improved recognition of error and/or consequences
    of error
  • Develop capacity to manage consequences of error

6
Advantages of Simulation
  • Structured learning
  • Guaranteed and scheduled opportunities for
    teaching learning
  • Uncommon situations can be presented
  • Teacher can model process, give feedback, repeat
    process, modify process
  • Repetition as often as needed

7
Successful strategies for crisis management
  • Use of written checklists to help prevent crises
  • Use of established procedures in responding to
    crises
  • Training in decision making and resource
    co-ordination
  • Systematic practise in handling crises including
    part-task trainers and full-mission realistic
    simulation

8
Whos who in medical education
  • Basic medical education
  • Medical students
  • Pre-vocational medical education
  • Interns, RMOs, PGY 12
  • Specialist training (discipline-based)
  • Registrars/Senior registrars/Fellows
  • Specialists and GPs (life-long learning)
  • CME, MOPS, IRM, etc
  • Teachers and trainers

9
Simulation technologies used in medical education
  • Computer-based simulations (micro-worlds,
    micro-simulation)
  • Virtual environments /- haptics
  • Part-task trainers
  • Low-fidelity simulators/manikins
  • Simulated or standardised patients
  • Hybrid simulations
  • High-fidelity (full mission) simulation

10
Cost and benefit in simulation
Full mission simulation
Manikin training

Part-task trainers
CBT
Increasing level of fidelity and exclusivity
11
Medical Education includesKnowledge/Skills/Attitu
des
  • Individual psychomotor skills
  • Appropriate application of skills
  • Communication / Team performance / Leadership
    skills (CRM)
  • Supervision/teaching
  • Assessment

12
Knowledge/Skills/Attitudes
  • Teaching best practice
  • integrated
  • learner centred
  • appropriate use of technology
  • Assessment best practice
  • valid and reliable
  • reproducible

13
The Flinders Clinical Skills and Simulation Unit
  • Grew from a project to improve airway management
    teaching to medical students
  • Value to teaching other health professionals and
    other skills quickly recognised
  • Now involved in teaching across disciplines and
    outside the medical school

14
Endotracheal intubation
  • Learnt on patients under anaesthesia
  • No special consent
  • but
  • Duty of care to protect patient from harm
  • Increased risk when performed by a student or
    trainee

15
Endotracheal intubation
  • ETI needed by many health professionals,
    including anesthesiologists, paramedics/EMTs,
    rural GPs, emergency physicians, ICU staff,
    respiratory therapists, etc.
  • Competence requires practise

16
When and how should ETI be taught?
  • Animals
  • Small, e.g. cats
  • Large, e.g. dogs or monkeys
  • Unconscious patients
  • In the OR
  • In ICU
  • Newly dead/recently deceased
  • Cadavers
  • Simulators

17
The learning environment
  • Quiet, few distractors
  • Clinical equipment
  • Expert tutors
  • Realistic models
  • Many different models
  • Easy ? difficult? very difficult

18
Outcomes of the ETI program
  • Goal of reducing patient risk of trauma has been
    achieved
  • Improved confidence of students and trainees
  • Trainees receive more teaching
  • Improved trainer satisfaction

19
The Flinders Clinical Skills and Simulation Unit
  • CBT
  • ResusSim
  • CathSim
  • PA simulator
  • ECG
  • Local anaesthesia
  • Part-task trainers
  • BLS ALS
  • IVI CVC
  • Trauma
  • Adult
  • Gynae Obstetric
  • Neonatal
  • Premature (28wks)
  • Paediatric (age range)

20
Adult A-A Female (Nasco)
CPR Prompt (Compliant)
Fat Old Fred (Lifeform)
Little Anne (Laerdal)
David/Adam (Nasco)
CPR Pal (Ambu)
Basic Buddy (Lifeform)
Economy Saniman (Nasco)
21
The Flinders Clinical Skills and Simulation Unit
  • Several whole body manikins including
  • ResusciBaby
  • ALS baby
  • ResusciAnne with SkillReporter
  • Mr Hurt
  • Nursing Anne
  • Megacode Kid
  • etc
  • SimMan UPS
  • Postoperative care modules
  • Trauma modules
  • Severe Trauma modules
  • Local produced dental trauma modules

22
Anatomy of a simulation (1)
  • Components
  • Student/trainee/health professional
  • Procedure/task/skill/test/treatment or equipment
  • Patient and/or disease process
  • Trainer/supervisor

23
Anatomy of a simulation (2)
  • Function of components
  • Passive
  • Enhance setting for realism
  • Active
  • Change in a programmed way
  • Interactive
  • Responds to action or event

24
  • Trainees learning cricothyrotomy on a part-task
    trainer
  • (Note educational aids in background)
  • Trainee performing an emergency cricothyrotomy in
    a full-mission simulation.
  • (Note more realistic setting)

25
High fidelity simulation (1)
  • Determine educational needs and choose most
    efficient and effective
  • Need to balance resource availability and student
    demand
  • May need to promote low-tech solutions

26
High fidelity simulation (2)
  • Confirm teaching goals can be achieved using
    simulation
  • Develop scenario, acquire equipment needed and
    prepare associated materials
  • Test and validate the simulation

27
Resources
  • Equipment
  • Simulators, monitors, defibrillator, trolleys,
    etc
  • Disposables
  • Appropriate for scenario, setting and
    participants, re-use w/o compromising fidelity
  • Faculty
  • Trained, available, practised
  • Support staff
  • Bio-medical technician essential! Also clerical.

28
Before and after simulations...
  • Set-up scenario
  • eg. make blood, set up OR, X-rays, etc
  • Load up simulation program
  • Check everything works
  • Cameras, VCR, communicators
  • Afterwards...
  • Check simulator
  • Clean everything used and put away
  • Replace/reorder all used items

29
High fidelity simulation (3)
  • Allow time for familiarisation with the simulator
    equipment
  • Brief participants on
  • The scenario
  • Educational objectives
  • How to get help

30
High fidelity simulation (4)
  • Always follow the script but...

have alternative outcomes planned and rehearsed
Simulation control room
31
High fidelity simulation (5)
  • Using simulation situations can be re-run to
    explore outcome with different treatments

Mission critical tasks can be performed by
learners without putting patients at risk
32
High fidelity simulation (6)
  • Facilitated debriefing with an expert
    practitioner. Participants reflect on their own
    performance and discuss this with the group

33
How we use the SimMan UPS
  • Anaesthesia
  • Emergency medicine
  • Family Medicine/GP
  • CCU/ICU
  • Trauma/retrievals
  • Paramedics/EMT
  • Specialist nurses
  • Medical Imaging
  • Paediatrics
  • Rural health workers
  • Sim Centre settings
  • OR, PACU, ER, Imaging suite, post-op ward,
    clinic, aircraft, ambulance, home, roadside,
    terrorist incident, etc
  • Outreach settings
  • Regional hospitals, rural settings, etc

34
Source Jones A (BMSC)
35
Simulation centres
May 2003
11
9
10
20
195
25
2
10
6
5
2
2
Flinders Uni
36
Publications on patient simulation in clinical
care
Year
37
Research needed on simulationin healthcare
training
  • Improved outcomes
  • Fewer adverse events, fewer preventable
    incidents, fewer near miss events
  • Increased efficiency of training
  • Improved outcomes in same or (preferably) less
    training time
  • Improved use of resources
  • Fewer failures, more efficient training, quicker
    performance

38
Simulation technologies used in medical education
  • Computer-based simulations (micro-worlds,
    micro-simulation)
  • Virtual environments /- haptics
  • Part-task trainers
  • Low-fidelity simulators/manikins
  • Simulated or standardised patients
  • Hybrid simulations
  • High-fidelity (full mission) simulation

39
The future of simulation...
  • Skills training tool for all disciplines
  • Acute care
  • New techniques and/or equipment
  • Managing complications
  • Retraining
  • Multi-disciplinary training
  • inter-professional communication
  • team performance
  • Training in decision-making/resource co-ordination
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