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John C' Messenger, MD, FACC

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Association between hospital processes of care and outcomes among patients with AMI ... Health Nursing. Colorado Foundation for Medical Care. Medical Simulation ... – PowerPoint PPT presentation

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Title: John C' Messenger, MD, FACC


1
Simulation Training to Improve Heart Attack Care
for Rural Hospitals
  • John C. Messenger, MD, FACC
  • Associate Professor of Medicine
  • Division of Cardiology
  • Director, Cardiac Catheterization Laboratories
  • University of Colorado Denver

November 5th, 2008
2
Background
  • Multiple therapies have been demonstrated to
    improve survival in patients suffering a heart
    attack--acute myocardial infarction (AMI).
  • Published guidelines, endorsed by multiple
    medical societies, are now update almost yearly.
  • Despite this, the rates of guideline-recommended
    treatment adherence for AMI care are suboptimal
    in many healthcare settings
  • Rates lower in rural hospitals versus urban
  • Effective dissemination and education of rural
    providers may play a role in this.

3
Background
  • CRUSADE Registry Data
  • Association between hospital processes of care
    and outcomes among patients with AMI
  • Better adherence to guideline-based treatments
    for heart attack patients ? Better Clinical
    outcomes

Peterson ED et al. JAMA 2006 295(16)1912-20.
4
Why a Rural Hospital Setting?
  • Rural hospitals have not been specifically
    targeted in recent national quality campaigns
  • No mandatory reporting requirements for AMI
    quality measures
  • Care teams appear to differ from urban hospitals
  • Low volume AMI centers

5
Rural Health Care and AMI
  • Acute Myocardial Infarction
  • Small Numberslimited opportunities to care for
    these patients
  • 3 of pts were discharged home from the ED
    despite a final diagnosis of MI in rural
    hospitals
  • No mandatory QI programs for AMI care
  • Unknown which quality improvement methods work
    best for AMI care in the rural setting
  • Unknown which educational programs are effective

Westfall JM et al. Ann Fam Med 20064153-158
6
How do healthcare providers learn about changes
in care?
  • Read journals with updated scientific statements
  • Throw-away magazines on medical topics
  • Attend annual or semi-annual meetings of
    professional societies with didactic lectures
  • E-mails sent with links to educational websites
  • Local continuing education programs
  • Lunch or dinner programs with speakers
  • Word of mouth through practices/hospitals

7
Human Learning Level of Interactivity
Retention Teach Others 90 Collaborative
Simulations Learn By Doing 75 Simulations Discuss
ion Groups 50 Web Seminars, IM,
chat Demonstration 30 Animation Audio
Visual 20 PowerPoint Slides Lecture 5 Streaming
media Source Andersen Consulting
Why Use Simulations?
  • Interaction is associated with learning
    achievement and retention of knowledge
  • Participants learned faster and had better
    attitudes when they used an interactive
    instructional environment

Najjar, L. J. (1998). Principles of educational
multimedia user interface design. Human Factors,
40(2), 311-323.
8
Pilot of a novel educational program
  • Use medical simulation as a platform for
    education in rural hospitals
  • Embed an up-to-date didactic curriculum
  • Create a realistic setting
  • Exposure to rare events
  • Team training
  • Cover the spectrum of care
  • Create a safe environment to practice and teach
  • Take education to rural hospitals

9
Medical Simulation
  • Training tools developed to imitate
  • Anatomic regions
  • Clinical tasks
  • Real patients
  • Real-life circumstances in which medical care is
    rendered

Issenberg SB and Scalese RJ. Persp Biol Med,
(51)131-46, 2008
10
Spectrum of Simulations
Computerized Case Scenarios
Case Scenarios with role playing
VR Surgical Simulations MIST-VR, ES3, GI Mentor,
etc
High-Fidelity Endovascular Simulators
Flight Simulators for Airline Industry
Programmed Patient Training
Mannequin based Simulation SimMan (Laerdal) or
METI HPS
Surgical Box Trainer
Anesthesia OR Simulations
Lower Cost Higher Cost
11
Recommendations from IOM
  • Use simulators to ensure that clinical training
    is safe for patients
  • Develop simulators for use in skills assessment
  • Use simulation technology to improve individual
    and team performance through interdisciplinary
    team training
  • Use simulation for problem solving and recovery
    from problems crisis management

To Err is Human Building a Safer Health System,
Institute of Medicine, Committee on Quality,
National Academy Press, 1999
12
Features and Uses of Medical Simulations That
Lead to Most Effective Learning
  • Feedback
  • Repetitive Practice
  • Range of Difficulty
  • Multiple learning strategies
  • Clinical variation
  • Controlled environment
  • Individualized learning
  • Defined outcomes and benchmarks
  • Simulator validity and realism
  • Curricular integration

Best Evidence Medical Education (BEME)
Collaboration Issenberg SB et al. Med Teach
27(1)10-28, 2005
13
Goal of Rural Hospital Simulation Project
  • Implement a novel training program aimed at
    improving adherence rates to guideline-recommended
    treatment of AMI in rural hospitals in order to
    improve clinical outcomes.
  • Incorporate most recent guidelines
  • Directed at appropriate levels for EMS, Nursing,
    Physicians
  • Encourage team training as it really occurs in
    the management of AMI
  • Provide for interaction and practice
  • Incorporate immediate and summative feedback on
    performance
  • Take education and training to rural providers to
    maximize benefit

14
Project Objectives
  • Evaluate acceptance and effectiveness of a
    simulation-based educational program
  • Focus on recognition and management of AMI
    patients presenting to rural hospitals
  • Assess the state of AMI care in rural hospitals
    in Colorado before and after simulation training

15
Our Team
  • Multidisciplinary group
  • University of Colorado Denver
  • Cardiologists
  • Family Medicine
  • Rural Health Nursing
  • Colorado Foundation for Medical Care
  • Medical Simulation Corporation
  • Funded by AHRQ

16
Target Audience
  • Rural Healthcare Providers
  • Physicians
  • Nurse practitioners
  • Physician assistants
  • Nurses
  • ER technicians
  • First responders/EMS

17
Rural and Critical Access Hospitals in Colorado
100 miles
18
Project Outline
  • Simulation-based training
  • On-site training with physicians from UCD
  • Formal didactic curricula using simulation
  • Recognition of AMI
  • Guideline-based treatment of AMI
  • Recognition of life-threatening complications of
    AMI
  • Focus on core quality measures and best
    practices
  • Pre and Post training assessment of AMI
    management
  • Survey of participants regarding utility of
    simulation training
  • Retrospective and prospective chart review of AMI
    patients at participating hospitals

19
Simulation Training
  • Use of SimMan, with four AMI scenarios
  • Touch screen interface with introduction to the
    simulator by the proctor
  • Proctor records orders/instructions
  • Team training with 3-5 participants per group
  • MD, RN, EMS

20
Components of the Scenarios
  • Brief introduction to each case on computer
  • Patient can be interviewed and examined by
    participants
  • Continuous heart rhythm and vital sign monitoring
  • Labs, X-ray, EKGs available for interpretation
    by participants
  • All treatments recorded, with pharmacology
    algorithms built in to simulation
  • Simulated adverse events occur in each case
    requiring appropriate treatment

21
Example of Simulated Case
22
Simulation Implementation
23
Components of the Simulation Training Program
  • Each scenario with 4-5 post-simulation questions
  • guideline recommended care
  • risk assessment and reperfusion therapy
  • Expert feedback during simulations provided by
    faculty during and after each case
  • Following the simulation training, review of
    didactic curriculum on updated AMI management
    guidelines for 2008 performed
  • Post training assessment of the simulation
    training program by participants

24
Participants in Simulation Training Program
95 healthcare professionals at 5 rural hospitals
25
Healthcare Provider Evaluation of Simulation
Training
  • Proportion
  • Strongly Agree or Agree
  • 98
  • 99
  • 98
  • 98
  • Proportion Strongly Agree
  • 85
  • 86
  • 65
  • 87
  • Questions
  • Simulated cases realistic and engaging
  • Requires critical thinking skills
  • Using this system confidence and skills can be
    improved
  • Useful for on-site training of healthcare
    providers

n85 respondents
26
Performance on case-based questions
Overall correct
Range
  • Case 1
  • Case 2
  • Case 3
  • Case 4
  • 95
  • 79
  • 90
  • 100
  • 75-100
  • 40-100
  • 50-100
  • 100

Scores from 18 groups at 5 hospitals
27
Variability in Performance on case-based questions
Scores from 18 groups at 5 hospitals
28
Ongoing Research Efforts
  • Determination of quality of care for AMI patients
    at the participating rural hospitals
  • Baseline In the period from 1/2007 to 12/2007
  • Following Simulation Training From
    7/2008-6/2009.
  • Chart abstraction by CFMC into the ACTION
    Registry (Duke Clinical Research Institute)
  • Allow for benchmarking of AMI care compared to
    hospitals participating in ACTION.

29
Challenges Encountered
  • Despite using a commercially available simulator,
    development time was longer than anticipated.
  • While many hospitals were eager to participate,
    the chart abstraction component of this project
    limited many due to limited staffing resources
  • Tailoring the evidence based guidelines to all
    levels was more difficult than expected.
  • Coordination of training at each hospital took
    more effort than expected.

30
Lessons Learned
  • The actual delivery of on-site rural healthcare
    training was easier than anticipated
  • Having on-site faculty to discuss AMI care was
    well received
  • Partnering with CFMC (that had pre-existing
    relationships with these hospitals) enabled this
    project
  • Provision of CME and CEU credit hours resulted in
    significant participation at each site

31
Conclusion
  • Use of a novel simulation based training program
    focusing on AMI care in rural hospitals was felt
    to
  • Be realistic and engaging
  • Require critical thinking skills for AMI care
  • Improve confidence and skills in AMI care
  • Useful for on-site training
  • Education was easily delivered on-site to a large
    number of participants
  • Accepted by physicians, nurses and EMS
  • Evaluation of the impact of simulation on
    guideline-based AMI care is ongoing

32
Collaborators on this project
  • University of Colorado Denver
  • Jack Westfall MD, MPH
  • Andrew Klein MD
  • John Rumsfeld MD, PhD
  • Fred Masoudi MD, MSPH
  • John Carroll MD
  • Michael Kim, MD
  • Cathy Jaynes RN, PhD
  • Medical Simulation Co.
  • Amy Ketron
  • Shannon Gettings
  • Colorado Foundation for Medical Care
  • Deb Chromik
  • Niki Hyde
  • Nancy Borgstadt

33
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