MEdSim Magazine - Issue 4/2013

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Issue 4.2013

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SimulatioN Assessment

Competency, Mastery and Deliberate Practice Interview

Interview with Margareta Berg, MD, PhD SimulatioN

The New Mandate for Simulation Training in Orthopaedic Surgery ISSN 2165-5367 | US $7.50

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Stop by for the newest developments Simbionix at IMSH booth #425 infousa@simbionix.com | www.simbionix.com | 1-866-746-2466

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ISSUE 4.2013

Editorial comment

Editor's Comment

" The number of surgeons trained over the past 20 years has remained almost static while populations have continued to increase."

We (the Halldale staff) have been fortunate to attend a number of conferences in the past few months to include the Armstrong Institute’s Patient Safety Forum where we listened to retired US Airways pilot Chesley “Sully” Sullenberger talk about the imperative for training in the airline industry. He and the co-pilot of that fateful day on the Hudson River had never met until that morning. They both, however, were so skilled and well trained they were able to accomplish a Hudson landing. In the Q & A that followed he was asked when he knew that he had to make the decision to land on the Hudson. His response was fascinating. “I always knew” and he went on to explain that the alternate airport simply would not have time to clear incoming and outgoing flights in the time he had to save lives. He was confident in his and his co-pilot’s ability to successfully land. That confidence came from hours of training in actual flight hours but also in the training simulator which pilots are required to train for 4/5 days every six months throughout their careers.

At the ACS Clinical Congress we heard about the shortages of trained surgeons around the world and the need to train not just more surgeons but more doctors in all fields. AAMC made a similar request several years ago and the medical schools are now turning out about 5,000 more graduates per year.

However, while medical school graduates are increasing, residency slots for continued training have not increased at the same rate. Resident programs are bearing more cost in training residents with less time to train. The number of surgeons trained over the past 20 years has remained almost static while populations have continued to increase. Many reasons can be cited for this surgeon shortage: reduced payments, higher practice cost, heavier caseloads, time and rigors of surgical residency and fellowships and for us and many other nations’ healthcare systems that are in flux.

At this year’s AAMC meeting there were many group meetings discussing changes for medical school curricula and education. The fact that medical schools are dealing with “digital natives” – comfortable with technology and all its aspects – will require medical schools to develop curricula to meet their needs. They are exploring changing medical school timelines based on proficiency

and mastery of skills rather than time based education. Libraries are being digitized and can be accessed remotely. Space consolidated provides schools more room to develop simulation training not just in simulation centers but throughout their hospitals.

A serious study is under way to determine why many medical students are choosing to change their pathways half-way through their programs; why fewer women are studying to be MD’s and are instead choosing to become nurse practitioners or physician assistants; why fewer medical students are choosing to become surgeons. These questions need to be answered and when answers are found, may lead to more efficient effective education and training systems in healthcare.

Many medical schools have changed their curricula and are more effectively meeting their students’ needs. University of Michigan, Dartmouth, Texas Tech, Ohio State and University of Central Florida, to name a few have developed an integrated curriculum that provides problem solving and professional development in hand with team training where they practice as they learn and it becomes the foundation for their knowledge. Patient safety is a key component of the curricula and education. Training and practice are the keys. Technology has provided the tools to help insure competency but nothing can take the place of caring clinical faculty to inspire, encourage and teach. These faculty members should be as comfortable in their knowledge of their students’ skills and capabilities as Sully was in his ability to safely land on the Hudson.

Judith Riess Editor in Chief, MEdSim Magazine

e judith@halldale.com MEDSIM MAGAZINE 4.2013

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Contents

ISSUE 4.2013

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06 The New Mandate for Simulation Training in Orthopaedic Surgery: A Coordinated and Strategic Approach. Robert A. Pedowitz, MD, PhD describes recent efforts to provide a strategic and coordinated approach to advance the use of simulation in orthopaedic surgery.

10 Interview with Margareta Berg, MD, PhD. Consultant Orthopaedic Surgeon, Chairman and Project Director of the Surgicon Foundation.

14 Competency, Mastery and Deliberate Practice: Revisiting the goals of simulation based assessments. Carla Pugh, MD, addresses lingering questions regarding which type of simulation and assessment venue best meets specific learning objectives.

20 Incorporating Disclosure of Adverse Events into Simulation Learning Experiences. Bonnie Haupt, DNP (C), MSN, RN, CNL, CHSE defines disclosure of adverse events and efforts to incorporate best practice components of disclosure into community scenarios.

24 Strengthening Surgeon Training. Camran Nezhat, MD describes progress in studying the methods of simulation training in order to determine which is easiest to learn and best for the surgeon.

27 Simbionix is on Course for Continued Innovation and Portfolio Expansion. Group Editor Marty Kauchak provides insights of his recent discussion with Inbal Mazor, Simbionix’s vice president of global marketing.

28 Seen & Heard. Updates from the medical community. Compiled and edited by the Halldale editorial staff.

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Editorial

Editor in Chief Judith Riess, Ph.D. e. judith@halldale.com

Group Editor Marty Kauchak

e. marty@halldale.com US & Overseas Affairs Chuck Weirauch e. chuck@halldale.com US News Editor Lori Ponoroff e. lori@halldale.com RoW News Editor Fiona Greenyer e. fiona@halldale.com

Advertising Director of Sales Jeremy Humphreys

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03 Editor's Comment. Patient safety is a key component of the curricula and education. Training and practice are the keys. Technology has provided the tools to help insure competency but nothing can take the place of caring clinical faculty.

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On the cover: Shipley Medical Simulation Center, Newton-Wellesley Hospital.

Image credit: Newton-Wellesley Hospital.

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All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise – especially translating into other languages – without prior written permission of the publisher. All rights also reserved for restitution in lectures, broadcasts, televisions, magnetic tape and methods of similar means. Each copy produced by a commercial enterprise serves a commercial purpose and is thus subject to remuneration.

MEdSim Magazine, printed November 2013, is published 4 times per annum by Halldale Media, Inc., 115 Timberlachen Circle, Ste 2009, Lake Mary, FL 32746, USA at a subscription rate of $55 per year.

MEDSIM MAGAZINE 4.2013

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annotations roles and permissions checklist creation scheduling notifications self-enrollment participant portfolios

everything simulator data iPad debriefing inventory and resources usage statistics live-evaluations scores and reports conflict detection pre-evaluations post-evaluations www.blinemedical.com ©2013 B-Line Medical, LLC, an Atellis® company. All rights reserved. Patented technology.

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SIMULATION

The New Mandate for Simulation Training in Orthopaedic Surgery: A Coordinated and Strategic Approach Robert A. Pedowitz, MD, PhD provides a summary of a strategic and coordinated approach to address simulation and other important concerns in the field of orthopaedic surgery.

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imulation has been used for decades in the field of orthopaedic surgery. Although simulation has been used widely in US residency training programs, there has been little in the way of structured curriculum or validated performance metrics for orthopaedic simulation technology. Recently, a number of intersecting factors have converged, and these factors will probably transform our surgical training paradigm from the apprenticeship model toward a proficiency-based approach. Simulation technology has advanced dramatically in parallel with the computer and gaming industries. Safety concerns have pushed us to find better educational alternatives, in order to protect patients from the “surgical learning curve”. Recent changes in resident work hour restrictions force us to find more efficient and effective training paradigms. This article provides a summary of a strategic and coordinated approach to address these important concerns in the field of orthopaedic surgery.

“Surgical simulation” is often associated specifically with high tech virtual reality (VR) training devices. But in the most basic sense, medical simulation involves anything that offers educational value outside of the clinical domain. From that perspective, orthopaedic surgeons have been using simulation for many years. Examples include dissection of cadavers (to learn and rehearse surgical approaches), performance of partial procedures using task simulators (bone and joint models), and development of arthroscopic knot tying skills (using rope and then practicing with

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suture). However, orthopaedic surgery has had little in the way of structured curriculum for the implementation of these simulation alternatives, and there is a paucity of information regarding useful, quantitative, and validated metrics that can be used to objectively measure surgical skills.

Developments in the Last 15 Years The American Academy of Orthopaedic Surgery (AAOS), along with the Arthroscopy Association of North America (AANA) and the American Board of Orthopaedic Surgery (ABOS) began investigating virtual reality and surgical simulation around 1997. Five years later, the three organizations entered into an agreement with Touch of Life Technology (ToLTech) to invent a high-tech VR simulator for arthroscopic knee surgery, under the visionary leadership of Dil Cannon, MD. ToLTech currently offers a VR training device for purchase, Simbionix, Virtamed, and Swemac/Augmented Reality

Above Arthroscopy simulator ArthroS offers basic skills and full procedural training.

Image Credit: VirtaMed. Opposite Demonstration of ToLTec VR arthroscopy simulator – ArthroSim. Image Credit: Robert Pedowitz.

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Figure 1. Barriers to implementation in orthopaedic surgery.

Source: Robert Pedowitz.

100% 90%

87.3%

80% 70%

60% Percentage

Solutions are among the companies that have also entered this highly competitive business sector. The marketplace has expanded, in part due to the development of a mandate for implementation of simulation in orthopedic training as described below. It is likely that the affordability index for VR technology will increase, as computers, haptic devices, and software proliferate.

Looking back at the evolution of simulation in orthopaedic surgery during the last 15 years, most of our effort focused upon the educational “gizmos”, with particular emphasis upon high fidelity ultra-realistic surgical simulation. There has been relatively little emphasis upon our fundamental training objectives, as defined by a structured educational curriculum. This is a natural tendency for most surgeons (especially orthopaedic surgeons), who especially love their surgical “toys”. But our focus on technology and ultra-realism may have led us slightly astray.

This realization was enhanced by several presentations at the December 2010 Executive Workshop on the Role of Simulation in Surgical Education. This workshop was coordinated by Richard Satava, MD and Jeffrey Levy, MD. It was a precursor to creation of the Alliance for Surgical Simulation in Education and Training (ASSET). Two key observations were presented at that meeting, which strongly influenced subsequent efforts in orthopaedic surgery. First, Dr. Satava remarked, “It’s all about the curriculum.”

And in retrospect, Dr. Satava wished that he had coordinated with the Board of Surgery and the Residency Review Committee (RRC) from the start, so the simulation end-products would provide greater value for those key oversight bodies.

We paid attention. Our efforts over the last few years have been directed at development and implementation using a coordinated and strategic approach.

On November 3, 2011, the AAOS sponsored the first Orthopaedic Surgery Simulation Summit, Co-Chaired by Robert Pedowitz, MD, PhD and Larry Marsh, MD. The purpose of the Summit was to pull together key stakeholders in the field of orthopedic surgery, in the hopes of developing a mandate for simulation

50% 40%

34.2%

30% 20.3%

20%

16.5% 8.9%

10%

3.8% 0% Lack of available funding

Lack of available curriculum

Lack of faculty/instructor interest

training in the United States. We invited Dr. Satava, Dr. Levy, and Gary Dunnington, MD to share their experiences from general surgery, obstetrics and gynecology, and other medical specialties. Summit participants included senior leadership from the ABOS (which sets the requirements for Board Certification) and from the orthopaedic RRC (which sets the requirements for all US orthopaedic residency training programs), in addition to representatives of various orthopaedic subspecialty societies.

In retrospect, inclusion of the ABOS and the RRC was a very important factor that influenced our subsequent success.

Our objectives were well defined, but in honesty, we were not confident that they

Lack of dedicated space

Other (Please specify)

Lack of resident interest

would be rapidly achieved. We hoped to: establish a mandate for simulation (if possible); place simulation in the formal orthopaedic curriculum; promote objective proficiency assessment; identify short-term action items, and create a goforward management plan for simulation within our specialty.

Leading up to the Summit, we performed a “needs assessment”, in order to facilitate and focus subsequent conversations. We learned that only 50 percent of orthopaedic residency programs had a motor skills lab or a motor skills program.

There was high interest among program directors in a standardized orthopaedic skills curriculum (which did not exist at the time). Most program directors had little knowledge of the department budget for skills training or the cost of running a skills lab, and cost was perceived as a major implementation challenge for surgical simulation in residency training programs (see figure 1).

To our very pleasant surprise, within a year of the Summit, both the ABOS and the Orthopaedic RRC approved mandates for surgical simulation in all US orthopaedic training programs. These mandates were strongly facilitated by Larry Marsh, MD (who served both bodies), and by Shep Hurwitz, MD, Executive Director of the ABOS. This was a fortuitous lesson re-emphasized: We had the right leaders with the right influence MEDSIM MAGAZINE 4.2013

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SIMULATION at the right time, and they were able to manage and coordinate what otherwise could have been a divisive and slow conversation. As a result, the ABOS and RRC approved mandates that defined rapid programmatic implementation requirements with a July 2013 start date.

Initial implementation required basic motor skills training for all orthopedic surgery training programs, as part of a major structural overhaul of the PostGraduate Year 1 (PGY1 year). The mandate indicated that basic motor skills training must include dedicated time, dedicated space, a structured educational curriculum, and the PGY1 skills program should be integrated with subsequent training years. The next challenge became immediately obvious: How could we help residency training programs meet these substantial implementation requirements, given the short and demanding timeline?

To this end, the ABOS sponsored a workgroup, Co-Chaired by Larry Marsh, MD, and Robert Pedowitz, MD, PhD, to develop examples of curriculum-based motor skills training modules. The workgroup defined basic motor skills modules that could be offered during the PGY1 year and provide continuity into subsequent training years. We agreed to use a standardized curriculum template, which was derived in part from curriculum templates developed by the American College of Surgeons and by the ASSET consortium. We defined very specific and achievable goals, and adhered to an ambitious timeline. Prior to the start date for the new simulation mandates, we posted the skills curriculum on-line.

The modules were offered open access, without charge, for any orthopaedic program that wished to utilize the program in whole or in part (https://www.abos. org/abos-surgical-skills-modules-forpgy-1-residents.aspx).

FAST and Other Initiatives In parallel to these efforts, other initiatives were underway to provide practical and relevant simulation training alternatives for orthopaedic surgery programs. The Fundamentals of Arthroscopic Surgery Training (FAST) Program is a collaborative project of AANA, AAOS, and ABOS that offers core motor 08

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Top to bottom FAST workstation with lucent dome, FAST workstation with opaque dome, and Knot tying mandrel.

Image Credit: Robert Pedowitz.

skills training in the field of arthroscopic surgery. Arthroscopy is one of the most common orthopaedic procedures done today, it is technically demanding, and it is hard to learn. The arthroscopic image is presented on a two dimensional video screen, which makes it suitable for VR simulation. Arthroscopy requires ambidextrous use of all instruments, which can be quite difficult for many learners.

The FAST project team deconstructed arthroscopic skills into six

specific sub-modules (using the common curriculum template described previously), which were then incorporated into the ABOS basic skills program (https://abos.org/media/7665/preamble_to_fast_modules_for_abos_curriculum_project.pdf).

Once the curriculum was welldefined, the project team created the FAST workstation, which was designed specifically for training of these fundamental arthroscopic motor skills.

Another collaborative project, between the AAOS and the Orthopaedic Trauma Association (OTA), focuses upon basic fluoroscopy skills and associated radiation safety. Fluoroscopy is used commonly in orthopaedic surgery, and the associated radiation risks are not trivial, both for patients and for surgeons and other operating room personnel.

Since the image is projected on a twodimensional screen, fluoroscopy is also well-suited for haptic-based VR simulation training.

Our hope is that training programs will refine, expand, and share these simulation alternatives. Additional information must be collected in order to create relevant and reliable performance metrics. We anticipate that more orthopaedic sub-specialties will get involved, as they seek opportunities to develop their own simulation training solutions.

And we expect that most programs will struggle with financial issues as they assess between low-tech / low-expense simulation compared to high-tech / high- expense VR alternatives. These assessments will naturally change over time, as the marketplace responds to increasing demand for simulation alternatives in orthopaedic surgery.

To this end, the AAOS sponsored the Second Orthopaedic Surgery Simulation Summit, which was held at the Westin O’Hare, Rosemont, Illinois on November 22, 2013. The purpose of Summit II was to bring together program directors, department chairs, residency coordinators, and interested faculty, in order to help them better define their simulation training objectives and to provide information about what is available from a practical implementation perspective.

This Summit included a number of companies from the VR domain, in addition

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Simulation Summit Participants.

Image Credit: Robert Pedowitz.

to vendors that offer lower-cost training alternatives, so program leaders can make informed decisions about expenditures that affect their bottom line. We also discussed opportunities for collaborative validation research for emerging simulation technologies in orthopaedic surgery. The Second Simulation Summit was no longer about the mandate. Now we are talking about efficient solutions that facilitate the shift toward proficiency-based simulation training.

A lot has been happening with simulation training in orthopaedic surgery.

We’ve seen rapid acceleration, remarkable buy-in, deliberate leadership, and a lot of hard work. In the future, we will probably appreciate the insightful advice that we got a few years ago: it’s all about the curriculum, and if possible, key stakeholder organizations should create a coordinated and strategic mandate for the shift to simulation based surgical skills training. medsim

About the Author Robert A. Pedowitz, MD, PhD is a Professor of Orthopaedic Surgery at the David Geffen School of Medicine at UCLA. Dr. Pedowitz received his MD from UC San Diego School of Medicine, his PhD from the University of Gothenburg, Sweden and Fellowship in Sports Medicine, Duke University Medical Center. He has extensive clinical and research experience in the field of orthopaedic sports medicine and arthroscopic surgery of the knee and shoulder, including many years of experience caring for athletes at the recreational, collegiate, and professional levels.

REFERENCES Karam, MD, Pedowitz RA, Mevis H, Marsh JL: Current and Future use of Surgical Skills Training Laboratories in Orthopedic Resident Education - A National Survey.

Journal of Bone and Joint Surgery (Am), 95(1):e4, 2013.

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INTERVIEW

Interview with

Margareta Berg, MD, PhD Consultant Orthopaedic Surgeon, Chairman and Project Director of the Surgicon Foundation.

Margareta Berg, MD, PhD, Consultant Orthopaedic Surgeon, Chairman and Project Director of the Surgicon Foundation.

Image Credit: Margareta Berg, MD, PhD.

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r. Berg peformed her residency, and was awarded her PhD degree in Orthopaedic Surgery, at the Sahlgrenska University Hospital, Gothenburg Sweden. During this period she invented and organized “The Hip Replacement Project”. In 1989 she founded the association for female orthopaedic surgeons in Sweden. As a consultant orthopaedic surgeon at a rural Hospital in Skene, she became interested in medical informatics and in 1996 became the project leader of a major regional project dealing with computerized patients’ records. This position allowed her to head the informatics department and become a member of the hospital direction board at the NU-Hospital group (five hospitals with 5,000 employees and 2,500 computers). She was concurrently a member of the regional and national boards of medical informatics. From 2001-2005, she worked for Pascal Boileau, MD, at the Centre Hospitalier Universitaire de Nice, France, and was responsible for the research activities and organized the 1st

and 2nd version of the “Nice Shoulder Course” (2003 and 2004).

During the same period she was Medical Advisor at two different French companies, successively, where she worked with the registration process of new surgical implants, in accordance with European Union standards and directives. As a community subject matter expert with global recognition, Dr. Berg was a guest lecturer at the South Brazilian Orthopaedic Society in Florianopolis (2003), the 50-year jubilee meeting of the Indian Orthopaedic Association in Mumbai (2005) and at the Ruth Jackson Orthopaedic Society in San Diego (2011), an affiliate meeting of American Academy of Orthopaedic Surgeons. In 2009 Dr. Berg was named “Ambassador for Female Entrepreneurs” by the Swedish Minister Maud Olofsson. In 2010 she initiated and started the Surgicon Project, a world-wide informal network of leading surgeons dealing with Surgical Quality & Safety. Her efforts resulted in the convening of two World Congresses on Surgical Training (2011, 2013) and the book “Cutting Edges in Surgical Training” (ISBN 978-83-7599-561-9). The 2013 Surgicon meeting was accredited

by The European Accreditation Council for Continuing Medical Education (www.surgicon.org). As this issue was being published, Dr. Berg accepted an invitation to complete a three month "Internship" at World Health Headquarters in Geneva beginning this January. Her time in residence will initiate a collaboration between the organization’s Global Initiative for Emergency and Essential Surgical Care and Surgicon.

MEdSim: Your assessment on the European healthcare community's current use of simulation and other learning technologies throughout the members' continuum of learning.

Dr. Margareta Berg: There is a huge variation throughout Europe, not only among countries but also within countries.

Geographically the use is most developed in the Northwestern region, in paticular Sweden, Denmark, the Netherlands, Switzerland, the UK and Ireland. Younger professors in surgery, born in the era of informatics, are more trendsetting in this area. We should also keep in mind that European medical education originated from medieval universities that historically developed their own knowledge and educating systems – depending on personal profiles taking the lead in ancient times. Communication and coordination were strongly limited, explaining why we still suffer from inconsistencies and differences in our education systems.

The use of simulation and learning technologies depends on financial resources, development levels, and personal interest and engagement.

MEdSim: As one follow up, how do you see the healthcare simulation market evolving in Europe through the next several years?

Dr. MB: As soon as the financial situation in Europe stabilizes, I think we will see a “slowly exploding market”. A crucial factor will be the insight and understanding by hospital and university leadership, to create dedicated budgets for learning technology. I feel there is a huge knowledge gap between health care providers trying to run surgical hospital care in an efficient way on one side, and the needs for surgical training and education on the other side. Yet it seems that consciousness is generally limited in this area. In the end it all comes down to hard facts: Decision makers and health care economists will need to calculate long

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term costs for efficient care that minimizes avoidable surgical complications, and compare the figures with the necessary investments in simulation and learning technology. This also means that we will need to make health care budgets for more than one year at a time.

MEdSim: How might healthcare providers in Europe and their counterparts in the US and elsewhere, increase their collaboration in simulation and other learning technologies?

Dr. MB: Personally I have been a strong advocate for 15 years on the need for new, combined education and university degrees in “Medicine & Informatics” or “Medicine & Economics & Informatics”. Health care providers have limited knowledge in informatics, industrial collaboration and agreements – and vice versa. Specialists in informatics have a limited knowledge about health care systems and their financing systems.

This creates a recurrent problem which has to be overcome to increase fruitful collaboration and mutual understanding. We have seen too many examples in the last 20 years where health care providers have paid fortunes to receive mediocre computerized solutions, evident by the knowledge gap between medical experts in health care and industrial suppliers of hardware and software.

MEdSim: Your thoughts, on implementing standards for training in healthcare curricula in the US and Europe?

Dr. MB: At the last Surgicon Congress [June 2013] the following comment was made: “Today we have three quite well developed surgical curricula, in Ireland, Australia and the US. Why not try and combine these three and create a kind of “Golden Standard” – instead of each country and each surgical specialty inventing the wheel over and over again?” The ultimate long term goal must be “Global Surgical Licenses”, as the human anatomy is the same regardless of country, culture or skin color. Presenter Richard Reznick, MD, from Canada showed a slide of an appendicitis event in Canada, and another slide of an appendicitis event in Africa – that is, the same slide was shown twice.

In addition, we live in an era of increasing migration and travelling. If we could spare the administrative paper work, and the obstacles for a skilled surgeon to work in a new country, we might find the financial resources needed to invest in simulators and learning technologies.

MEdSim: As one follow up, what are some of the obstacles to implementing regional and even global standards in healthcare curricula?

Dr. MB: Well, the obstacles seem to be endless. First, we need to make politicians and decision makers fully aware of the problem and interested in the topic. When we have managed to make them understand, then the practical work remains to be done. Then we need to agree about the benefit in letting go of local and national prestige factors, to be able to focus on the two main issues: Patient’s Safety and Surgeon’s Safety – that is, “The surgeon’s feeling of security, entering the profession”. In this process we need to accept the increasing role of informal networks and communities, replacing old and very slow hierarchic structures.

To manage we also need some common informatic systems to keep track of completed training steps in the curriculum. There are a few domains where a strong “Top-Down” leadership is necessary, and informatics is one of these – to avoid a jumble of technically noncompatible computer software systems, often seen today as a doctor’s nightmare.

At this very moment in 2013 it is not uncommon where I work to have 10-15 different software programs open to run a normal out-patient consultancy (patient record, booking system, surgery waiting list, billing system, x-ray image system, sick leave report system, etc.). But before this top-down implementation stage we need a humble and open collaboration as a first step to define a common baseline and the steps of “The surgical education staircase”. This process will take years of work and financial resources.

MEdSim: And as another follow up, are standards needed in the health care simulation equipment industry?

Dr. MB: Yes. It is most easily compared with the building industry where there

are standards for plumbing, electrical components, door and window sizes, etc.

From the beginning houses were built of the material available, like stones, wood and mud. Now one company makes the windows and another the house’s walls and you can buy standard components for your plumbing system in the local store and fix it yourself. Future informatic systems, as well as simulation systems, should be made of limited components and the principle of “plug & play”. It is not practical, or technically and financially possible, to build one single system covering everything. Industry would better support the rapid development of new solutions.

MEdSim: As a community leader, your "help wanted list”: how can the health care simulation equipment community better meet the learning needs of you and your community colleagues?

Dr. MB: We now see a tendency of “normal users” creating limited software solutions themselves, testing them within their internet communities even before they are completely mature, and spreading them in a split second. This is a complete paradigm shift compared to traditional software development, when a software program should be “ready” before release, delivery and implementation. My personal opinion is a software program is never ready, but is in a constant development process. This also changes the financial side, where we will need “subscriptions over time” combined with some power to influence the development – to replace the traditional phone book of “specification of requirements” which takes three years to create and gets old before it is ready, resulting in one huge invoice after delivery, often with minimal returns on investment.

Maybe this was not your expected answer as regards the learning needs of surgeons; but looking around the corner the learning needs are not static but eternally and very quickly changing.

To start with, it would be very helpful to have simulation equipment support to confirm the basic skills achieved e.g. at two years in surgical residency regardless of specialty, creating the basis for an international and general surgical exam.

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INTERVIEW

MEdSim: What are some of the advancements you are seeing in team training for healthcare professionals?

Dr. MB: At this moment in the interview I think it is about time to explain that I am the creator and organizer of the Surgicon Project, based on my experiences from more than 30 years' work in orthopaedics and informatics. I am not engaged as a surgical teacher, which means that my views come from a distant and very personal perspective. Regarding team training I believe this can be most valuable to achieve in the OR, and that we have a lot to learn from commercial airplane pilots. They use principles that could easily be transformed into the operating theatre – the necessity to explain your plan before take-off, to answer all questions, the obligation to alert the air traffic control system in case of deviation from the original plan - even if you are in a lower position in the hierarchy, a nurse or resident, for example.

MEdSim: We've discussed some important advancements in medical simulation and other learning technologies. What are some of the other challenges to more effectively and efficiently introduce these technologies into health care providers' learning curricula?

Dr. MB: The crucial question for residents is to get access to different forms of simulation and technical simulators, meaning dedicated time and money for training. Here’s another technology development to keep in mind: surgical video films will replace the traditional written medical record, showing the patients exactly how their surgery was performed. This will come in a very short time, in the computerized medical records.

So the organizational bodies responsible for surgical training and re-training at different stages should include surgical simulators and learning technology equipment as a natural part of their budget. I also think financial decision makers need a much better understanding of this entire topic.

MEdSim: MEdSim was pleased to attend the 2013 Surgicon.

Share with us the importance of this and other conferences in an era of constrained budgets for many.

Dr. MB: My personal conviction is that the above mentioned health care providers, financial decision makers and health care politicians should have listened to the entire program at Surgicon. The surgical community should also be present, to illustrate and discuss the topics with health care providers. The reason behind these thoughts is the three factors rapidly changing modern surgery: 1. On going retirements in the surgical community, where a huge amount of knowledge will disappear in a few years; 2. Regulated work hours for young surgeons, meaning less time for training; and 3. The technical access to surgical simulators.

In the 1980s it took 10 years to form a skilled surgeon, with a 70 hour working week. With a 40 hour working week a new skilled surgeon will be ready for retirement at the end of the training program. To me it seems as if the question about who is responsible for addressing the rapidly changing dynamics in 12

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health care training is not clearly defined, meaning that we are still fumbling in the dark to find the correct target audience for the Surgicon meetings.

Surgicon is also very different from ordinary surgical congresses targeted on narrow surgical specialties to report scientific results. Our focus is at “the 30,000foot” level, trying to broaden views and collaboration to save time and energy for all people involved in creating surgical curricula for each specialty in each country.

Some useful data were presented from Vårdskademätningen, Socialstyrelsen [Care Period Measurement, National Board of Health and Welfare] 2008 study in Swedish revealed 105,000 unintentional injuries in hospital health care in a population of 9 million inhabitants, of which 3,000 were lethal. In all she reported about 50 percent of injuries were related to surgical procedures. Each injury led to six extra days of hospitalization. Simply counting an average of $(US)1,000 per hospital night, the cost could be 6 x 105,000 x 1,000= $630,000,000 per year only in Sweden! This might be a financial

In the end it all comes down to hard facts: Decision makers and health care economists will need to calculate long term costs for efficient care that minimizes avoidable surgical complications, and compare the figures with the necessary investments in simulation and learning technology.

This also means that we will need to make health care budgets for more than one year at a time.

Image Credit: Margareta Berg, MD, PhD.

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incentive for investments in surgical simulation equipment, and a reason why Surgicon should attract attendants.

As a comparison, Sweden has invested vast sums in a “Zero Vision” that addresses how to “zero out” lethal and serious injuries from traffic accidents – now about 300/year.

MEdSim: As a final follow up, how do you see Surgicon and similar conferences evolving in content and other attributes through the next several years?

Dr. MB: First of all I would like to emphasize the principle “No competition – Only collaboration”.

Competing and prestige seem to be counterproductive in this specialized field, and all efforts and contributions are welcome. To manage we will also need a kind of neutral umbrella or mother-organisation sanctioning the global efforts. This important policy matter remains unresolved. The question about who is the organiser is of less importance, compared to the question of making every meeting a natural continuation of the last one. We do not have the time to start all over again at each meeting. The amount of research, work and efforts between the meetings should also be considered as important as the meetings themselves. medsim

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Simulation Assessment

Competency, Mastery and Deliberate Practice: Revisiting the goals of simulation based assessments.

Carla Pugh, MD, addresses lingering questions regarding which type of simulation and assessment venue best meets specific learning objectives.

Joshua Ross, a pediatric emergency medicine physician at the University of Wisconsin, conducting a debriefing session with residents and nurses.

Image Credit: Carla Pugh, MD.

U

se of simulation-based assessments has continued to evolve. In the early iterations, mannequinbased trainers were used for classroom and group based training in cardiopulmonary resuscitation for basic and advanced cardiac life support certification. With the advent of objective, checklist driven assessments, the 1970s brought us the Objective Structured Clinical Examinations (OSCE). This venue allowed for several types of simulations including task trainers, mannequins and standardized patients.1 History taking, physical examination and procedural skills were some of the clinical competencies assessed. Subsequently, the development of full body physiologic mannequins and virtual reality trainers allowed for more dynamic assessments where decision making, communication and complex procedural skills can be assessed. Despite these advances, there are still lingering questions regarding which type of simulation and assessment venue best meets specific learning objectives. The goal of this article is to revisit some of the broader end points of assessment: competency, mastery and deliberate practice.

Competency While mastery may be the implicit goal of learners exploring career specific content domains, competency is the tried and true 14

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minimum requirement expected and used for work place decisions. In 1999, the Accreditation Council for Graduate Medical Education and American Board of Medical Specialties categorized six core competencies: Patient Care and Procedural Skills (updated in 2010); Medical Knowledge; Interpersonal & Communication Skills; Professionalism; Practice Based Learning and Improvement and Systems Based Practice. Similarly, competencies for nurse residents and nurse professionals were developed. For example, the National CNS (Clinical Nurse Specialist) Competency Task Force published a list of core competencies for clinical nursing including: Direct Care; Consultation; Systems Leadership; Collaboration; Coaching; Research and Ethical Decision-Making, Moral Agency and Advocacy.

Today, most healthcare professionals have a specific set of core competencies

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by which they are assessed and taught.

A common theme in the process of developing core competencies is the use of consensus agreement and a focus on providing high quality patient care. Well defined core competencies provide a strong framework for simulation based assessments. Curriculum developers and simulationists may use the competencies to ensure global coverage of important clinical areas. Transitioning from a list of competencies to an actual assessment requires careful attention to the desired learning outcomes. While this can be facilitated by defining the knowledge, skills and attitudes necessary for successful patient care interactions, the wide variety of behaviors, responses and situations in clinical practice adds considerable complexity to the process.2 In a 2003 article entitled “Reliability and Validity of a Simulation-based Acute Care Skills Assessment for Medical Students and Residents”3 the authors detail the process of developing and evaluating a simulation based assessment of acute care skills. Figure 1 highlights the

major steps in this process. The starting point for this process was a needs assessment. In reviewing the literature, the group found that the knowledge base for acute care skills was traditionally assessed using a pencil and paper test. In addition, the physical examination skills had traditionally been assessed using standardized patients. In review of their assessment, it was duly noted that critical care events are not easily modeled with standardized patients. Moreover, the ability to cite and describe acute care management strategies does not ensure that the physician can actually provide treatment. Despite these known weaknesses in the current curriculum, graduate physicians are expected to be able to manage acute care patients.

Developing the simulation based assessment of acute care skills was a multistep process. Once a full body physiologic simulator was chosen, faculty used a consensus approach to select 10 clinical scenarios that fairly represented the content domain and skills unique to critical and emergency situations. The next step

Figure 1.

The multi-step process of developing valid and reliable simulation based assessments.

Source: Carla Pugh, MD.

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Simulation Assessment involved development of performance checklists. A key notation in this process was the depth of attention applied to checklist development: “The checklist items were limited to less than 20 actions.

A scoring weight ranging from 1 to 4 was also provided for each checklist item.

The magnitude of the weight reflected the importance of the particular action in terms of patient care.� The checklists were then piloted to determine how well each scenario matched the clinical environment and expected clinical actions.

After updating the checklists and scenarios based on the pilot, the formal assessment was administered. The assessment was video recorded and debriefing sessions were conducted to review participant performance and experience with the simulation-based assessment.

The raters were chosen carefully. Final scoring was conducted using video tapes of the assessment. The results of this study indicate that reasonably reliable and valid measures of clinical performance can be obtained from simulation exercises, provided that care is taken in the development and scoring of the scenarios. Another important study finding was that it is likely that a relatively large number of performance scenarios will be required to obtain sufficiently accurate ability estimates.

Core competencies provide a useful framework for developing simulation based assessments. However, transition from a list of competencies to a reliable and valid performance assessment is a complex process.4,5 Lastly, it appears that a wide variety of clinical scenarios must be used in order to adequately assess competency in a pre-defined content domain.

Mastery and Deliberate Practice Mastery is defined as comprehensive knowledge or skill in a subject. It has also been defined as control or superiority over someone or something. While competency focuses on minimum proficiency in a broad content domain and is often the goal of certification examinations, mastery focuses on high end expertise and is usually a self-motivated goal. In addition, attainment of mastery is historically judged by collegiate consensus.

The term mastery learning was coined 16

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by Benjamin Bloom in 1971. In a mastery learning classroom, students are helped to master each learning unit before proceeding to more advanced tasks. Formative assessment is frequent and inherent in the process. In addition, performance criteria are explicit and inform the learning process. As such, mastery learning is more about the step-by-step achievement process as opposed to traditional content focused curricula where students are serially exposed to content unrelated to achievement goals.

Additionally, mastery learning requires well-defined learning objectives and performance criteria and focuses on overt behaviors that can be observed and measured. In this environment students must show evidence of understanding of specific material before moving on to the next lesson. Using criterion referenced assessments students are able to focus on achieving their personal best. Critics of mastery learning cite time constraints as a major flaw and note their preference and need to cover a lot of material in a small amount of time. This is a breadth versus depth argument.

When applied in healthcare learning environments using simulation, mastery learning requires that learners meet or exceed a minimum passing score on a simulated examination prior to performing the procedure or skill in actual clinical practice.

Simulation-based mastery learning featuring deliberate practice gives residents and fellows the opportunity for individualized skills development and feedback.

Dr. Anne O’Rourke, a trauma surgeon at the University of Wisconsin, in the performance measurement and motion tracking laboratory.

Image Credit: Carla Pugh, MD.

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Simulation Assessment Deliberate practice has been defined as activities designed for the sole purpose of effectively improving specific aspects of an individual's performance. Formative assessments and timely feedback are a highly integral component of deliberate practice. Research has shown that levels of expertise are highly correlated with the number of hours spent practicing. In a classic study of musicians, researchers found that high level experts (or masters) spent, on average, around 10,000 hours in solitary practice during their music development by age 20 whereas the least accomplished expert musicians spent around 5,000 hours. Amateurs were noted to spend around 2,000 hours. This same trend was noted for athletes, chess players and other professionals.

A closer examination of the path to expertise reveals the distinct development of pattern recognition and information retrieval processes that are not present in amateurs or novices. Advances in our understanding of how experts think derive primarily from studies where experts are instructed to think aloud while completing representative tasks in their domains, such as chess, music, physics, sports and medicine. A close look reveals that experts select relevant information from a situation, encode it in special representations in working memory and use this information for planning, evaluation and reasoning about alternative courses of action. In essence, the difference be-

tween experts and novices is not the amount and complexity of accumulated knowledge that can be memorized. The difference is more closely related to the organization of knowledge and how it is represented. Experts' organization of knowledge around key domain-related concepts and solutions allow for rapid and reliable retrieval of relevant information. In contrast, novices encode knowledge using every day concepts that are not domain specific. This type of encoding makes retrieval and use of relevant knowledge difficult and unreliable. In addition, experts typically acquire domain-specific memory skills that allow them to

Medical students at Northwestern University engaging in a classroom based deliberate practice exercise using a manikinbased simulation with computer feedback.

Image Credit: Carla Pugh, MD.

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rely heavily on long-term memory and dramatically expand the amount of information that can be kept accessible during planning and reasoning regarding alternative courses of action. The superiority of experts' mental representations allows them to adapt rapidly to changing circumstances and anticipate future events in advance. These same representations appear to be an essential component of experts' ability to monitor and evaluate their own performance. Deliberate practice is a natural part of this process.

Simulation based assessments can greatly facilitate deliberate practice and help to pave the road to mastery. To achieve this goal, a mastery learning approach with well-defined performance criteria appears essential.

Conclusion We have reviewed the major components of competency and mastery. While both rely heavily on assessment, use of simulation to achieve these goals requires different approaches. When the focus is competency, it is highly advisable to use nationally accepted and pre-defined core competencies as a framework. Design of simulation based experiences for competency assessment purposes is a complex process requiring consensus on scope of content and continuous evaluation of scripted scenarios to ensure applicability. A wide variety of carefully designed scenarios is essential in achieving this goal. In contrast, mastery learning requires access to expert based perfor-

mance criteria. A unique aspect of this process is the potential for exceeding performance criteria. In this instance, if the predefined criteria are met or exceeded, the learner may then focus on achieving a personal best. This can be a continuous process guided by self-assessment and individually defined achievement goals based on desired level of expertise. medsim About the Author Carla Pugh, MD, PhD, FACS is Associate Professor, Vice-Chair for Education and Patient Safety and Clinical Director, University of Wisconsin Health Clinical Simulation Program.

In 2011 Dr. Pugh received the Presidential Early Career Award for Scientists and Engineers. Dr. Pugh is also the developer of several decision-based simulators that are currently being used to assess intra-operative judgment and team skills.

She received her MD from Howard University College of Medicine and her PhD from Stanford University School of Education and a Clinical Fellowship in Acute Care Surgery, University of Michigan, Dr. Pugh’s research interests include the use of simulation technology for medical and surgical education. She holds a method patent on the use of sensor and data acquisition technology to measure and characterize the sense of touch. Currently, more than 100 medical and nursing schools use one of Dr. Pugh’s sensor enabled training tools for their students and trainees. The use of simulation technology to assess and quantitatively define hands-on clinical skills is one of her major research areas.

References 1. Harden RM, Stevenson M, Wilson Downie W, Wilson GM. Assessment of clinical competence using objective structured examination. BMJ. 1975;1:447-451.

2. Cannon-Bowers, J, Salas, E 1997, Teamwork competencies: the interaction of team member knowledge, skills and attitude, in Workforce readiness: competencies

and assessments, ed. H F O’Neil, Lawrence Erlbaum Associates, Mahwah, pp.151-174.

3. Boulet JR, Murray D, Kras J, Woodhouse J, McAllister J, Ziv A. Reliability and validity of a simulation-based acute care skills assessment for medical students and

residents. Anesthesiology. 2003 Dec;99(6):1270-80.

4. Cook DA, Brydges R, Zendejas B, Hamstra SJ, Hatala R. Technology-enhanced simulation to assess health professionals: a systematic review of validity evidence,

research methods, and reporting quality. Acad Med. 2013 Jun;88(6):872-83.

5. Linn, R.L., Baker, E.L., Dunbar, S.B. Complex, Performance-Based Assessment: Expectations and Validation Criteria. Educational Researcher, Vol. 20, No. 8

(Nov., 1991), pp. 15-21.

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SIMULATION

Incorporating Disclosure of Adverse Events into Simulation Learning Experiences

Bonnie Haupt, DNP (C), MSN, RN, CNL, CHSE defines disclosure of adverse events and efforts to incorporate best practice components of disclosure into community scenarios.

M

Our Mr. Sims, VA Connecticut.

Image Credit: Bonnie Haupt.

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r. Sims is a 78 year old white male who presents to the Emergency Room with signs and symptoms of pneumonia. Sims’ wife states he has had increased shortness of breath, a wheezy cough and fever for several days. His vital signs and monitor readings are: oxygen saturation 88-91%; blood pressure 90/50; elevated respiratory rate of 36 and heart rate of 120 sinustach. The team collaborates and believes Mr. Sims is exhibiting signs and symptoms of sepsis requiring transfer to Medical Intensive Care Unit (MICU).

After arrival in the MICU, Sims has continued hypotension (BP 70/40), requiring IV pressors and placement of a triple lumen catheter. The new line is established. While awaiting

X-ray placement for confirmation the ER patient experiences increased respiratory rate over 40 and heart rate in the 160s. His wife is expressing concerns to the team that her husband just doesn’t “look right.” Suddenly Sims complains, “I don’t feel right. I can’t catch my breath.”

He begins to de-sat quickly and becomes unresponsive. It is identified there are no respirations and no pulse.

The case study reviewed above is a typical simulation scenario that is practiced in many simulation centers across

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the globe. Yet, how many simulation learning centers are focusing on what happens after the medical crisis? At VA Connecticut Healthcare System we are focusing on creating a collaborative simulation learning experience for Inter-professional and student team members during adverse events. Select simulation scenarios identify relevant practice issues that may constitute disclosure of adverse events and incorporates best practice components of disclosure and communication tips for learners to apply.

Background In 1998, The Institute of Medicine (IOM) reported that 98,000 deaths a year were related to medical errors. The IOM findings lead to the final report “Crossing the Quality Chasm” which called for a re-design of America’s healthcare system in 2001 to reduce the number of deaths. Simulation has played an integral role in educating our healthcare teams. According to new research, James (2013) estimates an increase to 210,000 deaths caused by preventable hospital error annually. If factors such as failure to follow guidelines, errors of omission and diagnostic errors are included, the preventable deaths rate jump to 400,000 lives lost annually. How are facilities communicating these unfortunate events to patients and families?

Since 2006, the Agency for Healthcare Research and Quality has recommended full disclosure. Other organizations including The Joint Commission, National Patient Safety Foundation and numerous professional ethics councils have voiced clinicians’ legal and ethical obligation to disclose adverse events. The media and families of victims, including actor Dennis Quaid, have brought forth the importance of disclosure.

Key terms requiring understanding by simulation teams incorporating disclosure of adverse events into scenarios include: • “Safety” is freedom from accidental injury; • “Errors” are planned actions that are not completed as intended; and • “Adverse Events” are events that cause patient harm or injury, resulting from a medical interventions, this also includes acts of omission or commission. This implies that something went bad, not necessarily that anyone did anything wrong (IOM, 2012).

Causes of Adverse events result from: • Practice related to communication; • Mishaps related to equipment malfunction or failure; • Procedures related to diagnostic and treatments, this includes failure to make timely diagnosis or institute the appropriate therapeutic interventions. Or, adverse reactions or negative outcomes of treatments; and • Systems related to inadequate training (National Center for Ethics in Healthcare, 2003).

Before the IOM report in 1987 VA Lexington Medical Center researched the benefits of full disclosure and found a reduction in financial payments of $15,000 compared to $100,000 nationally (1990-1996). The University of Michigan decreased claim costs from 1995-2007 by $5 million to $1 million (Boothman, Blackwell, Campbell Jr. Commiskey & Anderson, 2009). Several other hospitals have found that full disclosure has dropped malpractice lawsuits by 50% (Lamo, 2011).

Frequently asked questions about disclosure of adverse events have revealed uncertainty among team members. Questions have included: • Is there a policy?

• What events constitute a disclosure?

• Who is responsible for making the disclosure?

• When is the appropriate time to address patient and families?

• What information is communicated and in what manner?

• What documentation is needed?

This ambiguity has prompted VA Connecticut to incorporate disclosure training into simulation learning experiences.

Methods Inter-professional and students from diverse backgrounds including medical, nursing, pharmacy, physical/occupational therapy, dietary management, physician’s assistant and respiratory therapy participate in the unique disclosure experiences.

Prior to developing the simulation scenario, topics are developed through an analysis of high risk and sentinel events, evidencebased practice issues, policy and procedure skill proficiencies.

The goal of each simulation scenario is to improve Veteran safety and outcomes. Code blue-PEA (Pulseless Electrical Activity) / Asystole (TLC insertion), narcotic overdoes with respiratory arrest, blood administration and transfusion reactions, hypoglycemia with a trauma related fall, urinary catheter induced infections, deep vein thrombosis and pulmonary emboli are a few of MS1312

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SIMULATION

Yale medical residents and interns.

Image Credit: Bonnie Haupt.

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the scenarios VA Connecticut has developed that include disclosure of adverse events. Following selection of the scenario topic three to five specific objectives are developed. Examples of three PEA objectives might include: • Demonstrate effective team communication; • Identify common causes of PEA; and • Create three (3) situational needs for ethical disclosure in a healthcare setting.

Objectives for disclosure scenarios focus on components of clinical management, team skills and disclosure communication. A treatment outline is developed in a checklist format for participants who are not directly involved to observe and assess participants’ performance. These individuals share what they observed during debriefing. A pre-post quiz designed in true/false and/or multiple selection formats is given to determine learner knowledge prior to training and post session. During debriefing the team reflects on successes and areas for improvement. All team members have initially focused on the clinical management of the patient.

When team members are asked to address the family member they historically review the code scenario and current treatment plan. Some have commented to the family member, “We saved him.” However, there has been little focus on the adverse event caused by placement of a triple lumen which produced the tension pneumothorax that led to the need for patient saving.

The debriefing discussion shifts to the facility policy, the three specific types of disclosure, the different definitions of use and where to obtain it. The facilitators of the debriefing highlight what warrants a disclosure: • Potential to harm or affect patient care; • Changes in patients care; • Serious future health consequences; • Need to provide treatment or procedure without consent and • Close call events are advisable.

A disclosure of an adverse event is reviewed with the patient or family member as soon as the practitioner is made aware. Members of the leadership team not limited to Chief of Staff, Nursing Executives, Risk Manager and Inter-professional team members may be included in the family meeting. VA Connecticut has a template in the Computerized Patient Record System and an Online Incident Reporting System where notes are documented.

The major components of disclosure addressed with the teams are to disclose all harmful errors, explain why and how the event happened and explain what process will take place to prevent reoccurrences. A key points and tips brochure on communication highlight items covered in the scenario and completion certificate are provided to the participants.

Tips include: • Find a quiet private environment to disclose; • Find out what is known and more importantly understood; • Speak slowly and in simple terms; • Listen; • Be empathetic and compassionate; • Discuss the investigation; • Follow-up • Offer additional support teams.

Evaluation/Findings A comprehensive evaluation tool was utilized to measure learner’s achievement of each objective. All participants documented that the five main objectives related to Q1 (Question 1). "Recognizes correct medications for use during PEA algorithm." Q2. "Identifies common causes of PEA." Q3. "Demonstrates appropriate ACLS protocol in PEA arrest." Q4."Demonstrates effective team communication during crisis situation."

Q5."Identifies ‘3’ situational needs for ethical disclosure in healthcare setting” were met at 100%.

Additional evaluation items were met at greater than 97%. Qualitative data and remarks by the participants included: “Everyone participated as a team during the scenario. I felt important and staff treated us (the students) like we were members of the healthcare team”; “I feel the scenarios will guide me in providing better care to the Veterans”; “I have

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a clearer understanding of staff roles during crisis situations and disclosure”; “Very informative, I really liked the interactive scenario and working with many staff who I have never met before, wish to have more” and “It was great to work with the staff during the simulation; this will help me in my clinical interactions with patients and staff. I learned a lot.”

The goal of this initiative is to enhance communication, collaboration and develop a better understanding and respect for inter-professional and student team members’ role in caring for our Nation’s Veterans. Participants have shared their positive feedback of working together on the unique simulation experience.

the key clinical educational components outlined in simulation scenarios. Ethical benefits promote transparency, customer service and trust and may reduce financial claims. The concept promotes positive relationships, improves collaboration, communication and increases understanding of each team member’s role in providing care to our Nation’s Veterans. medsim About the Author Bonnie Haupt holds a Masters’ Degree in Nursing Education and is presently pursing her Doctorate of Nursing Practice. She is currently the Acute Care Clinical Nurse Leader and Simulation Specialist at VA Connecticut. Bonnie has worked at the West Haven VA for over 15 years, most recently for the VA Nursing Academy and Fairfield University as an Assistant Professor, and in the Surgical Intensive Care unit. Her research interests are; communication of inter-professional team members, utilization of simulation education in the healthcare setting, and bringing evidenced based practice issues to the bedside, improving Veteran safety and overall patient care outcomes.

Conclusion/Implications The focus on disclosure of information to patients and their families or other indiviudals, continues to be a prominent topic in healthcare. This new innovative idea incorporating use of disclosure into simulation scenarios will close the knowledge gap of ethical health care practices, while continuing to focus on all ReferenceS

- Agency for Healthcare Research and Quality (AHRQ). (2011). 20 Tips to Prevent Medical Errors. Retrieved from http://www.ahrq.gov/consumer/20tips.htm.

- Boothman, R., Blackwell, A., Campbell Jr., D., Commiskey, E., Anderson, S. (2009). A better approach to medical malpractice claims? The university of Michigan experience. Journal of Health & Life Sciences Law. 2,2:125-159.

- Brunnquell, D. (2006). What we've learned. Retrieved from http://www.childrensmn.org/web/aboutus/072550.pdf - Gallagher T.,H, Garbutt J.,M, Waterman A.,D, et al. (2006) Choosing your words carefully: how physicians would disclose harmful medical errors to patients.

Arch Intern Med.166:1585-1593.

- Institute of Medicine. (2003) Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academy Press.

- Institute of Medicine. (2001) Shaping the future for health. Crossing the quality chasm: a new health system for the 21st century.

Retrieved from http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf - Institute of Medicine. (1999). To err is human: Building a safer healthcare system. Washington, DC: National Academy Press.

- James, J.,T. (2013). A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety, 9 (3),122–12. doi: 10.1097/PTS.0b013e3182948a69 - Joint Commission. (2008). Comprehensive Hospital Accreditation Manual: The Official Handbook. Oakbrook Terrace, IL: Joint Commission Resources.

- Kraman, S. S., Hamm, G. (1999). Risk management: Extreme honesty may be the best policy. Annals of Internal Medicine, 131, 12, 963-967.

- Lamo, N. (2011). Disclosure of Medical Errors: The Right Thing To Do, But What is the Cost?

Retrieved from http://www.lockton.com/Resource_/PageResource/MKT/Lamo_Disclosure%20of%20Medical%20Errors_Winter2011.pdf - Senate Committee on Labor, Health, Education and Pensions. Hearing record, June 2006.

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lator. These particular exercises are to be completed before the more formal training, and then we continue to evaluate the time the trainees take to complete the tasks. This takes place periodically to measure the improvement in different individuals.

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Why the Study

Strengthening Surgeon Training Camran Nezhat, MD reports on his efforts to encourage simulation to become even more realistic, to influence surgical curriculum and to impact training protocols.

W

simulAtion Assessment

Practice Competency, Mastery and Deliberate interview PhD Interview with Margareta Berg, MD,

e now know that the limiting factor for performing minimally invasive surgery is surgical skill and experience, as well as the availability of proper instrumentation.

In my career-long search for the best quality for patients, I have been absolutely committed to minimally invasive surgery with and without robot assistance. It has been proven that better results are afforded through this minimally invasive, modern technology. But such complex surgical methods require indepth training, otherwise surgeons will do harm not only to their patients but also slow the progress of medicine.

It is no longer accepted to say that skilled surgeons attain their expertise through years of observation and experience. We can and must encourage the best, most efficient training possible for the benefit of our patients. So it is essential to train surgeons with the most modern simulation technology, independently 24

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In my field, about 60 percent of hysterectomies are performed through open surgery, resulting in more risk and pain to women. I am deeply concerned that most surgeons use a large incision to gain access to the uterus and other pelvic organs. The hope is that through better quality training more surgeons will adopt more up-to-date methods of caring for their patients. Determining which methods are easier to teach and learn will help us reach that goal.

We must continue to conduct research to demonstrate the effectiveness of simulation training and how it can affect patient outcomes. An analysis of previous studies finds that the use of technology-enhanced simulation training in health professions education, in comparison with no intervention, is associated with significant effects for outcomes of knowledge, skills, and behaviors and more moderate effects for patient-related outcomes, according to an article in the September 7, 2011 issue of The Journal of the American Medical Association.

validating the method and quality of the procedure through our academic centers. There is no substitute for such training in terms of overall patient recovery and for minimizing post-operative risks and adverse consequences for patients.

The Study For the past two years we have been studying the methods of simulation training in order to determine which is easiest to learn and best for the surgeon. We are currently comparing simulation training between traditional laparoscopy and Mimic Technology’s for robotic-assistedsoftware for the da Vinci Robot. Mimic’s

The da Vinci Surgical System. image Credit: intuitive Surgical.

Determining an Easier Path to Training training technology has been independently validated by academic medical centers throughout the country, and for this reason their technology is an important part of the study. We are evaluating the best, least-invasive ways of surgically managing intraabdominal pathologyI in order to help surgeons avoid the more traditional open surgery.

Our study is made up of a group of postgraduate trainees at Stanford University Medical Center. In order to evaluate the benefits, the tasks we’ve chosen include suturing, knot tying, and moving of the objects from one location to another on the dV Trainer, a robotic surgery simu-

There are advantages to training surgery with and without robot assistance.

When looking at outcomes for both laparoscopic with and without robot assistance surgery in the past, we see that they have been similar; however, robotic assistance offers the surgeon threedimensional images, helpful instruments, and an opportunity to be seated during surgery. Traditional laparoscopic is more established, and that familiarity can be an advantage, even at the training stage.

As reported by the Mayo Clinic, both are preferable to the traditional open incision because there is less blood loss, shorter hospital stays and fewer postoperative complications. One of the aspects of this study that is so impor-

tant is how simulators enable surgeons to become proficient in a much shorter time. It is not enough to allow surgeons to become proficient with learning only during postgraduate courses. We need better protocols so that surgeons go into surgery with an acceptable level of skill from day one. Our study is important in demonstrating how simulators enable surgeons to become proficient in a much shorter time.

Additionally, we are looking at whether the training techniques have a significant effect for patients. Anything that helps us preserve the uterus and other vital organs in a way that is much less invasive to women is the way to go.

Training surgeons with the most up-to-date technology prevents complications during surgery and relieves patients of having to undergo more complicated procedures in the future to repair problems from previous surgeries.

The Importance of Teaching Simulation There are simply not enough surgeons in the United States and worldwide that are trained to perform advanced minimally invasive surgery with and without robot assistance. If you want to be great at anything, and surgeons should be at their craft, you have to practice frequently.

Obviously this practice cannot occur on humans; we need simulators for them.

The shortcomings in available training technology have introduced an opportunity for skilled medical device manufacturers who have sophisticated experience, such as Mimic Technologies, to develop simulators that train surgeons on performing minimally invasive surgery. We need to do a much better job explaining or teaching the importance of simulation. As I have told many, in the same way that pilots, before they start flying, must log in thousands of miles of flying in simulators—we should be going in the same direction for surgery.

The Advantages: Current Technology Some simulators can recreate the same consistency, to some degree, of tissues, vessels, and breathing. Every year, we train hundreds of surgeons to become minimally invasive or robotic surgeons. mEdSim maGaZinE 4.2013

The New Mandate for Simulation Training in Orthopaedic Surgery issn 2165-5367 | us $7.50

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Strengthening Surgeon Training Camran Nezhat, MD reports on his efforts to encourage simulation to become even more realistic, to influence surgical curriculum and to impact training protocols.

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e now know that the limiting factor for performing minimally invasive surgery is surgical skill and experience, as well as the availability of proper instrumentation.

In my career-long search for the best quality for patients, I have been absolutely committed to minimally invasive surgery with and without robot assistance. It has been proven that better results are afforded through this minimally invasive, modern technology. But such complex surgical methods require indepth training, otherwise surgeons will do harm not only to their patients but also slow the progress of medicine.

It is no longer accepted to say that skilled surgeons attain their expertise through years of observation and experience. We can and must encourage the best, most efficient training possible for the benefit of our patients. So it is essential to train surgeons with the most modern simulation technology, independently

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validating the method and quality of the procedure through our academic centers. There is no substitute for such training in terms of overall patient recovery and for minimizing post-operative risks and adverse consequences for patients.

The da Vinci Surgical System.

Image Credit: Intuitive Surgical.

The Study For the past two years we have been studying the methods of simulation training in order to determine which is easiest to learn and best for the surgeon. We are currently comparing simulation training between traditional laparoscopy and Mimic Technologies for robotic-assistedsoftware for the da Vinci Robot. Mimic’s

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lator. These particular exercises are to be completed before the more formal training, and then we continue to evaluate the time the trainees take to complete the tasks. This takes place periodically to measure the improvement in different individuals.

Why the Study In my field, about 60 percent of hysterectomies are performed through open surgery, resulting in more risk and pain to women. I am deeply concerned that most surgeons use a large incision to gain access to the uterus and other pelvic organs. The hope is that through better quality training more surgeons will adopt more up-to-date methods of caring for their patients. Determining which methods are easier to teach and learn will help us reach that goal.

We must continue to conduct research to demonstrate the effectiveness of simulation training and how it can affect patient outcomes. An analysis of previous studies finds that the use of technology-enhanced simulation training in health professions education, in comparison with no intervention, is associated with significant effects for outcomes of knowledge, skills, and behaviors and more moderate effects for patient-related outcomes, according to an article in the September 7, 2011 issue of The Journal of the American Medical Association.

Determining an Easier Path to Training

training technology has been independently validated by academic medical centers throughout the country, and for this reason their technology is an important part of the study. We are evaluating the best, least-invasive ways of surgically managing intraabdominal pathology in order to help surgeons avoid the more traditional open surgery.

Our study is made up of a group of postgraduate trainees at Stanford University Medical Center. In order to evaluate the benefits, the tasks we’ve chosen include suturing, knot tying, and moving of the objects from one location to another on the dV Trainer, a robotic surgery simu-

There are advantages to training surgery with and without robot assistance.

When looking at outcomes for both laparoscopic with and without robot assistance surgery in the past, we see that they have been similar; however, robotic assistance offers the surgeon threedimensional images, helpful instruments, and an opportunity to be seated during surgery. Traditional laparoscopic is more established, and that familiarity can be an advantage, even at the training stage.

As reported by the Mayo Clinic, both are preferable to the traditional open incision because there is less blood loss, shorter hospital stays and fewer postoperative complications. One of the aspects of this study that is so impor-

tant is how simulators enable surgeons to become proficient in a much shorter time. It is not enough to allow surgeons to become proficient with learning only during postgraduate courses. We need better protocols so that surgeons go into surgery with an acceptable level of skill from day one. Our study is important in demonstrating how simulators enable surgeons to become proficient in a much shorter time.

Additionally, we are looking at whether the training techniques have a significant effect for patients. Anything that helps us preserve the uterus and other vital organs in a way that is much less invasive to women is the way to go.

Training surgeons with the most up-to-date technology prevents complications during surgery and relieves patients of having to undergo more complicated procedures in the future to repair problems from previous surgeries.

The Importance of Teaching Simulation There are simply not enough surgeons in the United States and worldwide that are trained to perform advanced minimally invasive surgery with and without robot assistance. If you want to be great at anything, and surgeons should be at their craft, you have to practice frequently.

Obviously this practice cannot occur on humans; we need simulators for them.

The shortcomings in available training technology have introduced an opportunity for skilled medical device manufacturers who have sophisticated experience, such as Mimic Technologies, to develop simulators that train surgeons on performing minimally invasive surgery. We need to do a much better job explaining or teaching the importance of simulation. As I have told many, in the same way that pilots, before they start flying, must log in thousands of miles of flying in simulators – we should be going in the same direction for surgery.

The Advantages: Current Technology Some simulators can recreate the same consistency, to some degree, of tissues, vessels, and breathing. Every year, we train hundreds of surgeons to become minimally invasive or robotic surgeons.

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Simulation Study Now, instead of sending them to the animal lab, they can practice on a simulator.

That has been the purpose of the study.

We are working with Mimic Technologies directly to encourage simulation to become even more realistic, to influence surgical curriculum and to impact training protocols.

Studies have proven that good quality simulators can divulge whether surgeons are an expert or new surgeon. We have figured out that training on the simulator translates to improved skill on the robot itself. However, most of these findings involve studies that are conducted with a “dry lab”, but our study takes it further by measuring actual patient outcomes and how simulation training curriculum affects those outcomes.

Challenges: Investment The challenges in training surgeons to use robotic-assisted surgical technology involve the time, the cost, and the available resources. For each surgery, instruments total close to $2,000. Add the cost of bringing in a team to set up the robot, a proctor for observation, physical models, and then the price of sacrificing surgery time to train with the robot and you have a significant investment. These costs are added to the cost of the robot for $1.6 million and a simulator for less than $100,000.

However, this investment is well worth the cost. As reported by many hospitals , surgeons report they like the fact that they are allowed a three-dimensional view, as opposed to traditional laparoscopy, where the view is twodimensional. This gives them more detail and more ability to manipulate the view, which is important to some surgeons.

The robot removes the sometimes confusing, counterintuitive motion of traditional laparoscopy, where the endpoints move in the opposite direction of the surgeon's hands. To some, the robotic instruments are more flexible because they operate like the human wrist. Performing while sitting is another advantage of robotic surgery.

There are subjective views about technical difficulty. For many surgeons,

it could make sense to embrace robotic assisted surgery once trained. For others who are already traditional laparoscopic surgeons, they should become great laparoscopic surgeons, by investing in further training.

But the most important aspect is that minimally-invasive surgeries, with and without robot assistance, offer better outcomes.

When patients leave the hospital sooner, and with less pain, then we have succeeded. When they are able to return to work more quickly and resume their lives with their families – that is what counts.

There has been tremendous growth in the use of simulation for robotic assisted surgery. This is evident in the fact that we are seeing many more hospitals building simulation centers.

With many improved outcomes for patients, there is no doubt this trend will continue.

Dr. Camran Nezhat with his fellows Erica Balassiano, Jillian Main and Diana Aldape.

Image Credit: Maia Dinglasan.

Conclusion Our study will produce short- and long-term results and could last for years. Our hope is that it has a significant effect on the use of simulation technology. If it shows the strengths of laparoscopic and robotics with and without robot assistance, administrators might be willing to invest more in a laparoscopic simulator. In any case it is going to have an impact on the way that people train surgeons, and that will help build a foundation, so that training can be applied consistently throughout hospitals and in academic centers around the world – that is our overall goal. medsim About the Author Camran Nezhat, MD, is the internationally renown minimally invasive surgeon at Stanford University Medical Center in Palo Alto, California. Nezhat is widely recognized as a pioneer in the field and is recognized by many as “The Father of video assisted laparoscopic surgery.”

Reference 1. Hospital and Health Networks; Boston Business Journal; San Francisco Business Times.

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SIMULATION

Simbionix is on Course for Continued Innovation andMargareta Portfolio Expansion Interview with Berg, MD, PhD Group Editor Marty Kauchak provides insights of his recent discussion with Inbal Mazor, Simbionix’s vice president of global marketing.

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his October MEdSim had an opportunity to speak with Simbionix’s Inbal Mazor in an ideal environment – away from the frenetic exhibition floor of a major community conference. In a brief, wide-ranging discussion, the industry veteran provided insights about developments across her company’s portfolio.

Simbionix’s PELVIC Mentor advanced simulator allows OB/GYNs, medical students and nurses to obtain detailed knowledge of pelvic anatomy and to acquire the comprehensive skills required to perform pelvic exams.

The technology underpinnings for this device are new, Mazor said. “Until now most pelvic exams were conducted on a mannequin. What we are doing now is incorporating our innovative technologies with special sensors and special mannequins to provide hands-on training exams. This will be a nice solution for physicians and nurses to learn tactile skills and develop muscle memory competencies – using their fingers, let’s say.” The device’s special sensors fitted on the operator’s fingers will further be correlated and synchronized with the accompanying screen presentation.

The new device will be unveiled for the community at this November’s AAGL

Simbionix's U/S Mentors operational effectiveness is based, in part, on state-of-the art sensors.

Image Credit: Simbionix.

2013 in Washington, DC and again at the January 2014 IMSH in San Francisco.

Following this year’s introduction of the U/S Mentor high-end medical simulator for the training of ultrasound-related examinations and interventions, Simbionix plans to offer a follow-on product, the TEE Ultrasound simulator. With the new product, the learning audience will be able to better learn and enhance their skills with enhanced 3-D anatomical representations and other system capabilities. “This is the perfect educational tool to enhance orientation, anatomical knowledge and understand the change of the image with the ultrasound,” Mazor pointed out.

Mazor further noted the U/S Mentor’s operational effectiveness is based, in part, on state-of-the art sensors. That statement generated this observation from MEdSim: the company appears to be focused on refining and improving its tracking technologies for use in many training devices. Mazor, responded, “Yes, with each product we’re trying to find

the best, cost-effective sensor and the right haptic system to provide a specific feeling that is unique for a specific procedure.”

A prototype TEE Ultrasound simulator was scheduled to be introduced to the community at this coming ACEP Seattle, Washington. Simbionix had expectations to obtain end-user comments and other inputs from the conference delegates about the new product.

Simbionix is also addressing several other themes that are becoming increasingly important in MEdSim’s editorial program: team training and return on investment.

Mazor pointed out the company’s ANGIO Mentor suite is among its innovative virtual reality training simulators that were designed to provide hands-on practice for teams in a simulated environment – in this instance, for endovascular procedures.

“This is a mannequin-based system on an adjustable table. The accompanying monitors and other material allow the attending physicians and others on the team to walk around the mannequin to monitor the drugs, develop their communication skills and other competencies, and train authentic endovascular procedures and scenarios in a simulated cath lab or angio suite. This is new, ideal team training for the endovascular field,” Mazor said.

The ANGIO Mentor will be unveiled for the community at TCT 2013 in San Francisco this October and again at the 2014 IMSH. Simbionix is also refining its MentorLearn on-line, Learning Management System (LMS) to help its customers gain efficiencies. Mazor was asked how this MentorLearn offering differs from legacy systems in community simulation centers. She responded, “This is a dedicated LMS to manage simulation systems. For example, a simulation center can use the MentorLearn to minimize the time on the course and system itself. It allows the learner to prepare themselves at their desks – learning the didactical material, reviewing reports and other content. So we save time, making learning much more efficient,” Mazor concluded. medsim MEDSIM MAGAZINE 4.2013

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World News & Analysis

MedicalNews Updates from the medical community. Compiled and edited by the Halldale editorial staff. For the latest breaking news and in-depth reports go to www.halldale.com.

Novel 3-D Simulation Technology Helps Surgical Residents Train More Effectively – A new interactive 3-D simulation platform offers surgical residents a unique opportunity to hone their diagnostic and patient management skills, and then have those skills evaluated according to a new study covered in the August issue of the Journal of the American College of Surgeons. The findings may help establish a new tool for assessing and training surgical residents.

Previous research studies showed the management of patient complications following operations is an important skill set for surgeons to master. That’s why surgeons must also be able to effectively manage surgical patients in the emergency room, on the hospital floor unit, or in the intensive care unit in addition to performing operations. Until now, the standard approach for this instruction was to learn this skill set on patients.

Using an online virtual world called Second Life, a multidisciplinary team of researchers from Imperial College St. Mary's Hospital developed three virtual reality environments -- a standard hospital ward, an intensive care unit and an emergency room. They also created modules for three common surgical scenarios: gastrointestinal bleeding, acute inflammation of the pancreas and bowel obstruction. Each of these scenarios, which could be accessed through a laptop or personal computer, was designed to put the residents through their paces at three different levels of complexity.

Moving forward, the research team plans to study how the implementation of this technology will improve clinical outcomes of surgical patients cared for by residents. In future research, surgical residents and interns will train on this 28

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ACCP First Medical Association to Get SSH Accreditation – The American College of Chest Physicians’ (ACCP) clinical simulation program received accreditation from the Society for Simulation in Healthcare (SSH). It is the first medical association to earn SSH accreditation, and one of only 22 clinical simulation programs accredited nationally. The ACCP received special recognition from SSH in the areas of assessment, education and teaching, and research. The association offers nearly 80 different simulation-enhanced educational opportunities each year, attracting clinicians who specialize in chest medicine from across the United States and abroad. Next year, ACCP's simulation education offerings will be housed in a brand-new 15,000-square-foot Innovation, Simulation, and Training Center in Glenview, Illinois. The new facility will continue ACCP's effort of furthering an emphasis on advanced clinical education, training, simulation, and educational research efforts. It will feature an auditorium, six simulation suites, and breakout rooms that will integrate a variety of educational methods including task trainers simulators and will offer hands-on learning opportunities for practicing physicians and their teams.

program to achieve the skill level of a senior resident or an attending physician – with the ultimate goal of maintaining and improving patient safety.

Healthcare/Medical Simulation Market Worth $1.9 Billion by 2017 – A new “Healthcare/Medical Simulation

Market” report produced by MarketsandMarkets says this market will be worth $1.9 billion by 2017.

The "Healthcare/Medical Simulation Market By Product (Patient Simulator, Surgical Simulator, Imaging Simulation, Task Trainer), Technology (Haptic, Virtual

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Reality), End-Users (Academics, Hospitals, Military) & Services Trends & Global Forecasts To 2017" analyzes and studies the major market drivers; restraints; and opportunities in North America, Europe, Asia, and the rest of the world.

The report point out the healthcare/ medical simulation market has experienced extensive growth over the past few years, mainly attributed to advancements in technologies. The increasing focus on training of medical practitioners, rising healthcare costs, the growing focus on patient safety and availability of funds has helped increase the purchasing power of academic institutes, thereby driving the growth of the market.

The healthcare/medical simulation market mainly consists of simulation products and services that are used to train students and healthcare practitioners. Academics, hospitals, and military are the major end-users of medical simulation products, with academics being the largest market share in 2012 due to increased focus on training of medical students and availability of government funds.

IBM and Boston Children’s Hospital Team on Cloud-based Pediatric Education Platform – IBM and Boston Children’s Hospital developed a Cloud-based global education technology platform to transform how pediatric medicine is taught and practiced around the world. The initiative aims to improve the exchange of medical knowledge on the care of critically ill children – no matter where they live.

The new Cloud-based technology platform called OPENPediatrics equips doctors and nurses with the knowledge and skills they need to save children’s lives during intensive care situations.

Developed in IBM Labs in Cambridge, Massachusetts, OPENPediatrics trains medical professionals using an on-demand, interactive, digital and social learning experience that equips them to perform life-saving procedures and treatments for children who would not otherwise have access to intensive care. The content is supplied by experts at Boston Children’s Hospital and includes seminars from international expert clinicians.

The benefit of Cloud is that it overcomes the need to build a global technology infrastructure in favor of a highly efficient, cost-effective model. By putting OPENPediatrics in the Cloud, clinicians are guaranteed to have access to the latest medical information, training modules, best practices, and social interactions between users.

Medical personnel can access state-of-the-art simulations, video seminars and illustrations in real-time to treat critically ill patients. To fuel social interactions and learning, OPENPediatrics will host a global social collaboration forum that connects experts from around the world to share break through findings, best practices and patient care examples.

Early reports show that OPENPediatrics is changing the course of treatment. One physician in Israel reported that OPENPediatrics video demonstrations helped him master a feeding tube procedure, to ensure adequate nutrition and hydration in critically ill children and at the Fundación Aldo Castañeda in Guatemala, physicians using OPENPediatrics learned new ways to avoid infections, resulting in a new infection prevention program. In its pilot phase, OPENPediatrics is being used by more than 1,000 doctors and nurses in 74 countries on six continents.

UK’s Emergency Next of Kin Card Celebrates 14th Anniversary – The UK's Next of Kin Card is celebrating its fourteenth anniversary by reminding the British public it can be a lifesaver.

The card is already carried by more than three million people but, with 195,723 reported casualties on British roads last year and millions more accidents and emergencies at home, the card could be the reason someone gets a second chance at life.

The Next of Kin Card company says having ICE stored in your phone doesn't work, as most phones are pin locked or the phone can end up smashed in traffic accidents.

Call to Action at ACS Clinical Congress to Reduce Death Toll Among Mass-Casualty Victims – Too often, victims of active shooter or mass-casualty incidents bleed to death waiting for

medical treatment, according to members of a collaborative group of federal law enforcement, trauma surgeons, and emergency responders who participated in a panel discussion during the Annual Clinical Congress of the American College of Surgeons (ACS).

Representatives of this collaborative committee, whose recommendations are called the Hartford Consensus, launched a call to action for cities to develop an integrated response system focused on the importance of initial actions to control hemorrhage as a core requirement of the emergency response.

At the first meeting they concluded the leading cause of preventable death in these incidents was uncontrolled bleeding or hemorrhage. “The key to improving survival in active shooter mass causality incidents is expanding the pool of first responders,” said Alexander Eastman, MD, MPH, FACS, Chief of Trauma at UT Southwestern/Parkland Memorial Hospital, and Dallas Police Department Lieutenant. He said many lives were saved in the Tucson, Arizona shooting because law enforcement implemented the same techniques the Hartford Consensus recommends and that if you give responders the training and equipment to control bleeding, they will use it well and they will save lives.

The committee made a national call-to-action to establish first responder protocol to minimize preventable deaths of victims involved in mass-casualty incidents – and recommends additional training, education, and equipment for the public since uninjured bystanders or minimally injured victims would already be on the scene and could respond right away. It also recommends additional training and education for better coordination and communication among emergency responders.

Robotic Surgery Training Memorial Hermann Katy Hospital Gets da Vinci Si Surgical System – Memorial Hermann Katy Hospital in Texas acquired a new da Vinci Si Surgical System – a third generation robot that offers technological advancements including unparalleled precision, dexterMEDSIM MAGAZINE 4.2013

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World News & Analysis ity and control that lets physicians take a minimally invasive approach for many complex surgical procedures, such as removal of the uterus or the prostate gland. These new advancements benefit patients by enabling smaller incisions and less blood loss, reducing a patient’s length of stay and recovery time.

Academic S&T Centers Medical School Applicants, Enrollment Reach All-Time Highs – A record number of students applied to and enrolled in United States medical schools in 2013, according to data released by the AAMC (Association of American Medical Colleges). The total number of applicants to medical school grew by 6.1 percent to 48,014, surpassing the previous record set in 1996 by 1,049 students – and the number of firsttime applicants increased by 5.5 percent to 35,727. The number of students enrolled in their first year of medical school exceeded 20,000 for the first time, a three percent increase over 2012.

The overall growth in medical student enrollment can be attributed, in part, to the creation of new medical schools and existing schools’ efforts to expand their class sizes after the AAMC, in 2006, called for a 30 percent increase in enrollment to avert future doctor shortages. In 2013, 14 medical schools increased their class sizes by more than 10 percent and four new medical schools welcomed their first classes this year. Since 2002, medical schools have increased the number of first-year students by 21.6 percent.

Center for Medical Simulation Director Receives ASA’s Highest Award – The Center for Medical Simulation's Executive Director, Jeff Cooper, PhD, was awarded the highest honor given by the American Society of Anesthesiologists, its Distinguished Service Award, for his lifetime contributions, especially for this efforts in making anesthesiology the leading specialty in patient safety at the ASA. Elmhurst College, Hospital to Build Simulation Center – Elmhurst College and Elmhurst Memorial Hospital in Illinois are collaborating on a $1.4 million new simulation facility in the 30

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hospital that will let the College’s nursing students practice and build clinical knowledge. The center is scheduled to open by Fall 2014.

The 4,600-square-foot Elmhurst College Simulation Center at Elmhurst Memorial Hospital will create healthcare environments that represent inpatient, outpatient and community settings and give students the opportunity to practice protocols and procedures and run through intense scenarios without risk to patients. Staff members at Elmhurst Memorial Hospital – and, potentially, first-responders and other outside medical-service providers – will be able to use the Simulation Center for training and professional development.

Fox Valley Tech Opens Health Sim Tech Center – Fox Valley Technical College opened its $12 million, Health Simulation and Technology Center (HSTC) on the college’s Appleton, Wisconsin campus. It features 14 human patient simulators in the new 66,000 square-foot, three-story high-tech facility designed to train career-starters and existing health care professionals.

The HSTC houses simulation technology for newborn to adult, addresses the need for more clinical experiences in health care, creates an environment that fosters interdisciplinary healthcare education, and provides increased opportunities for healthcare workers to enhance and retain their skills.

Dakota Wesleyan University Opens New Health Sciences Facility – Dakota Wesleyan University in South Dakota opened its new Glenda K. Corrigan Health Sciences Center that houses the school’s College of Healthcare, Fitness and Sciences and Department of Nursing.

The four-story, 48,000-square-foot building contains four nursing simulation labs, classrooms, and undergraduate research labs equipped with stateof-the-art equipment for student use.

Wake Tech Opens Health Sciences Building Addition – Wake Tech Community College in Raleigh, North Carolina opened a new addition to its Health Sciences Campus that has a nursing simulation suite, hospital-sized radiography labs, an EMS ambulance bay and

other state-of-the-art training features.

The $20 million, 100,000-square-foot facility is the fourth instructional building on the campus and achieved LEED Gold certification for environmentallyresponsible construction by the U.S. Green Building Council. The new building houses the college’s training programs for nurses, x-ray technicians and MRI/CT technicians.

Northeastern University Opens New Simulation Suite – Northeastern University in Boston, Massachusetts, opened its new Arnold S. Goldstein Simulation Laboratories Suite in the Bouvé College of Health Sciences, made possible by a $2 million donation by the former faculty member’s widow and a $500,000 donation by Orbis Education.

The lab suite features video capture technologies, four simulation bays, two debriefing rooms, and high-fidelity patient simulators.

UT ArlingtonTests Model for Implant Device Reactions – A University of Texas (UT) at Arlington team used mathematical modeling to develop a computer simulation it hopes will one day improve the treatment of dangerous reactions to medical implants such as stents, catheters and artificial joints.

The work resulted from a National Institutes of Health-funded collaboration by research groups headed by a professor of bioengineering in the UT Arlington College of Engineering, and the chairman of the UT Arlington College of Science’s mathematics department.

Results from their computational model of foreign-body reactions to implants were consistent with biological models in lab tests. A new paper describing the results was accepted for publication in the Journal of Immunological Methods.

University of Southern Indiana Renovates Clinical Sim Center – The University of Southern Indiana College of Nursing and Health Professions renovated its Clinical Simulation Center to make it a more realistic clinical learning environment. The space was subdivided into separate areas to more closely resemble a hospital setting – complete with sliding glass doors found in intensive care units, a patient assessment room, and a dedicated control room

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to run the three Laerdal high-fidelity simulation mannequins that are patients in the Simulation Center.

Hospital S&T Houston VA Medical Center Aims to Improve Health Care Through Simulation – The Michael E. DeBakey VA Medical Center (MEDVAMC) in Houston, Texas, opened a new simulation lab to help improve the quality and efficiency of Veterans health care through realistic simulations of routine processes and to train the center’s clinical staff to better respond to emergency situations.

MEDVAMC plans to increase the use of medical simulation training for clinicians so they can learn how to conduct complex procedures in a setting that imitates real-life situations.

Helen DeVos Children’s Hospital Opens Pediatric Simulation Suite – Helen DeVos Children’s Hospital in Grand Rapids, Michigan in the US opened a new pediatric simulation suite that mocks actual medical scenarios for training and education purposes.

It is designed to support the hospital’s goal of being the safest children’s hospital in the country improve the technical expertise of clinicians; strengthening multidisciplinary teamwork and enhancing communication among physicians, nurses and other health care providers.

Nursing Education & Training Appalachian State University Gets New Simulation Equipment – Appalachian State University’s College of Health Sciences in North Carolina added another level of realism for students training in the Department of Nursing’s simulation lab thanks to a $20,000 gift from David and Tamela Everett of Hickory and Everett Chevrolet Buick GMC Cadillac and $6,500 worth of inkind technical support from Wake Med Health & Hospitals in Raleigh.

The donation was used to purchase five in-ceiling cameras, hanging microphones and a recording/monitoring control station used in the lab’s simulated hospital setting that are used to record student’s interactions with the mannequin patients.

Thomas Edison State College Opens Nursing Simulation Lab – Thomas Edison State College in Trenton, New Jersey, opened its new Nursing Simulation as part of the course work for students in the Bachelor of Science in Nursing (BSN) program. The patients in the lab are high-fidelity simulators and the caregivers are students in the College’s Accelerated 2nd Degree BSN Program.

Wesleyan College Opens Nursing Simulation Lab – Wesleyan College in Macon, Georgia opened its new 1,500 square-foot nursing simulation lab. The

lab includes a state-of-the-art control room containing audio and video equipment, a home-health room, a pediatric intensive care unit, six high-fidelity human patient simulators, a medication dispensing system, and other equipment features valued at almost $400,000.

Colleges Open Joint Nursing Education Facility in Missouri – Lindenwood University and St. Charles Community College in St. Charles, Missouri opened their new LU/SCC Center for Nursing and Allied Health Sciences.

LU and SCC announced the public/ private collaboration in March, with SCC relocating and expanding its Nursing and Allied Health Sciences Program. As part of the collaboration, SCC moved its state-of-the-art simulation lab to the new location and expanded the space to create a virtual hospital.

USC's Mary Black School of Nursing Gets $350,000 for Simulation – The Mary Black School of Nursing at the University of South Carolina Upstate received $350,000 in private support this year to update and improve its simulation center. These gifts helped the university move closer to reaching its campaign goal of $50 million by 2017. The school also received grants from The Fullerton Foundation, the J M Smith Foundation and other community supporters to help expand the Simulation Center in the Health Education Complex.

21st Century Medicine

Reflections on Flexner’s Science with Today’s Ethos of Patient Safety and Technology This new publication, led by Dr Joseph Rosen at Dartmouth and Dr Rick Satava at Washington will review advances in medical and allied technologies and their potential impact on the healthcare sector over the next 30 years.

21st Century Medicine Reflections on Flexner’s Science with Today’s Ethos of Patient Safety and Technology

21st Century Medicine is included in a subscription to MEdSim Magazine. If you do not have a subscription already, order yours at halldale.com/medsim Coming January 2014

The original Flexner Report in 1910 revolutionized medical education in North America leading to much higher and more consistent standards. Healthcare education today stands at the brink of a new revolution – this report shows how it will unfold.

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World News & Analysis National League of Nursing Launches Joint Nursing Educational Initiative – The National League for Nursing (NLN) is launching an important initiative of the NLN Center for Academic and Clinical Transitions that is supported by grants from Laerdal Medical and Wolters Kluwer Health, publishers of Lippincott nursing content. The three are partnering on a not-for-profit, private enterprise that will develop collaborative programs to better prepare nursing students for the increasingly complex requirements of nursing practice.

The NLN Center's inaugural program, Accelerating to Practice, will focus on building partnerships to improve the transition of new nurses from education to practice. A team of nurse educators and hospital nursing administrators will define the specific competencies new nurses need to ensure job success. Then, in conjunction with Laerdal Medical and Wolters Kluwer Health, the NLN will develop Accelerating to Practice program courses and content.

University of Arkansas at Monticello to Build Nursing Lab – The University of Arkansas at Monticello plans to build a simulation laboratory for its nursing students, thanks to $400,000 in anonymous donations. The donations will pay for construction as well as all equipment needed for the laboratory.

The largest expenditures will be for high-fidelity mannequins that can be controlled remotely from a room adjacent to the lab and can simulate crying, seizures, genetic defects, heart attacks and many other health conditions.

Arkansas Universities Partner to Improve Medical Access – The University of Arkansas at Little Rock’s (UALR) Interpreter Education Program and the University of Arkansas for Medical Sciences’ (UAMS) Centers for Simulation Education are working on an initiative that benefits both UALR interpreting students and UAMS medical students – and ultimately, their deaf, deaf-blind, or hard-of-hearing patients.

Students from UALR and UAMS work on coached “patients” trained to portray certain symptoms and emotional characteristics are evaluated during the simulation. The interprofessional 32

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Simulab Introduces Surgical Abdomen for TraumaMan – Simulab Corporation released the Surgical Abdomen for its TraumaMan System. The TraumaMan System is an anatomical surgical mannequin designed for students to practice several surgical procedures.

The flexible abdominal surgical site for TraumaMan will accommodate an array of surgical modules such as the Nicked Aorta Module geared toward facilitating catastrophic event team training.

simulation is done on-site at the UAMS Centers for Simulation Education.

University of Pittsburgh Opens New Nursing and Health Sciences Building – The University of Pittsburgh at Johnstown opened its new $12 million Nursing and Health Sciences Building. The 26,000-square-foot facility features a nursing simulation laboratory, 11 laboratories, two seminar/classrooms and faculty offices.

The Sim Lab allows for more interdisciplinary teamwork with nursing students from other campuses, helps UAM’s nursing program achieve Gold Standard Certification, provides research opportunities, creates partnerships with area hospitals, and allows for faculty certification.

Central Ohio Nursing Program Adds Patient Simulators – Central Ohio Technical College’s (COTC) Coshocton campus added three new mid-fidelity human patient simulators and SimPad® portable computers for simulation-based training in its Nursing Program.

GE Healthcare Adopts Mirada Medical Atlas-Based Contouring – Mirada Medical, a provider of medical image analysis, formalized an agreement

with General Electric (GE) Healthcare for GE to license Mirada's powerful automatic atlas-based contouring software for implementation on its AdvantageSim MD 9 virtual simulation software suite for advanced radiation therapy planning. The technology is based on Mirada Medical's registration software for aligning image data for RT planning.

"In the era of advanced radiation therapy, contouring organs at risk and targets requires an environment and tools that facilitate productivity and accuracy through efficient automated and manual tools and intuitive user interface," explained András Szentmiklóssy, Global Product Manager of Oncology at GE Healthcare. "Our goal is to harness the potential productivity improvements and registration accuracy provided by the Mirada Medical atlasbased contouring engine to enhance the benefits of AdvantageSim. UMass Dartmouth College of Nursing Opens Simulation Laboratory – The University of Massachusetts (UMass) Dartmouth College of Nursing opened its new $500,000 Elisabeth A. Pennington Simulation Laboratory (SimLab), named after the former Dean of Nursing who donated $150,000 to support the new simulation lab and instructional technology center.

The new SimLab offers students and faculty in UMass Dartmouth's College of Nursing an experimental learning environment designed to prepare them with the equipment and experience necessary to practice basic and advanced nursing skills. The lab has hospital beds, advanced lab equipment, and adult and pediatric mannequins that can be programmed by the faculty to do a variety of things that require expert nursing intervention.

UCOL New Zealand Nursing Lab Gets Laerdal SimView – The Universal College of Learning’s (UCOL) Palmerston North campus nursing simulation lab is the first school in New Zealand to get Laerdal’s SimView, a new hi-tech audiovisual system. The installation will allow for full integration of patient voice and vital signs, video recording and debrief, and network access to activities within the school’s two simulation labs.

The two-room, four-bed facility

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replicates the layout, equipment and environment of a nursing ward and simulates normal practices – with lifelike mannequin patients that have their own personalities and medical histories and can be controlled from behind a twoway mirror.

New Products & Developments 3D Images from PET/CT Scans Help Surgeons Envision Tumors – Researchers at Jefferson Medical College in Philadelphia developed a hologram-like display of a patient's organs that surgeons can use to plan surgery. The approach uses molecular PET/CT images of a patient to rapidly create a 3D image of that patient, so surgeons can see the detailed anatomical structure, peel away layers of tissue, and move around in space to see all sides of a tumor before entering the operating room to excise it.

The researchers produced a surgical simulation of human pancreatic cancer reconstructed from a patient's PET scans and contrast-enhanced CT scans. Six Jefferson surgeons evaluated the 3D model for accuracy, usefulness and applicability of the model to actual surgical experience.

The surgeons reported the 3D imaging technique would help in planning an operation and indicated the 3D image would be most useful if it were accessible in the operating room during surgery, according to the report published in PLOS ONE. Simbionix Releases Endovascular Training Module for ANGIO Mentor – Simbionix USA Corporation released its Endovascular Basic Skills training module for the ANGIO Mentor simulator.

The Simbionix ANGIO Mentor is a virtual reality training simulator that provides hands-on practice in a simulated environment for endovascular procedures. It provides a training solution for a variety of endovascular procedures and the expanding library of modules supports the acquisition and honing of procedural skills in various endovascular techniques and procedures.

Kb Port Introduces BPsim Blood Pressure Cuff Simulator – Kb Port LLC introduced the BPsim Blood Pres-

Mimic Releases Latest MSim Robotic Surgery Trainer Software – Mimic Technologies released MSim™ 2.1, the latest simulation software platform for the dV-Trainer® robotic surgery simulator that lets dV-Trainer customers perform tube anastomosis and tube closure exercises. Mimic is providing MSim 2.1 to dV-Trainer customers and Mimic research partners.

Mimic says the MSim 2.1 upgrade expands and refines suturing and knot-tying exercises on the dV-Trainer, improving realism and simulating a broader set of surgical tasks. The MSim 2.1 release brings more than 40 new features and functionality upgrades.

sure simulator for programmable Systolic and Diastolic (mmHg) settings. The realistic, manual blood-pressure cuff can be used on both standardized patients and mannequin simulators. BPsim is managed from a remote tablet and can be programmed for any blood pressure range. According to Chuck Miller, CEO of Kb Port, this is the first product that allows users to simulate blood pressure on a live patient.

Elsevier Introduces SimChart for the Medical Office – Elsevier, a provider of scientific, technical and medical information products and services, launched SimChart for the Medical Office, a competency-based, simulated electronic health record (EHR) that gives medical assisting (MA) students handson practice performing front office, clinical care, coding and billing skills.

New RCSA Curriculum Uses Simbionix ANGIO Mentor Simulator – The Registry of Cardiovascular Specialists and Assistants (RCSA) ™ is using the Simbionix ANGIO Mentor simulator in its Cardiovascular Medical Simulation Training Course and Certification program. The program teaches cardiovascular care skills and procedural knowledge using the multidisciplinary surgical simulator that gives participants a realistic hands-on practice of

endovascular procedures typically performed under fluoroscopy in the cath lab, interventional suite or an OR. Medic Vision Uses Haptic Devices for Surgical Drilling Training – Medic Vision of Melbourne, Australia, incorporated SensAble Technologies, Inc’s haptic devices in its Mediseus® Surgical Drilling Simulator for improved surgical training.

By haptically-enabling its simulator, Medic Vision created a realistic virtual environment where otolaryngology surgical residents can practice to perfection on high-risk procedures – reducing risk to patients, improving surgical outcomes, and eliminating the use of costly (and sometimes prohibited) cadaver samples.

The Mediseus Surgical Drilling Simulator is the first commercially available solution for temporal bone drilling to rely on the same viewing and operating technology surgeons use during actual procedures.

CAE Helps Ambulance Victoria Paramedics Train in Virtual World – Ambulance Victoria launched a simulation-based training solution integrated with a learning management system to help prepare for mass casualty incidents.

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World News & Analysis solution that incorporates software from E-Semble.

Following a grant through the National Disaster Resilience Grant Scheme, Ambulance Victoria worked closely with CAE's Integrated Enterprise Solutions group to develop the overall solution, allowing paramedics to adopt the role of the triage officer, who is responsible for performing triage and life-saving treatment of victims.

International News Royal Free Hospital Opens Improved Simulation Centre – The Royal Free Hampstead Hospital in London opened a newly refurbished simulation center. According to Hampstead, it is one of a number of places in the UK that trains surgeons using virtual reality simulators.

The new simulation center includes dedicated laparoscopy, hysteroscopy, endoscopy and endovascular simulation rooms, and rooms for mannequin-based simulations, debriefing sessions and seminars. The center runs courses to train professionals in medical emergency scenarios and shares its learnings with other hospitals.

First Medical Skills Center in Rwanda Opens – A new simulation and skills centre that allows a wide variety of health professionals and trainees to practice their patient care

skills opened at the National University of Rwanda this summer. Rwanda has been working to re-establish its healthcare system since the genocide in 1994 that left only one anesthesiologist in a country of eight million people.

Nurses, medical students, residents, and physicians can now practice discrete skills such as suturing at the skills centre. They can also participate in team training around the management of complex emergencies.

New Simulation Centre Opens at Sunnybrook Health Sciences Centre – The Sunnybrook Canadian Simulation Centre opened its new state-of-theart surgical skills suite at Sunnybrook Health Sciences Centre. The new suite houses advanced medical simulation equipment that gives trainees instruction in both basic and complex surgical skills and the opportunity to practice in a controlled environment.

UAE Sim Center Holds Surgical Skills Workshop – Gulf Medical University's (GMU) new Center for Advanced Simulation in Healthcare (CASH) in Ajman, United Arab Emirates, conducted a workshop on basic surgical skills for close to 40 doctors and nurses from all over UAE. The workshop was accredited by Ministry of Health UAE for 11 CME hours and gave participants hands-on experience of basic surgical skills complemented by theoretical sessions to reinforce their skills. medsim

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