MEdSim Magazine - Issue 1/2013

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Issue 1.2013

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Training TECHNOLOGY

Learning Enablers Simulation Programs

Initial Foundational Questions To Help Build Your Simulation Program Patient SAfety

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ISSUE 1.2013

Editorial comment

Editor's Comment

" Are you getting the impression that healthcare providers are being asked to do more with less time and less compensation?"

From major newspaper headlines to esteemed healthcare publications all say 2013 will be an interesting year for healthcare... to put it mildly! There is continuing uncertainty around the implementation of the “patient protection and affordable health care act”... including healthcare exchanges, the Medicare physician fee schedule, the independent payment advisory board and the 30 million new patients coming into the healthcare system vis a vis “Obama Care”. These issues do not begin to address: • The loss of as many as 47,000 physicians over the next four years; • The fact that as many as 52% of practicing physicians are considering or have already limited access of Medicare patients; • The loss of physician autonomy due to decreasing payments, increasing regulatory requirements and liability concerns; • The rapid rate medical groups and hospital systems are playing “pacman” with private medical practices; • New consumer behaviors and last but by far not least; • Economic pressure to cut cost.

A survey of healthcare topics to 1,000 consumers showed that over 50% felt that the major issue to improving the US healthcare system is politics.

Of those surveyed 60% believe that doctors are our greatest hope for improving the healthcare system followed by hospitals and insurers.

While states decide on Medicaid expansion, health exchanges hospitals across the country will redesign health care delivery to reduce cost. Under the Hospital Value-based Purchasing Program, that took effect in October, 2012, hospital priorities will shift to value as the federal healthcare programs could withhold as much as one per cent of reimbursement or $850 million in 2013 if hospitals are unable to track customer satisfaction and cost savings. Hospitals will have to establish and align customer service with business goals.

Most of the US is still in fee-for-service reimbursement mode rather than value based payment models. As physicians evaluate payment and employment options, the American Medical Association has released a how-to manual to help them understand and negotiate new payment models.

Accenture released a report that stated only 36% of United States physicians will practice independently in 2013. One in three of the remaining minority will likely resort to subscription based

services, i.e., concierge, online consultations or direct-pay.

The Sunshine Act has drawn consumer attention to physicians ties to pharma and other industries regarding bias and conflict of interest.

Regardless of when Medicare and Medicaid begin collecting data, physicians must decide how to communicate conflict of interest to their patients.

Physicians will also be far more accountable in seeing that patients take medications and become more responsible for their health. (Interesting bit of the ACA considering any number of patients choose to be medically managed). Therefore, physicians must explore ways to educate and inform patients while ensuring they improve their communications skills so that they can help their patients medically mange themselves!

This year under the ACA, Medicare is allowed to pay certified registered nurse anesthetist for their state scope of practice. This will relieve some pressure on shortages while recognizing that in many states APRN’s still face regulatory barriers preventing them from practicing. There will also be a rise in care coordination for “medical extensivist,” a new term for an advanced practice nurse who extends their scope of practice from the hospital into other settings. The idea is to help chronic patients outside of the hospital thus reducing readmissions.

The Institute of Medicine’s Future Nursing Report called for increasing the number of nurses with baccalaureate degrees to 80% by 2020.

Coupled with the knowledge that specialty certification leads to better patient care you will see more nurses expanding their education.

Also the culture of safety must be extended to all healthcare professionals. Issues range from a safe work environment to making healthy lifestyle choices. Last, but by no means least, the issue of quality of healthcare provided and safety of patients.

Are you getting the impression that healthcare providers are being asked to do more with less time and less compensation? Couple that with the fact that the Affordable Care Act is projected to cost $7 trillion more than anticipated, then the old Chinese proverb “may you live in interesting times” certainly applies!

Judith Riess Editor in Chief, MEdSim Magazine

e judith@halldale.com MEDSIM MAGAZINE 1.2013

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Contents

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Editorial

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

Group Editor Marty Kauchak

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Publisher & Andy Smith CEO e. andy@halldale.com

03 Editor's Comment. Editor in Chief Judith Riess discusses some of the challenges for healthcare in 2013 as the Affordable Healthcare Act takes effect.

06 Learning Enablers. In the second in a series of articles on medical simulation centers, Group Editor Marty Kauchak explores developments in the technologies used by these facilities’ learners.

12 Talk to Me: One Facility’s Four-Year Path to Reducing Reported Patient Safety Events Associated with Poor Communication.

Will Enfinger, Gavin Gardner and Carole Durant from the U.S. Air Force describe how the TeamSTEPPS™ program has enhanced patient safety in their service.

18 Billings Comprehensive Program of Education and Training Significantly Reduced Hospital Acquired Infections. Editor Judith Riess journeys to Billings Clinic – Voted #1 in Patient Safety by US News and World Report.

22 Virtual Reality Warm-up Improves Robotic Surgery Performance and Reduces Errors. Thomas S. Lendvay, MD, FACS explores how one virtual reality application improves performance and reduces errors in both surgical trainees and experienced surgeons.

28 Initial Foundational Questions To Help Build Your Simulation Program.

Jane Kleinman, RN, MAOM, and Jeff Myers, MD, submit seven questions that should be addressed by managers establishing new simulation programs.

32 Training for Safety: What the Airlines really did… and do. Halldale Publisher and CEO Andy Smith observes how the underpinnings of civil aviation training programs may be translated and transferred to the healthcare industry.

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

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MEDSIM MAGAZINE 1.2013

On the cover: Immersive simulation focuses on overall patient care management, teamwork and communication.

Image credit: Behling Simulation Center.

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Training Technology

Learning Enablers In the second in a series of articles on medical simulation centers, Group Editor Marty Kauchak explores developments in the technologies used by these facilities’ learners.

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he burgeoning number of medical simulation centers around the world supports nothing less than a transformation in the healthcare community’s learning programs. These facilities allow individuals and teams to learn and rehearse their skills in a simulated environment until they achieve prescribed levels of proficiency or certification.

One foundation of healthcare providers’ training experiences at these facilities is a blend of learning devices and systems. This community, much like its counterparts at training centers for different military occupational specialties, civil aviation aircrews and other high risk occupations, learns skills and procedures through a “crawl-walk-run” process, with different technologies guiding learning at the next level.

One End User’s Insights The Palmetto Health – University of South Carolina School of Medicine Simulation Center is one representative facility that integrates learning technology into its curricula. The luster on the center’s brand increased last September, when the Columbia-based facility was granted a 3-year accreditation by the Society for Simulation in Healthcare. This accreditation was a significant accomplishment and a testament to the quality education at the center. The simulation center was the 22nd pro06

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gram in the world to achieve the society’s accreditation.

Eric A. Brown, MD, FACEP, pointed out that there is a blend of products at the simulation center, with devices providing instruction for disparate patient cohorts, from premie babies, to neonates, to adolescents and adult models.

Brown, who is dual-hatted as the director of the center and a faculty member in the Department of Emergency Medicine, further told MEdSim that his facility is “brand neutral”, in that it selects the best model for each particular educational endeavor with standardization as a secondary concern. “Towards that end we have a blend of Laerdal, CAE-METI and Gaumard products. Similarly our task trainers include a number of vendors’ products from Blue Phantom, to Limbs & Things to Laerdal,” he said.

The Palmetto Health – University of South Carolina (USC) School of Medi-

CAE's HPS can breathe in oxygen and breathe out CO2, interface with real clinical monitors and be used with real anesthetic gases to train anesthesiologists.

Image credit: CAE.

support with additional simulation equipment and personnel,” Brown pointed out.

Blend of Technologies

cine Simulation Center has a deliberate strategy to match its requirements with fielded products. Brown said his colleagues decide what the goals and objectives are for each project or course offering they are supporting and then find the best simulation technology to meet that need. “We avoid getting into the trap of building curriculum around a simulator's capabilities. As our older equipment becomes obsolete we do scan the marketplace for the latest technologies, but we will only justify that purchase if our customer demands or special initiatives call for the model in question.”

Similar to other facilities around the globe, the Palmetto Health – USC center plans to add more simulators this year to support expanded operations. The center’s mobile simulation platform will be operational by mid-year. “Additionally, we have a third hospital opening at the end of 2013 which we will also need to

Learning devices at the Palmetto center and other community venues provide a range of capabilities. On the low-end side, an observer may find SimScreen, which MEdSim learned about in early 2012 on the exhibition floor of a community conference. Joseph Burns, the president of Appleton Inc., SimScreen’s manufacturer, said the idea for the product and its design were generated by his wife Holly, who teaches Nursing and Nursing Simulation at Cecil College in Maryland. “She observed that simulation works best if you can create a realistic environment for the student nurse. Most students were always more concerned with her and what she was doing to operate the mannequin.” So not wanting the students to constantly be “cueing” on her actions she came up with the SimScreen concept.

Burns said SimScreen is a commercial, mobile panel with a two-way mirror that one could use throughout the simulation lab and, when finished, put away Some new developments that Appleton Inc. is working on include a sound panel which can help in noise reduction when used with the SimScreen.

Innovation is occurring in other spaces within this sector.

CAE Healthcare (CAE) is reported to have the widest breadth of healthcare simulation products in the industry, and has sold 7,000 surgical, imaging and patient simulators around the globe, according to Kim Cartlidge, the company’s marketing communications manager. Cartlidge recalled CAE’s “HPS (Human Patient Simulator) was one of the first commercial simulators on the market 16 years ago,” and said it is still considered “the gold standard today.” The HPS can breathe in oxygen and breathe out CO2, interface with real clinical monitors and be used with real anesthetic gases to train anesthesiologists.

Cartlidge also noted how CAE’s products are tailored to the end users’ requirements. In the case of the HPS, the simulator is “helping medical schools meet American College of Graduate Medical Education requirements for sim-

ulation practice. Practicing anesthesiologists meet part of their Maintenance of Certification in Anesthesia requirements through high-fidelity patient simulation training, often with the HPS.” The industry is also responding to the requirement to deliver devices for team training.

CAE’s iStan and METIman wireless simulators, for instance, remain very popular in simulation centers in colleges that are training interdisciplinary teams (such as paramedics, nurses and health sciences students) in one scenario, and hospitals that are practicing code responses or testing new procedures or facilities.

Systems Level Insights Another evolving commonality between medical simulation centers and similar venues in other high risk industries, is their embrace of technology solutions at the systems level – which permit integration of individual and other level devices.

It should come as little surprise that CAE’s fastest growing product is not one of the previously discussed devices, but rather a simulation center management system called LearningSpace, which allows centers to capture simulation on video for debriefing. “LearningSpace helps center managers schedule and assess learners and store data from one room, up to 25 different rooms at once, or among multiple simulation centers in different locations (such as on different college campuses within the same system),” Cartlidge explained.

In this same product space, B-Line Medical’s product line of digital solutions, which capture, and allow debriefing and assessment of medical training and events, also continues to evolve.

One of many products which may be found in service around the globe is B-Line’s SimCapture®, which combines up to four channels of synchronized video, native resolution video capture of medical devices, simulator physiological trending and powerful annotation / assessment tools into a single 100 percent, web-based solution. Sandy Yin, a marketing strategist at the company, pointed out such an all-encompassing recording of an encounter enables more accurate, objective review and debriefing of scenarios. “We think this type M E D S I M M AGA Z INE 1 . 2 0 1 3

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Training Technology of recording, bundled with powerful administrative functions such as assessment and report-generators and organization of participant portfolios means measurable improvements in learner outcomes,” she added.

SimBridge® is what the company calls the “backbone” of the simulation and clinical skills center. SimBridge centralizes all SimCapture activity and allows for the addition of powerful software modules such as the Central Control Module (CCM), assessment, courses, scheduling, and Lightweight Directory Access Protocol integration. “SimBridge increases accessibility and integration resulting in significant return on investment and allows users to more easily coordinate a large center, and increase ease of use for a larger number of learners and administrators,” Yin said.

Since 2011, B-Line Medical® has released several product updates, resulting from a need to unify its Clinical Skills® and SimCapture platforms.

As B-Line wanted to make it easier for these programs to team up, and make it easier for hybrid centers to operate, the company released the aforementioned CCM in January 2012. Yin told MEdSim the module allows clear, complete administration of simulation programs, standardized patient programs, or a fusion of both. “With CCM, administrators can control large centers with a single user interface, automate workflows and recordings, and even communicate with each room using an integrated messaging function.”

B-Line used the SimCapture platform as a building block for other products when it saw a need to provide a solution that was more flexible, portable, and affordable while still fully capable of capturing a wide variety of simulation activities. “That’s why we came up with SimCapture Ultraportable. SimCapture Ultraportable is fully compatible with B-Line Medical’s existing product line and is built on the exact same recording platform that has made SimCapture the choice of more top-tier medical institutions than any other solution,” Yin added.

The company has pursued other enhancements to fielded products as well as new capabilities. “One simple thing our clients also got really excited about was the addition of expanded color choices for 08

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color coding rooms in our control interface’s facility view,” Yin recalled, and continued, “We popped that little upgrade in when we created CCM, and we were delighted to find an outpouring of positive feedback. We’ve also introduced our MED360 data integration, which means we can integrate with any medical device, giving our users even more flexibility and choices for inputs.”

Also on the high end of the technology spectrum, the University of Toledo College of Medicine has installed Barco's I-Space and CADWall as the cornerstone of its virtual immersive reality center, which is chartered to educate its health care providers. Housed within the University of Toledo's Interprofessional Immersive Simulation Center (UT-IISC), the simulation solutions, the two 3-D stereoscopic immersive CADWalls and an I-Space system are fully operational in the virtual immersive spaces of the Center, allowing educators, researchers and students alike to explore the human body in a new way.

The four-sided I-Space “virtual room” portrays 3-D computer images of skeletons, organs, arteries and medical conditions, allowing participants to “walk through” parts of the body for a truly immersive learning and training experience. 3-D visualization of anatomy is projected to show normal and abnormal pathology as well as CT scan reading. The Barco I-Space is used to simulate entire environments such as operating suites.

Hernan Rodriguez, the company’s director of Channel Management for Control Rooms & Simulation for North America, said while Barco continues to increase resolution and image performance, the company is focusing on key customer concerns, specifically the real estate required by these systems and the cost of maintaining and operating them. “We are leveraging technology developed in our R&D department, which together with our existing products and technology, will enable Barco to deliver to its channel partners, best-in-class solutions that will provide space-saving, solid performance and lower maintenance and operating costs,” he added.

Services Provider CAE has also established a beachhead in the simulation center management sector.

For its part, the company manages the University of Montreal simulation center, which is accredited by the Royal College of Physicians and Surgeons of Canada for simulation training.

Cartlidge pointed out an interesting, symbiotic aspect of the

The University of Toledo College of Medicine has installed Barco's I-Space and CADWall as the cornerstone of its virtual immersive reality center.

Image credit: Barco.

Simulation is advancing at a brisk pace. We think it’s easier to keep up if you can fit comprehensive capture into a briefcase.

Portability meets affordability with SimCapture® Ultraportable. All the functionality of SimCapture in an all-inclusive, plug-and-play A/V hardware setup. Weighing under 20 lbs and able to record multiple channels of video with or without power, the ROI will also put a spring in your step.

www.blinemedical.com ©2013 B-Line Medical, LLC, an Atellis® company. All rights reserved. Patented technology.

Training Technology agreement. “That center is our laboratory for development and delivery of simulation that meets today’s end-user needs and requirements,” she added.

What’s New CAE’s product portfolio is rapidly expanding.

The trauma simulator, Caesar, was built to withstand extreme temperatures, rain, dirt and dust and body impact.

While Caesar was developed for the military, it is also reported to be generating enthusiasm among disaster response centers that simulate man-made or natural disasters on a large scale.

The company’s new VIMEDIX Women’s Health ultrasound simulator for the ob-gyn market simulates the 20-week fetal ultrasound exam. Cartlidge added, “The VIMEDIX ultrasound simulator uses both a mannequin and virtual reality technology to train residents and physicians in bedside ultrasound in medical schools and hospital simulation centers.”

CAE’s EndoVR and LapVR surgical simulators are training medical residents

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to get a feel for bronchial and gastrointestinal assessment and laparoscopic surgery.

The company has also upgraded its HPS simulator with a new Müse operating system and scenarios for anesthesia, emergency medicine and obstetrics.

Barco is in the midst of critical development of its I-Space and CADWalls product line, but is not ready to make an announcement yet. “We look forward to bringing this new technology to our partners first as they represent the commercial force behind our product line,” Rodriguez said, and continued, “At the appropriate time, we will make an announcement. We look forward to 2013 with the release of our new technologies.”

Another company, Smooth-On, has platinum-based silicone materials often used by mannequin manufacturers to build their training devices. Similar platinum silicone materials provided in Smooth-On’s Ultimate Wound Kit, are also used to modify the training devices throughout their life cycle in addition to

being utilized to create separate moulage for on-skin wounds.

Smooth-On's Brad Frikkers noted the silicone materials are used when the medical simulation center staff “doesn’t want to permanently modify the mannequin, for example, when it wants to build a moulage application directly on the device itself. Or the material can be used to pre-make moulage dressings and put in place anywhere on the mannequin in a short period of time – for many standard applications.”

Additionally, these silicone materials may be used to quickly manufacture suture pads and injection pads.

Frikkers also freely discussed the price point on his product and its high return on investment. “We’re suggesting that you can make the moulage or mannequin patch yourself – and if you spend roughly $60 on two different products you can make eight of these pads. So the cost to you becomes $7-$8 worth of material for items every first year medical student and others will use – the suture and injection pads,” he said. medsim

PATIENT SAFETY

Talk to Me: One Facility’s Four-Year Path to Reducing Reported Patient Safety Events Associated with Poor Communication Will Enfinger, Gavin Gardner and Carole Durant from the U.S. Air Force, provide details on how the TeamSTEPPS™ program, and its simulation underpinning, help improve patient safety.

Members of the ER respond to a TeamSTEPPS/Mock Code Blue scenario.

Image credit: Will Enfinger.

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n August 2009, the 673d Medical Group (MDG) at Joint Base Elmendorf-Richardson, Alaska, began a four-year journey to improve communication among health care teams. Seventeen staff members from inpatient, outpatient and ancillary services, including the Patient Safety Manager (PSM), were appointed by the MDG commander as the “TeamSTEPPS Change Team” and charged with developing a plan for the facility.

The Team Strategies & Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program meets the needs of a medical organization desiring to improve the quality of care offered to patients, and strengthen the competence of practitioners. TeamSTEPPS is a systematic approach developed by the Department of Defense (DoD) and the Agency for Healthcare Research and Quality (AHRQ) to integrate teamwork into practice1 .

The Change Team attended a three-day “Train-theTrainer” course and drafted an implementation plan for education, coaching and mentoring with a focus on "Briefs", "Huddles", and "Debriefs”. It was decided, in addition to offering on-going TeamSTEPPS classes for current staff, a session would be added to the monthly Newcomer’s Orientation (Calendar Year 2010). This introduced the program concepts and encouraged participants to seek out unit-based facilitators in

MEDSIM MAGAZINE 1.2013

their area for additional training, mentoring and coaching.

A simulation requirement for all inpatient staff was also added in 2010; with the expectation they would practice using the various TeamSTEPPS tools while providing patient care. The delivery of the best evidence based quality of care ultimately depends on the competences of practitioners as well as the system that supports their work.2 Therefore, the Change Team recognized the need to develop a formidable program of simulation training to improve the standards of patient safety and realistic education by exposing practitioners to clinical challenges, allowing them to encounter and be responsible for “real life” situations.

Medical simulation can ameliorate patient trust and establish a system that operates to improve task performance through experience and exposure. The use of simulation wherever educationally feasible conveys a critical message to the

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Total and Percentage of Communication Related

Total and Percentage of Communication Related Event Reports Submitted. clinician: patients are to be protected whenever possible and are Event Reports Submitted 2 100% not training commodities.

Total and Percentage of Communication Related The TeamSTEPPS initiative outlined for inpatient units by 90% Total and Percentage of Communication Related the Change Team focused on awareness, education, and susEvent Reports Submitted 80% tainment. The three-pronged approach adopted included: 1) An Event Reports Submitted introduction to the tools used throughout the facility at New70% 46 comer’s Orientation for newly arrived staff, 2) The opportunity on 79 60% 87 Nasco HealthCare Division the “First Friday” of each month for formal TeamSTEPPS class54 50% room instruction for all staff, and 3) Ongoing unit-oriented simuMedSim lation exercises and mentoring by trained facilitators working in Feb 2013 40% patient care areas. The Change Team was confident implementMS1302 30% ing these techniques for all units and each shift would not only increase the number of opportunities for communication, but 20% would also result in a decrease in the number of events related to 21 24 10% 25 communication issues.

8 The first prong of the initiative is geared towards aware0% 2009 2010 2011 2012 Other ness, providing an introduction to the facility wide program Other Communication during Newcomer’s Orientation. This 50-minute course highCommunication lights the use of Briefs, Huddles, and Debriefs and encourages “team” to participate. Robust scenarios, based on actual unit staff members to seek out unit facilitators for additional training events, were developed and the quality of the simulation experiand practice in using the various tools. For staff members who ence was greatly improved. have not completed a formal course, or desire a refresher on the The third, and final, prong of the initiative focuses on suskey elements, a four-hour TeamSTEPPS course is offered on the tainment by providing ongoing coaching and mentoring within “First Friday” of every month and acts as the second prong of individual units. Facilitators, who are senior-level staff and overthe initiative; geared toward education. A simulation exercise see many of the units, are able to provide reminders on speis incorporated into the local program, and provides a first-hand cific tools and techniques throughout a shift and demonstrate opportunity for trainers to highlight and/or refer to specific tools or techniques as they are introduced, which may have been useMS1302 2009 2010 2011 2012 ful during the simulation exercise.

2010 2011 2012 As an incentive to participants, Air Force-approved Continuing Medical Education courses and CNEs for staff are provided at no additional cost. The course is also taught for entire units, when requested. Several inpatient units have used this opportunity to provide a “refresher” during regularly scheduled training days to ensure everyone on the unit is familiar with the concepts.

A second aspect of the education prong was designed and implemented in August 2009 when the simulation director and PSM drafted a training plan which targeted several “high risk”, or “Priority One”, areas where communication issues are most critical. For the facility initiative the areas identified were the Emergency Room, Intensive Care Unit, Multi-Services Unit, Ambulatory Procedures Unit, Gastroenterology Clinic, Operating Room/ Post Anesthesia Care Unit and Labor & Deliver/Perinatal Unit.

Staff members in these areas are required to complete at least one simulation exercise each year.

A policy letter was signed by the MDG commander and individual training dates were tracked and reported quarterly.

Outpatient clinics and several ancillary areas were identified as Priority Two units and are included under the Newcomer’s Orientation and mentoring portions of the plan.

A simulation schedule was established for all areas of the facility, with a focus on the Priority One units. Time was allotted for unit-based teams to conduct simulations in both the lab or in situ during daily shifts. The plan was revised upon the arrival of the contract Simulation Coordinator in early 2011 after process assessments revealed difficulties with scheduling an entire

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Other Communication

PATIENT SAFETY their effectiveness. This allows time and opportunities to observe individual and team behaviors as well as provide oneon-one coaching and mentoring for junior level staff. Throughout any given day, staff may call a team huddle to clarify issues as they arise, especially in situations where the strength of an idea or individual “halo effect” could lead to a poor outcome for a patient. Unit facilitators are able to monitor staff during their shift and provide on-going coaching with several key tools such as SBAR (Situation, Background, Assessment, Recommendations) for handoffs, or advocating for their patient.

No specific computer hardware or software is required for others to implement this initiative. Anyone working on the standardized Office platform may duplicate this project without additional training or experience. Familiarity with the TeamSTEPPS program is the only specialized requirement. Facilities planning to trend the data following full implementation of the TeamSTEPPS program will need to retrospectively review reports for a specified time prior to implementation in order to determine the baseline percentage and prospectively track the data as reports are submitted.

For the four-year period of this study, 2009 – 2012, a total of 78 of 344 (23%) event reports submitted noted an issue with communication; representing an overall decrease of 8% from 2009, the base year for this project. This followed full implementation of the TeamSTEPPS program in 2010. During that year, 24 of 103 (23%) event reports were linked to poor communication, and represents a decrease of 8% from 2009, when 21 of 67 (31%) event reports noted a communication issue. In 2011, the decrease continued, with 25 of 112 (22%) reports submitted noting a communication issue and was observed for a third successive year in 2012 when 8 of 62 (13%) events were identified with issues related to poor communication.

Three categories (blood/blood products, falls and medications) were deemed as “high risk” wherein communication is a key factor for patient safety. The category of blood/blood products observed a 100% decrease from a high of seven reports submitted in 2009 to zero in 2012 14

MEDSIM MAGAZINE 1.2013

while falls decreased 61% from a high of 23 in both 2010 and 2011 to nine in 2012. Medication issues decreased 66% overall from a high of 59 in 2010 to 20 in 2012.

The increased number of opportunities for enhanced communication among the staff, including briefs and debriefs at the beginning and end of each shift, has resulted in an 8% overall decrease in events related to communication issues across the facility during a four-year period.

During this time frame, no obstacles or resistance to implementation were noted in any of the inpatient units, nor were any issues presented by facilitators with educating staff and employing the tools on individual units. Having the MDG commander, who is a cardiologist and also works in several of the Priority One units, as the executive champion has been a major factor in the success of the facility program.

Each morning, he and his executive staff meet for a morning brief in order to set the tone for the day. As issues crop up, the team huddles to determine how to handle the situation and identify who is responsible for given tasks. Feedback from the executive TeamSTEPPS course evaluations highlighted the importance of these daily Briefs and acknowledged all executive members did in fact have a “shared mental model” and understood what needed to happen. The support from the top to the bottom has created an environment of continued growth, education, and responsibility for all involved in the medical profession to improve patient safety and communication.

To date, this on-going TeamSTEPPS initiative has been highly successful on two fronts: 1) providing additional, structured opportunities for increased communication resulting in a decrease in the percentage of submitted inpatient event reports noting a communication issue over a four-year period, and 2) ensuring the on-going use of the TeamSTEPPS tools through simulation exercises, role-playing during staff meetings and coaching/mentoring of junior staff on a daily basis across all units.

Ongoing training of individual units also provides opportunities to develop role-playing situations that can be practiced

Air Force Chief Master Sergeant John Yun directs Coast Guard Petty Officer Second Class LeFleur during a TeamSTEPPS and ACLS scenario in the Sim Lab. Image credit: Will Enfinger.

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After the genuine success of the 1st World Congress on Surgical Training in Gothenburg, Sweden, in September 2011, 10 global workgroups led by their respective keynote lecturer has developed 10 new main topics for the new congress program:

2nd World Congress on

Surgical Training SurgiCON

June 17-19, 2013, Gothenburg, Sweden Opening: Dr Marie Wedin, Chairman of the Swedish Medical Association Honorary Guest Lecture: Pr. Carlos A. Pellegrini, University of Washington, USA

Main topics Keynote speakers 1. Quality and Safety in Surgical Training

Ajit K. Sachdeva, FACS, ILL, USA

2. The Imperative of Metric-based Surgical Assessment and Training

Anthony G. Gallagher, IRE

3. The Value of Scientific Research Activities in Surgical Training

Richard Hanney FRACS, Sydney, AUS

4. Surgical Training in Evolving Countries

Leon Snyman, MBChB, Pretoria, South Africa

5. The Governance Required to Provide Effective and Consistent Surgical Training Programs

Spencer Beasley FRACS, Christchurch, NZ

6. Social Media and E-learning in Surgical Training

Sean Tierney FRCSI, IRE

7. The Resident’s Dream Scenarios

Richard Reznick, FRCSC, Ontario, Canada

8. ‘Rules & Roles’ - Collaboration between Surgeons and the Industry

Kai Olms, GFFC, GE

9. Update on Simulation

Richard M. Satava, FACS, WA, USA

10. Teaching New Surgical Techniques to Mature Surgeons

Barbara L Bass, FACS, TX, USA

www.surgicon.org

during staff meetings or anytime the unit may be experiencing low census. Having multiple experiences builds confidence among the staff and ensures a safety net for everyone on the unit. Simulation is something that teaches not only empathy for patients, but should also be used for those activities for which it is best suited, particularly for activities that are hazardous, involve uncommon or rare situations, or for which experiential learning is of greatest value.3 Thus, more practice is created to improve patient care across the board.

The Change Team feels the greatest gift we can give our patients is the quality of care that comes with respectful discourse, continued practice, and experienced professionals. medsim About the Authors Carole A. Durant, MBA, CPHQ is Patient Safety Program Manager, 673d MDG, JBER, Alaska and a Master Team STEPPS trainer.

Gavin Gardner is the Director of the University of Central Florida’s College of Medicine Simulation Coordinator,

He has worked in education and simulation for 12 years and designed the 673d MDG JBER Simulation Center Will Enfinger spent seven years as a Hospital Corpsman in the US Navy as a nursing care provider and Field Medical Service Technician trained by the United States Marine Corps in combat casualty care. He was awarded the Operator of the Year award for all of Air Force simulation, and currently manages eight simulation labs across the Pacific Air Force.

References 1 King, H., Battles, J. Baker, D., Alonso, A., Salas, E., Webster, J., Toomey, L., & Salisbury, M., (2008). TeamSTEPPS™: Team strategies and tools to enhance performance and patient safety. Advances in Patient Safety: Agency for Healthcare Research and Quality.

Retrieved from: http://origin.www.ahrq.gov/downloads/pub/advances2/vol3/Advances-King_1.pdf 2 Ziv, A., Small, S., & Wolpe, P.R., (2000). Patient safety and simulation-based medical education. MedSim-Thomas Jefferson University Medical Simulation Center, Philadelphia, Pennsylvania, USA, and the Chaim Sheba Medical Center, Tel-Aviv, Israel; Department of Anesthesiology and Critical Care, the University of Chicago, Chicago, Illinois, USA; Department of Psychiatry and Center for Bioethics, University of Pennsylvania, Philadelphia, Pennsylvania, USA. Medical Teacher, Vol. 22, No. 5, 2000. Retrieved from: http://www.chinamedsim.com/uploadfile/200901/20090111022410618.pdf.

3 Gaba, D.M., (2004). Future vision of simulation in healthcare. Qual Saf Health Care: 13:i2-i10 doi:10.1136/qshc.2004.009878.

Retrieved from: http://qualitysafety.bmj.com/content/13/suppl_1/i2.full

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MEDSIM MAGAZINE 1.2013

17

Training

Billings Comprehensive Program of Education and Training Significantly Reduced Hospital Acquired Infections Editor, Judith Riess visited Billings Clinic and discussed with Dr. Mark Rumans the hospital’s approach to reducing MRSA.

M

illions of people are suffering from hospital acquired infections. Methicillin-resistant Staphylococcus aureus (MRSA) is an especially common and deadly bacteria that is resistant to penicillin related antibiotics and had been on the rise worldwide for the past three decades.

In 2010, encouraging results from a CDC study published in the Journal of the American Medical Association showed that invasive (life-threatening) MRSA infections in healthcare settings are declining. Invasive MRSA infections that began in hospitals declined 28% from 2005 through 2008. Decreases in infection rates were even bigger for patients with bloodstream infections. In addition, the study showed a 17% drop in invasive MRSA infections that were diagnosed before hospital admissions (community onset) in people with recent exposures to healthcare settings.

The main way the infection is transmitted is through human hands. Hands may be contaminated by contact with infected patients. Healthcare provider-to-patient transfer is common, especially when healthcare providers move from patient to patient without performing necessary hand-washing techniques between patients. It is estimated that in the US as many as 100,000 people develop MRSA infections each year. The average hospital cost for treating a MRSA patient is $20,000 to $27,000.

Therefore, reducing infection rates helps save patient lives and helps reduce the rising cost of healthcare.

These declines in MRSA rates can be directly attributed to 18

M E D S I M M AGA Z IN E 1 . 2 0 1 3

the education and training that has taken place over the past five years in hospitals and clinics.

In partnership with the Veterans Administration Pittsburgh Healthcare System (VAPHS) the Plexus Institute and the Delmarva Foundation, the PDI promoted the use of the Positive Deviance approach to eradicate MRSA infection transmission in a network of 40 hospitals nationwide.

The PD approach enabled the hospital staff to improve their adherence to evidence based precautions, “the MRSA Bundle”, which included hand hygiene, active surveillance, environmental cleaning and contact isolation precautions.

This resulted in a 50% reduction in MRSA rates which resulted in an expansion of the program in which Billings Clinic took part.

The potential of the Positive Deviance approach and the idea that small changes can have significant impact, motivated Nick Wolter, Billings Clinic’s CEO, and Nancy Iversen, Billings’ Direc-

Experiential learning makes the invisible become visible.

Here, chocolate pudding is used to show how germs spread.

Image credit: Julie Burton/Billings Clinic.

tor of Patient Safety and Infection Control, to actively seek participation as one of the beta sites in the Plexus Institute collaboration with Positive Deviance funded by Robert Woods Johnson Foundation to reduce MRSA. This was based on the success of the Veterans Administration, Pittsburgh’s MRSA Reduction program using Positive Deviance.

Innovative Activity Description The Billings Clinic made MRSA prevention a top priority and in the process transformed its organizational culture. By creating a comprehensive package that combines adoption and monitoring of strict infection control protocols, active surveillance, training and education, and the solicitation and implementation of employee ideas through “positive deviance”, Billings Clinic’s 272 bed hospital reduced health care associated MRSA infections by 84% over a 7.5 year period earning for itself a ranking of #1 Patient Safety Hospital by US News and World Report, Consumer Report and the Lucien Leap Foundation. The following are key elements of the program: • Creating a culture where MRSA control is a top priority, with focus on supporting employee-generated ideas: Leaders adopted and promoted the positive deviance approach to create social and behavioral change, as positive deviance emphasizes the role of frontline employees in generating solutions to problems. Leaders encouraged employees to come forward with solutions, and strove to create a culture which motivated employees to do so. In communications to employees, Billings’ leaders emphasize the significance of the MRSA issue and the need for employees to think of infection control as their problem rather than something handled only by infection control specialists. To that end, they encourage employees to share their ideas on infection control and to point out and correct – in a collaborative, collegial manner – any errors they may witness in the infection control behaviors of coworkers.

• Hand hygiene and disinfection procedures: Staff members are required to wash hands before and after every patient contact and to disinfect all items that come in contact with MRSA-positive patients. A number of employee-generated ideas have increased adherence to this protocol: - Disinfection of all items: Staff began disinfecting previously overlooked items that can spread MRSA, such as keys to drug storage compartments and dinner trays.

- Larger garbage cans: To accommodate the increased use of disposable gowns, gloves, and other items that help prevent transmission, Billings Clinic purchased larger garbage cans that help reduce the time spent emptying trash.

- Isolation carts: Isolation carts were purchased so that isolation precaution supplies were organized and readily available for staff outside patient rooms.

- End-of-day rounding on MRSA patients: Physicians decided to begin rounding on MRSA patients at the end of the day, when they had more time to take precautions. In addition, some male physicians stopped wearing ties and lab coats because of their potential to transmit MRSA. - Active surveillance and quicker test results: Beginning August 2011 all patients admitted to the hospital receive a

nasal swab test for MRSA on admission, transfer, or discharge.

Patients who stay longer than one week are swabbed every seven days. Patients who are found to be positive for MRSA, are placed in contact precautions. Billings Clinic continues to use a specialized culture media which allows for quicker, more accurate results, allowing staff to begin taking contact precautions with MRSA-positive patients more quickly. Rapid PCR testing is also offered for surgical patients when their MRSA status is needed to adjust prophylactic antibiotic and treatment with topical mupirocin to reduce their risk of a surgical site infection.

• Patient flagging system: Billings Clinic created an alert system that flags all patients who have a history of MRSA and electronically sends a notice to the units with an order to begin isolation precautions. The purpose of the flagging system is to begin isolation more quickly, therefore reducing the potential for MRSA transmission.

• Isolation of MRSA positive patients: Patients infected or colonized with MRSA are placed on contact isolation protocols based on the Centers for Disease Control and Prevention (CDC) 2006 Multi-Drug Organism Resistant Guidelines.

• Monitoring and feedback: Staff members in all inpatient units where active surveillance testing is conducted, receive prevalence, incidence (transmission), and swabbing rate compliance information each week.

• Education and training: Billings put in place a variety of educational and training programs focused on reducing MRSA transmission.

M E D S I M M AGA Z IN E 1 . 2 0 1 3

19

Training - Monthly unit educational meetings: Each unit holds a monthly meeting to discuss MRSA prevention practices.

The group’s coordinators use a range of educational methods during these sessions, including imitation, where an experienced worker demonstrates a tactic (e.g., the proper technique for nasal swabbing or disinfecting a room) and then participants practice the tactic with each other. Program coordinators also use unusual teaching methods, such as having employees dunk their gloved hands in chocolate pudding and wipe it on their isolation gowns to illustrate contamination with MRSA bacteria. This helps make the invisible germs visible to staff so they can discover for themselves the need to practice more carefully so as to not contaminate their surroundings or themselves while providing care to patients.

- Improvisational theater for training: In response to frontline worker requests for more training, program coordinators converted an unused space into a simulated patient room. Known as

20

M E D S I M M AGA Z IN E 1 . 2 0 1 3

Healthcare-associated MRSA Infections Intensive Care Unit January 1, 2004 - September 30, 2011

“the theater in the round,” this space serves as host to a mandatory 1.5-hour training session in which 12 to 15 individuals participate in one of four improvisational sketches. After each MRSA-related scenario is acted out, the audience provides feedback about what the staff did well and where they can improve.

Scenario-playing emphasizes a key positive deviance principle – that participants find it easier to act their way into a new way of thinking than to think their way into a new way of acting.

Information provided improvisational theater–style learning sessions continue to be a part of the nursing fundamentals course

ICU decline in MRSA Infections.

Credit: Julie Burton/ Billings Clinic.

for newly hired nursing personnel and remain an ongoing and effective method for infection prevention.

- Patient education: Billings staff developed a patient-friendly brochure and use Washington State Health Department's Living with MRSA publication to share information with patients to prevent MRSA transmission. In July 2010 another patient education brochure entitled MRSA & Athletics: What's YOUR Game Plan? was developed to provide information to help prevent the spread of MRSA in athletic settings. This brochure was co-created with Billings Clinic, the local health department, and another local hospital. It is provided to all patients who receive sports physicals at all Billings Clinic locations.

• Active solicitation and support for implementation of employee ideas: A group of 20 to 40 MRSA champions, known as the Positive Deviance-MRSA Partnership and representing all hospital units and ancillary departments, meets monthly to solicit ideas for preventing MRSA and to identify staff who are already using positive infection practices. During these “discovery-and-action dialogues,” staff members identify barriers to successful MRSA prevention, which the Positive Deviance-MRSA partnership team then works to eliminate. With the partnership’s encouragement and support, employees implement many of the ideas that emerge from these dialogues. When needed, program coordinators provide direct assistance, such as help in securing funding or other resources.

The Clinic’s approach to MRSA prevention focused on what worked, believing that among its pool of employees – doctors, nursing staff, housekeepers, therapists, patient transporters, technicians, pastors, social workers, and support staff – there are individuals who practice certain simple yet uncommon behaviors that prevent MRSA transmission. For instance, in doing his hospital rounds, a physician purposely sees his MRSA patients last – a simple practice that greatly reduces the risk of transmitting MRSA. A Billings Clinic patient transporter uses his gait belt to strap a MRSA patient’s oxygen cylinder to an IV pole, so it won’t brush against other surfaces during transport.

These individuals are “positive deviants”. PD goes handin-hand with Improvisation Learning which was used throughout staff training. Fifty” Improv” sessions were conducted and Nancy Iversen, said it was not always easy and at first there was a great deal of resistance. However, the Improv sessions helped staff learn for themselves to solve problems and find solutions. The Improv scenarios explored practical problems, how to deal with a rehab patient, how to transport a patient, how to provide food trays without spreading infection, how to discuss problems with those in power positions and how to dispose of contaminated gear. In one Improv session, a physician, while examining a patient’s leg wound that was oozing brown goo, paused to shake hands with the patient’s family, back-patted a nurse, touched some objects, and resumed the examination. Within seconds, the patient’s body, the bedding, the hands and clothes of the doctor, the nurse, and the patient’s family showed brown stains. The brown goo, chocolate pudding, substituted for MRSA, making visible how the invisible, bacteria spreads. Improv participants, front-line

workers from multiple units, emphasized that the Improvs were a fun and refreshing way of learning. It was not another lecture, or a briefing. The scenes provided continuous “aha” moments.

The PD processes at Billings Clinic were guided by a constant stream of data gathering, analysis and action. When the MRSA initiative was launched a baseline on MRSA prevalence was carried out. Piloting units in the study made a commitment to support and draw more resources and people into the MRSA prevention initiative and tap more sources of support and influence. Network mapping helped identify “suspects” whose influence could then be tapped. In studying the maps with her team, Nancy Iversen found “unlikely suspects” who were highly connected with others and served as resources but had not previously been recognized as leaders.

Plexus has found Billings Clinic’s results so impressive that their story has been included in the book, “Inviting Everyone: Healing Healthcare through Positive Deviance.”

The entire staff feel privileged to have created an environment that is safer for patients. Billings Clinic has personal service expectations for each member of its staff that comes in contact with patients, guest, superiors and colleagues. Their vision is “to be recognized as the healthcare organization providing the best clinical quality, patient safety and service experience in the nation” and the organization has been recognized as #1 for their patient safety initiative. medsim

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M E D S I M M AGA Z IN E 1 . 2 0 1 3

21

SIMULATION

Virtual Reality Warm-up Improves Robotic Surgery Performance and Reduces Errors.

Thomas S. Lendvay, MD, FACS reports on how virtual reality, robotic pre-surgical rehearsal improves performance and reduces errors in both surgical trainees and experienced surgeons.

E

fforts to reduce the more than 98,000 US lives lost annually from medical complications have included the use of simulation curricula for teaching novice and practicing clinicians basic and advanced skills.1,2 Access to surgical simulation for residents has been mandated by the American Board of Surgery among other professional societies.3,4 Presurgical rehearsal or warm-up has been shown to enhance surgical performance and reduce operative times. Now that high fidelity simulators have been created for robotic surgery, we sought to explore whether virtual reality (VR) robotic surgical warm-up would improve performance and reduce errors in both surgical trainees and experienced surgeons.

Athletes and musicians warm-up, so why don’t surgeons?

Surgery is a high stakes, technically challenging, and cognitively intense profession. In addition, the benefits of warm-up may be particularly important for robotic surgery due to the increased information presented to the surgeon through the visual monitor.

Surgeons need to process and transform visual cues into forces applied because of the lack of haptic feedback from the platform.

Methods Surgical residents and faculty from the Departments of Urology, General Surgery, and Gynecology at the University of Washington Medical Center (UWMC) and Madigan Army Medical Center (MAMC) were recruited for our study. [Table 1.]

22

MEDSIM MAGAZINE 1.2013

PGY-1 and 2 residents were excluded as we felt that robotic surgery performance was not level appropriate for junior residents. We enrolled 51 subjects and after a proficiency curriculum to bring every subject to a baseline of VR and da Vinci (Intuitive Surgical Inc., Sunnyvale, California) robotic surgical skills level, we randomized them to a series of trial sessions either exposing or not exposing them to a brief VR robotic simulator (dV-Trainer simulator, MIMIC Technologies, Inc., Seattle, Washington) warm-up.

The proficiency curriculum included four VR and four da Vinci dry lab modules that exercised basic robotic manipulations such as instrument and camera clutching, suturing, object transfer between instruments, and spatial relations capabilities. [Figures 1. and 2.] To achieve proficiency, each subject had to pass performance benchmark criteria with zero error rates to advance to the next degree of task difficulty.

Demonstration of our set-up in the ISIS simulation center with the da Vinci.

Tasks are affixed to acrylic plates so that the orientation of the robot remains constant between modules. (Resident: Daniel Avery, Urology PGY-4) Image credit: Author.

Warm Up (N=26) 33.85±5.82

p-value 0.396

10 (40.0%)

9 (34.6%)

0.691

15 (60.0%)

17 (65.4%)

7 (28.0%) 18 (72.0%)

9 (34.6%) 17 (65.4%)

0.611

Ambidextrous Left Right Training Year PGY1 PGY2 PGY3

0 (0.0%) 2 (8.0%) 23 (92.0%)

1 (3.8%) 0 (0.0%) 25 (96.2%)

0.216

1 (4.0%) 0 (0.0%) 4 (16.0%)

0 (0.0%) 2 (7.7%) 9 (34.6%)

0.299

PGY4 PGY5 PGY6 Faculty

3 (12.0%) 3 (12.0%) 2 (8.0%) 12 (48.0%)

1 (3.8%) 1 (3.8%) 1 (3.8%) 12 (46.2%)

Urology

14 (56.0%)

14 (53.8%)

General Surgery OBGYN Recent Video Game Use

7 (28.0%) 4 (16.0%)

5 (19.2%) 7 (26.9%)

None <2 x Week 2+ x Week

15 (60.0%) 7 (28.0%) 3 (12.0%)

16 (61.5%) 6 (23.1%) 4 (15.4%)

0.89

Laparoscopic Cases (primary surgeon) None 1 (4.0%) 10 or less 3 (12.0%)

0 (0.0%) 3 (11.5%)

0.497

Variable Age Gender

Control (N=25) 35.32±6.47 Female

Male Musical instrument for >3yrs No Yes Handedness

Sub Specialty

01/11/25 3 (12.0%) 25+ 18 (72.0%) Robotic Cases (primary surgeon)

1 (3.8%) 22 (84.6%)

None 10 or less 11-25

9 (36.0%) 6 (24.0%) 3 (12.0%)

8 (30.8%) 10 (38.5%) 1 (3.8%)

25+

7 (28.0%)

7 (26.9%)

0.568

0.564

Table 1. Subject demographics between control and warm-up groups. P-values denote similarities between the cohorts.

We designed a da Vinci tool tracking method - SurgTrak™ - to locate the tools in space so we could get path length data to calculate economy of motion. [Figure 3.] Using this technology, we had already demonstrated construct validation of the proficiency curriculum1.

Four trial sessions per subject were performed. The first three tested a similar 1VR to dry lab task – the rocking peg board. And the fourth session tested a dissimilar task from the rocking peg board warm-up – da Vinci suturing. [Figure 2.] The warm-up took 3-5 minutes to

complete and the control subjects spent 10 minutes reading a leisure book immediately prior to performing the da Vinci criterion task. We tracked total task time, path length for right and left handed tools, technical errors, cognitive errors, and economy of motion for each of the sessions on the simulator and on the da Vinci.

Results The warm-up group performed with decreased task time (-29.29 seconds, p=0.001) and path length (-79.87 mm, p=0.014) for the similar tasks. There was a >6-fold reduction favoring warm-up for sessions with errors of placing the rings on incorrect pegs (sequence errors). In Tables 2 and 3, performance metrics for the first three similar sessions are detailed.

When we tested whether the dissimilar VR task can warm-up subjects for robotic suturing, we observed a 4-fold reduction in the proportion of sessions with global technical errors for the suturing (needle entrance, exit errors and air knot errors, collectively, p=0.020). [Table 4.]

When we divided the groups by level of MIS experience (> 10 laparoscopic and > 10 robotic cases as primary surgeon vs. < 10 cases in each modality experience), we observed that the warm-up effect was more pronounced with experience.

Economy of motion (p=0.007), task time (p=0.001), and path length (p=0.093) favored the warm-up ‘experienced’ subgroup. [Table 5.]

Discussion & Conclusions Warming-up on a VR platform before doing similar and dissimilar skills modules on the da Vinci improved surgeon performance. It is intuitive that some form of priming before doing a task would be beneficial, but the finding that dissimilar tasks can elevate surgeon performance is compelling to bring this into

Figure 1. MIMIC dV-Trainer VR simulation modules from left to right: Pick and Place, Ring Walk Level 1, Pegboard Level 1, Pegboard Level 3.

MEDSIM MAGAZINE 1.2013

23

A

SIMULATION

5 S

N 5 N

Figure 2. da Vinci dry lab modules from left to right: Fundamentals of Laparoscopic Surgery (FLS) block transfer, FLS intracorporeal suturing (this was the criterion task for sessions #4), Ring tower (The Chamberlain Group, Great Barrington, Massachusetts), Rotating rocking pegboard (this was the criterion task for sessions #1-3).

Figure 3. Retrofitted da Vinci training instrument with electromagnetic sensor housing on back end (left) and task module jig that housed modules and transmitter in fixed distances from each other for standard tool tracking (right).

the operating room. Testing whether Control Warm-Up Outcome Mean SE Mean SE Difference (95% CI) P-Value warm-up improved robotic suturing was Economy of Motion 4.42 0.1 4.63 0.1 0.21 (-0.06, 0.47) 0.132 critical because the suturing task was Task Time 264.31 6.49 235.01 6.36 -29.29 (-47.03, -11.56) 0.001 analogous to suturing that would be perTotal Peg Touches 21.68 1.63 19.38 1.59 -2.29 (-6.71, 2.12) 0.313 formed in human surgeries. The value Cognitive Error 0.12 0.04 0.06 0.04 -0.06 (-0.17, 0.06) 0.340 of this finding is that the ideal warm-up Path Length 1149.23 23.27 1069.37 22.71 -79.87 (-144.48, -15.25) 0.014 curricula may not need to look like the Table 2. Outcomes by study group for sessions 1-3, analyzed with repeated measures ANOVA. planned robotic surgery tasks - generalizability. Furthermore, the observation that experienced surgeons derived more Proportion of Sessions with Error Error Type of a benefit than inexperienced surgeons, Control Warm-Up RR 95% CI P-Value Ring Drops makes this finding relevant to the prac0.320 0.333 0.96 (0.58, 1.59) 0.873 Air Transfer 0.040 0.051 0.78 (0.19, 3.14) 0.727 ticing clinician and not just the trainee.

Out of Order (Sequence) 0.080 0.013 6.24 (0.77, 50.76) 0.087 This finding parallels Mucksavage et al.â&#x20AC;&#x2122;s finding that laparoscopic warm-up Table 3. Binary outcomes for sessions 1-3 by study group and relative risk (RR) of errors by type, analyzed with relative risk regression. decreases operative times in experienced surgeons in the OR.2 Control (n=25) Warm Up (n=26) Our observation that warm-up Outcome Mean SD Mean SD P-Value improved not only technical, but trended Task Time 111.20 5.85 107.58 7.41 0.703 towards improving cognitive skill as well Economy of Motion 3.69 0.17 3.82 0.16 0.560 suggests that recruiting not only simple Path Length 401.42 22.89 401.46 26.97 0.999 psychomotor centers of the brain, but Global Technical Error 0.44 0.12 0.12 0.06 0.020 also spatial relations centers, may be Table 4. Outcomes by study group for session 4, analyzed with t-tests. Global Technical Error = composite of additive to the warm-up benefit.

Air knot, Needle targeting errors by FLS (Entrance and Exit dots errors).

Our study design yielded some limitations. Because of the variability way to avoid this confounder in (N=34) the future is to design >the in skill level between different subjects <= 10 Rob & Lap 10 Robotic and Laparoscopic Cases (N=17) each own controls receiving despite passing the proficiency curOutcome study with Warm up subject Controlas their Difference (95% CI) either P Warm up Control Difference (95% CI) not receiving warm-up through a series sessions.

The 4.31 (0.15) riculum, we recognize that if the betEconomy ofof Motion 4.51 (0.11)the 4.49 (0.12) 0.02 (-0.3, 0.34) of0.897 4.94 (0.18) 0.63 (0.18, 1.09) 240.8 (7.2) (8.1) be, however, -17.8 (-39.2, 3.5) 219.4 (11.9) 272.9 (10.0) -53.5 (-83.9, -23.0) here258.6 would that 0.102 the sequence ter performing surgeons tended to Task be Time only challenge Peg Touchesof either receiving 20.7 (1.8) 24.2not (2.0)receiving -3.6warm-up (-8.8, 1.7) 0.184 15.9 (2.9) 17.9 (2.4) -2 (-9.4, 5.5) or would have to randomized to the warm-up group, this Cognitive Errors 0.05 (0.05) 0.13 (0.05) -0.08 (-0.22, 0.06) 0.265 0.10 (0.08) 0.10 (0.07) 0 (-0.21, 0.20) be varied so that prior sessions do not yield a practice effect. could have skewed the findings. One Path Length

24

MEDSIM MAGAZINE 1.2013

1077 (27)

1152 (30)

-75 (-154, 4)

0.063

1049 (44)

1145 (37)

-97 (-210, 16)

P 0.007 0.001 0.600 0.963 0.093

April 23-25, 2013

Plenary Speakers:

Keynotes to include:

5th International Pediatric Simulation Symposia and Workshops (IPSSW) New York Academy of Medicine 5th Avenue New York NY

Kathryn Schulz

Cynthia Breazeal PhD

International “TED” Speaker and Author of “Being Wrong: Adventures in the Margin of Error”

International “TED” Speaker and Director of Personal Robotics Group, MIT, Cambridge MA

Adam Dubrowski PhD Pediatric Technical Training Choon Bong MD Stress and Performance Stephanie Sudikoff MD Total Center Development Debra Nestel RN Faculty Development

Pediatric Simulation IPSSW2013 NYC

Marc Adler MD Curriculum Development

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Join Pediatric Simulation Colleagues from Around the Globe Largest Meeting Devoted Entirely to Pediatric and Perinatal Simulation Target Audience: All Pediatric Subspecialties, Nursing, Allied Health Care, Simulation Educators, Researchers, Technicians, Administrators All Levels of Simulation Experience (Novice to Experts) Stockholm, Florence, Madrid, Toulouse, and now coming to New York City, NY USA 3-day Expanded Format Internationally renowned Keynote (“TED”) Speakers Roundtables, Hands-on Workshops, Plenaries All Devoted to Pediatric Simulation Historic New York Academy of Medicine with festivities at the Famous Central Park Loeb Boat House

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Control (N=25) 35.32±6.47

Warm Up (N=26) 33.85±5.82

10 (40.0%) 15 (60.0%)

17 (65.4%)

9 (34.6%)

9 (34.6%) 7 (28.0%) 17 (65.4%) 18 (72.0%) halldale.com/medsim

Handedness Ambidextrous Left Right

0 (0.0%) 2 (8.0%)

1 (3.8%) 0 (0.0%)

23 (92.0%)

25 (96.2%)

Training Year PGY1 PGY2 PGY3 PGY4 PGY5 PGY6 Faculty

1 (4.0%) 0 (0.0%)

0 (0.0%) 2 (7.7%)

4 (16.0%) 3 (12.0%) 3 (12.0%) 2 (8.0%) 12 (48.0%)

9 (34.6%) 1 (3.8%) 1 (3.8%) 1 (3.8%) 12 (46.2%)

14 (56.0%) 7 (28.0%) 4 (16.0%)

14 (53.8%) 5 (19.2%) 7 (26.9%)

15 (60.0%) 7 (28.0%) 3 (12.0%)

16 (61.5%) 6 (23.1%) 4 (15.4%)

Sub Specialty Urology General Surgery OBGYN Recent Video Game Use None

on how virtual reality, robotic pre-surgical Thomas S. Lendvay, MD, FACS reports and reduces errors in both surgical trainees rehearsal improves performance and experienced surgeons.

E

98,000 US lives lost fforts to reduce the more than have included the annually from medical complications novice and pracuse of simulation curricula for teaching skills.1,2 Access to surgical ticing clinicians basic and advanced by the American mandated simulation for residents has been societies.3,4 Presurgiprofessional other among Surgery of Board shown to enhance surgical cal rehearsal or warm-up has been times. Now that high fidelperformance and reduce operative for robotic surgery, we sought ity simulators have been created (VR) robotic surgical warm-up to explore whether virtual reality reduce errors in both surgical would improve performance and trainees and experienced surgeons. so why don’t surgeons?

Athletes and musicians warm-up, challenging, and cognitively Surgery is a high stakes, technically benefits of warm-up may be intense profession. In addition, the surgery due to the increased particularly important for robotic through the visual monitor. information presented to the surgeon visual cues into forces Surgeons need to process and transform feedback from the platform. applied because of the lack of haptic the Departments of UrolSurgical residents and faculty from at the University of ogy, General Surgery, and Gynecology and Madigan Army MedWashington Medical Center (UWMC) for our study. [Table 1.] ical Center (MAMC) were recruited

PGY-1 and 2 residents were excluded perforas we felt that robotic surgery was not level appropriate for mancetrAining technoLosubgy junior residents. We enrolled 51 jects and after a proficiency curriculum of to bring every subject to a baseline Inc., Surgical VR and da Vinci (Intuitive Sunnyvale, California) robotic surgical simuLAtion progrAms to a skills level, we randomized them exposseries of trial sessions either VR ing or not exposing them to a brief robotic simulator (dV-Trainer simulator, MIMIC Technologies, Inc., Seattle,

<2 x Week 2+ x Week

Laparoscopic Cases (primary surgeon) 1 (4.0%) None

Demonstration of our set-up in the ISIS simulation center with the da Vinci.

Tasks are affixed to acrylic plates so

Learning Enablers that the orientation of the robot remains constant between modules. (Resident: Daniel Avery, Urology

pAtient

warm-up.

Washington.)sAfety The proficiency curriculum included modfour VR and four da Vinci dry lab manipules that exercised basic robotic camulations such as instrument and era clutching, suturing, object transfer relaspatial and between instruments, 2.] To tions capabilities. [Figures 1. and had achieve proficiency, each subject criteria to pass performance benchmark the to with zero error rates to advance next degree of task difficulty.

8 (30.8%)

p-value 0.396 0.691

0.611

0.216

0.299

spent complete and the control subjects imme10 minutes reading a leisure book Vinci diately prior to performing the da time, criterion task. We tracked total task path length for right and left handed errors, tools, technical errors, cognitive of the and economy of motion for each the da sessions on the simulator and on Vinci.

Results

with The warm-up group performed decreased task time (-29.29 seconds, mm, p=0.001) and path length (-79.87 was p=0.014) for the similar tasks. There for a >6-fold reduction favoring warm-up rings sessions with errors of placing the In on incorrect pegs (sequence errors). metrics performance 3, and 2 Tables are for the first three similar sessions detailed.

When we tested whether the dissimilar VR task can warm-up subjects 4-fold for robotic suturing, we observed a reduction in the proportion of sessions suturwith global technical errors for the and air ing (needle entrance, exit errors [Table knot errors, collectively, p=0.020).

4.]

When we divided the groups by level and of MIS experience (> 10 laparoscopic vs. > 10 robotic cases as primary surgeon < 10 cases in each modality experience), effect we observed that the warm-up was more pronounced with experience. time task (p=0.007), motion Economy of (p=0.001), and path length (p=0.093) subfavored the warm-up ‘experienced’ group. [Table 5.]

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0.568

0.89

0.497

0.564

10 (38.5%) 1 (3.8%) 7 (26.9%)

control and warm-up groups. P-values

We designed a da Vinci tool tracking tools method - SurgTrak™ - to locate the data in space so we could get path length [Figure to calculate economy of motion. already 3.] Using this technology, we had of the validation construct demonstrated 1 proficiency curriculum .

Initial Foundational Questions To Help Build Your Simulation Program PGY-4) Image credit: Author.

0 (0.0%) 3 (11.5%) 1 (3.8%) 22 (84.6%)

3 (12.0%) 10 or less 3 (12.0%) 01/11/25 18 (72.0%) 25+ Robotic Cases (primary surgeon) 9 (36.0%) None 6 (24.0%) 10 or less 3 (12.0%) 11-25 7 (28.0%) 25+ Table 1. Subject demographics between between the cohorts.

Date:

t r A i n i n g

volume 2 Variable Age Gender

ic Virtual Reality Warm-up Improves Robot Errors. es Reduc and mance Perfor ry Surge

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t h r o u g h

Female Male Musical instrument for >3yrs No

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A d vA n c i n g

F o r M

denote similarities

Four trial sessions per subject were a simiperformed. The first three tested peg lar 1VR to dry lab task – the rocking tested board. And the fourth session peg a dissimilar task from the rocking [Figboard warm-up – da Vinci suturing. to ure2.] The warm-up took 3-5 minutes

Job Function (please tell us your job function in one or two words):

Discussion & Conclusions

PAYmEnT dETAilS

before Warming-up on a VR platform moddoing similar and dissimilar skills ules on the da Vinci improved surgeon some performance. It is intuitive that a task form of priming before doing that would be beneficial, but the finding perdissimilar tasks can elevate surgeon into this bring to compelling formance is

Training for Safety: What the Airline s really did… and do

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Figure 1. MIMIC dV-Trainer VR simulation

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1.13

Economy of Motion Path Length Global Technical Error

3.69

0.17

3.82

0.16

0.560

401.42 0.44

22.89 0.12

401.46 0.12

26.97 0.06

0.999 0.020

<= 10 Rob & Lap (N=34) Outcome

Warm up

Warm up

Control

Economy of Motion

4.51 (0.11)

4.49 (0.12)

0.02 (-0.3, 0.34)

0.897

4.94 (0.18)

4.31 (0.15)

0.63 (0.18, 1.09)

0.007

Task Time

240.8 (7.2)

258.6 (8.1)

-17.8 (-39.2, 3.5)

0.102

219.4 (11.9)

272.9 (10.0)

-53.5 (-83.9, -23.0)

0.001

Peg Touches Cognitive Errors Path Length

Control

Difference (95% CI)

> 10 Robotic and Laparoscopic Cases (N=17) P

Difference (95% CI)

P

20.7 (1.8)

24.2 (2.0)

-3.6 (-8.8, 1.7)

0.184

15.9 (2.9)

17.9 (2.4)

-2 (-9.4, 5.5)

0.600

0.05 (0.05)

0.13 (0.05)

-0.08 (-0.22, 0.06)

0.265

0.10 (0.08)

0.10 (0.07)

0 (-0.21, 0.20)

0.963

1077 (27)

1152 (30)

-75 (-154, 4)

0.063

1049 (44)

1145 (37)

-97 (-210, 16)

0.093

Table 5. The table below shows the mean values and differences (Warm-Up – Control), 95% confidence intervals, and p-values for the 5 continuous outcomes measured in sessions 1-3 in the study overall and broken up by Robotic/Laparoscopic Case experience.

In addition, intervals between sessions varied among subjects because of the difficulty in scheduling times for active residents and faculty. This could have led to performance variability as Jenison et al. showed that after 4 weeks of rest, robotic surgery skills degrade, thus we minimized the number 2 of intervals that exceeded this threshold.3 We did not also control for fatigue as the subject’s post-call level was not questioned or recorded.

Our findings were unambiguous in a dry lab setting, yet demonstration in the operating room as Mucksavage et al. and Calatayud et al. did for conventional laparoscopy, needs to be performed. 2,4 Because the desktop dV-Trainer runs the same software as the Intuitive backpack simulator, our findings may be easily translatable into the OR. In the future we envision a generation of robotic systems capable of downloading patient specific images (from CT or MRI scans) to allow a surgeon to sit at the console and rehearse the case through performance on a 3-D VR rendered anatomy module. 5 Robotic VR simulation warm-up improves technical and cognitive performance on the da Vinci robot in a dry lab setting.

These results provide a foundation for predictive validation studies in the OR evaluating the role of warm-up for improving surgical outcomes, reducing operative cost, and paving the way for patient-specific procedure rehearsal. medsim

References 1 Tausch TJ, Kowalewski TM, White LW, McDonough PS, Brand TC, Lendvay TS. Content and construct validation of a robotic surgery curriculum using an electromagnetic instrument tracker.

J Urol 188:919-923, 2012.

2 Muchsavage P, Lee J, Kerbl D, Clayman R, McDougall E. Preoperative warming up exercises improve laparoscopic operative times in an experienced laparoscopic surgeon. J Endourol 26:765768, 2012.

3 Jenison EL, Gil KM, Lendvay TS, Guy MS. Robotic surgical skills: Acquisition, maintenance, and degradation. JSLS 16:218-228, 2012.

4 Calatayud D, Arora S, Aggarwal R, et al.Warm-up in a virtual reality environment improves performance in the operating room.

Ann Surg. 251:1181, 2010.

5 Makiyama K, Nagasaka M, Inuiya T, et al. Development of a patient-specific simulator for laparoscopic renal surgery. Int J Urol 19:829-835, 2012.

Acknowledgements This study was supported by the Department of Defense U.S. Army Medical Research and Materiel Command under award number W81XWH-09-1-0714 (PI: Lendvay). Views and opinions of, and endorsement by the author(s) do not reflect those of the Army or the Department of Defense. The Seattle Children’s Core for Biomedical Statistics is supported by the Center for Clinical and Translational Research at Seattle Children’s Research Institute and grant UL1RR025014 from the NIH National Center for Research Resources.

About the Author Thomas S. Lendvay, MD, FACS, is an associate professor of urology, University of Washington School of Medicine, Department ofD-024 Urology.

Contact: thomas.lendvay@seattlechildrens.org.

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MEDSIM MAGAZINE 1.2013

27

SIMULATION PROGRAMS

Initial Foundational Questions To Help Build Your Simulation Program In the first of three articles of particular interest to program administrators, Jane Kleinman, RN, MAOM, and Jeff Myers, MD, provide seven compelling questions that should be considered prior to implementing any simulation project.

Skills, Task & Procedure Training.

Image credit: Clinical Simulation Center Las Vegas.

28

T

aking the right action at the right time for the right reason in the right way ensures coordinated, complete, competent safe patient care.

Simple, right? Yet our learners and practitioners, all with demonstrated proficiencies and excellent test scores, often fall victim to the “practice gap”, unable to transfer what they know into what they do. Today’s healthcare environment is a rapid paced dynamic of complex care continuums without margins for any practice gap.

To help mitigate this gap there has been a rapid evolution and use of experiential learning modalities on all levels of healthcare education, often referred to as “simulation”. Unfortunately, simulation has become a catch-all phrase that encompasses a host of different types of experiences. Each type has

MEDSIM MAGAZINE 1.2013

its own unique needs for environment, equipment, and resources. And therein lays the crux of why implementing a “simulation program” can be so frustrating or difficult. In any given group of educators and administrators the term simulation has different meanings and expectations.

Whether you are developing a focused in-situ experiential learning or university level interprofessional simulation center, there are seven critical questions that must be asked and answered prior to any implementation action. The answers are inter-related and help frame the scope of the answer for the seven, subsequent questions. While not all inclusive, these questions form the basic and foundational information needed to establish your project.

Question #1 What types of simulation are we talking about?

We have created and use the following quick reference summary guide in Table 1 that allows for different types of simulation modalities to be categorized in ways that relate to operational realities. This ensures that all levels of stakeholders are on the same page during discussions, decisions, and commitment.

Question #2 Who needs to be involved?

Identifying all possible stakeholders up front is key to creating a shared mental model. Without a shared mental model of what will be provided for the learners,

there will be competing agendas, silos of dogma, fragmented program development, limited resources, funding constraints, ad hoc utilization, and ultimately, poor outcomes.

Finding out who is doing what, who needs what, who has what and who wants what, may take some time. Cast the net wide. Think outside of your normal circle of organizational contacts.

What other departments could benefit or be of benefit to yours? Who has a stake in ensuring optimum patient care? What about external clinical, business, and philanthropic relationships that could be mutually beneficial?

Identify a functional representative group that includes line personnel through key decision makers. We always like to include a “nay-sayer” for two reasons: the opportunity to allow the initially non-supportive individual to become a part of the solution, and, often that questioning voice helps push the group to better define the shared mental model.

That shared mental model, developed and therefore supported by this representative group, will be the key to both driving and holding together your program development and implementation at all levels.

Description

LECTURE ANIMATION

IMMERSIVE PATIENT CARE MANAGEMENT

Task training

Didactic with demonstration of pathophysiological changes Faculty lecture, demo, & test

Realistic 10-15 minute immersive experience designed to allow learners to put knowledge into actions in order to pro-actively identify & mitigate gaps

Patient Presentation: -case study -ad hoc progression -course specific

Faculty facilitate a standardized scenario without interrupting the learners Non-testing

Faculty lecture, demo, & test May be self paced learning with interactive devices

Video Use

May be used for psycho-motor skill review

May incorporate some: -performance of tasks -demo of tasks in sequence -discussion of next steps May be used for psycho-motor skill review

# of Learners to Faculty Length of Session Debriefing

10-40 learners: 1-4 Faculty

10-75 learners: 1 Tech + 1-2 Faculty

1,4 hour/session

1,2 hour/session

None

None

Static mannequin Body part trainers Haptic trainers Standardized Patients

Mid or high fidelity mannequins Hybrid mannequin Haptic trainers Standardized Patients

Equipment

Question #3 Who are the learners and what do they need? (In tandem with #2) In order to know what equipment, space and types of patient encounters are needed, we need to identify our learners. Defining who the learners are by level(s) of expertise, demographics, and groups is critical to determining who needs how much of what type of simulation is required when. This ensures that planned simulation activities meet the learners’ needs and are aligned with curriculum and/or requirements. It is also very important when designing specific simulation programs desired outcomes so that the experience can be customized to the learner groups’ needs.

It is important to recognize evolving educational and regulatory mandates for provision of different types of simulation.

Planning for incremental growth and utilization impacts on resources required to start, run, and grow the program must occur early.

SKILLS & TASK

Patient care supplies

Evaluation

Testing/ Competency certifications

Limited realistic - environment - patient equipment - patient care supplies Testing/ Competency certifications

Realistic, dynamic, environment & patient challenges Critical component to ensure objective review for performance gap identification & data analysis 6 -10 learners: 1 Tech + 1 Facilitator/Debriefer 2,4-8 hour sessions Immediate targeted video review with group participants to discussion to proactively mitigate performance gaps Mid or high fidelity mannequin Hybrid mannequin Haptic trainers Standardized Patients Realistic - environment - patient care equipment - patient care supplies Non-testing Performance Measures Gap Analysis

Table 1. Types Of Medical Simulation Training

Questions #4 What outcomes are desired?

This is where program buy-in and sustainability are created. Alignment of specific activities with core indicators with a defined soft or hard return on investment (ROI) demonstrates needs being met. ROI is the cost of providing the experience as it relates to improved outcomes, costs or reductions elsewhere.

Get very specific with the outcome definitions. What measurable, observ-

able, critical thinking transferred to knowledge- in- action, do we want our learners to demonstrate and gain from the experience?

How will the outcomes be measured? The examples in Table 2 represent only a small number of possible outcome measures. The list is endless. Making the outcomes relatable to a significant problem that needs to be solved is the critical component, even if that problem is just being able to start identifying where the practice gap is.

MEDSIM MAGAZINE 1.2013

29

SIMULATION PROGRAMS

• • • • • • • • • • •

Cost savings Patient outcomes Staff satisfaction Reduction in training costs Reduced length of stay Improved teamwork Decreased infection rate Error prevention Error reduction Refined processes Coordination across the care continuum

Table 2. Examples of Program Outcome Measures

Question #5 What methodology will be used?

Beware of confusing “buttonology” with methodology. Equipment vendors participate in excellent “simulation training” conferences with variable presentations, but the focus is really on how to use their technology to drive the learner experience.

Methodology is how they create, present, and manage the learner experience with technology as an adjunct to cue or support the learners.

Defining the methodology for each type simulation to be used directly translates into the operational plan for learner through put, utilization, space, equipment, supplies and personnel resources necessary.

It is critical for the credibility of your program to have standardized methodology employed by all educators for each type of simulation provided. Learners will not risk demonstrating practice gaps or learning through mistakes if there is a lack of trust that defined processes are uniformly used and fairly applied.

While there are several different valid ways to run a simulation program, consistency is key. The answer to this question will drive planning for the program’s administrative structure, staffing, faculty and staff development, core operations and the operating budget.

Question #6 What resources will be necessary to support the methodology?

Get out the calculator. Time to count up the number and size of groups and their use of simulation by hours per year, week and/ or day. Those numbers determine how many personnel in what roles, how many pieces of equipment in what type of space, and even the amount and type of disposable supplies that will be necessary.

These numbers establish the operational budget for your program. Comptrollers need to know what the costs are up front and their justification. The different types of simulation require different types of personnel and equipment resources. This initial pro-forma helps define program needs and estimated operating expenses.

“Cash is King,” is a statement that describes the need for solid and accessible operating funds. Money that is tied up in an endowment, long term investment or in capital may not be accessible in the critical early stages of program development.

Simulation is a resource intensive educational methodology. Not 30

MEDSIM MAGAZINE 1.2013

only is the equipment expensive, but the time and human capital required in developing and executing the educational experiences is significant. This all translates into needing adequate start up and sustainability funding.

Startup funding is often made in the form of an initial investment in a program by an organization, donor, or philanthropic campaign. In raising funds for “stuff”, it is easy to provide tangible benefit to the stakeholder who puts forth the investment. It is much easier to raise funds for a room to place a plaque identifying the sponsor of that space, or to a piece of equipment. It is much more difficult to put a plaque on a person.

Operating expenses for staff salary and overhead should not rely on external donations or grant funding. Both sources tend to be for the short term, leaving you with an unusable area full of equipment in the long run.

Early frank and realistic operational funding agreements among the stakeholders are essential for program survival. How will the program operations be funded? What proportions are assigned to the different stakeholders?

In return for what level of access? Who is responsible for what piece of funding?

And when? Make sure these decisions are secured with letters of agreement otherwise once the bill arrives it may be difficult collecting the funds.

Funding is a key area that should not be glossed over in the excitement to start a program. The time taken to finalize these details1at the beginning will save a significant amount of future worry and time taken away from the educational mission of the program. There is no right or wrong answer to how funding is established, so come to whatever consensus is mutually beneficial for the stakeholders.

We cannot stress enough that this key question should be answered as soon as possible in program development.

Question #7 What are the next steps?

Now that you have answered these questions you will have a good idea of how the program will look, from the equipment and space needs, types and scope of learners and activities, staffing needs, faculty development and funding.

Practicing invasive skills on task trainers has been shown to decrease complications when performed on live patients.

Image credit: Behling Simulation Center.

Time to bring it all together into a functional timeline with assigned roles, responsibilities, and deadlines so that the stakeholder shared mental model is not lost and development proceeds in a focused, tangible manner.

Starting with a limited, focused, pilot program provides the grace period to gain valuable experience, work out the uncertainties, identify gaps and create efficiencies. This is an excellent way to establish a proof of concept, credibility and internal public relations to ensure full support for next level steps.

In Summary

linking desired outcomes to tangible problem solving that can be measured.

5. Standardize methodology to support operations, trust, credibility, and allow for outcome measures to be obtained.

6. Identify budget and funding details based on clearly defined utilization metrics.

7. Create a focused timeline for activities with clear responsibilities and resources for accomplishment defined.

These are the foundations to build your simulation program. Make sure your beginning gets off to the right start! medsim

1. Use a clear definition of the different types of simulation and their resources to harmonize the stakeholders’ expectations.

2. Establish a simulation usage plan to help develop funding for operations personnel, equipment, space, logistics, and supplies.

3. Identify and use key representative stakeholders to create the shared mental model for program development so that resources can be optimized.

4. Create sustainability and buy-in by

About the Authors Jane Kleinman, RN, MAOM, is the CEO of Performance Gap Solutions, LLC and founder of Medical Simulation Design, Inc. She may be contacted at jane@performimprove.com Jeff Myers, MD, is the CEO of Fast Track Solutions, LLC and is a practicing emergency physician and emergency care consultant and educator in Buffalo, NY. He can be reached by e-mail at jeff@ fasttracksolutionsllc.com.

Come and Visit the Lustrum Congress of the Dutch Society for Simulation in Healthcare in Amsterdam, the Netherlands on 20th March 2013!

The DSSH Lustrum Congress of the DSSH, the largest European National Society or Simulation in Healthcare, will take place on the 20th of March 2013 at the Academic Medical Center in the beautiful city of Amsterdam, the Netherlands.

This year the Congress is themed: "Medical Simulation, What's Next?" Latest developments in Simulation and Serious Gaming for training health care professionals are featured. The language of the Congress is Dutch, but many presenters will present in English. All presenters will support their presentation using English slides to accommodate our visiting non-Dutch language audience. Many exciting keynotes, presentations and interactive workshops are programmed; and visitors are welcomed at the large exhibition and sponsorship area at the central square of the Academic Medical Center. During the Congress, a separate 'pop-up' innovation center will be staged, to support promising start-ups and non-commercial initiatives.

Combine education, simulation and/or business with pleasure and visit Amsterdam this spring!

Visit our website: http://www.dssh.nl/en/dssh-congress/dssh-congress-2013 for the latest updates on our exciting Congress Program, and to register for this exciting Congress at very reasonable rates!

Our Congress partner is: Congress & Meeting Services Holland. Please contact Mrs. Sanne van den Biggelaar at info@congresservice.nl or +31 20 040-2132222 should you require help with your travel arrangements or hotel booking.

Email: info@dssh.nl • Website: www.dssh.nl and www.dssh.nl/en (international) • Follow us on Twitter: @dutchsimulation / join us on Facebook!

MEDSIM MAGAZINE 1.2013

31

PATIENT SAFETY

Training for Safety: What the Airlines really did… and do.

Halldale Publisher and CEO Andy Smith, places into context his insights gained from several decades of watching the civil aviation sector achieve unprecedented levels of safety. The Herculean advancements in civil aviation safety may be tailored to and replicated by the healthcare industry.

A

t each and every healthcare training, safety or education event reference is made to “what the airlines did” to achieve their unprecedented record of safety. This is quickly passed over with one or two comments that indicate a varying level of knowledge of how airline personnel are trained and a statement to the effect that “of course medicine, or the human body, is considerably more complex than airplanes. So moving on...”

While that is of course true, there are multiple lessons that the healthcare sector can learn from aviation, another complex system of many moving parts, people and opportunities for miscommunication and error. The airline industry has created many procedures and actions that can be translated and transferred to help support and improve healthcare.

Improved training is only one element of the mix. Improvements to technologies such as avionics, improved engine and airframe reliability, instruments to warn of “controlled flight into terrain” i.e., an impending crash, and improved air traffic control all had a major impact on airline safety, as changes in medical technologies will have in healthcare safety.

The airline sector, like healthcare, is a people business.

Without well trained people working together as a team, all the technology in the world will make little difference. So, just as the healthcare sector improves its “avionics” via electronic health records, and its hospitals and ORs with increasing technology, so too, it must improve the education and training of all its personnel.

32

MEDSIM MAGAZINE 1.2013

As acknowledged by increasing numbers of health experts, the healthcare community must transform its system into a patient centered, safety driven standard of operation, just as the airlines had to do, to enable its transition from a high risk to a very low risk business.

(CAT issue 4 2012, People, Planes, and Pilots, by Chris Lehman, fig 2 p 7) Without that cultural shift it is difficult to see how the transformational change needed in healthcare and healthcare training will be generated. In a recent online forum the audience was told, “we have been talking healthcare safety for 30 years.” Biting off the obvious retort of “OK, where is the improvement then?” I was left to reflect that the airlines have been “doing airline safety” for about the same time. Surely it is time for more action and less talk; there is huge room for improvement even if, as was the case in aviation, the tools available are not yet fully up to requirement. That they soon will be is beyond doubt; and we all need to start the difficult process of changing ourselves.

Career-long learning is well established within the airlines' safety culture.

Image credit: CAE.

The current excellent airline record of safety stems from actions taken across the history of flight but the vast improvement took place in the last 30 years.

Around 1980 the major airlines realized that with no improvement in accident rates, [extrapolating the size of the global fleet to meet the expected needs of the year 2000, roughly a doubling of capacity], would lead to an accident a week globally by the early 2000s.

The fact that this did not happen was due to the actions of national governments, the entire aviation community: airlines, aircraft manufacturers, the avionics industry, the simulation and training industry, safety and professional organizations and others. Only latterly did national and global air regulators codify these changes into new standard operating procedures, though they watched closely and encouraged the industry to rectify its problems. It should be noted that these actions were taken for the safety of crews and passengers but also to ensure the commercial survivability of a critical industry. Pilots,

cabin crew, airline and airport managers, air traffic controllers and maintainers all needed to get it right. After all, passengers can choose not to fly, and they can certainly carefully select the airline on which they fly. So here are some of the highlights of the airline industry pertaining to training for safety: 1. The airline industry is a safety based industry in which a culture of continuous career-long learning, improvement and evaluation is embedded.

2. Such is the cost of flight training that recruits in many countries are subject to academic and psychomotor skills testing before they are accepted into a program to ensure that the likelihood of completing the course is high – 97% or higher is typical. This is both to ensure that limited training resources are not wasted but also that funding for the program can be secured.

3. It is also an industry in which proficiency is thoroughly tested prior to qualification. Mandated refresher training and proficiency simulator check rides for pilots are carried out every six months

until retirement. Failure in the check ride would require remediation and a further check ride prior to a return to line operations.

4. Before transitioning to a new aircraft type or model the pilots undergo “bridge training” to qualify them for the type of aircraft they will be flying, the “type rating” that proves proficiency on that aircraft type.

5. Cabin crews are also required to undergo similar type rating training. The number of cross qualifications is limited to ensure that the opportunity for confusion is minimal. If you are required to work with your fellow cabin crew to evacuate 150 or more passengers from a downed aircraft in less than 90 seconds this really helps!

6. Regarding the introduction of new equipment, no civilian airliner is ever flown until the entire flight deck crew has demonstrated its ability to proficiently operate the aircraft in the simulator. This enables the pilots to fly the actual aircraft for the first time with a full load of paying passengers in the cabin.

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PATIENT SAFETY 7. Also in that cabin is a crew that has been fully trained to operate effectively in normal flight and if necessary evacuate all passengers safely in an emergency.

They are also trained and encouraged to alert the pilots to anything which, in their opinion, may endanger operations.

The best captains are the first to praise them to the passengers.

8. The airlines have spent considerable sums developing CRM (crew resource management) training for its flight crew and maintenance teams working on crisis management and communications, not only for aircrew but also for maintainers, to ensure â&#x20AC;&#x153;hand offsâ&#x20AC;? to the operators are thorough.

9. The airline industry has deployed preflight briefings, "walk arounds" and preflight checks for years. These latter are not options for the teams involved and failures and avoidance are heavily penalized.

10. In more recent years as personnel have become more mobile the industry has also realized the need to standardize where possible the language used during flight to ensure that when the pressure is on there is less chance for misunderstanding. "Aviation English" is now taught in an increasing number of locations around the world.

The airlines today have an enviable safety record. This benchmark is one that they are well aware is constantly under threat from changes in technology, an expected doubling of passenger capacity again in the next two decades, the loss of many experienced pilots, the lack of prior military flight hours for new pilot accessions, the way incoming recruits learn and so on. As a global industry (from the news reporting viewpoint) the industry is also aware that the biggest growth today is in areas of the world with the smallest cadre of experienced pilots and the lowest training capacity. It is acutely aware that standards will be under pressure and must be maintained and improved. Globally it is estimated that the annual need for pilots is about 25,000 per year while training capacity might provide about 15,000 of whom about 11,000 may be trained to currently acceptable levels. The numbers for cabin crew, maintainers and air traffic controllers needed is similarly stark.

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MEDSIM MAGAZINE 1.2013

Maintaining the Standard Technology is constantly changing and has benefited many industries including the airlines. Increasing automation has lessened the pilot workload leading to a two person cockpit in all commercial jets. It has also blunted the manual flying skills of many pilots who have come to rely on automation and in some cases have not recognized warning signs that a previous generation had. As a result the aircraft and avionics manufacturers with the airlines and the simulation manufacturers have come together to redress the balance and build training devices and curricula to correct this training gap.

Recruitment is a problem and this generation of recruits would prefer accounting and law to piloting an aircraft (or becoming a surgeon?). Many governments have reduced training funding and in some cases have put in place legislation that will slow the supply of pilots in the pipeline. In addition the U.S. government imposed restrictions on flight hours. That alone increased the need for 5% more pilots in 2014.

The industry has responded by proposing what is seen by many as a radical new training program. Known as MPL, the Multi Crew Pilot License, this program is designed to produce a proficient pilot able to sit in the right hand seat of a commercial aircraft as co-pilot through the very heavy use of simulation and a curriculum specifically designed to produce an airline pilot. The traditional route of flying progressively bigger, more complex aircraft and accumulating hours of general flying has been replaced in MPL with a tailored, carefully designed course which must be sponsored/proctored by an airline. Uptake is far from universal as the cost of the simulation and the need for airlines to sponsor the programs means that few entities can easily afford it. As ever there is resistance from established programs. But it seems likely that simulation-intensive primary training schemes will eventually be adopted by most.

The parallels between the airlines and the healthcare sector are again close. In another instance there does not appear to be a shortage of personnel aspiring for a healthcare career. In the US alone 46,000 potential nurses were turned away in 2006 and last year about 1,500 medical students were also turned away due to a lack of residency programs, indicating an accession pipeline as well as a funding problem.

Cabin crew members have been trained to operate in normal flight and emergency situations.

Image credit: Czech Airlines.

The retirement issue for the airline and healthcare industry is also similar and we are at the beginning of the “baby boomer retirement spike”. In both cases, as the professions become less attractive, it seems likely that the retirement rate may be steeper than expected. An aging population and growth in services, and in the US, the emerging challenges of the Affordable Care Act of March 2010, seem to indicate a large and growing gap between the service expected and the sector’s ability to supply it.

It seems doubtful at this time that either the airline sector or the healthcare sector can cover the need for its services. Just as the airlines have moved to streamline their selection, training and supply system it seems the healthcare profession needs to do the same. A radically new way in which healthcare students are trained, coupled with a significant reduction in the time it takes to produce a trained doctor, nurse or other healthcare professional, all done while the hours available for this training have been drastically cut seems to be required.

It will certainly take an acceptance that the current model is broken or at least outmoded and will no longer serve.

Once that consensus is reached the sector will have to work together with its suppliers of instruments and simulators A d v a n c i n g

P at i e n t

to devise a way ahead. The “wheel” cannot be continually reinvented and we do not have the luxury of time. As much standardization of procedures and training as possible will need to be sought.

How are hospitals to learn to fly?

First of all a “no fault found reporting” system has been key to improving airline safety. Near misses, errors and problems with procedures or equipment are required to be reported and not just within an airline but, if needed, globally. They are tolerated because if they were not the errors would be hidden and no “teaching moment” would result.

Outright transgressions are not tolerated. (MEdSim has already reported that some practitioners are reluctant to report improvements to procedures or protocol initiatives for fear that previous errors are highlighted and would negatively affect their practice, hospital, or other entity. It may be impossible to completely change this state of affairs but it surely must be possible to share best practice?)

The airlines have become heavily regulated with mandatory training specified by government. While this is seen as a contributor to the overall success of the industry, and it is, it also slows down the adoption of new technology which is costly at a time of such rapid change, as each device must be approved for its training task. A surer way forward in the S a f e t y

T h r o u g h

healthcare sector, especially given its complexity, would seem to be to incorporate a “systems approach” where medical boards, specialty associations, medical organizations and medical schools adopt a uniform process and, as in aviation, for equipment manufacturers, training technology companies, educational specialist to be involved in the process with boards, educators and practitioners.

Finally to return to the original theme of a needed change in culture toward safety for staff and patients, two other airline aphorisms come to mind: 1. There are old pilots and there are bold pilots but there are no old bold pilots.

2. If you think training is expensive try paying for an accident. medsim About the Author Andrew Smith, the publisher and CEO of Halldale Media Group, has been observing for more than two decades the returns on investment, efficiencies and other benefits of using technologyenabled learning in the military and civil aviation community and other high risk sectors. His newfound professional passion is to help educate and inform the healthcare sector about the opportunity to improve patient safety and achieve other ROIs from their investments in learning technologies.

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MEdSim is the world’s only magazine for news, information and commentary on healthcare education, simulation and training.

It is circulated in printed and electronic format to over 37,000 healthcare training professionals in hospitals, universities, the military and veterans’ organisations.

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Learning Enablers in the second in a series of articles on medical simulation centers, group editor Marty Kauchak explores developments in the technologies used by these facilities’ learners.

T

he burgeoning number of medical simulation centers around the world supports nothing less than a transformation in the healthcare community’s learning programs. These facilities allow individuals and teams to learn and rehearse their skills in a simulated environment until they achieve prescribed levels of proficiency or certification.

One foundation of healthcare providers’ training experiences at these facilities is a blend of learning devices and systems. This community, much like its counterparts at training centers for different military occupational specialties, civil aviation aircrews and other high risk occupations, learns skills and procedures through a “crawl-walk-run” process, with different technologies guiding learning at the next level.

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One End User’s Insights The Palmetto Health – University of South Carolina School of Medicine Simulation Center is one representative facility that integrates learning technology into its curricula. The luster on the center’s brand increased last September, when the Columbia-based facility was granted a 3-year accreditation by the Society for Simulation in Healthcare. This accreditation was a significant accomplishment and a testament to the quality education at the center. The simulation center was the 22nd pro06

MeDSiM MagaZine 1.2013

gram in the world to achieve the society’s accreditation.

Eric A. Brown, MD, FACEP, pointed out that there is a blend of products at the simulation center, with devices providing instruction for disparate patient cohorts, from premie babies, to neonates, to adolescents and adult models.

Brown, who is dual-hatted as the director of the center and a faculty member in the Department of Emergency Medicine, further told MEdSim that his facility is “brand neutral”, in that it selects the best model for each particular educational endeavor with standardization as a secondary concern. “Towards that end we have a blend of Laerdal, CAE-METI and Gaumard products. Similarly our task trainers include a number of vendors’ products from Blue Phantom, to Limbs & Things to Laerdal,” he said.

The Palmetto Health – University of South Carolina (USC) School of Medi-

CAE's HPS can breathe in oxygen and breathe out CO2, interface with real clinical monitors and be used with real anesthetic gases to train anesthesiologists. image credit: cae.

cine Simulation Center has a deliberate strategy to match its requirements with fielded products. Brown said his colleagues decide what the goals and objectives are for each project or course offering they are supporting and then find the best simulation technology to meet that need. “We avoid getting into the trap of building curriculum around a simulator's capabilities. As our older equipment becomes obsolete we do scan the marketplace for the latest technologies, but we will only justify that purchase if our customer demands or special initiatives call for the model in question.”

Similar to other facilities around the globe, the Palmetto Health – USC center plans to add more simulators this year to support expanded operations. The center’s mobile simulation platform will be operational by mid-year. “Additionally, we have a third hospital opening at the end of 2013 which we will also need to

Learning devices at the Palmetto center and other community venues provide a range of capabilities. On the low-end side, an observer may find SimScreen, which MEdSim learned about in early 2012 on the exhibition floor of a community conference. Joseph Burns, the president of Appleton Inc., SimScreen’s manufacturer, said the idea for the product and its design were generated by his wife Holly, who teaches Nursing and Nursing Simulation at Cecil College in Maryland. “She observed that simulation works best if you can create a realistic environment for the student nurse. Most students were always more concerned with her and what she was doing to operate the mannequin.” So not wanting the students to constantly be “cueing” on her actions she came up with the SimScreen concept.

Burns said SimScreen is a commercial, mobile panel with a two-way mirror that one could use throughout the simulation lab and, when finished, put away Some new developments that Appleton Inc. is working on include a sound panel which can help in noise reduction when used with the SimScreen.

Innovation is occurring in other spaces within this sector.

CAE Healthcare (CAE) is reported to have the widest breadth of healthcare simulation products in the industry, and has sold 7,000 surgical, imaging and patient simulators around the globe, according to Kim Cartlidge, the company’s marketing communications manager. Cartlidge recalled CAE’s “HPS (Human Patient Simulator) was one of the first commercial simulators on the market 16 years ago,” and said it is still considered “the gold standard today.” The HPS can breathe in oxygen and breathe out CO2, interface with real clinical monitors and be used with real anesthetic gases to train anesthesiologists.

Cartlidge also noted how CAE’s products are tailored to the end users’ requirements. In the case of the HPS, the simulator is “helping medical schools meet American College of Graduate Medical Education requirements for sim-

ulation practice. Practicing anesthesiologists meet part of their Maintenance of Certification in Anesthesia requirements through high-fidelity patient simulation training, often with the HPS.” The industry is also responding to the requirement to deliver devices for team training.

CAE’s iStan and METIman wireless simulators, for instance, remain very popular in simulation centers in colleges that are training interdisciplinary teams (such as paramedics, nurses and health sciences students) in one scenario, and hospitals that are practicing code responses or testing new procedures or facilities.

Systems Level Insights Another evolving commonality between medical simulation centers and similar venues in other high risk industries, is their embrace of technology solutions at the systems level – which permit integration of individual and other level devices.

It should come as little surprise that CAE’s fastest growing product is not one of the previously discussed devices, but rather a simulation center management system called LearningSpace, which allows centers to capture simulation on video for debriefing. “LearningSpace helps center managers schedule and assess learners and store data from one room, up to 25 different rooms at once, or among multiple simulation centers in different locations (such as on different college campuses within the same system),” Cartlidge explained.

In this same product space, B-Line Medical’s product line of digital solutions, which capture, and allow debriefing and assessment of medical training and events, also continues to evolve.

One of many products which may be found in service around the globe is B-Line’s SimCapture®, which combines up to four channels of synchronized video, native resolution video capture of medical devices, simulator physiological trending and powerful annotation / assessment tools into a single 100 percent, web-based solution. Sandy Yin, a marketing strategist at the company, pointed out such an all-encompassing recording of an encounter enables more accurate, objective review and debriefing of scenarios. “We think this type MeDSiM MagaZine 1.2013

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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.

Surgical Team Training and Checklist Can Reduce Complications – Researchers at the University of Connecticut Health Center in Farmington and Saint Francis Hospital and Medical Center in Hartford, Connecticut have confirmed two simple cost-effective methods to reduce expensive postoperative complications - communications team training and a surgical checklist.

Investigators found that when surgical teams completed communications training and a surgical procedure checklist before, during and after high-risk operations, patients experienced fewer adverse events such as infections and blood clots. The study is published in the December 2012 issue of the Journal of the American College of Surgeons.

Surgical teams come together to treat patients using surgical procedures, but occasionally unforeseen circumstances occur during the process.

Sometimes surgical equipment isn’t on hand or the patient requires more blood than expected, which delays the procedure and requires dispensing more anesthesia while a team member hurries to get needed supplies. Surgical team members may also have inconsistent information about priorities for the procedure, according to Lindsay Bliss, MD, lead study author and general surgery resident at the University of Connecticut.

McGraw-Hill, Simbionix Collaborate on Medical Training – McGrawHill Professional, a provider of information resources for scientific and medical communities, and Simbionix, a provider of medical education and simulation, are 36

M EDSI M M A G A Z I N E 1 . 2 0 1 3

CAE Healthcare Acquires Blue Phantom – CAE Healthcare acquired Blue Phantom™, a provider in the medical ultrasound imaging simulation business, to help advance CAE's healthcare simulation vision and help its customers in their pursuit to improve clinical training and delivery of patient care. With the Blue Phantom acquisition, CAE plans to expand its healthcare simulation business by integrating tissue-based simulation into its product offerings and enhance its human patient simulators and VIMEDIX™ line of computer based ultrasound simulators.

collaborating on McGraw-Hill Professional's online surgical training resource AccessSurgery and the Simbionix MentorLearn system. This editorial partnership expands the marketing agreement between the two companies.

The partnership is poised to bring the full suite of surgical knowledge to the resident and student communities – from readings from the top minds in medicine including Schwartz's Principles of Surgery on AccessSurgery, to

practice using the most realistic handson experience in medical training using surgical simulators.

New Patient Safety Research Grant – SIM-one is partnering with the Canadian Patient Safety Institute to offer a $25,000 grant to a simulationbased project that specifically addresses patient safety improvement. This new grant is the sixth in SIM-one’s grant program. $125,000 is available to simulation researchers and innovators in Ontario.

All funding is provided by the Ontario Ministry of Health and Long-Term Care.

For more information go to http://www. sim-one.ca/ResearchDevelopment.aspx.

GE Healthcare Gives Simulation Equipment to Marquette University – GE Healthcare, a provider of health care technologies to hospitals, clinics and health care networks, is giving the Marquette University College of Nursing’s Wheaton Franciscan Healthcare Center for Clinical Simulation a $440,000 educational grant of items including patient monitors with advanced technological capabilities, a central nursing station, telemetry technology, infant incubators and ventilators.

CAE Healthcare Sells 1,000th iStan Patient Simulator – CAE Healthcare’s 1,000th iStan patient simulator was sold to the Paris Simulation Center at the University of Louisville School of Medicine in the United States. Developed in 2007, iStan was the first high-fidelity patient simulator that could be operated wirelessly for added mobility and realism in healthcare training.

New Simulators HeartWorks Heart Simulator Advances Echocardiography Training – A new HeartWorks simulator is raising the standard for training in echocardiography, a procedure that uses high-frequency sound waves to create a video image of a functioning heart. The simulator uses ultrasound probes containing Ascension Technology Corporation sensors that allow cardiac physiology students and clinical practitioners to develop imaging and interpreting skills that are in demand in the field of intensive care, without risk to patients.

In echocardiography, images of the functioning heart are obtained through either a transthoracic procedure using a hand-held probe placed over the chest, or a transesophageal procedure (TEE) that creates close-up images of the heart via a probe guided through the mouth into the esophagus. The HeartWorks simulator uses a lifelike manikin torso, visualization software and an ultrasound probe to provide training in both procedures.

High expectations on the 2nd Surgicon Congress Immediately after the 1st World Congress on Surgical Training (Surgicon)1 held in Sweden in September 2011, ten new working groups were created with the aim of keeping the interesting discussions at the meeting alive. At the moment the result of this work is taking shape, in the form of the first preliminary program of the 2nd Surgicon Congress coming up in June 2013 (www.surgicon.org). Members of the working groups are internationally recognized opinion leaders from different surgical specialties, making a “world wide web” of leading surgeons – as a “side-effect”.

The program concept is based on a number of main topics, each forming a coherent program session built on a keynote lecture and 4-5 additional lectures illustrating the actual topic and a following open debate with the panel and the floor.

Leaders of the ten working groups will be the respective keynote speakers for 10 new main topics. Their mission has been to identify the additional lecturers for their session, with the goal to find them in different surgical specialties on different continents. In this way we strongly believe that international contacts have been created along the way, and we now count more than 40 distinguished speakers from the USA, Canada, Hong Kong (China), Australia, New Zealand, India, Russia, South Africa, Kenya, Malawi and 6 different European countries.

In a group video discussion in January 2013, some young residents from USA and Europe spontaneously stated that there evidently should be one international licence for all surgical specialties - as the profession is the same and the human anatomy is the same everywhere. Such an approach feels like a healthy breeze and puts established conventional systems under the spotlight, being at the same time quite demanding for healthcare leaders dealing with questions of governance, curriculums and exams. It is hoped that the global network of working groups created within the Surgicon organisation might be useful in addressing and finding answers to these questions. Like a snowball which just has started to roll we must endeavour to keep it rolling and growing.

At Surgicon 2011 several questions were pinpointed in the session debates, regarding the practical training of future surgeons. One comparison was made with military pilots, who are regarded to be at their peak performance at the age of 20-25 years while surgeons are kind of “driving a truck for 10 years before being allowed to fly a plane”. Simulators have a key role in pilot training, as well as the regular checks of performance, skills and health.

Another parallel development is the increasing activity in scientific research about surgical training (Table 1). Before 1990 the number of published articles mentioning this subject did not exceed 1,000/year, while in 2011 the figure was 5,311 articles. This could be interpreted as one of the signs of the need to increase the efficiency in forming new surgeons. Globally the paradigm shift is already ongoing with retirements of experienced surgeons, working hours regulated for young surgeons and surgical simulators increasingly developed and available.

Table 1. The number of search results by year for the words “Surgical Training”, showing the exponential increase since 1990. PubMed 20132

1990 2000 2004 2007 2010

Number of articles exceeding: 1000 2000 3000 4000 5000

In May 2012 the organisational platform for Surgicon was stabilized by the creation of the not-for-profit Surgicon Foundation, with the goal to continue the initiated work and to organize the future congresses. A fundraising process has started to enhance ongoing efforts, and later to be able to support scientific research and development in this area.

Margareta Berg MD, PhD, Orthopaedic surgeon Congress organizer References: 1 MEdSim Magazine Issue 1:2012, p29. 2 PubMed search for “Surgical training” M EDSI M M A G A Z I N E 1 . 2 0 1 3

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World News & Analysis New University of Florida Simulator Teaches Catheter Placement – The University of Florida, in collaboration with Ascension Technology Corporation, developed a new simulator to teach placement of central venous catheter lines. The 3-D mixed simulator helping medical students, residents, faculty and staff gain valuable experience in placing a central venous catheter without risk to patients.

The Institute for Healthcare Improvement, an independent not-forprofit that promotes best practices in medicine, recommends inserting these catheters in the vein beneath the clavicle, a technique known as subclavian central venous access, to lower the risk of infection. Training and supervision are needed to insert a needle safely and accurately with this approach.

Computer Simulator to Manage Hospital Emergencies – Researchers at the Universitat Autonoma de Barcelona developed an advanced computer simulator to manage hospital emergencies. The model was created with data from the Hospital of Sabadell’s Emergency Services, and the researchers say it can be adapted to any hospital center.

The system offers optimal solutions for human resources, costs, time, space, equipment available and distribution of patients for different emergency scenarios. The system analyzes the reaction of the emergency unit when faced with different scenarios and optimizes the resources available. eoSurgical Launches Portable eoSim Laparoscopic Simulator – eoSurgical launched its new, take-home laparoscopic simulator called eoSim. The simulator comes with the tools needed to learn, develop and master laparoscopic skills – it includes instruments, practice models, HD scope, sutures and training videos and it comes in a selfcontained and portable package.

Robotic Surgery Training Robot-Assisted Surgical Training for Radical Cystectomy Released – Simulated Surgical Systems, LLC has announced the release of its newest HoST module, Cystectomy. RoSS-users now have the ability to practice radical 38

M EDSI M M A G A Z I N E 1 . 2 0 1 3

cystectomy procedure, as performed by expert robotic surgeons. HoST has been shown in scientific studies to improve important surgical skills. RoSS—Robotic Surgery Simulator—is the only portable, stand-alone surgical simulator in its class that allows surgeons to practice real surgeries outside the operating room (OR) on patented, procedure-specific Hands-on Surgical Training (HoST) technology.

The HoST Cystectomy module will be demonstrated at the IMHS conference in Orlando, FL from January 26-30, 2013, at APGO conference in Phoenix, AZ from Feb 26 – March 2nd, 2013 and at AUA annual meeting in San Diego, CA from May 4-8, 2013.

Gaming Technology UT Study Shows Gaming Skills Mimic Robotic Surgery Skills – According to a new study from researchers at the University of Texas Medical Branch at Galveston, the superior hand-eye coordination and hand skills gained from hours of repetitive joystick maneuvers mimic the abilities needed to perform today's most technologically-advanced robotic surgeries.

The study placed high-school and college students head-to-head with resident physicians in robotic surgery simulations. The results, presented at the American Gynecologic Laparoscopists' 41st Annual Global Congress on Minimally Invasive Gynecology in Las Vegas, showed that the high-school students who played video games an average of two hours per day and college students who played four hours per day matched, and in some cases exceeded, the skills of the residents on parameters that included how much tension the subjects put on their instruments, how precise their hand-eye coordination was and how steady their grasping skills were when performing surgical tasks such as suturing, passing a needle or lifting surgical instruments with the robotic arms.

Courseware and Texts HeartWorks eLearn Online Transesophageal Echocardiography Course – HeartWorks eLearn - a

comprehensive online transesophageal echocardiography (TEE) course - is a complete introduction to Transesophageal Echocardiography’ that is being jointly sponsored by the American Society of Echocardiography and Inventive Medical. The course is suitable for individuals such as anesthesiologists, cardiologists, intensivists, emergency room physicians, sonographers and teaching institutions who want to learn, teach and/or consolidate their understanding of TEE. For more information or to enroll, go to http://learn.heartworks.me.uk/ New Manson Publishing Paediatric Medical Books – The new books, Pediatric Neurology, Pediatric Clinical Opthalmology and Pediatric Rheumatology, follow a problem-based approach recognizing how diseases present themselves. The books are in full color and they employ practical, symptom and sign-based strategies for virtually all conditions encountered by a practitioner. These new paediatric titles in the Colour Handbook series provide a problem-based approach to neurological disorders, ocular and rheumatic disease in infants and children.

Academic Simulation Centers Lake Superior State University Gets $400,000 to Purchase Mannequins – Lake Superior State University (LSSU) got a $400,000 donation from the R.W. Considine Foundation to be used to purchase high-fidelity mannequins as part of the school’s proposed new nursing simulation center in Sault Sainte Marie, Michigan. The center is a joint project between the school, the city, and War Memorial Hospital that will train LSSU students, hospital staff, first responders and other healthcare professionals in the region.

Gannon University Gets Patient Simulation Center Equipment Grant – A $50,000 grant from the Lake Erie College of Osteopathic Medicine provided sophisticated new equipment for Gannon University's Patient Simulation Center in Erie, Pennsylvania. The grant was used to purchase a simulated human torso and an ultrasound system for the center, where students practice medical procedures on interactive

robots. Students will be able to practice minor surgical skills on the lifelike torso.

The ultrasound system provides quality images as students practice placing tiny tubes in veins.

Virginia Western Community College Gets Sim Lab Gift – Virginia Western Community College in Roanoke has received a $150,000 gift from Friendship Retirement to name the RN Nursing Lab and RN Simulation Lab in the Center for Science and Health Professions. The $26 million center is under construction and scheduled to open for student access in the Fall Semester 2013. It will house classroom and lab space for the School of Science, Math and Health Professions.

Tusculum College Gets Grant for New Simulation Lab – Tusculum College in Tennessee installed a simulation laboratory for its Bachelor of Science in Nursing program using a $263,996 grant from BlueCross BlueShield of Tennessee Health Foundation. The lab will also be used by emergency medical technician students, other health care students and

community healthcare partners to simulate real-life health response situations other academic programs.

University of Oklahoma Gets $6M Grant for Sim Center – The University of Oklahoma (OU) School of Community Medicine received a $6 million grant to establish a medical simulation center from the A.R. and Marylouise Tandy Foundation. The simulation center will include a viewing room; nurses’ station; patient rooms and equipment such as simulators, computers, software, cameras, monitors and trainers.

The simulation center will be available to all OU nursing and School of Community Medicine students, physician assistants, resident physicians and faculty. The center also will offer community hours during which it can be utilized by medical physicians practicing in the Tulsa community who need additional training and certifications.

The university anticipates the simulation center will be used by 1,000 health care professionals annually.

Western Michigan Medical School’s $68M Renovation – Western Michigan University School of Medicine broke ground on a $68-million renovation project that includes the renovation of six of eight levels of its 320,000-squarefoot building and construction of a 30,000-square-foot building addition.

The lower-level building will contain a state-of-the-art simulation center that will replicate hospital and clinical operating rooms. It will have eight simulation rooms, five training rooms, 12 patient examining rooms and eight classrooms. The W.E. Upjohn Campus for the medical school is slated to be complete in May 2014.

Arkansas College Getting New Simulation Lab – A $250,000 gift from Washington Regional Medical Center in Arkansas is being used to expand the Northwest Arkansas Community College’s nursing program and other health related disciplines. The money will help with the purchase of the newest technology available to create a nursing simulation lab that mimics a hospital

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CROWD CROWD Wondering who you’ll meet at our conference? Our crowd consists of a mix of medical professionals, patients, digital Wondering who you’ll meet at our conference? Our crowd consists of a mix of medical professionals, patients, digital designers, developers and publishers, public health professionals, researchers, academics, investment funds, banks, designers, developers and publishers, public health professionals, researchers, academics, investment funds, banks, students and many more interested parties. You name it, we’ve got them! students and many more interested parties. You name it, we’ve got them!

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As a non-profit dedicated to healthcare andGames wellbeing, we are always looking forfornew to offer non-profit foundation to healthcare wellbeing, we jogging are always looking new to offer suggestions, proposededicated new activities or just chat and about your favorite app. Check us for out on ourfriends online hanging suggestions, new activities or get justmore chat involved about your jogging app.

Check us out on our online hanging places andpropose drop a line if you want to withfavorite Games for Health Europe. places and drop a line if you want to get more involved with Games for Health Europe. >> Go to www.GamesforHealthEurope.org for more details. >> Go to www.GamesforHealthEurope.org for more details.

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World News & Analysis room. The center is expected to be complete later this fall, and classes should start this Spring.

New Simulation Labs at University of Pennsylvania – Nursing students at the University of Pennsylvania in Philadelphia this semester are the first to take advantage of the newly renovated simulations labs that feature an operating table, anesthesia and oxygen machines and mannequins with vital signs. The expanded simulation lab also has an intensive care room and a homecare suite.

Anderson University Gets MegaCode Kelly Simulator – MegaCode Kelly™, a body simulation device made

by Laerdal, joined the Anderson University School of Nursing in Indiana, in collaboration with Community Hospital Anderson and Saint John’s Health System. The device will help nursing students practice on a realistic subject and grows the school’s expanding nursing program. MegaCode Kelly is a mannequin for training in a wide range of advanced life-saving skills. Students can practice with chest tubes, tracheotomies and a variety of cardiac rhythms in a simulated care setting within the AU nursing laboratory, which also has SimMan®, SimJunior® and SimBaby™.

Hospital Simulation Centers Minneapolis Hospital Opens Simulation and Education Center – Hennepin County Medical Center (HCMC) in Minneapolis, Minnesota opened its new Interdisciplinary Simulation and Education Center to support its education programs that train more than 20,000 caregivers each year. The 10,000-square-foot Simulation Center provides a safe environment for health care professionals to practice real-life medical situations and procedures in rooms with the equipment found in operating rooms, emergency departments or other treatment areas – including the electronic health record.

Mount Carmel Health System Expands Patient-Simulation Facility – Mount Carmel Health System recently dedicated its expanded $1.2 million Mount Carmel Clinical Skills and Simulation Center (CSSC). The facility allows all members of healthcare delivery teams to work and train together to enhance and develop new skills and processes, identify problems and implement patient-focused team treatment.

The CSSC brings together Mount Carmel College of Nursing, Mount Carmel Medical Education and Mount Carmel

Medical Staff in a system-wide training center that features high-fidelity human patient simulators and clinical education resources.

Health Sciences North Opens New Simulation Lab – Health Sciences North (HSN) in Ontario, Canada officially opened its new state-of-the-art Simulation Laboratory. The hospital says the Simulation Lab uses the latest in simulation technology and equipment to provide skills training to medical learners and health-care professionals of all disciplines.

HSN’s Simulation Lab has adult, pediatric and newborn mannequins used for the perfecting of advanced life-savings skills and simulators that allow learners to practice such procedures as delivering babies, suturing, lumbar punctures, insertion of central lines, surgical techniques and airway management involving ventilation and intubation.

International Simulation Dutch SSIH Conference – The DSSH Lustrum Congress of the DSSH, the Dutch Society for Simulation in Healthcare, will take place on the 20th March 2013 at the Academic Medical Center in

2012 I/ITSEC Report MEdSim editorial staff members Chuck Weirauch and Marty Kauchak attended the 2012 Interservice/Industry Training, Simulation and Education Conference (I/ITSEC) and report on developments from the conference floor of interest to the medical simulation community.

As in recent years, the latest advances in medical simulation, training and education were a prominent feature of the 2012 I/ITSEC held Dec. 3-6 in Orlando. Special Sessions entitled "Innovation in Healthcare Training & Education and "Supporting the Veteran of Tomorrow Through Medical M&S," along with the Healthcare Pavilion sponsored by the Society for Simulation in Healthcare (SSIH), were some of the highlights of the three-day event.

In addition, a number of related papers, including "Using Simulators to Measure Communication Latency Effects in Robotic Telesurgery" were presented during conference.

Healthcare Pavilion exhibitors included BigC, Dino-Lite Scopes, Gaumard Scientific, Innovation in Learning Space, Laerdal Medical, Lifeline Mobile, MammaCare, Smooth On, Simulab and Techline Technologies, all of whom were demonstrating their latest products.

Also on the show floor, Orlando-based Engineering & Com40

MEDSIM MA G A Z INE 1 . 2 0 1 3

puter Solutions discussed a number of cutting edge initiatives to further advance the state-of-the-art in virtual learning for the healthcare community. Howard Mall, the company’s vice president for engineering, told Group Editor Marty Kauchak that several of corporate customers are using ECS’s vMedic, a serious game platform developed to teach and reinforce the concepts of tactical combat casualty care, for experimentation to expand the envelope of the possible in learning. “One of the many things we’re doing is taking the Kinect sensor camera in Xbox 360, and incorporating it as an input device in medical training. This allows you to do full body gestures and movements in a volume of space to control the experience in simulation,” he pointed out.

ECS is also taking parts of its vMedic platform and using them in other programs. In one instance the company is using the assessment component and as a plug-in for VBS2. “So now we can do the assessment in addition to using our physiological abstraction model in VBS2. This is all for the purpose of obtaining the exact, same experience we have in our other products in VBS2 – now you have a combat medic component within VBS2 that is medically accurate and doctrinally sound, approved by the Army Medical Department School,” Hall added.

Amsterdam, the Netherlands. This year the Congress is themed "Medical Simulation, What's Next?" Latest developments in Simulation and Serious Gaming for training health care professionals are featured. During the Congress, a separate 'pop-up' innovation center will be staged to support promising startups and non-commercial initiatives. www.dssh.nl/en/dssh-congress-2013 Pakistan College of Physicians and Surgeons' Simulation Donation – The College of Physicians and Surgeons of Pakistan (CPSP) was given a Rs 5 million (US$ 52,000) donation by Getz Pharma Limited to purchase simulators for the college’s surgical skills training and education laboratory.

The college says the simulation devices will be used to teach basic skills and surgical techniques through repetitive proctored challenges and will enable detection and analysis of surgical errors and near miss incidents without risk to patients. The college also says near miss detection capabilities anticipate potential errors before they occur and prevent resulting complications and that the risk free training of surgeons on simulators before they work on real patients will substantially improve skills and reduce complications – reducing the litigation rate as well.

Chinese University of Hong Kong’s Computer-Assisted Tumor Surgery – The Department of Orthopedics and Traumatology at The Chinese University of Hong Kong (CUHK) developed Computer Assisted Tumor Surgery (CATS) to overcome the disadvantages of the conventional approach of bone tumor surgery. Orthopedic surgeons at CUHK have been developing and refining the techniques of CATS since 2006 – and have just received research funding from the Hong Kong Government Research Grants Council to further develop CATS and explore other possibilities, such as using patient-specific tumor cutting templates in the management of bone tumor surgery.

CATS is particularly useful in complicated tumor surgery, such as pelvic / sacral tumors removal and pediatric bone cancers – and has successfully been applied to 32 bone cancer patients.

This technology helps increase the chance of total tumor resection and the preservation of normal bone tissues.

Nursing Education & Training University of Tennessee Expanding Nursing Simulation – The University of Tennessee in Knoxville is renovating a building to improve its simulated instruction and research for its College of Nursing. The Health and Information Technology Simulation Laboratory is a joint endeavor of the colleges of nursing and engineering and will feature simulated learning experiences and opportunities to explore research scenarios. Construction is scheduled to be completed in January..

WSU Tri-Cities Gets Funds for New Nursing Teaching Facility – Washington State University Tri-Cities has received $2.9 million in contributions from regional healthcare donors to use in the renovation of a commercial building in Richland, Washington, into a state-ofthe-art teaching facility for its College of Nursing program. Group Health Cooperative, Kadlec Health System, Lourdes Health Network, and Lampson International have provided the donations and in-kind support, including Kadlec’s offer of a $1-per-year lease for 20 years, with an additional 10-year extension.

Methodist University Dedicates Nursing Building – Methodist University has dedicated its new $3.2 million Professional Nursing Studies Building that opened for classes last Fall. Almost half of the 10,000-squarefoot facility houses the MU General Simulation Hospital, complete with an admitting/ discharge area, pharmacy, triage, two Nurses Stations, four critical care rooms, a pediatric ward and a triage suite.

York College Adds Nursing Simulation Labs – York College’s Nursing school renovated and added a two-story addition to its existing building to better accommodate its Nursing Program and new Department of Hospitality, Recreation, and Sport Management.

The renovations provided space for new simulation labs for nursing, along with offices and classrooms for the graduate programs in nursing – and federal grants and outside donations provided funds to

purchase new simulation equipment.

The nursing program now has 12 electronic manikins, including four Laerdal SimMan3Gs; one Gaumard Noelle childbirth simulator; one Gaumard Baby Hal, a full-sized newborn simulator and five adult and one child VitalSims, full-body, anatomically correct manikins.

University of Connecticut Opens New Nursing Facility – The University of Connecticut’s School of Nursing dedicated its new 15,800 square-foot Widmer Wing – a learning environment tailored to the special needs of nursing education and practice. The facility includes exam rooms, clinical simulation labs and a case-study hall that can seat up to 175 people. It is also equipped with high-tech broadcast capabilities, featuring ceiling-mounted pan tilt zoom cameras in eight rooms, enabling students to observe and critique their peers.

Military Medical Simulation Mechdyne Completes First VR WAVE Phase at National SimCenter – Mechdyne Corporation completed the “Phase One” installation of a Wide Area Virtual Environment (WAVE) virtual reality facility at the National Capital Area Medical Simulation Center (SimCenter) in Silver Spring, Maryland.

SimCenter is part of Uniformed Services University of the Health Sciences .

The WAVE facility will be used to educate health care professionals – including uniformed officers and other personnel in the Army, Navy, Air Force and Public Health Service – to deal with wartime casualties, disasters, and other public health emergencies. The virtual reality environment performs a key role in training active duty personnel who are supporting operations in Iraq, Afghanistan, and elsewhere.

CAE Healthcare’s LearningSpace for Air Force Medical Sim Centers – The United States Air Force chose CAE Healthcare’s LearningSpace as its center management solution in 25 medical simulation centers worldwide. Prime contractor Telos Corporation will provide program management services and information M EDSI M M A G A Z I N E 1 . 2 0 1 3

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World News & Analysis assurance and accreditation required for connection to the Air Force network under the NETCENTS task order.

The U.S. Air Force will install LearningSpace in Tier 1 and Tier 2 medical simulation centers in the United States, the United Kingdom, South Korea and Japan. LearningSpace is a Web-based learning management system that captures simulations and patient data on video for learner debrief and assessment. Tier 1 medical simulation centers are the largest in the Air Force Medical Support Agency and are responsible for curriculum development, mentoring and training instructors.

CAE Healthcare Caesars for NATO, US Department of Homeland Security – CAE Healthcare has announced the sale of Caesar trauma patient simulators to the NATO Supreme Headquarters Allied Powers Europe (SHAPE) in Casteau, Belgium for use in training Special Operations Forces on a multinational level. The Center for Domestic Preparedness (CDP), located in Anniston, Alabama, purchased five Caesar trauma simulators for disaster response exercises The CDP is the United States Department

of Homeland Security 's only federally chartered Weapons of Mass Destruction training center.

Accreditation

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CMU College of Medicine Achieves Next Step in Accreditation – Central Michigan University received notification from the Liaison Committee on Medical Education (LCME) that it voted to continue the preliminary accreditation status of the CMU College of Medicine’s educational program leading to a medical degree.

This accreditation report from LCME addressed the following standards: bylaws, medical student interaction with other health professionals, residents, physicians and trainees, research opportunities, financial aid and debt counseling, learning environment and professionalism, student mistreatment, sufficient faculty, and dean and faculty determination of academic policies.

The survey visit for provisional accreditation of the College of Medicine’s educational program will take place during the 2014-15 academic year. medsim

Cardionics www.cardionics.com

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Dutch Society for Simulation in Healthcare www.dssh.nl/en 31 Games for Health Europe www.gamesforhealtheurope.org

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International Pediatric Simulation Society www.ipssw2013.com 25 ITEC www.itec.co.uk

IBC

MEdSim Magazine www.halldale.com/medsim

26 & 35

Mimic Technologies www.mimicsimulation.com

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IFC

Simply-Sim www.simply-sim.com

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Simulab Corporation www.simulab.com

Calendar

www.simulatedsurgicals.com

9-13 February 2013 American Academy of Emergency Medicine 19th Annual Scientific Assembly Las Vegas, USA

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Simulated Surgical Systems 21

SMi Group

www.aaem.org

www.battlefield-healthcare.com

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Smooth-On www.smooth-on.com

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SurgiCON

20-23 February 2013 Medicine Meets Virtual Reality San Diego, USA 11-14 March 2013 Congress on Healthcare Leadership Chicago, USA 14-16 March 2013 6th Annual Meeting of the Consortium of ACS-Accredited Education Institutes Chicago, USA 23-25 April 2013 5th International Simulation Symposia & Workshops – International Pediatric Simulation Society New York, USA

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M EDSI M M A G A Z I N E 1 . 2 0 1 3

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Sales Representative, USA (East) & Canada: Justin Grooms [t] 407 322 5605 [e] justin@halldale.com

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Image: CAE

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The International Forum for the Military Training, Education and Simulation Sectors > Peer-reviewed Conference, including ‘Medical Training Challenges’ theme: from live to virtual and constructive, this theme will explore the advancements in technology that are leading to a healthcare training revolution

National Training & Simulation Association, USA

> Over 140 Exhibiting Companies: review, benchmark and engage with industry and academia showcasing solutions and ideas at the forefront of military education, training, modelling and simulation

> Networking Opportunities: unique and cost effective way to meet with senior military and policy customers, industry partners, and those at the forefront of academic research

Find out more and register to attend at:

WWW.ITEC.CO.UK/MED

National Training & Simulation Associatio

Organised by:

National Training & Simulation Association, USA

Valerie Melton

has only one standard. Perfection.

Valerie Melton Manufacturing Group Leader

Valerie is what you’d call a perfectionist. She likes things to work right. Every time. All the time. If they don’t, it’s personal. That’s because she knows what we do here is meant to help people save lives. Nothing is more precious than that.

Whether it’s learning application software, a patient simulator or anything in between, the more clinically perfect we make it, the better training and outcomes you will have. And that’s what she pushes for. No defects. No glitches. No bumps in the road. Valerie will do whatever it takes to make it happen. She runs a tight ship. And as far as we’re concerned, that’s perfect.

The Way Healthcare Learns.

Visit us online and see Valerie at work.

iamcaehealthcare.com