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Volume 3
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Issue 1.2014
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SIMULATION CURRICULUM
Perfect Practice Makes Perfect
Simulation
The Next Zone of Reality for Health Care and Simulation
SIMULATION
The Time for SuperHuman Healthcare
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ISSUE 1.2014
Editorial comment
Editor's Comment Looking over the medical headlines over the past couple of weeks it has been difficult to decide the focus for this editorial. Since October the US has been bombarded with the debacle of “Obama Care” (the Affordable Care Act) which seems to become more unaffordable daily; to the childish antics and name calling of the US Congress. Unfortunately, this has distracted attention from other legislation that can be equally devastating for doctors and patients alike. A recent New York Times article described a new medical coding system that must be implemented by fall 2014 called ICD-10. The Center for Medicare and Medicaid Services (CMS) has, for decades, established billing codes for documentation and reimbursement purposes. These codes are created by the World Health Organization (WHO) for the purposes of standardizing diagnoses in order to track diseases throughout the world – wallowing for comparative study of disease around the world. Some governments (the US, France, Germany, Canada, and others) have adopted these codes as a way to standardize billing for medical procedures. These codes fall short of a specific description of the patient’s symptoms and treatment and have led to difficulties in accurately charging for medical services and procedures. There is now, however, a new iteration of the coding system known as ICD10 that will be mandated by the US government, effective this fall, that has entered into the “theatre of the absurd”. There are now codes for injuries that occur while skiing on water skis that are on fire as well as codes for orca bites. As you may imagine, these codes will certainly streamline a doctor’s ability to treat his/her patients with these very common ailments. Why does the US government and its agencies think that their administrators are well qualified to develop codes for medical diagnoses? How is it that bizarre codes for humorous and extremely unlikely scenarios are being included and programmed into the system? If you ask CMS administrators, they will tell you that these new codes were adopted by the US government after careful consultation with coding experts, CMS administrators and physician advisers. Do you believe physicians were involved in signing off on codes for “balloon accidents,” “spacecraft crash injuries,” and “orca bites?” Well maybe “orca bites” since that seems to be one of the least absurd of the new codes. The issue at hand is the fact that government is once again working to regulate situations and concepts that they do not understand. Moreover, they mandate changes without adequate input from experts in the field in which they plan to regulate (in this case, physicians). What are the ramifications of ICD-10 and how might it affect health care delivery? ICD-10 will increase the number of available codes from 17K to more than 155K. Certainly, if the Healthcare.gov website is any indication, the coding process will likely bring efficiency and productivity to a slow crawl as the new codes are phased in. The technology side of implementation of the new coding system is likely to be plagued with errors and inefficiencies.
Before you think that these absurdities are relegated to the US system lets examine the report from the British Safety Council which acknowledged the importance of the role played by the Health and Safety Executive (HSE) as the national, independent regulator and that its functions in preventing death, injury and ill health to those at work were still required and that its status as a non-Departmental Public Body should be retained. However, government funding has fallen significantly over the last 10 years and that is likely to continue. HSE must embrace innovation and efficiency to make the most of the money it receives and the government must be realistic about what HSE can realistically do with its finite resources. To put a more positive spin on headlines there are some wonderful developments that will enhance patient care and safety. Med City News described a new surgical adhesive that is strong enough, and elastic enough, to seal a beating heart and a hospital redesign to more efficiently see ER patients. Many infants born with heart defects have to undergo repeated surgeries as they grow. Replacing the sutures and staples used in surgery today with fast-acting, biodegradable glues could help make these cardiac procedures faster and safer. Researchers at the Brigham and Women’s Hospital in Boston have developed a surgical glue with promising properties: it doesn’t dissolve in blood, and it’s rubbery enough to hold a seal inside a beating heart. The cardiac adhesive has been tested in mice and pigs and is being developed as a commercial product by French startup Gecko Biomedical. The cardiac adhesive is described in a paper published today in the journal Science Translational Medicine. St. Anthony's Medical Center in south St. Louis County started the new year with a new emergency department designed to dramatically improve wait times. The $1 million renovation project means patients will be met with a welcome desk near the entrance and a more open waiting room. Time in the waiting room should be reduced because six triage rooms were added to more quickly assess patients and move them into one of the 33 treatment rooms depending on the seriousness of their condition. The point being made is that healthcare is a very complicated process made up of many systems that seem to function independently of one another. While great strides are being made in technological areas there is still much that needs to be done to change the education and training of doctors. The articles in this issue describe some of these process and we will continue to highlight these advancements.
Judith Riess Editor in Chief, MEdSim Magazine
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Editorial Editor in Chief Judith Riess, Ph.D. e. judith@halldale.com Group Editor Marty Kauchak e. marty@halldale.com US & Overseas Affairs Chuck Weirauch e. chuck@halldale.com US News Editor Lori Ponoroff e. lori@halldale.com RoW News Editor Fiona Greenyer e. fiona@halldale.com Advertising Director of Sales Jeremy Humphreys & Marketing t. +44 (0)1252 532009 e. jeremy@halldale.com Sales Representative Justin Grooms USA & Canada t. 407 322 5605 e. justin@halldale.com Sales Representative Chris Richman Europe, Middle East t. +44 (0)1252 532007 & Africa e. chrisrichman@halldale.com Sales & Marketing Karen Kettle Co-ordinator t. +44 (0)1252 532002 e. karen@halldale.com Marketing Manager Ian Macholl t. +44 (0)1252 532008 e. ian@halldale.com
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Circulation t. +44 (0)1252 532010 e. stephen@halldale.com
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Editor's Comment. Healthcare is a very complicated process made up of many systems that seem to function independently of one another. While great strides are being made in technological areas there is still much that needs to be done to change the education and training of doctors. Perfect Practice Makes Perfect: Designing a Simulation Curriculum for Off-Pump Coronary Artery Bypass. Fuad Moussa, MD, MSc, MMEd, FRCSC, FACS, FCCP provides insights on the design of a curriculum to teach this skill set to aspiring surgeons.
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The Next Zone of Reality for Health Care and Simulation. Allen J. Giannakopoulos, PhD examines the opportunity for simulation to improve our business.
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The Time for Superhuman Healthcare. We are at the start of the Century of Simulation and Human Intelligence declares Richard Boyd.
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Increasing Psychomotor Capacity of Healthcare Professionals for Breakthrough Performance. Gary Hamill, EdD, provides insights on recent research to demonstrate the potential of physiologic self-regulation and imagery training strategies to increase psychomotor capacity and improve performance.
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The Gap in Medical Education. Insights on medical education are provided by Rahul Rekhi, a deferred first-year student.
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AAOS VR and Surgical Simulation Summit II. Highlights from AAOS VR and Surgical Simulation Summit II.
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Seen & Heard. Updates from the medical community. Compiled and edited by the Halldale editorial staff.
On the cover: Off-pump coronary artery bypass is a highly technical procedure. Image credit: Doug Nicholson/ Sunnybrook Health Sciences Centre.
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All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise – especially translating into other languages – without prior written permission of the publisher. All rights also reserved for restitution in lectures, broadcasts, televisions, magnetic tape and methods of similar means. Each copy produced by a commercial enterprise serves a commercial purpose and is thus subject to remuneration. MEdSim Magazine, printed January 2014, is published 5 times per annum by Halldale Media, Inc., 115 Timberlachen Circle, Ste 2009, Lake Mary, FL 32746, USA at a subscription rate of $55 per year.
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SIMULATION CURRICULUM
Perfect Practice Makes Perfect: Designing a Simulation Curriculum for Off-Pump Coronary Artery Bypass Fuad Moussa, MD, MSc, MMEd, FRCSC, FACS, FCCP discusses how he designed a curriculum to teach off-pump coronary bypass surgery to new surgeons.
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atients who need coronary artery bypass are getting older and more frail, and the procedures they require are complex. Off-pump coronary artery bypass – performed while the heart is beating – is a viable alternative but it is extremely technically demanding. The author discusses how he designed a curriculum to teach this highly technical skill to new surgeons using simulation.
Background When a narrowing or blockage in the arteries that supply blood to the heart causes a heart attack, a cardiac surgeon builds a graft to go around the blockage and open the blood flow. Typically, patients are connected to a heart-lung machine, which provides those functions during the procedure. The heart is stopped, and the surgeon works to build the grafts. During off-pump coronary bypass – or beating-heart surgery – the surgeon builds these grafts while the heart continues to beat on its own. Off-pump coronary bypass has traditionally been taught using the apprenticeship model – but there are challenges. This procedure is performed by just 13 per cent of cardiac surgeons in Canada.1 At the University of Toronto, only two 06
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surgeons perform this procedure with any relative consistency. The University of Toronto Cardiac Residency Program is a six-year directentry training program that provides wide exposure to adult and congenital abnormalities. Residents are trained using the apprenticeship model complemented by wet lab sessions and weekly didactic sessions. For off pump coronary artery bypass, there have been twice yearly wet lab sessions using anesthetized pigs, but without specific assessment tools. A survey of cardiothoracic residencies across the United States in 2000 revealed that only 22 per cent of residents had performed more than 20 off-pump coronary bypass procedures during their training, and only 4 per cent of these had performed a complete operation including the most
Dr. Fuad Moussa is one of just two surgeons at the University of Toronto who perform off-pump coronary artery bypass with relative frequency. All Images: Doug Nicholson/ Sunnybrook Health Sciences Centre.
difficult bypass grafts of the circumflex coronary artery.2 This may not be enough exposure to produce technical proficiency. In addition to these concerns, other stresses on the apprenticeship model such as reduced work hours and ethical concerns about practicing on patients have created a need to develop a new way of teaching these highly technical skills. What has been missing is a structured program that integrates simulation, didactic teaching, progressive skills acquisition and specific assessment tools. As a cardiac surgeon, surgeonteacher, and fellow of the Wilson Centre for Research in Education with an interest in simulation, the author set out to develop a progressive simulation-based training program for off-pump coronary artery bypass. The program is grounded in educational theory, and provides a safe opportunity for deliberate practice of the technical skills required to perform the procedure.
Xperience Team Trainer™
Dr. Fuad Moussa set out to find a better way to teach off-pump coronary artery bypass to cardiac surgery residents.
Methods To learn all the steps of this surgery at once is overwhelming for residents. We set out to break the procedure down into reproducible tasks.
Working in collaboration with engineers from Colombia, South America, and an educational scientist at the Wilson Centre for Research in Education, the author mapped out the operation. The team observed and recorded 10 off-pump coronary bypass surgeries, with “think aloud� audio recordings of the critical issues that were perceived during the procedures, in order to capture and identify the points where surgical flow deviations are likely to occur during a standard procedure. Using the diagrammatic language of the Motor and Cognitive Modeling Diagram,3 baseline performance for the first five procedures was mapped into a task-flow diagram, and refined during the remaining five procedures. Analyzing the diagram allowed us to break the procedure down into small reproducible components that lend themselves well to the creation of simulation modules. Using the Challenge Point Framework4 we created five simulation stations and arranged them in increasing order of
Introducing the first robotic surgery simulator designed to help the first assistant and console side surgeon develop better teamwork. See the debut of the Xperience Team Trainer at IMSH 2014 (booth # 330) or visit:
www.MimicSimulation.com/XTT MEDSIM MAGAZINE 1.2014
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SIMULATION CURRICULUM graft, lie of anastomosis: parallel to LAD, symmetry, efficiency of motion.
Station 4: Anastomosis on the beating heart The bench top heart simulator has a pneumatic mechanism that is able to duplicate the beating properties and rhythms of the human heart. • Objective: perform a complete anastomosis on the beating heart between the left internal mammary artery (LIMA) and the left anterior descending artery (LAD) • Assessment: asks for help, application of octopus stablilizer, arteriotomy, bevels graft, lie of anastomosis parallel to LAD, symmetry, efficiency of motion.
Station 5: Anastomosis on the enucleated beating heart A silicone replica of the heart created by engineers at Pontificia Bolivariana University, Colombia. The simulator contains a pneumatic mechanism capable of duplicating the rhythm of the human heart. The trainee can practice end to side anastomosis, or suturing the bypass.
difficulty. Experience gained at each simulation station is built upon in the next. Each station has an objective and assessment criteria. We worked with engineering students at the Universitad Pontificia Bolivariana in Colombia, South America, to build the simulation stations and beating heart simulator.
Station 1: Knot Tying Knot tying represents the most basic task during the off-pump coronary artery bypass procedure, and so it was the first station. A SmartSIM bench-top simulator was developed by the engineering students that measure air pressure in rubber tubing while the trainees ties surgical knots. • Objective: complete three throws of a one-handed slip knot. • Assessment: appropriate tension, knot security, efficiency of motion.
Station 2: Vascular Anastomosis (Suturing the bypass) Creation of a vascular anastomosis is common to all parts of this operation. This is when the surgeon sutures the blood vessels together in an end-to-side fashion. A bench top simulator was developed for simulating this suturing technique. Rubber tubing is used to replicate conduits and targets. • Objective: perform the suturing steps for a standard vascular anastomosis. • Assessment: symmetry, efficiency of motion.
Station 3: Anastomosis on the stopped heart The engineering students built a silicone replica of the heart. It allows a simulated left internal mammary artery (LIMA) and left anterior descending artery (LAD) end to side anastomosis. This bypass is the most common and most important bypass. • Objective: perform a complete anastomosis on the static heart between the LIMA and the LAD. • Assessment: arteriotomy: in the centre and straight, bevels 08
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The most technically challenging anastomosis is between a conduit and the obtuse marginal branches of the circumflex coronary artery. To do this, the surgeon is required to move the heart out of the chest cavity (enucleate) to access the underside. • Objective: perform enucleation, perform a complete anastomosis on the beating heart between saphenous vein graft and the obtuse marginal artery. • Assessment: proper positioning, enucleation of heart, application of octopus stabilizer, arteriotomy, lie of anastomosis parallel to obtuse marginal artery, symmetry, efficiency of motion.
The Workshop Determining and designing the simulation stations for off-pump coronary artery bypass wasn’t enough: these steps are of value when put into a total education curriculum. And so, we developed the simulation-augmented curriculum into a four-phase workshop that takes place over three days. Phase 1: Didactic session. A powerpoint session with intraoperative video was showed to capture the residents’ attention. Objectives of the workshop set out, and the off-pump procedure and technical skills required explained to the participants. The simulation modules were presented with instructions on proper technique and a video with the surgeon performing the tasks on the simulators.
Phase 2: Pre-test. Participants performed the tasks at each station – in order of increasing complexity – to establish a baseline. Tutors/assessor were briefed on how to conduct global rating. Phase 3: Deliberate practice with immediate feedback. Participants practiced as long as they wanted at each station. They received feedback back on the spot from the course tutors and other participants. Phase 4: Post-test. The participants performed all the tasks again, and postpractice performance was determined.
Evaluation We conducted the workshop with five surgical residents from the University of Toronto. We used a hybrid model to evaluate the program, encompassing traditional outcome-based evaluations as well as process-based evaluations. We also used qualitative methods to further identify areas for improvement. Overall, we found that using this framework was effective and well received by the participants. Participants thought that the latter
simulation stations were more authentic but recognized the earlier stations were equally important. Two participants stated that all of the simulation felt authentic: “All of them were equally essential. Probably the offpump components were most authentic. All of them were realistic.” (Participant 2). “The sutures and instruments were authentic. The conduits were reasonable. The heart model was more realistic.” (Participant 3) The participants agreed that having a tutor standing with them during the simulated procedure was helpful. Three said it would be beneficial to have more tutors present. One participant said the setting (an office space) was not authentic, and suggested being gloved and gowned in an OR with the supervisor present would be more realistic. The trainees appreciated the technical skills being presented in a progressive way: “I think the process of the graduated skills was very good.” (Participant 4). All five said the sequencing of the tasks worked well.
Also of value was the repetition of task in a stress-free environment, the participants agreed. “There was exposure to new things in a non-threatening environment – an easy way to develop new skills and knowledge.” (Participant 5). “It was very different from doing a technique for the first time in the operating room. It was more relaxing in the simulation. It was much safer than doing it on a real patient. For time issues, during the simulation you can take your time during the simulated procedure or skill. It was a much more comfortable than doing it for the first time in the OR.” (Participant 2).
Conclusion and Next Steps We developed and implemented a progressive simulation-based training program for off-pump coronary artery bypass that is rooted in educational theory, and that provides a safe opportunity for deliberate practice of the technical skills required to perform the procedure. The residents who participated,
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SIMULATION CURRICULUM though few, rated the experience highly and demonstrated improvement in efficiency and skill development. Simulation stations for teaching technical skills can’t stand alone: using simulation in conjunction with didactic teaching and organized into a structured workshop, is beneficial for teaching offpump coronary artery bypass. A larger, multi-site study is necessary to achieve statistical power. I have since received a grant through the Sunnybrook Education Research Committee to study this simulation-augmented training program further, with the hope it will be added to the cardiac surgery curriculum at The University of Toronto in the near future. medsim
About the Author Dr. Fuad Moussa, is a cardiac surgeon at Sunnybrook Health Sciences Centre, Director of Undergraduate Surgical Education, and Assistant Professor in the Department of Surgery at the University of Toronto and recently completed a master’s degree in medical education. He is a member of The Wilson Centre for Research in Education with a special project in simulation in cardiac surgery. His special interest is in "offpump" (beating heart) coronary artery bypass surgery and minimally invasive beating heart coronary bypass surgery and he performed Toronto's first double bypass surgery through
a small (5 cm) incision under the left breast. Acknowledgements Special acknowledgements are given to the guidance and mentorship of Drs. Adam Dubrowski and Rola Ajjawi. Dr. Sayra Crisancho and The Faculty of Engineering at The Pontificia University in Buccaramanga, Colombia were instrumental in facilitating the design of the simulators and the simulationaugmented curriculum. David Rojas Gualdron provided technical support during the management of the workshop. My clinical partners have shown support and patience for this endeavor.
ReferenceS 1 Desai
ND, Pelletier MP, Mallidi HR, Christakis GT, Cohen GN, Fremes, SE, Goldman (2004). Why is off-pump coronary surgery uncommon in Canada? Results of a
population-based survey of Canadian heart surgeons. Circulation, 14;110(11 Suppl 1):II7-12. 2 Ricci
M, Karamanoukian HL, D’ancona G, DeLaRosa J, Karamanoukian RL, Choi S, Bergsland J, Salerno TA, MD et al (2000). Survey of resident training in beating
heart operations. Ann Thorac Surg, 70:479-482. 3 Cristancho
SM, Hodgson AJ, Pachev G, Nagy A, Panton N, Qayumi K. (2006). Assessing Cognitive & Motor Performance in Minimally Invasive Surgery (MIS) for
Training & Tool Design. Medicine Meets Virtual Reality 14: Accelerating Change in Healthcare: Next Medical Toolkit. IOS Press. 108-113. 4 Guadagnoli
Ma, Lee Td (2004). Challenge Point: A Framework For Conceptualizing The Effect Of Various Practice Conditions In Motor Learning. Journal Of Motor
Learning 36:212-224.
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SIMULATION
The Next Zone of Reality for Health Care and Simulation Allen J. Giannakopoulos, PhD describes how simulation shows the most promise in improving our business as we move into the next zone of reality.
I
n much of the present day model of health care our role as management has us looking to new ideas and processes in order to move us to the next zone of reality for health care. I’m not coining zone of reality to create a new buzzphrase. But rather to impress to everyone in health care that the health care environment that we’ve been accustomed to is rapidly shifting: complex changes that we are now seeing in health care, agreeable or not, are moving forward and are creating a zone of reality that this industry has never experienced. While a few still believe that this will all settle down and we will get back to the ways things were, the vast majority recognize undeniable shifts in the manner that business will be conducted. Simply put, the past is the past, and a new landscape emerges. To this end, two things are certain: Primarily, reimbursements are going to decrease. Every component of the health care user continuum is pushing for costs to come down (including ourselves as patients and purchasers of health insurance) and for quality of care to increase. Several major initiatives by the government already match reimbursement amounts to quality of care and patient satisfaction. Dealing with cuts in the past is going to be dramatically different than how we will deal with it in the future. In the past we could change 12
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vendors to trim the costs for supplies. But how many times can we do that? There are certain elements of the business that we cannot trim further than has already been done. Second – since reimbursements are decreasing, health systems need to address maintaining their revenue stream else face the same fate as many other industries. Since prices cannot go up, then a knee-jerk reaction typically insists that costs go down. Whereas, this strategy does not address the issue of falling revenue, it is not the correct solution. The solution lies in what manufacturing has had to do for decades: increase productivity by improving processes so that more work is performed with the same amount of manpower in a shorter period of time. How do health systems differ as a business from other industries? Aside
Transporting a patient. Image Credit: Baptist Health South Florida.
from the expected ranks of physicians, nurses, and scores of other allied health professional trades, our health systems function nearly as stand-alone cities with food services, security forces, landscaping, trash collection, all the skilled trades including electricians, plumbing, and HVAC crews; and naturally all the corporate departments that represent the areas required to run a business. When we measure all of the support groups for a health system, it’s easier to list the skilled staff that we don’t have versus those that we do have. All of these different trades represent processes that occur between many areas and as any process engineer has experienced, it is there that we have gross inefficiencies and extra costs. When no one looks at how processes are performed over different areas, inefficient elements flourish.
Computer Simulation Simulation, as we have become accustomed to it, concerns training health care givers on mannequins in either a training environment or a controlled environment. What has been the reality in performing this type of simulation activity shows that this is both time intensive and staffing intensive – two characteristics that do not coincide with our new zone of reality. Unless a simulation budget exists that will not be scrutinized and reduced then these activities will also have to adjust according to the new zone of reality. There are more faces to healthcare simulation than the one just described. In the past five years a growing number of firms have presented better tools to provide us with the ability to use
computer simulation of discrete and specific processes. Using these tools shows that the path to improvement does not lie in providing expensive immersive simulation training to everyone; it simply cannot be sustained. So the area of simulation is affected as the rest of the health system is – it must adjust to the new zone of reality. Computer simulation aids from that perspective. Simulation is not new, having been used by industry and the government, such as NASA, for decades.
Emergency department examination room. Image Credit: Baptist Health South Florida.
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SIMULATION
Entire emergency department. Image Credit: Baptist Health South Florida.
It’s only recently that simulation is being embraced by health care as a cost-effective tool to realize true process improvements that allows processes to perform more value-added activities while maintaining staffing numbers and improving efficiency of operations. Our teams have used this to redesign processes in clinical and administrative areas of the health system.
It Takes a Village Coordination of many efforts results in the successful completion of healthcare processes; the same is true for any business. In the grocery industry computer modeling is performed to improve the logistics of the supply chain and inventory arrival, and modeling is used to determine what position within the store specific merchandise should be placed. The reasoning is clear: there are multiple factors affecting the flow of product and consumer through the store. In the past managers would simply move things around in the store and then measure the results to see what would improve, or in some cases, what would be negatively impacted. While effective to a degree, this is both time intensive and staff intensive – both factors that the grocery industry has to deal with in their environment of narrow profits. Using computer modeling shortened the amount of time to see results and allowed instant changes to the floor-plan without having to perform the actual physical moving of store merchandise. Now the model is changed and improved, and then these elements are put into place on the grocery floor. A health system is more than a hospital; it is an entity with multiple hospitals, support service locations, transport services, and corporate campuses. These elements have people and processes that flow between them, with the important factor being that not all of these are direct patient care; most are supportive of patient care. In the new zone of reality looking at how these elements interact is a key in improving the efficiency and thus adjusting to the constraints that many other industries have become accustomed to – doing more with the same amount of time and staff. 14
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Thus the concept of “It Takes a Village” takes root to impress that the change in the industry can occur when the realization surfaces that indeed a village is what it takes to make the improvements – not one area alone can accomplish that. The cost factors here for staffing and for time are tremendous when looking at an entire process. If we can take some non-value-added time out of any process and plan that no other unnecessary steps fill the void created by their removal, then the time remaining theoretically becomes available to perform more value-added functions that will produce chargeable activities – adding revenue without adding staff. Modeling using 3-D rotational tools allows us to look at processes from the perspective of the person that is going through that process, be it the patient, an allied health professional, support personnel – whoever is actually a part of the process. In an Emergency Department simulation we created a model that actually takes us through the day to day functions of all these personnel – and then run them simultaneously to mimic real time. Once that is done, we began modifying various elements of the model to start measuring improvements. Think this was done by just two or three people? You guessed correctly – it took a village of people to provide the information to build the model of the area itself, then to gather the data on all of the requirements to accurately construct a model that included everything that occurs in an ED. These were just some of the components that had to be modeled: • The building and all entries; • The walls, furniture, and non-movable structures; • Electrical, plumbing, and HVAC systems; • Computer and IT equipment; • Nursing supplies cabinets; • Medical supplies cabinets; • Ambulance point of entry; • Patient waiting and exam rooms; • Pharmacy, Laboratory, and Radiology sites; • Daily support services and cleaning / sterilization; • Staffing of all personnel; and • Patient flows and acuity levels.
Each of these was discussed, flowed, and then entered into the simulation. Teams for each of these areas gathered data which was entered into the simulation. The current data sets then flow into the model; the model is actually run several hundred times to simulate several hundred days of actual operation. This allows the staff in the ED Nasco HealthCare Divisionand to review the information that is generated judge if theMedSim model is simulating reality as closely as possible.Jan Once done, the model is certified and 2014 the benchmark data used in the model is saved. MS1401 The modeling changes that occur afterwards are then compared against the initial benchmark. The changes occur one or two at a time as the downstream effects of multiple changes tends to create a “domino” effect and skew end results. The impacts in the computer model are apparent from the beginning of the data entry and show up as gaps, bottlenecks, and metrics that cannot possibly be true, given time constraints. Distance to walk for supplies, elapsed time for labs and radiological events, and staffing issues all percolate to the surface giving the team starting points from where the model can be changed.
Evolutionary Change Minor improvements – even minutes a day in just one process – accumulate and create both upstream and downstream savings in time and efficiency of operation. This succeeds in accomplishing the goal of maintaining staffing while increasing throughput. We have called this evolutionary change, and there is no doubt that this is a strong component of the next zone of reality. Other industries have been down this pathway, and it is now healthcare’s turn. Has health care made large gains in the past, which we could even call revolutionary change? Certainly and almost always within the confines of the clinical setting. Investments are made in most clinical areas to provide the most current technology along with the capital for expansion and remodeling. Health care has as an industry lagged behind most other industries in automation, administrative and financial technology. Operationally health care lags behind in most of the support services in terms of automation and current technology. While most businesses have been using some sort of anti-theft devices, for example, on merchandise and proprietary devices, most health care institutions have yet to embrace the change to that technology, much less entertain the use of RFID (radio frequency identification) technology to safeguard assets at all points of entry. Some areas within the hospitals have embraced that technology for some time now, and nearly all of those areas reside in the clinical setting.
The next zone of reality for healthcare is changing the manner in which we will look at the supporting processes of the administrative, financial, and operational services. Until now each was on their own to provide improvements and maintain their costs. This will no longer suffice. The drive to reduce costs can only be attained through greater efficiencies in the interrelated processes between these areas and the clinical setting. Computer simulation shows the most promise in improving our business as we move into the next zone of reality. medsim About the Author Allen J. Giannakopoulos, PhD is the Corporate Director for Reengineering and Redesign at Baptist Health South Florida in Miami. His duties include process reengineering and computer simulation of processes in clinical and business departments; knowledge reports development; auditing for ePHI and HIPAA; and the management of processes for Role Based Security. Dr. Giannakopoulos earned his academic credentials from the State University of New York in Brockport, BS in Business; University of Rochester, MBA in Business and Marketing; and his PhD in Health Administration from Kennedy–Western University. Dr. Giannakopoulos been published in over 50 health care journals and publications and has been a featured speaker and presenter over the past 25 years in health care, quality improvement and process simulation. MS1401
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Improving Education and Training to Promote Enhanced Safety, Efficiency, C and Performance 22-24 August 2014 Rosen Shingle Creek Resort Orlando, Florida, USA
Why HEATT? Numerous initiatives are underway to address aspects of healthcare education and training (E&T) and a vast number of healthcare events address E&T at some point in their usually overcrowded meeting schedules. 95% or more of those meetings are ‘single community’ meetings; like minds focused on one aspect of healthcare talking amongst themselves about their needs in which E&T may be raised. And yet, it takes 15 ‘full time equivalents’ to treat todays patient, from many different disciplines, working together to treat one patient. We know that healthcare is not working properly and aside from the well documented, unacceptable, human cost, up to a half of healthcare expenditure in the US, or $1.2 trillion is lost due to avoidable error and waste.
How? By drawing the best minds in the sector from all disciplines and professions in a focused forum, HEATT will address the overall need for a ‘training renaissance’. By making best use of new and emerging teaching techniques, technology, training and assessment tools and drawing on best practices the event, and its
It will take new and better, individual and team training
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30 years of experience in publishing magazines for
Hospital and healthcare executives, need to be aware of the potential for improvement that other high risk industries have already realized. Hospital managers, risk specialists, insurers and government will be key to the change that is needed in healthcare E&T to develop a system of affordable quality care.
the education and training communities in high risk sectors. Halldale’s team has well over 200 manyears of involvement in training, production of training equipment, teaching and learning technologies, and publishing on simulation and training. Over the past 15 years Halldale has organized 50
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SIMULATION
The Time for SuperHuman Healthcare Richard Boyd asserts that we are seeing the start of the Century of Simulation and Human Intelligence use
I
f you could manage to ignore the purveyors of even higher definition (4K) displays at the 2014 Consumer Electronics Show in Las Vegas, you could see the pattern emerge above the noise. Something new is happening. It is becoming clear that the last century was about the recorded moving image and the birth of computing; but the beginning of this century is about something else. It is about ubiquitous intelligence. In the clamoring halls and private venues of Las Vegas last week there was abundant evidence that the revolution in sensors and artificial intelligence was in full swing. At a press conference there on Sunday before everything had really geared up, Shawn DuBravac, chief economist for the Consumer Electronics Association, talked about the “Age of Autonomy” and the “Internet of Things”. He was quoted in the LA Times as saying the number of intelligent gadgets in our lives is expanding at an accelerating rate and “they are increasingly talking directly to each other and making decisions without consulting us pesky humans.” My perspective on this is that this is but an opening chapter in what will become the Century of Simulation and Super Human Intelligence. We are just now coming to grips with the Marshall McLuhan idea that the things we make, in turn make us. Our digital progeny are outstripping our understanding, beginning 18
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to evolve and emerge as new things we could not have even conceived of a decade ago. And it is time that we also become comfortable with the understanding that our poor human brains have not had an upgrade since the Pleistocene Epoch. The synapses in our poor dumb brains occur at around 200 Hz. Not megahertz, not giga; just plain old Hertz. Once robots develop a sense of humor they will undoubtedly snicker at our woeful inadequacies. We are in an exponential age; an age of increasing complexity and uncertainty. Aided by advancing computer power we humans are creating systems thousands of times more complex than our comprehension of what emerges. It should not be surprising in an interconnected world of such complexity to see events frequently spin out of our control and overwhelm us; to see “Black Swans” and unanticipated events1 appear more frequently. Grains of sand cause avalanches. Butterflies flap
Above Richard Boyd at the simulation lab at Weill Cornell Medical College in New York. Image Credit: Richard Boyd. Opposite Technologies exist now to simulate all of the physical processes, team work flow and equipment using virtual models of hospitals. Image Credit: Z-Shift.
their wings and unleash hurricanes on distant shores. Financial markets crash and digital viruses wrack the Internet while biological viruses take wing with air travel to sweep through entire populations. On the network-centric battlefield and in the technology-laden hospital we are asking humans to adapt to enormous complexity and perform flawlessly where mistakes can lead to death. As complexity increases (and it shows no signs of abating) it becomes vitally important that we look for help from the machines who (which) are obviously becoming so much better than us at certain things. In his 2011 commencement address at Harvard Medical School, Atul Gawande, MD, explained a central problem of medical practice today. He said that healthcare providers must learn a complex cooperative choreography akin to what pit crews perform during a Formula One race. He described how modern medical practice was designed during a time when there were very few medical interventions available to a practicing physician, and it was therefore conceivable for a single physician to hold
industry that combines complexity with high risk, should be adopted by healthcare. While healthcare struggles to adopt checklists and basic systems engineering, aviation, oil and gas and other industries are adopting a new level of team integration: the integration of teams of humans in cooperation and symbiosis with automation. Last year over seven hundred million passengers boarded over ten million
“If being in a hospital bed made a difference, it was mostly the difference produced by warmth, shelter, and food, and attentive, friendly care, and the matchless skill of the nurses in providing these things. Whether you survived or not depended on the natural history of the disease itself. Medicine made little or no difference.” himself forth as a master of all knowledge in the profession. He goes on to say that "Resistance... surfaces because medicine is not structured for group work".2 Yet, the increasing complexity of the 4,000 and growing surgical procedures and more than 6,000 drugs that an MD is legally allowed to inflict on a patient requires a cooperative team effort to avoid errors. In 1975, a hospital patient required the care of 2.5 full time equivalents (FTEs). Because of increasing complexity and advancing technology, a typical patient in 2014 requires as many as 15 full time equivalents for care. Gawande went on to state the thesis of a number of other articles over the last two years. The engineering processes and technologies used in aviation, engineering and construction, virtually any
Lewis Thomas in “The Youngest Science” commercial flights in the United States. The logistics and maintenance systems and engineering required to manage all of those flights safely required command of some of the most complex systems ever devised. Yet, last year there was only one (Asiana, SFO) crash with fatalities (not a US Carrier). In fact, three of the last four years we had no fatalities in commercial aviation in the United States. It is not because aviation is not subject to the vagaries of chaotic natural systems and human error; quite the contrary. Human flight remains an unnatural act that continues to rank highly among our greatest fears. Perhaps that is why errors are less tolerated in this domain than in automobile operation or other engineering domains. In aviation we have learned to use checklists, safety interlocks, prognostic maintenance, system of systems
engineering and simulation training to essentially engineer human error out of the system. In contrast, last year, approximately 39 million people checked into just over 5,000 hospitals in the United States. Depending on which study you believe and how you slice the statistics, somewhere between 90,000 and 200,000 of those people died unnecessarily, because of a medical mistake or error. Yet these deaths do not inspire a public outcry and seem to go virtually unnoticed. A recent study of routine hospital visits to 10 hospitals in North and South Carolina determined that patients have an 18% chance of being harmed by medical care.3 Since a 1999 report released by the US Institute of Medicine determined that medical errors in hospitals were causing close to 100,000 deaths and 1 million injuries each year there has been increasing scrutiny of patient safety measures, but those efforts are trailing woefully behind advances in technology and complexity and there has been no measurable improvement. If there was an 18% chance of injury every time someone got into a car, how many people would drive? Yet, this error rate seems to be tolerated in healthcare. What is most distressing is that technologies and engineering approaches exist to dramatically diminish these errors, but they are not being used. Only recently, under the chiding pen of Atul Gawande, have surgeons started to use simple checklists to avoid mistakes in operating rooms. When I speak at conferences on this topic I often bring up highway safety MEDSIM MAGAZINE 1.2014
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SIMULATION as a good example for why we tolerate errors in healthcare. We certainly seem to tolerate errors with automobiles. As with healthcare, we have engineering solutions today that make the 35,000 annual deaths and more than one million injuries on our nation’s highways unnecessary. But we have not yet decided, as a society, that the deaths and injuries are unacceptable. Google robotic cars have safely navigated over 140,000 miles without incident.4 Numerous efforts have proven that robotic cars are a very viable option and the savings and safety improvement could revolutionize our economy and society; but switching from our existing highway system to a fully robotic system will require massive investment in retooling cars and adding sensors to highways. And that is the easy part. The biggest change will be asking people to give up the freedom of driving and trust in technologies that will reduce costs and increase safety. For the moment, we would rather continue to endure the deaths and injuries, the lost productivity (estimated at about 8% of GDP) from commuting in traffic and the extra energy consumed by inefficiency. If we are not moved to action as a society by the toll in human death and suffering from these avoidable mistakes, perhaps focusing on the cost will rally us to the cause. One of the fascinating outcomes from the recent studies of waste and errors in our healthcare sys-
tem is that the size of the bogey is just about the same as our annual deficit. In other words, if we could just solve this one problem, we stand a good chance of eliminating the sucking chest wound that is our annual deficit. In the United States we spent around $2.4 trillion last year on healthcare; around 16% of our gross domestic product. Studies show that around half of this cost is avoidable error and waste, or around $1.2 trillion. While I was at Lockheed Martin, we became interested in the challenge this waste presented to our national security and began looking at healthcare and identifying areas where we believed we could help. As we went across the country meeting with leading teaching hospitals and surgeons like Richard Satava, MD at the University of Washington and Fabrizio Michelassi, MD at New York Presbyterian; and advocates for device interoperability like Julian Goldman, MD at CIMIT in Boston we found a number of areas where technologies and processes from aviation and space systems could address the healthcare crisis.
The SuperHuman Prescription We have a timely opportunity to reduce waste and cost and improve outcomes in the healthcare system by recognizing the limits of the old system and our human capacities and gaining a comfortable fluency with automation and sensors.
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Increasing intelligence: Given the human limitations above and the trend of ever-increasing complexity, it seems obvious that we should be augmenting our healthcare providers with always-on ubiquitous intelligence. IBM’s Watson super computer made headlines when it beat two Jeopardy champions in 2012. Since then, Watson has “gone to medical school” and is now beginning to serve as a decision support tool to help human doctors correctly diagnose disease and prescribe personalized treatment.5 There are some who are already warning of this Jetson-esque idea of a synthetic doctor dispensing healthcare and rendering human intervention obsolete, as many saw on TV in the early 1960s. Despite the Ray Kurzweils of the world who warn of the Singularity – a turning point where machines excess human intelligence and replace, or have no further need of humans – it is far more likely and advantageous for us to embrace these creations of ours to become what Hans Moravec calls “ourselves in more potent form”. If we are to conquer complexity, we must achieve fluency with our automation and no patient should accept anything less than SuperHuman healthcare. Thankfully, access to heavy breathing super computers like Watson is not a necessity in order to incrementally improve human performance in the cor-
Accredited Accredited Program Program SSHʼS SSHʼSACCREDITATION ACCREDITATIONPROGRAM PROGRAM
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rect diagnosis and prevention of disease. For all of its short comings over the last few decades, the field of Artificial Intelligence has made great strides and is commoditizing rapidly along with everything else driven by Moore’s Law. Good AI systems like MASA Life out of Paris, France and Discovery Machine out of Pennsylvania and Therasim in Durham, North Carolina, have powerful and accessible systems for capturing knowledge in expert systems that can assist human healthcare providers in an expanding range of capacities. “…no patient should accept anything less than SuperHuman healthcare.”
loved ones when patterns emerge that indicate illness or need of assistance. (See Carecam as one example http://www. carecamhealthsystems.com/#vhealth) Remember that the best chess player in the world is not a computer, but a team of humans working with computers and perfected algorithms. The 21st century imperative is determining how to achieve the right balance between humans and automation to optimize outcomes. Those who do master this balance and achieve a comfortable fluency with simulation, sensors and analytics will not only outperform those who do not, but they will begin to appear super human.
The 21st century imperative is determining how to achieve the right balance between humans and automation to optimize outcomes. Since Microsoft Kinect unleashed a commodity interest in 3-D sensors for machine monitoring of human activity, a gold rush of innovation has erupted in the field of cheap ubiquitous sensors that can monitor humans and help us overcome bad habits or notify care givers or
The 21st century imperative is determining how to achieve the right balance between humans and automation to optimize outcomes. Super human healthcare provided by teams of humans in cooperation with increasingly powerful artificial intelli-
gence, sensors and automation may be our only hope for staunching the sucking chest wound of escalating errors and costs in healthcare. Thankfully, the models for this cooperation and comfortable fluency exist and are now available to be adopted by healthcare. medsim About the Author With 22 years of experience working with computer gaming technologies for entertainment, design and the film industry, leading the virtual world labs group within Lockheed Martin, and now leading a company focused on artificial intelligence and neural nets, Richard Boyd brings a unique perspective to the looming healthcare crisis. His efforts seek to harness unprecedented, even revolutionary, recent progress in computer gaming technologies, sensors, artificial intelligence and development processes that make this an opportune time to bring the best technologies both computer gaming and aviation have to offer to address our healthcare crisis.
REFERENCES 1 Ericsson, Anders K.; Prietula, Michael J.; Cokely, Edward T. (2007). "The Making of an Expert". Harvard Business Review July–August 2007). 2 http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address. html#ixzz26BHIjYDL 3 A study of 10 North Carolina hospitals published in The New England Journal of Medicine in November (2010;363:2124-2134) 4 http://ideas.4brad.com/topic/robocars 5 http://spectrum.ieee.org/computing/software/ibms-watson-goes-to-med-school
SSH PROVISIONAL ACCREDITATION Provisional Accreditation allows programs that are new or do not yet have 2 years of outcome data to apply for an initial level of accreditation.
SIMULATION Research teamwork, underlie many errors and sentinel events as reported by the Institute of Medicine.3 Most recently, in the Journal of Patient Safety, the number of premature deaths associated with preventable harm to patients was estimated at more than 400,000 per year and serious harm seems to be 10 to 20 times more common than lethal harm.4
Self-Regulation and Guided Imagery
Increasing Psychomotor Capacity of Healthcare Professionals for Breakthrough Performance Gary Hamill, EdD, describes recent research efforts to demonstrate the potential of physiologic self-regulation and imagery training strategies to increase psychomotor capacity and improve performance.
Medical facility staff train as a team so they can "be on the same page" during challenging procedures. Image Credit: Stanford CAPE Study.
P
erforming a medical procedure requires a tremendous amount of psychomotor capacity - your head, hands, and the team with whom you are working have to share the same mental model, i.e., “be on the same page�, while simultaneously anticipating potential outcomes of your actions and planning the next steps to be taken. Few domains present such challenges.
Debilitating Effects of Stress and Anxiety Stress and anxiety can severely compromise the mental and physical capacities of individuals and teams, ultimately inhibiting their ability to function at their highest level during challenging clinical situations. This occurs because stress and anxiety impair central executive processes, particularly when the task being performed is complex and demands constant attention.1 In addition to negatively affecting cognitive processes, there is a clear, negative impact that stress and anxiety can have on motor performance. For example, trembling hands or tense muscles can greatly impair the ability to guide the use of an instrument or medical device, placing the patient at risk. Additionally, as reported by the Joint Commission, anxiety induced by high-stakes, emotionally-charged situations hurts team performance and contributes to disruptive behavior.2 Furthermore, poor behavioral skills, including ineffective communication and inadequate
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Stress and anxiety are psychophysiological processes; therefore, to improve performance, psychophysiological solutions are needed. Using self-regulation techniques improves your ability to think clearly and re-orient to the procedure. Essentially, by being relaxed, you free up areas of your brain that help with your decision-making and ability to access your working memory and procedural knowledge. Furthermore, when you are relaxed, it can help improve your motor coordination and dexterity - you can feel the instruments in your hands better or are more sensitive to the feedback when touching the patient. While self-regulation attenuates the cognitive (worry, self-doubt, lack of concentration) and somatic (increased heart rate, respiratory rate, and muscle tension) components of the anxiety response, guided imagery serves as the muscle and mental primer for optimal performance. Increasingly, evidence suggests there is a functional equivalence between picturing yourself doing a task and actually performing it – meaning, that when you imagine yourself doing an activity, similar or complementary neural pathways are activated as if you were actually doing the activity.
Pilot Research to Improve Learning, Psychomotor Capacity, and Performance under Pressure In response to these extremely compelling needs, in 2009, Ranjan Sudan, MD and this author began a study using self-regulation and guided imagery with medical students on their surgery rotation while working in the Surgical Education and Activities Laboratory at Duke University. The goals of the study were to improve procedural strategy and management of intra-operative stress. The
subjects were novices and their physiological measures such as heart rate, respiratory rate, and skin conductance were measured while they performed simulated surgical procedures. Study subjects demonstrated a 20% to 100% improvement while completing elements of the Fundamentals of Laparoscopic Surgery (FLS) curriculum (pattern cutting and peg transfer) and using Laparoscopic Cholecystectomy virtual reality training. These results were presented at the 2011 American College of Surgeons Education Consortium. For the FLS pattern cutting exercise, having < 2 cm3 of excess material when cutting out the pattern is one of the criteria for certification. In this study, a subject without any experience with this procedure completed their baseline procedure in 9:25 minutes with > 2 cm3 of error. After training with the guided imagery module, the subject performed the procedure the next day and completed it 2:52 minutes quicker with < 2 cm3 of error. For the peg transfer, a subject using guided imagery training after their baseline peg transfer exercise demonstrated reduced time for task completion (1:58 minutes quicker), no dropped pegs, and a lower mean heart rate. Diagram 1 displays a subject’s physiologic data and their view of the operative field during the procedure. Descriptors under the image provide quantified outcomes between pre- and post-intervention con-
sisting of physiologic self-regulation and guided imagery training. For some of the subjects using the laparoscopic cholecystectomy simulator, specific quantitative measures included reductions in the numbers of clips used, blood loss, injury to patient, elapsed time on completion of the procedure, and lower subject heart rate. Qualitative responses and outcomes included improved procedure planning and increased relaxation.5 More information can be found on the Duke Surgery Surgical Education and Activities Lab website at the following link: http://surgery.duke.edu/education-and-training/surgical-educationand-activities-lab-seal/seal-research (Augmenting Technical Skills Training through Application of Video, Neurofeedback and Guided Imagery Training).
Pilot Research on Team Adaptation and Synchronization Pilot research on the psychophysiological aspects of team performance optimization was conducted in August 2013 at the Center for Advanced Pediatric and Perinatal Education (CAPE) at Lucile Packard Children’s Hospital at Stanford University School of Medicine. To better understand how patient care teams react to stress in high-pressure situations, subject physiological data such as heart rate, heart rate variability, and respiratory rate were recorded while performing a simulated neonatal
resuscitation. In addition to physiological data, the State Trait Anxiety Inventory, Teamwork Perception Questionnaire, video analysis, and technical performance outcomes were also used. This provided a 360° psychophysiological study of team performance. (See Diagram 2). Visit the following link to learn more about this project: www.youtube. com/watch?v=VZSZNU_xSGo (Improving Psychomotor Performance of Patient Care Teams). Two significant findings from this study included: 1) The ability to quantify, through heart rate and heart rate variability, a psychophysiological response to complex cognition and collaboration. For example, when providing chest compressions, one’s physiology will increase beyond the pure mechanical load of providing compressions because the life is on the line. Please see notes on the diagram below regarding chest compressions. In some cases, with this very experienced team of subjects, there was a 5% to 10% increase over practice / baseline chest compression measures. With a less experienced team, the arousal due to cognitive load could be much higher consequently resulting in performance decrement which was described earlier in this article. 2) A psychophysiological “zone of optimal functioning” emerged during the procedure. Please see notes on diagram regarding team synchronization.
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SIMULATION Research Summary of Findings:
Diagram 1. Source: Duke Surgery Simulation Education and Activities Laboratory Study.
These results demonstrate the potential of physiologic self-regulation and imagery training strategies to increase psychomotor capacity and improve performance. In fact, using psychomotor analytics helps pinpoint opportunities for growth. For example, in Diagram 3, as heart rate continues to escalate as a measure of arousal, subjects move out of their “zone of optimal functioning” resulting in performance decrement. When this is correlated with the procedural video and discussed during the debriefing, it is now more clear what needs to be further developed. In fact, it was noticed in the Duke study the subject could begin increasing their physiological arousal as they anticipated a limitation in a technique they may not need to use for a few minutes. Physiologic self-regulation and guided imagery can be used to expand trainees’ zone of optimal functioning and make them more resilient to performing under pressure – concepts central to the science of learning.
Diagram 2. Source: Stanford CAPE Study.
Going Forward: Shared Mental Models
Diagram 3. Source: Adapted from the Yerkes-Dodson Law. (Wikipedia.org; accessed 2013-9-1)
Strategy is a mental map of what you are going to do. Mental simulation or guided imagery is the primer for training the brain to accomplish complex tasks. Therefore, picturing in your mind’s eye how you move from one aspect of the patient’s care to the next will improve the mental and physical execution of the tasks. In turn, this augments your capacity for teamwork – knowing how and being able to help one another take care of the patient, as well as re-orient as a team in the event a new course of action is needed to deliver excellent patient care. About the Author Gary Hamill, Ed.D., is the senior research scholar at the Center for Advanced Pediatric and Perinatal Education (CAPE, http://www.cape.lpch.org), Packard Children’s Hospital at Stanford, Division of Neonatology, Department of Pediatrics Stanford University School of Medicine. Hamill specializes in human performance optimization and has helped professional, collegiate, and amateur athletes perform at their highest levels during competitive, stressful situations for two 24
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decades by incorporating psychophysiological training into their regimens. He has over 50 publications and presentations on peak performance and has interviewed numerous professional athletes including Super Bowl Most Valuable Players and NBA All Stars. During the past five years, Hamill has translated and applied the science of Human Performance Optimization toward medical education and performance. He was a Consulting Associate at Duke Medical School in the Department of Surgery’s Surgical Education and Activities Laboratory where he collaboratively developed a curriculum to assist medical students in the management of intra-operative stress, allowing them to learn and execute surgical procedures more quickly and efficiently. Through applications of simulation, team science, and psychoneuromuscular theory, he works with faculty, trainees, and hospital staff to improve performance in emergency situations. Through these advances in active learning, healthcare professionals will achieve improvement in situational awareness, adaptive expertise, medical decisionmaking and ultimately, patient care. If you would like to learn more about Human Performance Optimization and the Peak Performance Research Consortium, contact Dr. Hamill at ghamill@stanford.edu. medsim
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MS IN HEALTHCARE SIMULATION
MASTER OF SCIENCE IN HEALTHCARE SIMULATION As clinical simulation quickly advances within healthcare training, clinical simulation professionals are highly needed to fill the demand. The MSHS is 30-units (4 semesters) with teaching intensives two times per semester in San Francisco. Classes start Summer 2014. Apply now!
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Blended Model (online and in person) Small Class Size Degree Completion in 18 Months Dynamic Faculty and Student Interaction
For more information Call 415.422.6681 or email storres2@usfca.edu www.usfca.edu/nursing/mshs
CHANGE THE WORLD FROM HERE
Medical Education
The Gap in Medical Education Rahul Rekhi provides one student’s perspective on medical education.
S
ince its inception more than a century ago, modern medical education has undergone a series of quiet revolutions, stretching and scaling to accommodate advances in biomedical science. Yet this comprehensive expansion in one critical area masks a relative neglect of another. Despite their staggering scope – spanning genetics to geriatrics and everything in between – medical curricula today largely omit training on health policy. The result? Even as today’s medical students graduate with a deep scientific fluency, they leave all but illiterate when it comes to the healthcare system. Consider, for example, the findings of a 2009 study in the journal Academic Medicine analyzing survey data from the Association of American Medical Colleges. Polling nearly 60,000 graduating medical students, the analysis demonstrated that less than half of the respondents felt they had an adequate grasp of health economics, managed care or healthcare systems. Compare this result to the corresponding statistic for clinical care, which clocked in at well over 80%. Moreover, in a 2011 New Eng26
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land Journal of Medicine survey of medical deans, almost 60% of respondents reported their institution’s curriculum as containing “too little” health policy training. I can bear witness to this disparity firsthand. The curriculum of Stanford Medical School, where I am a deferred first-year student, does not incorporate a single required, standalone course on health policy across four years and 249 credits of training. And this oversight comes with consequences. To illustrate, recent research in JAMA Internal Medicine found that fewer than half of medical students nationwide understand even the basic components of the Affordable Care Act. On a systemic level, this illiteracy directly impedes our ability to institute meaningful health policy reforms that tackle such thorny issues such as quality-based physician payments, comparative effectiveness guidelines or end-of-life care. Without willing and capable physician leaders to guide, implement and sustain such major shifts for the decades to come, reform efforts will almost certainly flounder.
Consequently, efforts to rein in healthcare costs and improve patient outcomes must begin by modernizing medical curricula to incorporate health policy training. For example, a national mandate that fundamental health systems knowledge be a prerequisite for medical licensing would encourage medical schools to incorporate coursework on basic principles of health policy and economics. This teaching, moreover, should be nonpartisan and nonideological, focusing instead on the nuts and bolts of health systems – akin to what law school students or business school students learn about policymaking and institutional governance. This training need not be comprehensive or all-encompassing. Just as preclinical instruction in the medical sciences provides a basic foundation that is built upon in later clinical training; health policy education in medical curricula can offer a baseline understanding that is reinforced in subsequent years. Even ensuring just a rudimentary level of health policy literacy could go a long way. Furthermore, the advent of so-called massive open online courses, or MOOCs, means that financial concerns – the costs of expanding medical curricula to encompass healthcare policy – may be unwarranted. Online health policy courses, such as the one taught by physician-policymaker Ezekiel Emanuel at the University of Pennsylvania, could serve as a functional stand-in where a university lacks a department or set of instructors dedicated to health policy. Whatever the medium, it is imperative that we install health policy as an integral part of the national medical curricula, lest we continue to churn out a generation of students who are ill-equipped to make sense of the challenges and changes to come. Amid the dynamism of our 21st century healthcare system, policy fluency is at least as important as a mastery of biomedical concepts. medsim About the Author Rahul Rekhi, a student at Stanford University School of Medicine, is currently studying as a Marshall Scholar at Oxford University. He served as special assistant to the Maryland Secretary of Health in 2013.
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CONFERENCES
AAOS VR and Surgical Simulation Summit II American Academy of Orthopaedic Surgeon and the American Association of Orthopaedic Surgeon (AAOS), Arthroscopy Association of North America (AANA) and the Orthopaedic Trauma Association (OTA) are moving forward on simulation-based training.
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he first Orthopaedic Summit (MEdSim 4, 2013 Pedowitz) guaranteed a top down, bottom up approach to developing simulation based training needed for orthopaedic surgeons. From the Board to medical school all agreed that new approaches for surgical skills training were needed and they would work together to see that simulation based training and new simulation devices were developed to provide the best possible training for orthopaedic surgeons and residents. Since the first meeting the organizations have been involved in updating current simulators and developing new ones. The second Summit was held in November with approximately 120 participants representing the various boards and organizations with guest speakers from different specialties providing different approaches that their specialties had used to develop simulations/simulators and curricula. Robert A. Pedowitz, MD, PhD, who co 28
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chaired both summits, said “Simulationbased training can have a positive impact on both graduate medical education for residents and continuing medical education for all of us in practice. “Creating a simulation-based training curriculum requires breaking down a procedure into individual tasks and setting proficiency standards that the trainee must meet. It requires development of unique measurement tools to provide continuous feedback to the trainee as a task is mastered. “We have an opportunity, through these new projects, to create training programs that help prepare residents for their initial surgical experiences,” Each project is beginning with curriculum design as the keystone for simulator development. Attendees at the first Summit recommended that surgical skills training for residents be mandated as a required part of residency training. Since then, both the American Board of Orthopaedic Surgery (ABOS) and the Resident Review Com-
mittee (RRC) in orthopaedic surgery have implemented this mandate with identical requirements. J.L. Marsh, MD, in his presentation updated attendees on the ABOS and RRC requirements for surgical skills training. He is chair of the residency review committee. He said the new requirements encompass a high degree of technical skills and are based on expert performance not just native talent. They are based on simulated events which require deliberate practice. During the Q and A after his presentation a discussion took place where one of the attendees questioned the criteria for selection of residents and wondered if perhaps the emphasis on selecting those with high test scores was a true indication of surgical competency or just their ability to score well on tests. A lively discussion ensued and all agreed that it was something that needed to be examined. Robert Sweet, MD, a urologic surgeon from the University of Minnesota, discussed his simulation center, Sim Portal and where urology is in context of other specialties in using simulation. During his residency, he did a two year American Foundation of Urologic Diseases Health Policy Fellowship under the mentorship of Dr. Richard Satava (MEdSim 3, 2013, Interview) Sweet focused on development and validation of simulation tools during his presentation. The community leader credits Satava for his ability to set up the University of Minnesota’s Sim Portal and his background in simulation and curricula development. As founding director of the Center for Research in Education and Simulation Technologies (CREST) his focus is developing and designing solutions to medical education needs through the use of simulation technologies. Dr. Sweet believes that simulation is the heart of the future of healthcare. He feels simulations need to be based on defined education goals, detailed assessment and established criteria levels. Simulation provides a safe environment to recover from errors and learn from mistakes, while enhancing psychomotor skills and technique without injuring a patient. Sweet encouraged attendees who are setting up simulation centers to engage their faculties from
the beginning. That way, they experience buy-in and feel they are part of the program. When asked about fidelity of simulators he said it must be sufficient to meet educational objectives. Mark Nousiainen MD, from Sunnybrook in Toronto, gave an update from the first summit and said simulation was very important to them because cadavers are far more expensive in Canada than in the US as people do not donate their bodies. They have a small teacherstudent ratio and their residents are subjected to a great deal of deliberate practice with frequent evaluations. They advance when they demonstrate proficiency so the curriculum is not time based. Because residents know they are going to have a mid-module evaluation by a panel of experts it makes them more responsible for their education. The first Summit called for the development of new simulation devices expressly designed for PGY-1 and PGY-2 residents. Two devices are currently being investigated – one focused on teaching basic arthroscopy skills and the other focused on basic fracture fixation, using hip fracture as the initial diagnosis. AANA, in partnership with the AAOS, is leading development of the basic arthroscopy simulator. The AANA/AAOS project team is defining the content delivery options that integrate with the simulator; content development will follow. As the development process proceeds, the
project team will seek a corporate partner to help invent the simulator. A new simulator focusing on basic fracture fixation training is being developed by an AAOS/OTA partnership, under the direction of Marcus F. Sciadini, MD. “Our goal is to create an affordable simulation trainer for residents, with the capability for expansion to include multiple fracture fixation procedures,” explained Dr. Sciadini. “Each procedure would be supported by a curriculum requiring the learner to meet certain proficiency requirements. The ideal trainer would incorporate authentic visual images that mimic the fluoroscopic imaging data obtained during routine orthopaedic procedures as well as realistic tactile feedback via a handheld haptic device.” The project team’s mandate includes designing a curriculum to integrate with the simulator so as to maximize the benefits to residents. The AAOS/OTA Project Team is currently seeking a corporate partner for the project. The Summit also called for development of a basic surgical skills training curriculum for orthopaedic residents with emphasis on the use of simulation prior to operating room experience. The ABOS has convened a project team to plan and organize such a curriculum, under the leadership of J. L.Marsh, MD, and Robert Pedowitz, MD. Representatives from
the ABOS, the AAOS, and the American Orthopaedic Association Council of Orthopaedic Residency Directors (CORD) program are also part of the project team, which is creating a standardized set of modules for all residency programs to use in implementing the required curriculum changes. Simple, low-cost simulations and new simulation technologies under development will be instrumental in implementing basic skills training, noted Dr. Marsh. “We have already agreed on a module template and a curriculum of 17 modules as surgical skills training exercises for orthopaedic PGY-1s.” Robert A. Pedowitz, MD, PhD gave an update on the FAST program which will teach arthroscopic skills progressively via a curriculum-based, hands-on, cost-effective education program. “Beginning with the basics, students will learn arthroscopic skills sequentially, before they are taught the full surgical procedure.” The FAST program has the following specific goals to: • Teach arthroscopy skills in a step-wise manner; • Train across cognitive, psychomotor, and affective domains; • Allow students to learn and practice at their own pace (advance via proficiency); • Create a flexible platform to be used for advanced arthroscopy skills training; • Integrate with existing educational programs;
Come and Visit the 6th Congress of the Dutch Society for Simulation in Healthcare in the Netherlands
Medical Simulation “Mind the (G) App!”
The DSSH is the largest European National Society for Simulation in Healthcare. This year’s annual congress will take place on the 19th of March 2014 at the University Medical Center Utrecht in the lovely city of Utrecht, located in the heart of the Netherlands. Latest developments in Simulation and Serious Gaming for training health care professionals are featured. Many presenters will present in English and all 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 area. Combine education, simulation and/or business with pleasure and visit Utrecht, Amsterdam and the Netherlands this spring! Visit our website: www.dssh.nl/en/dssh-congress/dssh-congress-2014 for the latest updates on our exciting Congress Program, and to register for this exciting Congress at very reasonable rates!
19th March 2014 University Medical Center Utrecht, The Netherlands
Our Congress partner is: Congress & Meeting Services Holland at info@congresservice.nl should you require help with your travel arrangements.
Email: info@dssh.nl • Website: www.dssh.nl and www.dssh.nl/en (international) • Follow us on Twitter: @dutchsimulation • Join us on Facebook!
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CONFERENCES • Develop opportunities for online CME and, possibly, Maintenance of Certification (MOC) programs; • Leverage existing educational content, expertise, and organizational resources; • Develop simple metrics to monitor learning progress and confirm proficiency; • Integrate FAST with virtual reality trainers and competency testers; and • Place the deliverables into the hands of the end-users in a cost-effective manner. To help achieve these goals, Dr. Pedowitz believes that training programs should take advantage of alternatives to expensive, high-definition virtual reality systems for teaching and assessing basic orthopaedic skills. For example, he noted, a Swedish company offers a fluoroscopy training system that, when combined with a USB connector and commercialgrade haptic arm, could serve as an inexpensive simulator for practicing placing pins. When combined with two haptic arms, the device could be used as an inhome arthroscopy trainer.. “To have a set of teaching tools that enables residents to practice arthroscopy skills at home, with more expensive
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able performance goals in terms of time, pin accuracy, and even radiation exposure equivalency, without actually having to experience it,” said Sciadini. “Radiation safety and fluoroscopy exposure are important; orthopaedists frequently use fluoroscopy, particularly in trauma.” Dr. Sciadini noted that, 90% of physicians underestimate the risk associated with pediatric radiographs and computed tomography, and that orthopaedists have limited understanding of radiation physics. As a result, the project team is hoping to incorporate the concept of decreasing radiation exposure into its education curriculum. “Although in the preliminary stages, being able to incorporate fluoroscopy training into the simulation realm is very exciting,” said Sciadini. “It lends itself to using the simulator in a very effective educational mode.” While the orthopaedic community might have seen themselves “as lagging behind general surgery in the use of simulation” as one speaker said, they are making great strides to rectify the problem and are already contemplating topics for their next Summit. medsim
simulation devices available at the residency program and hospital levels, and ultimately, state-of-the-art and highly sophisticated virtual reality equipment at regional centers where testing is performed is my vision for orthopaedic education and training” said Pedowitz. Charged with developing an educational curriculum designed for PGY-1 and PGY-2 residents, the AAOS/Orthopaedic Trauma Association (OTA) simulation project team chose hip fractures as their starting point. “We have established the concept of a progressive curriculum that begins with very basic procedures – but has the potential to incorporate increasingly complex cases applicable for upper-level residents or even fellows,” said Marcus F. Sciadini, MD. The project team has identified femoral neck fractures, iliosacral screw positioning, anterior column screw placement, retrograde and antegrade femoral nailing, and interlocking and blocking screw placement as the core group of procedures for simulation training. “The nice thing about these simulation models is that they provide quantifi-
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support with additional simulation equipment and personnel,” Brown pointed out.
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Blend of Technologies
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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.
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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
trAining technoLogy
Learning Enablers
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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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
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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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-
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-
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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.
Mimic Technologies Releases Xperience Team Trainer™ – Mimic Technologies released the Xperience Team Trainer that is designed to help first assistants gain experience and refine skills while working with the console side surgeon in a virtual environment. It is a complementary unit for the Mimic dV-Trainer® that lets the console surgeon and first assist safely train together. Within the robotic surgical environment, cooperation between the console side surgeon and first assistant is crucial; a high level of teamwork requires precise verbal communication and the ability to anticipate and react to one another’s movements. Mimic says the Xperience Team Trainer is the first simulation technology for first assistants to develop skills specific to their roles in robotic surgery and brings training to the first assistant outside of the OR. Many of the basic skills exercises on the dV-Trainer were modified to accommodate the first assistant. With the surgeon at the dV-Trainer while the first assistant operates the Xperience Team Trainer, these exercises build teamwork and synchronization for common maneuvers such as needle passing, tissue retraction and clip application. The Xperience Team Trainer leverages Mimic’s MScore evaluation system that allows options for scoring the surgeon’s and first assistant’s performance on exercises separately, as well as for combined proficiency. More information about the trainer is available at www. MimicSimulation.com/XTT. ECS and CNA Insurance Partner on Healthcare Admin Readiness Trainer – Engineering & Computer Simulations (ECS) partnered with CNA
Training on Simulators Improves Technical Performance in the OR A study featuring LapSim, Surgical Science’s virtual reality training system, was released in the Annals of Surgery titled “Individualized Deliberate Practice on a Virtual Reality Simulator Improves Technical Performance of Surgical Novices in the Operating Room: A Randomized Controlled Trial.” The purpose of the study by Vanessa N. Palter MD, PhD and Teodor P. Grantcharov MD, PhD was to investigate if individualized deliberate practice on a simulator results in improved technical performance in the operating room – and the results verify it does. The authors say this study is the first to investigate whether the individualized deliberate practice, where curricula tasks vary depending on prior levels of technical proficiency, would translate into the OR – and if the results could help improve the feasibility of implementing simulation‐based curricula in residency training programs, rather than having them limited to research protocols.
Insurance to support patient care during disasters. Under their agreement, CNA policyholders within the hospital and assisted-living healthcare sector will receive discounted access to ECS’ Healthcare Administration Readiness Trainer (HART). HART is a modified version of the company's Emergency Management Staff Trainer (EMST) developed for the
National Guard Bureau. EMST provides training for Crisis Planners and First Responders – and HART can assist responders and hospital personnel after catastrophic losses suffered by hospitals during disasters such as Hurricanes Katrina and Sandy. ECS and CNA say HART can benefit CNA's policyholders, because by using this web-based, virtual table-top M EDSI M M A G A Z I N E 1 . 2 0 1 4
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World News & Analysis exercise system, they can perform risk assessment and mitigation. CAE Healthcare Sells 44 Caesar Trauma Patient Simulators to U.S. Navy – CAE Healthcare sold a record 44 Caesar trauma patient simulators to the United States Navy Expeditionary Combat Command (NECC) for tactical medical care field training in sites throughout the US, Guam and Spain. In addition to the simulators, CAE Healthcare will provide NECC training and multi-year maintenance services. The Caesar trauma patient simulators will allow NECC to provide standardized core skills training across expeditionary forces. Navy Expeditionary Combat Command serves as the single functional command for the Navy's expeditionary forces that accomplish specific objectives in other countries including anti-terrorism, force protection, theater security cooperation and engagement and humanitarian assistance/disaster relief contingencies. Developed for combat casualty care training in harsh environments, CAE Healthcare's Caesar trauma patient simulator is rugged and resistant to extreme temperatures, rain, dirt, dust, sand and body impact. “Million Women March" to Create Call to Action in Women’s Health – Endometriosis Month is beginning with an internationally coordinated campaign and will coincide with the worldwide “Million Women March” on Thursday, March 13, 2014, in dozens of international capitals, as well as on the Mall in Washington DC. Approximately 7,000 women worldwide have been involved in preparing for March – launching it on Facebook about seven months ago. An estimated 176 million women and girls have endometriosis, according to several different reproductive health organizations. “Women who suffer from endometriosis wait on average more than six years before receiving an accurate diagnosis – that’s why the American Society of Reproductive Medicine (ASRM) is an advocate for the Million Women March,” says Dr. Linda Giudice, president of ASRM. “As a society, we need to take a hard look at the system and the way that economic forces are affecting both medicine 32
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and feminine diseases," says Dr. Camran Nezhat, chair, AACF Stanford University School of Medicine, director, Center for Special Minimally Invasive and Robotic Surgery and Stanford clinical professor of OBGYN, who is leading the effort. "The trend toward rationed medicine is making it difficult for medical providers to take the time to listen to the patient with ambiguous symptom profiles, instead of examining patients in a holistic way that ensures a good quality visit in the exam room.” In addition to the broad goal of simply raising awareness, organizers are seeking change in these sectors: • Government-Funded Health Organizations – A panel of experts will work with US governmental agencies: The National Institutes of Health (NIH), Centers for Disease Control (CDC), the Department of Health and Human Services (HHS), and the Office of the Surgeon General to redirect funds and efforts to focus on common women’s diseases such as endometriosis, fibroids and chronic pelvic pain so resources are visible to the public. • Health Screening in Public Schools – As is done with scoliosis, hearing, vision and now diabetes, the Department of Education will be involved in nationwide health screenings in public schools to test for chronic pelvic pain conditions that afflict girls. • Medical and Nursing School Educational Institutes – According to leading reproductive health organizations, even after numerous visits to their pediatricians, primary care physicians, gynecologists, school nurses and emergency room practitioners, millions of women and girls with endometriosis, fibroids and chronic pelvic pain are still undiagnosed for several years or are receiving grossly inadequate care. • Public Education Campaigns – Researchers, medical professionals and everyday women will continue to spread awareness in the media and in our local communities, making requests to private foundations to consider supporting research and outreach to find a cure and develop noninvasive screening tests. Participants can sign up at http:// www.millionwomanmarch2014.org/getinvolved/ and join the Facebook cam-
paign at https://www.facebook.com/ groups/130895160440864/.The program will consist of events around the Mall in Washington DC, as well as coordinated events in cities from 39 countries around the world on the same day.
Academic Centers Pharmacy & Nursing Grant Opportunity for Simulation Research – The US Agency for Healthcare Research and Quality (AHRQ) is interested in funding a diverse set of projects that develop, test and evaluate various simulation approaches for the purpose of improving the safe delivery of health care. As a training technique, simulation exposes individuals and teams to realistic clinical challenges through the use of mannequins, task trainers, virtual reality, standardized patients or other forms, and allows participants to experience the consequences of their decisions and actions in real-time. Applications that address a variety of simulation techniques, clinical settings, provider groups, priority populations, patient conditions and threats to safety are welcome. For more information go to http://www.ahrq.gov/funding/ fund-opps/index.html. TTUHSC Opens Louise and Clay Wood Simulation Center – Texas Tech University Health Sciences Center (TTUHSC) officially opened the TTUHSC Louise and Clay Wood Simulation Center at Medical Center Hospital (MCH) in Odessa, Texas. A donation from the Wood Family Foundation, a family of Texas Tech alumni, helped equip the facility. The new clinical simulation center is an interdisciplinary, multimodality facility that provides multiple realistic health care environments to assist learners in acquiring the competencies necessary to provide safe, culturally sensitive, quality patient care and transferring these competencies to actual care settings. MCH renovated a 13,352-square-foot space for $3.3 million to meet TTUHSC’s specifications for the new center. Simulation instruction areas include: • Authentic health-care environments including high-tech equipment, mannequins, simulators and supplies to
facilitate learning experiences like an operating suite. • Simulated hospital patient and clinic examination rooms to represent the patient care environment of a surgical unit or long-term care facility. • Virtual reality and 3-D visualization that support learning and competency evaluations. • Computerized digital audio-visual system in all rooms. More than 200 medical, nursing and physician assistant students from TTUHSC at the Permian Basin will use the simulation facility as well as other community health care professionals. LSUHSC Team-Training Simulation Improves Performance and Patient Safety – A study conducted at Louisiana State University (LSU) Health Sciences Center New Orleans found simulation-based operating room team training of medical and nursing students resulted in more effective teamwork by improving attitudes, behaviors, interaction and overall performance – leading to potential increased patient safety and better clinical outcomes. “Effective teamwork in the operating room is often undermined by the ‘silo mentality’ of the differing professions,” says lead author John T. Paige, MD, Associate Professor of Clinical Surgery and Director of Applied Surgical Simulation at LSU Health Sciences Center New Orleans School of Medicine. “Such thinking is formed early in one’s professional experience and is fostered by undergraduate medical and nursing curricula lacking inter-professional education.” An inter-professional faculty team divided 66 students (18 undergraduate nursing students, 28 fourth-year medical students, and 20 nurse anesthesia students) into ten groups that were trained for one month at the Russell Klein Center for Advanced Practice at the LSU Health Sciences Center New Orleans School of Medicine. Each two-hour training session used two standardized, authentic scenarios with a software algorithm designed to respond to team actions and decisions. Each OR team had two medical students (surgeon and first assistant roles), two undergraduate nursing students (circulating and scrub nurse roles), and
two nurse anesthesia students (primary and secondary anesthetist roles). Students switched roles within their discipline (e.g., an undergraduate nurse moving from scrub nurse to circulating nurse) for the second scenario. “Frequently, failed communication, ineffective inter-personal skills, inter-professional tension, poor team interaction and divergent inter-professional interpretations of the quality of collaboration combine to impact both patient care processes and outcomes,” notes John T. Paige, MD, who also serves as Director of the American College of Surgeons Comprehensive Accredited Education Institute at LSU Health Sciences Center New Orleans School of Medicine. “In this study, a single session of high-fidelity simulation-based interprofessional OR team training resulted in immediate improvement of students’ team-based attitudes and behaviors.” UALR Nursing Receives $100k Grant From Blue & You Foundation – The Department of Nursing at the University of Arkansas at Little Rock (UALR) got a grant from The Blue & You Foundation for a Healthier Arkansas that gives the school $102,608 for the purchase of two pediatric simulation models to help incorporate pediatric simulation in the nursing program’s clinical rotation. UM Fund Raising Challenge for New Simulation Hospital – The University of Miami (UM) School of Nursing and Health Studies (SONHS) created the R. Kirk Landon Challenge, where Landon will match all leadership gifts of $50,000 or more, up to a total of $1 million towards the construction of a Simulation Hospital. UM’s SONHS plans to open one of the nation’s first education-based Simulation Hospitals – a five-story, 39,000-square-foot facility that will replicate the flow of activities in a clinical practice and hospital ranging from birth to end-of-life care and from inpatient to home health care experiences. The school also received a $500,000 donation in support of its plans to build the education-based simulation hospital. With the Challenge, R. Kirk Landon and his life-partner Pamela Garrison, R.N. are hoping to engage a community of people who care about the future of
health care. Garrison is a retired recovery room nurse and is the School’s Momentum2 campaign co-chair. The goal of the “Momentum2: The Breakthrough Campaign for the University of Miami” campaign is to raise $1.6 billion by the 2016 to construct new buildings and labs to prepare tomorrow’s medical and scientific minds, create scholarships for students who might not otherwise be able to attend college, and a recruit a new group of talented and ambitious researchers and scholars with the knowledge to study and solve global problems. St. John Fisher College Dedicates Nursing Simulation Center – St. John Fisher College in Pittsford, New York opened its new two-story, 10,400-square foot Wegman’s School of Nursing Simulation Center. The new space mirrors an actual hospital unit – with five individual simulation rooms with specialized medical equipment, a control room for faculty simulation facilitation, debriefing rooms and classrooms and faculty offices Mississippi Gulf Coast Opens Healthcare Sim Center – Mississippi Gulf Coast Community College opened its Healthcare Simulation Center at its Advanced Manufacturing and Technology Center in Gulfport, Mississippi. The 5,000 square-foot simulated four-bed hospital is the only simulation center with public access on the Mississippi Gulf Coast. The new center has an Emergency Department/Triage area with ambulance bay, Obstetric/Pediatric Patient Room, Intensive Care/Critical Care Patient Room, Medical-Surgical Patient Room, Nursing Station, human patient simulators, debriefing, rooms and classrooms. The center is available for use by MGCCC students and faculty, and is open to community partners and the public for training and education. McLennan Community College Using Motion Computing Tablets in Healthcare Simulations – McLennan Community College in Waco, Texas is now using Motion Computing tablets to control Gaumard simulation mannequins to help prepare medical field students for a variety of field and in-facility treatment scenarios. Approximately 3,100 students a year M EDSI M M A G A Z I N E 1 . 2 0 1 4
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World News & Analysis pass through the school’s simulation training areas, including nursing, paramedic and surgical technology students. Motion Computing is a mobile technology provider for vertical markets such as healthcare. Before McLennan had the Motion tablets instructors had to manually control the mannequins and run training scenarios next to the bedside, which decreased the sense of realism. With the Motion tablets that are equipped with Gaumard software that power the mannequins' actions through radio frequency and monitor vital signs through a Wi-Fi connection, the training is more comparable to working with a real patient. McLennan faculty program the mannequins to behave a certain way and respond accordingly based on treatment provided by the student. Faculty can either program the mannequins ahead of time or make adjustments in real-time for active response simulations. The simulation lab at McLennan serves students in the nursing, respiratory therapist, paramedic and surgical programs. In addition, residents training to be doctors at the local Waco Family Medicine Residency Program are also active participants in the simulation lab and develop both discipline specific competencies and skills mandatory for professional collaboration. In the next month, nurses from a local hospital will also begin conducting additional training at McLennan. UALR Nursing School Opens SimCare – The University of Arkansas at Little Rock opened SimCare, a new 22-bed, simulation hospital that recreates clinical experiences covering the human lifespan – and soon after, the Arkansas Community Health & Education Foundation donated $32,000 to fund a new patient simulator for the center. SimCare is in the new 9,500-squarefoot Nursing Building that underwent extensive remodeling at a cost of about $7 million. It helps students learn from life-like interactions with its 10 high-fidelity beds and family of patient simulators and lets them deliver patient care in a realistic environment, decreasing the chance a critical error will be repeated on a real-world patient. The interactions are captured with both fixed 34
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and remote-controlled cameras and are equipped with audio capture abilities. SimCare can broadcast live from the patient’s bedside to any of the three classroom spaces on the second floor, bringing patient care from the bedside to the classroom. Southwest Adventist University Opens Simulation Center – Southwestern Adventist University, in conjunction with Texas Health Huguley, opened a 2,000 square-foot simulation center that will initially be used to train the school’s nursing students and Huguley’s employees and eventually the county’s emergency training personnel. The simulation center is designed to imitate scenarios a student would see in a hospital setting through the use of medical simulation mannequins – situations they might encounter with patients, such as heart failure, trauma or overdose. The center has four patient rooms; a waiting room where visitors can watch the classes taking place on a large flat-screen monitor; a kitchen; office and administrative space and a host of equipment including a crash cart, regulation hospital beds and six patient mannequins. Next on the list for installation includes headboard modules for oxygen simulation monitors and monitors so one teacher can monitor multiple students at the same time. Galen College of Nursing Opens Phase 1 of Advanced Simulation Center – Galen College of Nursing opened a 3,000-square-foot simulation center at its River Green campus in Louisville, Kentucky that is the first phase of Galen’s Advanced Simulation Center development. Phase I features three simulation rooms with highfidelity mannequins, supporting control and debriefing rooms. When Phase 2 is completed in mid-2014, the center will double in size. New Products & Developments Simbionix Introduces Pelvic Exam Training – Simbionix USA Corporation introduced PELVIC Mentor™, an advanced pelvic exam training tool for clinicians. The Simbionix PELVIC Mentor simulator is designed to let OB/ GYNs, family doctors, medical students,
nurses and other clinicians acquire detailed hands-on knowledge of pelvic anatomy and the comprehensive skills required to perform pelvic exams. The integrated hybrid system combines a physical mannequin with a computerized 3-D virtual system. A net of sensors translates the palpation, abdominal press and cervix manipulation into a real-time visual image. The mannequin gives learners and educators the ability to identify anatomy, conduct an exam and receive feedback – in a stress-free learning environment that increases the comfort level for both clinicians and patients. The Pelvic Exam module includes six interchangeable anatomies, each representing a different medical condition. Trainees can identify various pathologies before they encounter them in live patients. Red Llama, Inc. Releases SimPraxis Trainer for iPad – Red Llama, Inc. released the SimPraxis Laparoscopic Hysterectomy Trainer to the Apple App Store and made the SimPraxis surgical simulation platform available on iOS. The Trainer can be purchased from the iTunes App Store. SimPraxis training modules offer detailed surgical training for the operating room with high-fidelity video in highly interactive simulations, didactics and anatomy quizzes that run on the iPad as well as a personal computer. The learning objectives of the SimPraxis Trainers are to orient the user to the roles of the surgeon and assistant, learn the relevant anatomy, learn the specific steps of the procedure, understand the required port placements, become familiar with the necessary instruments and master the key risks of the laparoscopic hysterectomy. Users can also review the potential errors, injuries and complications associated with each step. All actions and decisions made in each Trainer are captured for complete formative tracking and summative scoring to provide meaningful and accurate assessment. Simulated Endovascular Neurosurgery on Real Patients by Mentice – Mentice, a provider of medical cardiovascular and endovascular simulation,
released what the company says is the world’s first solution that lets physicians import medical image data from cerebral anatomies of real patients into a simulated environment for hands-on preparation and training. VIST® Case-It lets users of the Mentice VIST line of medical simulators create virtual cases from patient-specific data and then practice the operation’s steps in a realistic and safe environment. The VIST Case-It technology holds promises for the future of medical education and patient safety, such as: • Hospitals can build their own unlimited library of virtual patient cases. • Complex cases can be easily shared with colleagues and students. • Aneurysms, lesions, blood clots and other pathologies can be added for training purposes. Mentice earlier released VIST Case-It for its Endovascular Aortic Repair (EVAR) training module, and as part of this new release, VIST Case-It support will be extended to the Acute Stroke Intervention, Neuro Intervention and Carotid Intervention modules. Endovascular Aneurysm Training Module Supports Vascutek's Anaconda™ Devices – Simbionix USA Corporation is increasing its library of training opportunities on the ANGIO Mentor™ with the new Endovascular Aneurysm Repair (EVAR) Vascutek module. The ANGIO Mentor products are multidisciplinary surgical simulators that provide hands-on practice of endovascular procedures in a simulated environment. Abdominal Aortic Aneurysm (AAA) is defined as an increase of the abdominal aorta by at least 3 cm (1.2 in.). In the US, annual mortality from AAA rupture is approximately 15,000 patients, making it the 13th leading cause of death. Traditional surgical treatment of AAA involves a large incision to place a synthetic graft to repair the diseased artery. This method can result in long hospital stays and painful recoveries, so physicians continue to seek less invasive alternatives to this major, open surgical approach. More physicians are treating AAA using the EVAR approach, which includes inserting a synthetic graft via the femoral artery and placing it inside the aorta to repair the disease. The EVAR approach is associated with shorter hospital stays, fewer complications and less mortality compared to the traditional surgical treatment; but it is a complicated procedure that requires advanced skills from surgeons. Simbionix provides training tools and Virtual Reality (VR) simulators for most of the leading devices for EVAR procedures in the industry. Now, the EVAR Vascutek module will help physicians practice the clinical and practical aspects of Vascutek's Anaconda™ stent graft system on various anatomies, using the latest techniques and therapeutic approaches available. The endovascular abdominal aortic aneurysm training module for Anaconda™ gives Vascutek a specialized simulator that lets its Clinical Support Specialists train clinicians worldwide on the deployment of the Anaconda™ stent graft system, according to Vascutek Ltd President & CEO Paul Holbrook. It also gives Vascutek the opportunity to further develop and enhance its clinician educational programs at international workshops and congresses.
Vermont Hospital Develops Technique to Prevent Infections Doctors at Fletcher Allen Health Care in Burlington, Vermont developed a technique to prevent infections in patients from having catheters inserted into the central veins of their chests – and the number of patients who developed infections dropped to about a tenth of the national rate in the two years since the new procedure was introduced. The results got physicians to question the long-held assumption that some central line infections were an inevitable byproduct of treating acutely ill patients about 15 years ago – important for many reasons, including financial, because federal health insurance providers no longer pay to treat them. Instituting the new protocol required a lot of training, breaking old habits, practicing using simulation mannequins, making sure proper procedures are followed, and giving nurses the power to challenge doctors. The new technique is being taught at the hospital's simulation lab run by Fletcher Allen and the University of Vermont’s College of Medicine and College of Nursing and Health Sciences. Since the new system was instituted at Fletcher Allen, the central-line infection rate in the medical intensive care unit dropped to 0.15 per 1,000 catheter days, about a tenth of the national median of 1.2. In the 18 months before the new system was implemented the rate was 2.72. Now the hospital boasts: • Infection rates that are approximately 82 percent below national averages. • Three years with zero bloodstream infections from central line infections in its Neonatal Intensive Care Unit (a fact the hospital says is unheard of). • More than two years with zero central-line infections in the Pediatric ICU. • More than two years with only one infection in the Medical ICU. It’s also helping to spread the word by leading a CDC effort to create new guidelines for dialysis care that are being adopted across the country. These steps have been shown to cut central-line rates by 50 percent – not quite the 80 percent cut at Fletcher Alan, but with increased adoption, those rates will likely improve. M EDSI M M A G A Z I N E 1 . 2 0 1 4
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World News & Analysis Hospital S&T Penn State Hershey Professor Develops Ophthalmology Surgical Simulator – Dr. Joseph Sassani, an ophthalmology professor and entrepreneur at Penn State Hershey Medical Center, developed a simulator for eye surgery called the Universal Microsurgical Simulator. Skilled closure of traumatic eye injuries is key to healing and rehabilitating the injured eye – but during residency training, ophthalmologists have decreasing exposure to performing surgical repairs, according to Sassani. Still, those who assess surgical skills of Boarded surgeons and accredit surgical educational programs are demanding documentation of trainee competency. Virtual reality simulation has become the de facto solution, says Sassani, but there weren’t any simulators adequate to the task, so he created one himself with some funding from the US Department of Defense. Based on strong positive feedback from civilian and military surgeons, as well as winning first place in the TechCelerator Hershey program, Sassani decided to form the Microsurgery Simulation Software company. The eye surgery prototype is about a year away from hitting the market – and was designed to be the first simulator technology for the company. Sassani says with the development of additional software and hardware, the core technology can be deployed to simulate virtually any human tissue. Northern Arizona Veteran Affairs Health Care System Opens New Sim Center – Northern Arizona Veteran Affairs Health Care System (HCS) opened a new 644-square-foot Clinical Simulation Center to allow clinicians to sharpen their skills. The HCS will offer educational opportunities in healthcare through experiential learning, refining of skills and environmental care. The center offers multi-disciplinary training to healthcare professionals as well as product trials and HCS activations.
Robotic Simulation Training Mimic Technologies Releases MSim™ 2.2 – Mimic Technologies 36
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released MSim 2.2, the latest simulation software platform for the dV-Trainer robotic surgery simulator. MSim 2.2 brings functionality upgrades and enhanced performance to existing dVTrainer customers and Mimic research partners. MSim 2.2 also brings a preview of new dry-lab simulation exercises developed in collaboration with the Robotic Training Network (RTN) that is devoted to standardizing the robotic surgical curriculum and education for residents/ fellows-in-training. The recently developed Tower Transfer and Roller Coaster exercises in MSim 2.2 are life-like simulations of physical dry lab exercises RTN uses in an assessment program for their robotic surgical training curriculum. The Tower Transfer and Roller Coaster modules are positioned as a preview of a full suite of RTN dry lab exercises on the dV-Trainer that will be available through an exclusive license to RTN members in 2014. As with other dV-Trainer exercises, the new Tower Transfer and Roller Coaster exercises let users objectively measure their performance with MScore. Standard on the dV-Trainer, MScore is a proficiency-based scoring system for robotic surgery simulation skills development. MScore assessment is built on data collected from more than 100 experienced surgeons that completed 75 or more robotic cases. Similar to the Fundamentals of Laparoscopic Surgery (FLS) standard, MScore is based on expert mean and standard deviation data to facilitate credentialing and privileging.
International NEWS Nigeria to Establish Medical Simulation Centers – Medical schools in Nigeria will begin teaching medical sciences through simulation in regional centers across the country by 2015, according to Visiting Professor to the National Universities Commission, Professor Eugene Okpere. He said if funds are adequately available, most of the medical schools in the country will have simulation complexes or provided regional centers where medical students can learn.
The use of simulation in teaching medical education is the safest way to train medical students competently, he said, adding that using patient simulators will help students identify forms of clinical signs or disease components. 3-D Printed Brain Model Lets Students Practice Brain Surgery – Researchers from the University of Malaya in Malaysia created an ultra-realistic 3-D-printed skull that recreates the texture of different layers of tissue. The simulated skull lets students practice drilling into bone and removing a tumor. The model is composed of a variety of materials that simulate the various consistencies and densities of human tissues encountered during neurosurgery, according to Vicknes Waran from the University of Malaya. He says the newest generation of multimaterial 3-D printers can aid neurosurgical training by creating models that simulate different diseases in a variety of body tissues – and at a much lower cost, because the reusable base piece of the model costs about $2,000 and the disposable inset costs $600. The researchers created a reusable, two-part model using a Stratasys Objet500 Connex multimaterial 3-D printer where he base piece has human features and the natural contours of a human skull that is used to train the novice in neuro-navigation techniques. The second part of the model defines the region where simulated surgery is performed and contains different materials that simulate skin, bone, dura mater and tumor and normal brain tissue. To test the quality of the model produced by the printer and to make minor adjustments, the researchers from Malaysia were aided by other researchers from the University of Portsmouth and the University of Oxford in the United Kingdom. Acute Cardiovascular Care Association Launches Pocket-size Toolkit – The Acute Cardiovascular Care Association (ACCA) of the European Society of Cardiology (ESC) in Sophia Antipolis, France introduced a pocket-sized manual on acute cardiac conditions to help first-aid teams across Europe make the best decisions in the seconds after a heart attack. The Acute Cardiovascular Care Association Clinical Decision-
Making Toolkit is available online at www.escardio.org/communities/ACCA/ education-research/awareness/Pages/ toolkit.aspx and is being distributed free of charge to 20,000 emergency cardiac care practitioners across Europe. “When patients have a heart attack they are initially seen by the first aid team who have little time to decide how to diagnose and treat them.” said Dr. Ervigio Corral Torres, Subdirector General of SAMUR - Protección Civil, the ambulance service in Madrid, Spain. In these critical moments, ambulance doctors will be able to quickly consult the ACCA toolkit to help them quickly make the correct decisions for patients. The manual’s small size makes it easily accessible and the treatment protocols are presented in clear tables and diagrams so doctors can immediately see the path their patient needs to follow. The toolkit is based on ESC Clinical Practice Guidelines 1-5 and covers key symptoms, coronary syndromes, heart failure, cardiac arrest and cardiopulmonary resuscitation (CPR), rhythm distur-
bances, acute vascular syndromes and acute myocardial/pericardial syndromes. A mobile application of the toolkit is set to be available this spring. Surrey's Innovation Boulevard Forges Partnerships in Israel – Innovation Boulevard of Surrey, British Columbia is hoping to change the way healthcare is delivered to the people of Surrey by working with Israeli companies and health facilities. Innovation Boulevard is a network of health institutions, universities and companies in Surrey with a shared vision of achieve remarkable results in: • Improving health care outcomes for patients. • Implementing intelligent solutions for the health care system. • Attracting talented clinicians and researchers. • Growing companies in health care technology and services sectors. The City of Surrey agreed to share its formula for Innovation Boulevard with Israeli innovation centre Be'ersheva's Gav Yam Advanced Technologies Park
and is fostering a partnership with the Israel Center for Medical Simulation (MSR) at The Sheba Medical Center. The University of British Columbia is ready to partner with Israeli research institutions aligned with the school’s programs in heart and brain diseases, according to Dr. Howard Feldman, Executive Associate Dean at UBCs Faculty of Medicine – and Simon Fraser University is assembling a team of various stakeholders to expand a research project in diabetes and dementia. Innovation Boulevard's Conquer Mobile, Kwantlen Polytechnic University (KPU) and the Fraser Health Authority will engage in joint projects with MSR to deliver medical simulation training to nurses, physicians and other healthcare related professionals. University of East Anglia Researchers Creating Patient-Specific 3D Birth Simulator – Computer scientists from the University of East Anglia in the United Kingdom (UK) are working to create a virtual birthing simulator that will help doctors and midwives prepare
2013 I/ITSEC Report Following are MEdSim editorial staff insights from the 2013 I/ITSEC. I/ITSEC exhibitors reported a number of contract awards and provided insights on their new products and systems. On Day 3 of the conference, Waymon Armstrong, Engineering & Computer Simulations’ (ECS) president and co-founder, modestly told Group Editor Marty Kauchak his company “has had a busy week.” Of the three announcements ECS released during the conference, two were in the medical sector. In one, the Orlando-based firm said it was awarded the Medical Training Command and Control (MTC2): Mannequin and Environment Control System Research system by the US Army Research Laboratory, Human Resource and Engineering Directorate, Simulation and Training Technology Center. This work is in support of US Army Program Executive Office for Simulation Training and Instrumentation (PEO STRI), Program Manager MEDSIM's Medical Simulation Training Center Program. ECS is focusing on research, development and integration of existing tools and technologies that can be leveraged together to create the prototype MTC2 application – and the company announced it was selected by PEO STRI and the Veterans Health Administration (VHA) to build a virtual VHA Medical Center under a program called the Virtual Medical Center. The purpose of virtually duplicating the medical center is to improve the patient’s access to care and contribute to
improvements in the overall health of the veteran population. This is expected to enhance medical readiness and save costs previously incurred by patients having to physically travel to actual VA centers to get, often mundane, healthcare tasks completed. Armstrong told MEdSim his customers’ current areas of interest include reuse, repurposing technology, cost effectiveness, mobile applications and optimizing what has been built and delivered. General Dynamics Information Technology reported its Virtual Health Care Training (VHCT) Suite remains in development with expected deployment in first quarter 2014. The product is powered by the Havok Vision Engine and is customized to support each customer’s individual training needs, including the tailored simulation of facility-specific medical devices, electronic charting procedures and communications systems. During a walkabout of the GDIT booth with Mark Meudt, the company’s vice president for Communications & Marketing, the VHCT Suite was supporting a chemotherapy training scenario, one of many that could be delivered by this platform. Orlando-based Intelligent Decisions entered the medical simulation space – and Clarence Pape, the company’s vice president for simulation and training, noted his company has one working prototype simulation product in development at the University of Central Florida and Baylor University. More information on the two prototypes will be made available to MEdSim at the end of first quarter 2014. M EDSI M M A G A Z I N E 1 . 2 0 1 4
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World News & Analysis for unusual or dangerous births – and actually see how a birth may take place before it has happened. The researchers are “creating a forward engineered simulation of childbirth using 3-D graphics to simulate the sequence of movements as a baby descends through the pelvis during labor,” according to Dr. Rudy Lapeer from UEA’s school of Computing Sciences is leading the project. “Users will be able to input key anatomical data – such as the size and shape of the mother’s pelvis, and the baby’s head and torso,” to set different scenarios for both the mother and baby. The simulation software will use ultra-sound data to re-create a geometric model of a baby’s skull and body in 3-D graphics as well as the mother’s body and pelvis. Programmers are taking into account the force from the mother pushing during labor and are modeling a ‘virtual’ midwife’s hands that can interact with the baby’s head. Simbionix Collaborating with Russian 1st MSMU to Enhance Laparoscopic Training – Simbionix USA Corporation, a provider of medical education and simulation training, signed a collaboration agreement with I.M. Sechenov First Moscow State Medical University (1st MSMU). MSMU developed and validated a comprehensive assessment and credentialing system based on the performance of tasks and cases on the Simbionix LAP Mentor™, a training simulator for laparoscopic procedures. Simbionix will develop the infrastructures to allow MSMU's scoring system to be integrated into the Simbionix MentorLearn – and the two will work together to provide a Russian-made clinical assessment tool to enhance the LAP Mentor capabilities for the Russian market. Weston College Opens Simulated Medical Treatment Room – Weston College in Weston-super-Mare, UK, opened a simulated medical Treatment Room to give Health and Social Care students the experience of hospital patient care. The £20,000-($32,000,US) treatment room includes two hospital beds, simulation mannequins, stethoscopes, pulsometers, a patient hoist and light boxes to show x-rays. 38
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University of Brighton Opens £250,000 Nursing Training Suite – The University of Brighton opened its Clinical Skills and Simulation Suite at the university's facilities at Westlain House, Falmer, UK. Students using the suite are taught a range of nursing skills to assess and care for the acutely ill and deteriorating patient. The students can be monitored and given instructions from a nearby studio during simulation exercises. The university has clinical suites at all of its locations – including Hastings, Eastbourne and Falmer, and plans to spend another £120,000 on a midwifery simulation suite at Eastbourne. medsim
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Trauma is the leading cause of death in people under the age of 45 . *
Control the Bleed Exposure to trauma simulation can help facilitate team training exercises, especially those including a need to perform rapid assessments and hemorrhage control interventions. Does your training program include simulation?
Visit us to learn more about how simulation-based education can support emergency medical training. * Centers for Disease Control and Prevention. (Aug. 29, 2012) Web-based injury statistics query and reporting system (WISQARS). In U.S. Department of Health and Human Services, CDC, National Center for Injury Prevention and Control. Retrieved from www.cdc.gov/injury/wisqars/index.html on September 23, 2013.
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The Way Healthcare Learns.
CAEH 18861 MEdSim Q1 2014.indd 1
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