MEdSim Magazine - Issue 2/2012 by Halldale Group

www.halldale.com The Journal for Healthcare Education, Simulation and Training MEDICAL SCHOOL EDUCATION AND TRAINING

A New Approach to Undergraduate Medical Education SURGICAL TRAINING

Enhanced Quality of Performance Through Surgical Simulation Simulation Centre

Transforming the International Healthcare Landscape

ISSN 2165-5367

US $7.50

Issue 2/2012

NextMed MMVR20 February 20 – 23, 2013 San Diego Marriott Mission Valley Hotel San Diego, California

Since 1992, the Medicine Meets Virtual Reality conference has nurtured collaboration between engineers, medical educators, and clinicians that has resulted in tangible progress in simulation, modeling, haptics, visualization, and related technologies.

Next year, the conference returns to San Diego, where it began, for its 20th gathering. The program will look to the future—just as it always has—but will also celebrate two decades of vision, innovation, and hard work.

Call for Presentations information at www.NextMed.com.

www.NextMed.com

Editorial Comment

Editor's Comment

our medical healthcare system has very publically become a statistic."

On the cover: The Ohio State University's new medical curriculum will produce a better equipped graduate. Image credit: The Ohio State University Medical Center.

Judith Riess Editor in Chief MEdSim Magazine

ISSUE 2.2012

past 13 years,

safety. On the contrary, it jeopardizes patient safety by creating an intimidating liability environment. Studies have consistently shown that health care providers are understandably reticent about discussing errors, because they believe that they have no appropriate assurance of legal protection. This reticence not only impedes systemic and programmatic efforts to prevent medical errors but impedes the sharing of practices that hospitals have implemented that have reduced medical errors and cost. There needs to be a systematic reporting system for sharing these “practices”. The Joint Commission Journal on Quality and Patient Safety, published monthly, might be one source to share “best practices” hospitals have implemented that improve patient safety and reduce cost. The Journal is a peer-reviewed publication dedicated to providing health care providers and quality and safety professionals with the information they need to promote the quality and safety of health care. Another avenue for sharing hospital “best practice” is to write an article for MEdSim publication. Individuals need to advocate for themselves within the healthcare system. To do this you must be well informed, ask pertinent questions and have on-going, two way communication with your healthcare providers. The very first principle of the Hippocratic Oath, which all doctors swear to, is: "First do no harm." We need to insist that our health care system adheres to that principle.

judith@halldale.com

MEdSim Magazine

" Over the

Over a decade has passed since the 1999 Institute of Medicine "To Err is Human” report brought public attention to errors that were occurring in hospitals and throughout the healthcare system. It reported that between 44,000 – 98,000 Americans died each year due to preventable medical errors in hospitals. With the latest numbers showing a higher percent of medical error, our progress seems to be... in the wrong direction. Joseph Stalin once said “One death is a tragedy; one million is a statistic.” Over the past 13 years, our medical healthcare system has very publically become a statistic! We should emphasize, the IOM report also stated that more than 90 percent of these deaths are the result of failed systems and procedures, not the negligence of physicians or other healthcare providers. Given this finding, we need to develop systems for improving the quality of our patientsafety practices, our medical education programs, and put in place assessment and evaluation criteria that ensure the competency of all healthcare providers, through the insertion of proved technologies such as simulation. Many institutions, organizations and individuals have already begun the transition of healthcare, however, an equal number, still fail to see hospitals, medical schools or private practices as part of an integrated system. Part of the problem lies in the fact that there are no national standards for hospital care, no national standards for the development of medical curriculum or in many cases even a standardized curriculum for oft repeated practices and procedures. Many efforts are underway to change the status quo but few have been completely integrated into the system. Each state has its own policies in place, and they vary widely. If we are to achieve a fair and equitable solution to this complex problem, all parties– physicians and other health care providers; hospitals, insurers, credentialing organizations and patients – must work together to improve patient safety. The current system does not promote open communication to improve patient

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CONTENTS

MEdSim Magazine The Journal for Healthcare Education, Simulation and Training 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 Pat Walker USA (West) t. 415 387 7593 e. pat@halldale.com Sales Representative Justin Grooms USA (East) & Canada t. 407 322 5605 e. justin@halldale.com Sales & Marketing Karen Kettle Co-ordinator t. +44 (0)1252 532002 e. karen@halldale.com Marketing Manager Mike Fitzgibbon t. +44 (0)1252 532008 e. mike@halldale.com Operations Design & David Malley Production t. +44 (0)1252 532005 e. david@halldale.com Distribution & Stephen Hatcher Circulation t. +44 (0)1252 532010 e. stephen@halldale.com Halldale Media Group Publisher & Andy Smith CEO e. andy@halldale.com US Office Halldale Media, Inc. 115 Timberlachen Circle Ste 2009 Lake Mary, FL 32746 USA t. +1 407 322 5605 f. +1 407 322 5604 UK Office Halldale Media Ltd. Pembroke House 8 St. Christopher’s Place Farnborough Hampshire, GU14 0NH UK t. +44 (0)1252 532000 f. +44 (0)1252 512714 Subscriptions 4 issues per year at US$25 t. +1 407 322 5605 t. +44 (0)1252 532000 e. medsim@halldale.com

10 21

06 03 Editorial Comment Editor in Chief Judith Riess discusses the rapidly evolving state of the art in medical education and introduces the community to MEdSim.

06 Medical School Education And Training

A New Approach to Undergraduate Medical Education. Daniel M. Clinchot, M.D. explains the steps taken and the guiding principles used to revise the Ohio State University Medical Undergraduate Curriculum, Lead. Serve. Inspire, and why it will produce a better equipped more effective physician.

10 US Army Simulation Center Training Initiatives

US Army Centralization and Standardization of Simulation-based Training. Dr. Shad Deering and Dr. Taylor Sawyer explain the Central Simulation Committees’ goals, foundation, program components and collaborative efforts to enhance training and simulation in the US military healthcare system

14 Simulation Center Assessment

ROI: What is it and does it really matter? Don Combs, Ph.D., Vice President and Dean of the School of Health Profession at Eastern Virginia Medical School, provides a groundbreaking examination of return on investment for expenditures in medical simulation.

18 INTERVIEW An Interview with Harry Robinson, National Program Manager, Simulation Learning, Education and Research Network (SimLEARN), Veterans Health Administration (VHA).

21 Surgical Training

MEdSim Magazine, printed January 2012, is published 4 times per annum by Halldale Media, Inc., 115 Timberlachen Circle, Ste 2009, Lake Mary, FL 32746, USA at a subscription rate of $25 per year. MEdSim is distributed in the USA by SPP 75 Aberdeen Road, Emigsville PA 17318-0437. Periodicals postage paid at Emigsville PA. POSTMASTER: send address changes to: Halldale Media Inc., 115 Timberlachen Circle, Ste 2009, Lake Mary, FL 32746, USA.

ISSUE 2.2012

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.

24 Command Profile

26 Simulation Centre

Command Profile: PEO STRI. The Orlando-based command’s Project Manager (PM) Combined Arms Tactical Trainers (CATT) with Assistant Project Manager (APM) of Medical Simulation (MEDSIM) is working “to put the power of simulations into the hands of our warfighters”.

Medical Simulation Centers Transforming International Healthcare Landscape. Sidra Medical and Research Center’s Clinical Simulation Center, will provide cutting edge training and patient safety for its Qatar-based learning audience, reports Group Editor Marty Kauchak.

28 News

Medical News. Updates from the medical community. Compiled and edited by the Halldale editorial staff.

MEdSim Magazine

www.halldale.com/medsim

Enhanced Quality of Performance through Surgical Simulation. Dr. Rajesh Aggarwal describes and discusses how healthcare professionals utilize simulation for practice and assessment of technical skills and procedures to enhance competency, improve transfer of knowledge, surgical performance and patient safety.

MEDICAL SCHOOL EDUCATION AND TRAINING

A New Approach to Undergraduate Medical Education Dr. Clinchot explains the steps taken and the guiding principles used to revise the Ohio State University Medical Undergraduate Curriculum, Lead. Serve. Inspire and why it will produce a better equipped more effective physician.

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MEDSIM MAGAZINE

ndergraduate medical education is undergoing a period of fervent curriculum renewal. Many forces such as global and national health disparities, rising cost of care without concomitant rise in quality and patient safety and the changing means by which care is delivered have come together to create a milieu that supports the need for change. Traditional methods of medical instruction have left graduates ill prepared to meet the Institute of Medicineâ&#x20AC;&#x2122;s expectations of providing care that is patient centered, effective, efficient, equitable and safe. The transition to the graduate medical educational environment has left many learners struggling to deal with the increased responsibility. In addition graduates describe difficulty dealing with uncertainty, patient relationships, and with the competencies required in a multi-professional care environment where patient care is a team rather than solo effort.1 These skill deficiencies coupled with the lack of continuity with patients and faculty

contribute to the observed movement away from careers that are focused on the longitudinal care of patients with undifferentiated complaints to more episodic management of patient problems at the subspecialty level. Longitudinal clinical educational experiences not only serve to benefit the learner but also their future patients by making medical education more effective and efficient.2 The tenants of any future curriculum renewal should include core themes of multi-modal learning, scientific inquiry and critical thinking, service learning, trans-disciplinary team work and self-directed learning and assessment. Many of these skills cannot be learned through classroom activities, by episodic encounters with a variety of clinicians and for that matter through episodic encounters with a variety of patients. Instead, they must be nurtured and coached by an expert clinician who works with the learner over time to help them develop the requisite skills. Furthermore, these skills cannot be learned independent of clinical context. For

Above The Ohio State University ensures that their graduates are better equipped to face the challenges of medical practice. Image credit: The Ohio State University.

example, it is difficult for the learner to really understand the longitudinal management of patients with chronic disease if the clinical context is a four week clerkship. This is especially true when we consider the development of critical thinking skills in the venue of clinical reasoning and problem solving. A model critical thinker will continually analyze, assess and improve upon the process by which they are applying information through reasoning and problem solving in a clinical contextual framework. At the Ohio State University College of Medicine we have redesigned our curriculum to include an early longitudinal immersion coupled with a linked longitudinal curriculum that supports the development of these skills. The desired outcome being a graduate

Longitudinal and integrated clerkships have been shown to be both feasible and effective. Longitudinal experiences enhance student satisfaction and reduce the impact of the hidden curriculum that acts to erode student empathy.3 Interestingly, longitudinal integrated clerkships have also been shown to increase the number of students selecting primary care residencies.4 In a focused longitudinal family medicine clerkship experience student interaction with patients over a longer period of time has lead to improvements in multiple measures of patient satisfaction.5 Students who participate in longitudinal care experiences report an enhanced understanding of illness and disease management by seeing the same patient at the time of presentation and through different stages of disease management.6 Early contact with preceptors in a clinical environment in undergraduate medical education has been shown to improve motivation to learn foundational science material. In addition early clinical exposure is associated with improved student confidence during the clinical encounter. Unfortunately preceptors often view this experience as increasing their workload with little if any additional support.7 Thus creating a framework where students can meaningfully contribute within the practice setting can act to mitigate some of the increased workload.

In the Lead.Serve.Inspire curriculum, all learners participate in a longitudinal practice based experience, which begins shortly after entry into medical school. This model was originally piloted in a small group of 12 students that expanded to 100 students the following year. The early pilot feedback helped us to create a design that models an early servicelearning hybrid environment for students. This is accomplished by having the students undergo intense skills based training that allows them to function as contributing members of the health care team. This model highlights the learning of skills from all members of the team in service to the patient whose health issues will shape their education. Modeled after the Utah School of Medicine the procedure based training includes skills such as: rooming the patient, taking vital signs, venipuncture, blood glucometry, spirometry, pulse oximetry, basic wound care/dressing changes, electrocardiogram, urine dipstick, ppd placement, rapid strep, throat culture, injections and vaccinations. Students will also receive training in the use of the electronic medical record, basic medical history taking and physical examination prior to beginning their longitudinal practice experience. Satisfactory performance in a competency based objective structured clinical exam (OSCE) ensures that students have the requisite skill level prior to participating in the experience. During the longitudinal practice experience students will empanel patients with key predetermined diagnoses and

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Figure 1: Curricular Outline.

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who is measurably better-equipped to face the challenges of medical practice today and well into the future. The Lead.Serve.Inspire curriculum at the Ohio State University College of Medicine was designed from a set of competency based core educational objectives developed by a multi-professional team that included physicians, foundational scientists, students, residents, program directors, patients, nurses, systems specialists, quality officers and pharmacists. Hallmarks of this curriculum include: • Reinforcing foundational science (basic sciences, behavioral/social sciences & the science of quality and patient safety) throughout the curriculum • Early meaningful clinical service-learning experiences • Emphasis on multi-modal learning, critical thinking skills and scientific inquiry • Preparing students to work in complex systems of care and to develop the ability to advocate for patients within these systems • Competency based evaluation and assessment The Lead.Serve.Inspire curriculum is a three part four year curriculum (Figure 1) that infuses foundational science throughout all three parts. Curricular content is presented in an integrated fashion enabling students to learn foundational science content in association with the clinical contextual framework. Thus learners build the structural foundation of basic and behavioral science in a way that overlays the clinical framework creating integrated building blocks. In Part 1 of the curriculum teams of foundational scientists and clinicians develop a content delivery framework that combines different learning methods with exemplar disease states. For example, in week 6 of the curriculum (Figure 2) the central foundational science concept is membrane transport. The exemplar clinical conditions are Cystic Fibrosis and Cholera, each representing dysfunction of chloride ion transport. Early in the week learners interact with the foundational science content through lectures, e-learning technologies and readings. Throughout the rest of the week students are exposed to the associated epidemiologic concepts, behavioral social science concepts and clinical context in a way that makes the content seamless. This design is carried throughout all aspects of Part 1.

MEDICAL SCHOOL EDUCATION AND TRAINING ISSUE 2.2012 MEDSIM MAGAZINE

behavioral/social science problems. Students will learn the empanelled patient case history well enough to be able to discuss the patientâ&#x20AC;&#x2122;s presentation and management in a facilitated small group setting. Therefore the longitudinal practice based experience will be linked with a longitudinal small group that is longitudinally facilitated by a clinical faculty member. The small group sessions will function to ensure: 1. Linkage of practice based clinical context with the foundational science concepts learned throughout the first and second year through case based presentation and discussion. Exemplar cases will be used to demonstrate the prototypical case presentation and management. Then students will discuss the way their empanelled patient was managed. This will not only highlight the reasoning associated with the variability in management but also depending on the studentsâ&#x20AC;&#x2122; clinical assignment (free clinic, community health center, private practice primary care etc.) bring forth health care systems, health care disparities and equitable care into the discussion. 2. Faculty guided progressive development of the knowledge, skills, attitudes and behaviors that are required of a graduate who is ready to fully participate in post-graduate training. 3. Faculty guided development of clinical reasoning and critical thinking skills. In Part 2 of the curriculum, longitudinal small group sessions continue so that students can work on longitudinal skill development, critical thinking and clinical reasoning and problem solving. This is accomplished by the development of small group case based discussions that include foundational scientists and clinicians. The translational application of scientific discoveries is integral to these discussions. Through this process students learn to apply scientific advances to patient care. Part 2 of the Lead.Serve.Inspire curriculum joins clinical disciplines in 4 month thematic experiences (Figure 3). Each of these three components of Part 2 starts out with a week-long ground school that delivers advanced foundational science concepts, building upon content already covered in Part 1. During the clinical immersion experiences learners take advantage of point-of-care technology to ensure that patients receive care that is safe, effective and evidence

Figure 2: Sample Week 6 of the Curriculum.

based. For example, utilization of i-touch technology at the bedside can have a significant impact on student learning and patient education. In addition students use mobile devices to document procedures and track performance. For example a direct observation mobile application allows faculty supervisors to directly input their observations of learners in the clinical environment so that it is available to the student, faculty coach and course directors. Learners in Part 2 will maintain contact with their assigned longitudinal practice from Part 1 by continuing to follow the management of their empanelled patients through the use of the electronic medical record. In addition Part 2 learners will mentor the students who took over for them in the practice, relieving the individual practices of this time intensive responsibility. Uniquely designed and building upon Parts 1 & 2, Part 3 of the Lead. Serve.Inspire curriculum will allow learners to develop advanced skills based competencies and advanced clinical competencies. Learners will have exposure to Advanced Management in Hospital Based Care through combined clinical experiences in emergency medicine and a sub-internship. They will also have exposure to Advanced Management in Ambulatory and Relationship Centered Care through experiences in ambulatory internal medicine and the management of patients with long-term needs. Throughout all three parts of the

Lead.Serve.Inspire curriculum an educational portfolio will serve as a basis for individual student coaching by a faculty member. Students will develop a four year relationship with their faculty coach who will guide them in the process of educational goal setting, reflective practice, and self-assessment. The longitudinal nature of this relationship is designed to facilitate the learnerâ&#x20AC;&#x2122;s ability to critically assess their own performance through the use of objective data and with this assessment create a clear path to improving performance. Longitudinal project work is another unique characteristic of the Lead.Serve. Inspire curriculum. Longitudinal projects will occur throughout various parts of the curriculum. The Community Health Education project will empower the learner with the skills needed to complete an effective needs assessment in order to determine the educational needs of a community of patients within their longitudinal practice. After the needs assessment the students will work in teams to develop a patient education program that will serve the need that was previously identified. Ideally this will benefit not only the patients but also the practice caring for these patients. The Longitudinal Health Coaching project involves learners being taught how to act as effective health coaches. Once students successfully demonstrate the requisite competency in health coaching they will be linked with a patient who has a chronic disease that is not well controlled. The learner will work with this patient over the course of an entire year to develop

criteria. Learners are expected to meet developmentally appropriate milestones by key branch points within the curriculum. Learners who are not able to demonstrate competency at these points will be required to remediate. The core educational competencies are not compensatory. Therefore learners will be unable to offset deficiencies in one domain by strengths in others. This approach to evaluation and assessment will enable those who receive graduates from our program to be confident in the skill level of these individuals. The Lead.Serve.Inspire curriculum strives to create a unique and comprehensive learning environment for future physicians. The development of longitudinal relationships with faculty who can attest to the learner’s skills and help guide them in the achievement of competencies assures consistency among graduates. In addition multimodal and competency based education and assessment provides a framework that the learners can carry with them into competency based graduate medical education. Continuous themes of quality and patient safety as well as critical thinking and scientific inquiry facilitates the ability of learners to bridge the gap of foundational science and clinical science. Learning the skill of valid self assessment and remediation strategies creates a practical understanding of continuous improvement within the learner. All recognizable characteristics of an effective physician. medsim About the Author Dr. Daniel Clinchot, an associate professor with tenure in the Department of Physical Medicine and Rehabilitation earned his MD degree at the Health Sciences Center at Syracuse of the State

University of New York and served an internship in internal medicine and a residency in physical medicine and rehabilitation at Ohio State University Medical Center. Dr. Clinchot is the Associate Dean for Medical Education in the College of Medicine. He has been recognized for excellence in teaching at the undergraduate and graduate levels of medical education. Dr. Clinchot has led a tremendous team effort to re-envision the undergraduate medical curriculum within the College of Medicine. References 1. Brennan N, Corrigan O, Allard J, Archer J, Barnes R, Bleakley A, Collett T, deBere S: The transition from medical student to junior doctor:today’s experiences of tomorrow’s doctors. Medical Education 2010;44:449-458 2. Irby, DM: Educational Continuity in Clinical Clerkships. N Engl J Med

2007:356(8);856-857 3. Bell S, Krupat E, Fazio S, Roberts D, Schwartzstein R: Longitudinal Pedagogy: A Successful Response to the Fragmentation of Third-Year Medical Student Clerkship Experience. Acad Med. 2008;83:467-475. 4. Norris T, Schaad D, DeWitt D, Ogur B, Hunt D: Longitudinal Integrated Clerkships for Medical Students: An Innovation Adopted by Medical Schools in Australia, Canada, South Africa and the U.S. Acad

Med. 2009;84(7):902-907. 5. Prislin MD, Morrison E, Giglio M, Truong P, Radecki S: Patients’ Perceptions of Medical Students in a Longitudinal Family Medicine Clerkship. Fam Med 2001;33(3):187-91. 6. Mihalynuk T, Bates J, Page G, Fraser J: Student learning experiences in a longitudinal clerkship programme. Medical Educa-

tion 2008; 42:729-732. 7. von Below B. Hellquist G. Rodjer S. Gunnarsson R. Bjorkelund C. Wahlqvist M: Medical students’ and facilitators’ experiences of an early professional contact course: active and motivated students, strained facilitators. BMC Medical Education. 2008;8:56

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Figure 3: Part 2 Clinical Immersions.

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healthy behaviors in the context of their chronic disease that will allow them to be more successful in their chronic disease management. The Quality and Patient Safety project occurs throughout all four years of the curriculum. Learners work in an inter-professional manner to understand the tenants of systems thinking and apply these concepts to quality and patient safety. The inter-professional group works on a culminating patient safety project that will utilize a medical informatics-Electronic Health Record interface. That will help with assessing potential risk but also be utilized to determine the effectiveness of their intervention. Students gain a true understanding of quality and patient safety as a team effort both in identification of concerns and the implementation of effective mechanisms to prevent poor outcomes. Another key feature of the Lead. Serve.Inspire curriculum is the use of simulation as a means to deliver curricular content in an interactive fashion. For example, in the small group setting learners work through exemplar patients portrayed in a standardized fashion. Prior to working with the standardized patients in small group, learners independently work through medical history taking and doctor patient relationship challenges by interviewing virtual patients. The interface of student voice recognition and artificial intelligence associated with a real-life avatar that can react physically in ways that are appropriate to the context enables students to practice their skills in a low stakes interactive environment. In Parts 2 and 3 of the curriculum use of a simulated operating room, trauma bay, delivery room and hospital room experiences, allow students experience to work through difficult and challenging scenarios in a high fidelity environment. Digital recording allows learners to debrief the interaction in a fashion that identifies domains of excellence and domains of difficulty. Working with the faculty coach, learners develop specific plans to improve performance. These types of environments also allow learners to clearly demonstrate competencies before doing more advanced work in the clinical environment. Evaluation and assessment is an integral component of the Lead. Serve.Inspire curriculum. Learners are assessed over time with multi-modal measures that have competency based

US Army Simulation Center Training Initiatives

US Army Centralization and Standardization of Simulation-based Training Dr. Shad Deering and Dr. Taylor Sawyer explain the Central Simulation Committees’ goals, foundation, program components and collaborative efforts to enhance training and simulation in the US military healthcare system.

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MEDSIM MAGAZINE

ources of simulation-based medical education in the U.S. Army today include the Army Medical Department (AMEDD) Center and School, which provides oversight of nursing simulation and policies, the Medical Simulation Training Centers (MSTC) that are responsible for all Army medic simulation training, and the Central Simulation Committee (CSC) which provides centralized oversight and support of graduate medical education (GME) simulationbased training and simulation-based redeployment training for physicians returning from the wars in Iraq and Afghanistan. The goals of the CSC are to create and implement standardized simulation-based curricula for resident education in the Army, provide a program for the redeployment training of physicians, and to improve patient safety throughout the AMEDD. In this report, we will describe the development, structure, accomplishments, and future vision of the CSC.

Development of the CSC

Above

The concept of a central committee to oversee and support GME and redeployment simulation-based training throughout the AMEDD was first proposed at the Uniformed Services Joint Service Selection Board in 2006. Following that presentation, a model for a ‘Central Simulation Committee’ was briefed to the Office of the Surgeon General (OTSG) in March 2007. The model was developed to overcome several of the challenges identified by individuals at medical treatment facilities (MTFs) conducting SBME at that time which included: challenges obtaining funding to purchase simulation equipment, difficulties with program sustainment in the face of frequent duty assignment changes and deployments, lack of validated curriculum for specific subspecialties, and limited administrative support. The mission of the CSC is to, “be a worldwide leader in managing and directing multi-disciplinary simulation training to enhance GME, assist in redeployment training, and improve patient safety.” Funding for the CSC was first

Residents at Madigan engaged in Mobile Emergency Simulation (MOES) exercise developed by Shad Deering, MD, USA. Image credit: Dr. Shad Deering.

approved by the OTSG in April 2007 for an initial equipment purchase of $2.88 million. Since that time, funding for the CSC has been appropriated yearly through the OTSG with an estimated annual operating budget of around $1.5 million.

Structure of the CSC The governance of the CSC consists of both central and local oversight and support. Leading the CSC is the CSC Chairman who is assisted by the CSC Administrative Staff, located at the Anderson Simulation Center in Fort Lewis, Washington. The CSC Administrative Staff is comprised of a Chief Administrator, an Information Technology Support Technician, an Educator, and a Research Scientist. Each medical subspecialty has an assigned Simulation Specialty Advi-

Figure 1. Central Simulation Committee (CSC) Simulation Centers

* *

** * *

** *

Table 1. Simulation Center Space and Training Volumes Current Space (sq ft) Number Trained, 2009 Number Trained, 2010 FBACH 500 1,092 1,013 MARTIN 520 713 1,496 WAMC 585 560 642 CRDAMC 780 1,523 4,731 TAMC 1,050 1,076 1,064 EAMC 1,200 3,162 5,366 BAMC 1,750 6,262 5,967 WBAMC 2,000 1,186 2,461 WRNMMC 5,000 2,442 2,607 MAMC 8,000 6,308 5,222 Total 21,385 24,324 30,569 Fort Belvoir Army Community Hospital (FBACH), Martin Army Community Hospital (MARTIN), Womack Army Medical Center (WAMC), Carl R. Darnall Army Medical Center (CRDAMC), Tripler Army Medical Center (TAMC), Eisenhower Army Medical Center (EAMC), Brooke Army Medical Center (BAMC), William Beaumont Army Medical Center (WBAMC), Walter Reed National Military Medical Center (WRNMMC), Madigan Army Medical Center (MAMC)

Accomplishments of the CSC One of the primary goals of the CSC has been to standardize SBME in Army GME programs. To accomplish this, each CSC Specialty Advisor has worked to create a core set of simulation scenarios that comprise a standardized, simulationbased, educational curriculum for their respective specialty. The scenarios were chosen after consultation with providers and residency directors in the specialties and include cases of importance for the specialty. Efforts were made to encourage and facilitate coordination between specialties where overlap is present in order to avoid duplication, and leverage simulation scenarios already developed by one specialty that are applicable to another. For standardization purposes, each simulation scenario follows a standardized CSC format that was developed and agreed upon by the members of the

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have been increasing on an annual basis. In the past two years, CSC Simulation Centers have trained over 50,000 Army medical students, residents, physician assistants, nurses, enlisted Soldiers and DoD civilian medical personnel. A table with the dedicated square feet and number of personnel trained in 2009 and 2010 at each of these CSC Simulation Centers can be seen in Table 1. Each CSC Simulation Center works to focus on the individual educational needs of its MTF, based on the types of training programs located there while taking into account local Army training requirements. The majority of defined training courses offered within CSC Simulation Centers are targeted at GME, involving medical residents from various specialties. A list of the GME programs supported at each MTF is provided in Table 2.

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sor who is appointed by their respective consultant to the Army Surgeon General. Presently, 14 medical specialties are represented on the CSC including: Anesthesia, Dermatology, Emergency Medicine, Family Medicine, General Surgery, Internal Medicine, Obstetrics/Gynecology, Orthopedics, Ophthalmology, Otolaryngology, Pathology, Pediatrics, Psychology and Urology. In addition to the medical Specialty Advisors, the CSC also includes advisors from the Army Nurse Corp, the Uniformed Services University of Health Sciences, the Army MSTC (Medical Simulation Training Centers) program, and the Director of Medical Education (DME) from each of the 10 MTFs with CSC Simulation Centers. At the individual MTFs, CSC members include the DME, Residency Program Directors (PDs), the Simulation Center Director and the Simulation Center Administrator. Some simulation centers also have a Surgical Director and a dedicated Simulation Technician, depending on the specialties covered and training volume. The individual DMEs are responsible for choosing the Simulation Center Directors at the MTF level. All Simulation Center Directors are active duty military physicians, and are required to have at least 0.25 fulltime equivalents (FTEs) dedicated to the Simulation Center in order to fulfill their duties. The CSC Simulation Center Director and Administrator are members of the MTFâ&#x20AC;&#x2122;s graduate medical education committee (GMEC) and local oversight is provided by the DME and GMEC. The CSC currently has Simulation Centers in all 10 Army MTFs that house residency training programs. These include: Brooke Army Medical Center (BAMC), Carl R. Darnall Army Medical Center (CRDAMC), Eisenhower Army Medical Center (EAMC), Fort Belvoir Army Community Hospital (FBACH), Madigan Army Medical Center (MAMC), Martin Army Community Hospital (MARTIN), Tripler Army Medical Center (TAMC), Womack Army Medical Center (WAMC), William Beaumont Army Medical Center (WBAMC) and the Walter Reed National Military Medical Center (WRNMMC). The size of the Simulation Centers varies from 400 sq ft to 8,000 sq ft. In total, the CSC oversees over 21,000 sq ft of simulation center space within the continental United States and Hawaii. Training volumes vary across the 10 centers, and

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US Army Simulation Center Training Initiatives

Table 2. Central Simulation Committee (CSC) Medical Treatment Facilities and Residency Training Programs Served

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Anesth Derm

FM Gen Surg IM

OB/Gyn Ortho

Ophth

Otol

Path

Peds

Psych

Uro

FBACH X MARTIN X WAMC X X CRDAMC X X TAMC X X X X X X X EAMC X X X X X BAMC X X X X X X X X X X X X WBAMC X X X WRNMMC X X X X X X X X X X X X X MAMC X X X X X X X X X X Fort Belvoir Army Community Hospital (FBACH), Martin Army Community Hospital (MARTIN), Womack Army Medical Center (WAMC), Carl R. Darnall Army Medical Center (CRDAMC), Tripler Army Medical Center (TAMC), Eisenhower Army Medical Center (EAMC), Brooke Army Medical Center (BAMC), William Beaumont Army Medical Center (WBAMC), Walter Reed National Military Medical Center (WRNMMC), Madigan Army Medical Center (MAMC). Anesthesia (Anesth), Dermatology (Derm), Emergency Medicine (EM), Family Medicine (FM), General Surgery (Gen Surg), Internal Medicine (IM), Obstetrics/Gynecology (OB/Gyn), Orthopedics (Ortho), Ophthalmology (Ophth), Otolaryngology (Otol), Pathology (Path), Pediatrics (Peds), Psychology (Psych), Urology (Uro).

CSC in 2007. All CSC simulation scenarios and specialty curricula are internally peer reviewed by the CSC Specialty Advisor, educators within the specialty, and the CSC Educator. In addition, some scenarios have been externally peer reviewed and published through services such as MedEdPORTAL.1 At present, the CSC has over 60 simulation scenarios available for use. All CSC simulation scenarios and specialty curriculum are available on the internet through a secure Army Knowledge Online website. Electronic grading forms have been developed for several specialties to facilitate centralized data acquisition and allow program directors to track performance and provide real-time feedback to trainees. In addition to the standardized simulation scenarios, some specialties have also developed procedural skills training modules.2 In order to support the simulation curricula of the various subspecialties, each CSC Simulation Center is provided with a centrally funded, standardized, and specialty specific Simulation Packages (SP). Each SP includes a group of simulation equipment (task trainer, manikins, virtual reality trainers, etc.) to be used for a particular specialty. The simulators included in the initial SPs were chosen at the CSC annual meeting in 2007, when the CSC Specialty Advisors evaluated available simulators and chose items that would support the core curriculum they were developing, provide reasonable fidelity for the assigned task, and would be able to be used by multiple specialties. This central pur-

chasing and distribution was done to save money by avoiding duplicate purchases. It has had the additional benefit of creating an SP that has been used to upgrade CSC sites that have added GME training programs since 2007. At present, minor equipment purchases and distribution takes place on an ongoing basis at a local level directed by simulation educator requests within the CSC and at the individual MTFs. The five-year life-cycle replacement for the initial SPs purchased in 2007 is planned for FY 2012. New SPs will be created and then purchased for each of the specialties. Simulation-based redeployment "refresher" training for military medical providers returning from duty in Iraq and Afghanistan is available at MTFs with CSC Simulation Centers. The same curricula and equipment used for GME are available for the returning staff physicians. Current OTSG Policy (09-078), published in September 2009, formalizes the process for assessing the needs of providers and offering refresher training after deployment. When providers return to their hospital, they meet with their Department Chair and discuss what, if any, refresher training they feel is needed. Each provider is contacted by the CSC and given an information packet about the policy with contact information for any questions and sent an online survey asking about their deployment experiences both when they return and approximately 6 months later. Within this OTSG policy information packet is an overview of

what simulation-based training is available at CSC Simulation Centers and points of contact within the CSC who can coordinate simulation-based redeployment training. The CSC is dedicated to improving the science of simulation, and is actively involved in simulation-based medical research. Since 2002, members of the CSC have published 40 articles in peerreviewed journals on medical simulation. The majority of these publications are original research, reporting results of rigorously conducted evaluations of simulation training methodologies and/or the validation of simulation trainers/technologies. Additionally, members of the CSC have authored, or co-authored, several book chapters. As of FY2011, members of the CSC have received and managed over $8.13 million in grants and external funding for simulation-based training and research and the CSC currently has several large-scale, multi-center, ongoing research projects. Currently underway are a multisite validation study of a new laparoscopic nephrectomy simulator, a multi-site study on the retention of pediatrics resuscitation skills by residents, and a multi-center investigation of laparoscopic skills before and after military deployment. In order to encourage simulationbased research within the AMEDD, the CSC has included a Simulation Research Forum at the annual CSC meeting. Presentations are solicited and accepted from any AMEDD personnel conducting simulation-based research, and the investigators do not have to be members of

received Accreditation by the American College of Surgeons (ACS), and 20% have received Accreditation by the Society for Simulation in Healthcare (SSH) Council for Accreditation of Healthcare Simulation Programs. This year, two additional CSC centers have submitted accreditation packets to the SSH and one has submitted a packet to ACS. Strategic plans for the CSC include a goal of 100% accreditation of all CSC Simulation Centers by 2013.

the CSC. Submissions and presentations are judged and the CSC grants a CSC Research Award, including a stipend for the winner to travel to a national meeting to present their research. The CSC has also encouraged MTFs to support local simulation research by including awards for outstanding simulation research at MTF research competitions.

Vision of the CSC

Conclusion

Dr. Taylor Sawyer conducting in-situ simulation training with pediatric residents in the Neonatal Intensive Care Unit at Tripler Army Medical Center. Image credit: Author.

and debriefing in simulation (2009), simulation curriculum development (2010), and simulation evaluation tool design and validation (2011). In addition, the CSC Faculty Development Day is approved for American Medical Association Physician's Recognition Award (AMA PRA) Category 1 credits through the U.S. Army Medical Command Continuing Medical Education (CME) Office. On a local level, several of the CSC Simulation Centers have developed faculty development courses that are offered on a regular basis to build and sustain internal simulation educators. The CSC is currently working to develop a standardized simulation educator course. Additionally, the CSC is collaborating with the Uniformed Services University of the Health Sciences (USUHS) and the Naval Postgraduate School in Monterey, California to create a postgraduate course in advanced medical simulation. Key to the mission of the CSC is to validate the quality of the education provided within its Simulation Centers. In order to do this, the CSC has placed an emphasis on application for accreditation by its individual Simulation Centers. As of 2011, 10% of the CSC Medical Simulation Centers have

The views expressed in this manuscript are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government. References 1. Hemann B, Hall N, Mikita J. Surviving Simulated Sepsis. MedEdPORTAL; 2010. 2. Sawyer T, Creamer K, Puntel R, Lin J, Steigelman D, Lopreiato J, et al. Pediatric

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Above

In this report we have described the development, structure, accomplishments, and future vision of the CSC. We hope this report provides simulation educators within the military, and our civilian simulation colleagues, insight into the workings of our organization. The CSC was established to provide a central and standard approach to implement simulation-based curricula for resident education in the Army, provide a program for simulation-based redeployment refresher training of physicians, and improve patient safety throughout the AMEDD. Although the CSC has made great progress towards many of these goals, there is still a significant amount of work that remains to be done, and research is needed to define the impact of the CSC on patient safety within the AMEDD. Building on the momentum the CSC has generated, and working with our civilian colleagues in academia, the CSC will continue to work to optimize the training our centers provide and improve patient safety both within and outside the AMEDD.

Procedural Skills Training Curriculum. Med-

EdPORTAL; 2010. 3. Deering SH, Rosen MA, Salas E, King HB. Building team and technical competency for obstetric emergencies: The Mobile Obstetric Emergencies Simulator (MOES) System.” Sim in Healthc. 2009;4:166-173.

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The vision of the CSC is to ensure that all Army providers are, “trained, competent, safe, and ready to care for our Soldiers and their families.” Since its inception, the CSC has been involved in numerous performance improvement activities and patient safety initiatives throughout the AMEDD. One example is the Mobile Obstetric Emergencies Simulator (MOES).3 This manikin-based simulation system includes a birthing manikin and integrated software program used to display a fetal strip. The system can be used to conduct simulation training in multiple common obstetric emergencies including shoulder dystocia, post-partum hemorrhage, and eclamptic seizure. The MOES includes a standardized curriculum, debriefing system, objective grading forms, and integrates TeamSTEPPS® concepts in order to identify and address actual individual, team, and system issues that arise during training. The MOES was recognized with the 2007 Patient Safety Award from TRICARE Management Activity and the CSC was given funding to propagate the program (which included funding to train a physician and nurse from each institution and also purchase the equipment for each MTF) to all 54 MTFs within the Army, Navy, and Air Force that provide obstetric care. The CSC recognizes the importance of faculty development and has a program in place to train simulation educators, operators, and facilitators. Each year at the annual CSC meeting there is a Faculty Development Day. The goals of the CSC Faculty Development Day is to allow simulation educators to become familiar with the simulation equipment available within the CSC Simulation Centers and improve the quality of simulation-based training in the AMEDD. In past years, topics presented at the CSC Faculty Development Day have included; facilitating

Simulation Center Assessment

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he emerging discipline of Modeling and Simulation (M and S) offers substantial opportunities to improve professional training in health care. The predominant training model in the medical and health professions remains a centuries-old pedagogical combination of lectures, small group discussions, and apprenticing, wherein learners with uncertain competence practice on real patients under the supervision of more experienced mentors. In this model, learning and mistakes occur in real time and affect real patients. The use of simulation in its various training manifestations is growing and offers a new paradigm for providing medical training across many contexts. A paradigm where trainees practice cognitive decision-making and procedural techniques deliberately, in simulated health care settings, and achieve competence, if not mastery, before they encounter real patients has great appeal. Rosen and others (2012) elaborated on this point in the MEdSim issue 1, 2012.

Most educational institutions and many hospital systems that train medical and health professionals are exploring the use of M and S technology. They think that it can facilitate effective training that reduces costs, reduces the use of animals and live tissue training, and minimizes risks over the range of professional and organizational practice. The promise of M and S is great, as attested through many other articles in MEdSim and the broader literature on medical simulation. If more tangible proof of the increasing enthusiasm for medical simulation is needed, the growth of medically oriented exhibits and attendees at the 2011 I/ITSEC and 2012 IMSH conferences for the simulation community should suffice. About 80 medical simulation organizations exhibited at each conference and the breadth of available simulators was stunning, as was the ever-growing number of conference attendees. That said, it is reasonable to ask for evidence that a new approach, such as simulation, is effective in fulfilling training objectives and, once

Above Eastern Virginia medical student reviews patient history in simulation center. Image credit: Author.

implemented, is more cost-effective than current or other approaches to training. M and S technologies represent a significant investment of capital, time, and other resources, and not all M and S training systems yield the same results. The increasing reliance on M and S technologies as an alternative approach to medical training makes it essential that we be able to assess the expected return on investment (ROI) in the context of specific training objectives and, conversely, to facilitate the design of training systems that yield the best ROI within given cost and resource constraints. ROI is a summary performance measure used to evaluate the efficiency of an investment and to compare the relative efficiencies of different investments. For example, if the ROI is 50 percent for one investment

and 75 percent for another, the presumption is that the second investment is more efficient, that is, better. The basic formula for calculating ROI is: Gain from Investment ROI = x 100 Cost of Investment Although the concept appears to be straightforward, the implementation of the calculus in a particular setting, with multiple stakeholders and value judgments is, or can become, complicated. Jack Phillips provides a comprehensive, yet not too complex, discussion of ROI in his 2003 book, Return on Investment in Training and Performance Improvement Programs. He describes the process of calculating ROI as a fifth level of the evaluation framework that has been widely accepted in the education and training domains since first published by Kirkpatrick in 1959. This framework, as modified by Phillips, has five levels of evaluation that range from the basic “How do you feel about the training?” to the comprehensive evaluation of ROI that is shown in Table 2. The evaluation process is not really complete until ROI is calculated. The basic ROI model as explained by Phillips (2003) involves the conversion of a variety of evaluation criteria into monetary terms as shown in Table 2. The challenge is, of course, immediately apparent. For the model to work correctly, a multitude of measures of satisfaction, learning, performance in practice, and effective-

Table 1: Definitions of Evaluation Levels Level 1. Reaction and Planned Action

Brief Description Measures participant’s reaction to the program and outlines specific plans for implementation.

2. Learning

Measures skills, knowledge, or attitude changes.

3. Application and Implementation

Measures changes in behavior on the job and specific applications and implementations.

4. Business Impact

Measures business impact of the program.

5. Return on Investment Compares the monetary value of the results with the costs for the program, usually expressed as a percentage. ness in the business of providing health care have to be converted appropriately to dollar values and the measures have to be isolated from the influence of other environmental factors. Therein is the rub of calculating ROI: How sensible is the conversion of multiple variables, some quantitative and some qualitative, and how confident are the users in the conversion process? The balance of this article provides an overview of M and S within the medical context and of the most common methods of calculating the ROI of simulations. (The term simulation is intended to incorporate a training event that employs one or more simulators as a means to fulfill training objectives—that is, the calculus of a ROI may include the costs of one or more individual simulators.)

What is Medical Simulation and What are its Attributes? A model is a physical, mathematical or logical representation of a system,

entity, phenomenon, or process. A simulation is the implementation of a model over time. The U.S. Department of Defense (DoD), possibly the world’s largest user of simulation, has established three classes of simulation – virtual, constructive, and live. Virtual simulations represent systems both physically and electronically – think Wii and Kinect games. Constructive simulations represent systems through mathematical and decision-based modules, think computer programs with drop-down menus. Live simulation uses real people and machines. Although this widely accepted schema is helpful, most readers will find Chakravarthy’s (2011) categorization of five types of medical simulation to be more helpful: • Standardized Patients (real actors who simulate medical conditions and scenarios); • Partial-task Trainers (devices that simulate tasks such as insertion of catheters and endoscopic procedures);

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Table 2: ROI Model

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• Mannequins (high fidelity, computerbased patient simulators); • Screen-based Computer Simulators (video games focused on medical issues); • Virtual Reality Simulators (a combination of all of the above within a specified context – that is, an operating room, a battlefield setting, etc.) Achieving wide consensus on an agreed-upon taxonomy of medical simulations is not merely an academic exercise. Determining the ROI of medical modeling and simulation begins with assigning a simulation to a category that is being investigated. All simulations share a broadly comparable set of core cost factors, benefits, system capabilities and metrics. Each category, however, also contains a set of costs, benefits, system capabilities, and metrics unique to that class of simulation. Such a schema enables fair comparisons of simulations within a specific class, such as comparing one part-task trainer to another, and comparisons across simulation classes, e.g., determining whether virtual patients are more efficient than standardized patients. Identifying the category of a medical simulation (and thus its attributes) is an important step in the calculus of ROI. Gaba (2004) developed a description of medical simulation applications that consists of eleven categories. The applications described by Gaba (including parenthetical examples of some of the dimensions of each application category) are: • Aims and Purposes of the Simulation Activity (education, training, performance assessment, clinical rehearsal, research); • Unit of Participation (individual, team); • Experience Level of Participants (college, continuing education) • Health Care Domain (procedural-surgery, dynamic high hazard ICU); • Professional Discipline of Participants (physician, nurse, physician assistant); • Type of Knowledge, Skill, Attitudes or Behaviors Addressed (decision-making, technical skills); • The Simulated Patient’s Age (neonates, elderly); • Technology Applicable or Required (see Chakravarthy, 2011); • Site of Simulation (home, work unit); • Extent of Direct Participation (remote viewing, immersive participation)

• Method of Feedback Used (none, contemporaneous, video-based post hoc) A modified version of Gaba’s applications might be used to specify the relevant attributes of a simulation that can then be assigned a weighted value for the purposes of determining ROI.

How is ROI Calculated? A comprehensive model for calculating ROI requires making a value judgment on a variety of attributes such as those described by Gaba and those other factors included in Table 2. In the terminology of analysis, this involves using a Multi Attribute Decision Making (MADM) model. That is, the method for calculating ROI has to allow for the systematic weighting of a broad variety of attributes. Although there are numerous MADM models to choose among, the three most commonly used are Simple Additive Weighting (SAW), the Analytical Hierarchy Process (AHP) and the Technique for Order Preference by Similarity to Ideal Solution (TOPSIS). Each method begins with the specification of the criteria that will be used to evaluate the simulation. Subject matter experts (SMEs) such as physicians, nurses, and educators need to determine the specific criteria that are appropriate for the evaluation of a particular simulation. In an organization, there are multiple stakeholders, each with a different perspective that needs to be taken into account. One way of conceptualizing the different levels and types of stakeholders whose values affect the determination of ROI follows, ranging from the program level (operating room) to the societal level (outcomes across the population). Program stakeholders focus on the usability of a simulation. Community stakeholders focus on managing M and S within specific areas, such as effecting a reduction in medical errors across an emergency department. Enterprise stakeholders focus on M and S capabilities that apply across the entire spectrum of activities of the organization. Federal stakeholders focus on M and S as it affects the operations and outcomes of activities funded by the U.S. Government. Society stakeholders focus on the role and impact of M and S on costs and outcomes of the health care system as a whole. A complete analysis of ROI needs to incorporate the criteria and

value weighting of each of these types of stakeholders. Once the criteria are established, they must be weighted because each criterion has an importance that needs to be reflected in the ROI calculus. SMEs are generally used to determine the value weights associated with each criterion. Once the weights are established, summing all weights and then dividing each individual weight by the sum will normalize each weight. The next step is to calculate a score for each criterion for each simulation. The three most common methods of calculating ROI are summarized in the following paragraphs. The first method of calculating ROI to be considered is Simple Additive Weighting (SAW), which is known as a weighted linear combination of scoring methods. It is simple and the most often used multi attribute decision-making technique (Afshari et al., 2010). The SAW method has developed over time and was initially used only with quantitative criteria. A weight would be determined for each criterion and then that weight would be multiplied by the quantitative value of the criterion. The products would then be summed to determine the overall score of the alternative. Several major drawbacks to the SAW method are readily apparent, for example, SAW cannot be easily used with qualitative criteria (i.e., professional judgment). Even among quantitative criteria, significant differences in the weighting of measures can cause extraordinary differences. In response to these concerns, the SAW method has evolved. It can now support both quantitative and qualitative criteria. The advantage of this method is that it is a linear transformation of raw data (Afshari et al., 2010). Thus, some of the key characteristics of SAW are that it is the best known and most widely used method, it uses all the attribute values of an alternative, and it uses the relatively simple mathematical operations of multiplication and addition (Sopadang, 2011). The Analytical Hierarchy Process (AHP) was created due to the limitations of SAW. AHP allows users to consider and compare both qualitative and quantitative criteria when making multi-attribute decisions. AHP is similar to SAW in that it is based on a weighted average that is calculated

for each alternative by multiplying the value of the alternative by the weighted value of the criterion. The major difference is AHP uses pair-wise comparisons to calculate both the weights of the criteria and the score for each alternative for each criterion. AHP has also evolved over time, although it still uses pair-wise comparisons to populate its matrices. In fact, one of the advantages of AHP is that the pair-wise comparison process allows a user to generate the weights in a consistent manner (McCafrey, 2005). Another method for making multiattribute decisions is the Technique for Order Preference by Similarity to Ideal Solution (TOPSIS). TOPSIS has been widely used to solve various multiple attribute decision-making and multiple criteria decision-making problems (Pie et al., 2010). Unlike SAW and AHP that determine a summary weighted score for each alternative, TOPSIS is based on the concept that the chosen alternative should have the shortest distance from the positive-ideal solution and the longest distance from the negative-ideal solution (Yoon et al., 1995). As the reader may surmise, the cal-

culus of ROI is complicated, involving many judgments and many variables and thus many opportunities for error. The basic take home message is that the “User should be wary.”

What difference does ROI make? The ultimate decision on whether to proceed with an investment in simulation often depends most heavily on the financial analysis. If an investment does not appear to add measurable value to an organization in terms of benefits outweighing costs, then a project rarely gains approval. The merits of any business venture always boil down to the “numbers” and, as illustrated above, there are several valuation tools and methodologies that describe how to calculate the return on investment. Assessing the value of simulation has long been described in terms of verification (Is a simulation built correctly?), validation (Was the right thing built?), and accreditation (Does it meet the needs of the trainers?). As substantial additional resources are shifted toward the emerging paradigm of modeling and simulation, the calculation of ROI, comparing

M and S approaches to one another and to the current approach for training, will become an essential fourth question – What do we get out of it? The real challenge is to take a simple concept, ROI, and a very complicated, assumption-based and error prone multiattribute calculus and do something that is helpful to decision makers. No manager or health professional wants to make an investment that costs more than it returns. At the same time, most organizations are not willing to spend the 5percent premium that Phillips estimates a comprehensive ROI analysis costs and the analysts have not yet developed a user-friendly software that does for the complicated chore of calculating the ROI of medical simulation what Turbo Tax does for the equally daunting U.S. Tax Code. medsim About the Author Dr. Donald Combs is Vice President and Dean of the School of Health Profession at Eastern Virginia Medical School. He also oversees the National Center for Collaboration in Medical Modeling and Simulation and the Sentara Center for Simulation and Immersive Learning.

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SimCapture® Central Control Module Manage a Room, Suite or Entire Building

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Left

Interview

Harry Robinson, National Program Manager, SimLEARN, Veterans Health Administration (VHA). Image credit: VA.

Interview with Harry Robinson, National Program Manager, VHA's SimLEARN program.

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Harry Robinson, National Program Manager, Simulation Learning, Education and Research Network (SimLEARN), Veterans Health Administration (VHA) was interviewed by Group Editor Marty Kauchak. The interview addressed a wide range of simulation and technology topics pertaining to the VHA SimLEARN program.

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MEdSim: Congratulations on your recent decision to accept this challenging community leadership position and thanks for taking time to speak with MEdSim. To start, provide a current overview of the VHA's SimLEARN program. Harry Robinson: We are continuing to execute the establishment of a national simulation training, education and research program within the Veterans Health Administration to improve the quality of our health care services. This is a two-fold process that involves trainingthe-trainers and getting the necessary training out to the field through our 21 geographically distributed Veterans Integrated Service Networks (VISNs) and the over 1,500 sites where health care is provided to our patient population of over 8.34 million enrolled veterans. SimLEARN is making strong progress towards identifying and developing: • clinical simulation-based curricula;

• policies and procedures for use of standardized patient, mannequin, task trainer, and virtual environment learning; and ; • simulated patient cases and scenarios to support clinical simulation with specific focus on veteran-specific scenarios. We're leveraging internal expertise such as Dr. David Gaba, Staff Anesthesiologist and Director, Patient Simulation Center of Innovation, VA Palo Alto Health Care System. He also serves as Associate Dean for Immersive and Simulation-based Learning, and Professor of Anesthesia at Stanford University, using Modeling & Simulation (M&S) for Crisis Resource Management training. In addition, we're benefiting from the expertise of Dr. Haru Okuda, our SimLEARN National Medical Director, who served as director and assistant vice president of the Institute for Medical Simulation and Advanced Learning for the New York City Health and Hospi-

tals Corporation, the largest municipal health care system in the United States. We have a well-integrated staff of clinical experts, educational specialists/curriculum developers, information technologists, biomedical equipment support specialists, and project/program managers. Additionally, we're aligning efforts of the VHA's REdI, or the Resuscitation Education Initiative (REdI) program established to standardize, document, track and monitor the provision of Advanced Cardiac Life Support, Basic Life Support and Advanced Trauma Life Support training throughout VHA. A key component for SimLEARN future product delivery is the construction of a new 52,000 gross square foot stand-alone building that will serve as our national learning center. This will be erected immediately adjacent to the new Orlando VA Hospital being built as part of the new Medical City complex at Lake Nona, Orlando, Florida. MEdSim: Briefly tell us about your responsibilities as National Program Manager for SimLEARN. HR: SimLEARN is a cross-functional entity with numerous stakeholders that directly reports to the Employee Education System (EES) and closely collaborates with both the VHA's Office of Patient Care Services (PCS) and Office of Nursing Services (ONS). I coordinate closely with Dr. Okuda and Dr. Lygia Arcaro, our Nursing Program Director, to ensure our products serve clinical training needs. I also look to coordinate with Dr. Tim Liezert, the Director of the Orlando VA Medical Center. Personally, I report to the Deputy Chief Learning Officer, Louise Van Diepen, a member of the senior executive service, who is a great advocate for our team. My charge is essentially to conduct "straight-stick" program management and support of our team members for bringing the various education, training, learning, and research component projects to fruition in an integrated fashion that gets

MEdSim: Describe SimLEARN's collaborative efforts in medical simulation with the U.S. DoD and other public and private sector organizations. HR: Understanding the close ties between clinical services provided by DoD and VHA, there are numerous opportunities to achieve effective and efficient patient outcomes through delivery of excellence in patient- centered health care using an enterprise approach that leverages state-of-theart Modeling & Simulation technolo-

on 5 pillars: knowledge management, curriculum, validation, research and development, and strategic partnerships. We've already identified some exciting opportunities for partnering, and we are preparing to brief our respective leadership on recommended paths forward. MEdSim: Highlight some of SimLEARN's milestones and goals for the remainder of 2012. HR: Last year, prior to my arrival, SimLEARN commenced delivery of many clinical training initiatives. These included training over 50 clinical simulation instructors through collaboration

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MEdSim: Discuss the accreditation process for VA medical center simulation centers. HR: As local VA medical center Simulation-Based Clinical Education (SBCE) programs evolve and local simulation centers are established, there will be increased interest in understanding VHA simulation center accreditation policy. Currently, VHA has no policy stipulating a requirement for accreditation of local programs - the decision to seek accreditation is a local decision. The SimLEARN program will periodically evaluate VHA's simulation accreditation policy position as more data becomes available on the requirements for and the value of accreditation. It is anticipated that the National Center will seek accreditation from certain recognized bodies. The American College of Surgeons (ACS) and the American Society for Anesthesiologists (ASA) and Society for Simulation in Healthcare (SSH) are the primary bodies currently accrediting simulation centers. As the use of healthcare simulation training grows, it is anticipated that additional accrediting bodies may offer simulation center accreditation as well, or formal certifications for trainers and educators.

gies. VHA EES was invited to participate as a key member of the Federal Medical Simulation and Training Consortium (FMSTC). Our colleagues include representatives from all the respective service medical providers, Uniformed Services University of the Health Sciences, Medical Education and Training Campus, and TRICARE Management Activity for Patient Safety. FMSTC's mission is to enhance the medical education and training practices of its member institutions by knowledge sharing, collaboration toward common goals, and participation in joint training initiatives. Our plan for achieving these goals is based

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the products delivered to our targeted workforce. I'm very honored to have been selected to come on board the SimLEARN team. This is an exciting and challenging task to leverage the modeling and simulation domain for the conduct of training, education and research in achieving health care excellence. I'm fortunate to be working with consummate professionals like Louise, Tim, Haru, Lygia and our dedicated staff members.

Interview ISSUE 2.2012 MEDSIM MAGAZINE

with VA Palo Alto and Dr. Gaba; coordination with the VA National Center for Patient Safety and National Surgery Office for a curriculum composed of web-based, video, and simulation training of 76 trainers for ensuring correct execution of surgery / invasive procedures; and supporting the Women Veterans' Health Care Office for conduct of a Women's Primary Health Care miniresidency for over 200 students using simulator equipment and standardized patients. 2012 kicked off with training provided at the International Meeting on Simulation in Healthcare (IMSH). We're following up with delivery of REdI training, delivery of web-based Women's Health/Specialty Care cognitive training courses, instructional development for Out of Operating Room Airway Management, Tele-ICU, and Code team training, and supporting activation efforts for opening new VA hospitals. MEdSim: Discuss some of the shortfalls in the state-of-the-art in medical simulation that SimLEARN needs the assistance of industry to solve. And as a follow-up, provide insights on returns on investment the VA is seeking to achieve from its funding of the SimLEARN program. HR: These are great questions! The smartest response I can give you is to respectfully request a "rain check" in providing answers. A lot of outstanding work has been done by our SimLEARN team and the stellar program management leadership provided by Dr. Paula Molloy and Dr. Kristin Day. Having been on board less than four weeks, I need a little more time to provide you with worthy and meaningful answers. We are in the process of completing our comprehensive evaluation of the "as is" situation within the VHA. Our next step will be to define further details for the overall strategy and tactical steps needed to derive the improvements in health care delivery to our veterans. The metrics to drive its execution will encompass improvements in both effectiveness and efficiency of training to clinical providers and end state delivery of patient -centered health care to our veterans. I'd be honored to be given another opportunity to answer these questions for you and your readers in the near future. In the meantime, I'm grateful for your patience and understanding.

MEdSim: We accept your invitation for a follow-up discussion. On another topic, what is the level for SimLEARN funding in the president's FY 2013 budget proposal submitted this February? HR: SimLEARN is a part of the Medical Care Appropriation and has been supported at appropriate levels in the Veterans Health Administration budget allocation process. Additionally, to the degree that non-Medical Care funding is required to accomplish parts of SimLEARN's mission (e.g., construction), the Department of Veterans Affairs has similarly supported SimLEARN's needs at appropriate levels. In general, federal budget proposals for Medical Care and other VA funding requests submitted by the administration require Congressional approval (authorization and appropriation) prior to being forwarded to the president for signature into law. For FY 2013, the Medical Care appropriation request was for $52.7 billion. That request, along with all of VA's appropriation requests, are currently under Congressional review. After administration and Congressional review, negotiation, and agreement (enactment), VHA SimLEARN's allocation request would be assessed in the context of all medical care priorities to determine the appropriate allocation level. MEdSim: Anything else to add? HR: This is a thrilling and invigorating time to be associated with the efforts to improve the delivery of health care services through increasing clinical provider human performance. The military has a long and venerable history

Above Group shot is most of the SimLEARN team in its Orlando office. Image credit: VA

obtaining synergies through Modeling & Simulation to accomplish better training modalities. More effective and more efficient. I got to see a lot of those toolsets while I was on active duty with the Navy, and I was honored to be a provider of training solutions for the fleet at the Naval Air Warfare Center Training Systems Division (NAWCTSD), the Navy's center of excellence in cradle-to-grave acquisitions, including development, evaluation, fielding, sustainment, and disposal. There are plenty of opportunities to comprehensively train critical personnel to be prepared to successfully accomplish and respond to normal and atypical clinical events. Many of the thought processes and good ideas behind the training systems acquired for improving our warfighters' performance, combat readiness, and proficiency have applications in the medical field. Especially, we need to be cognizant of lessons learned so that we can reap the benefits without the need to "re-learn" or "re-invent". Keep in mind solutions need to be scalable to meet user specific demands. Health care institutions, academia, accreditation entities, and industry need to continue to keep an open dialogue to develop a common and shared understanding of challenges and potential solutions. I think we're on the precipice of a watershed era for improving delivered health care. It's an honor and a privilege to be a part of this. medsim

Left

Surgical Training

Practicing to enhance laparoscopic skills.

Dr. Rajesh Aggarwal, Department of Surgery & Cancer, Imperial College London, UK, discusses how healthcare professionals utilize simulation for practice an assessment of technical skills and procedures to enhance competency, improve transfer of knowledge, surgical performance and patient safety.

rimum non nocere ‘above all, do no harm’ is a fundamental of medical practice. However, the Institute of Medicine’s report of 2000, To Err is Human, revealed that up to 98,000 hospital deaths occur in the USA as a result of medical error each year. Further global studies suggest that 10% of patients admitted to hospitals suffer harm. Medicine has relied upon a ‘see one, do one’ approach to learning and experience. Whilst this has been successful for hundreds of years, this also exposes patients to inexperienced healthcare practitioners, albeit supervised. The dangers and harm associated with this are ethically, politically and economically unacceptable. The term ‘learning curve’ has been used to account for higher complication rates, increased mortality, and longer procedure times among inexperienced practitioners and teams. Ascent of the learning curve should no longer be achieved through trial and error. It is necessary to explore, define and implement models of health professional train-

ing that do not expose the patient to preventable errors. One such model is simulation-based training. There are three broad domains in which healthcare professionals utilize simulation. Simulation techniques may be used for practice and assessment of technical procedures, which is the focus of this review. It can take a variety of forms ranging from simple bench models to sophisticated virtual reality machines. Second, simulated or standardized patients have long been used to teach clinical skills and are the foundation for performance-based assessment in numerous licensing examinations worldwide. Third, simulation technologies have been used for team training, to enhance function in tension-filled complex situations.

Laparoscopic Surgery The advent of laparoscopic surgery in the late 1980s has been described as ‘the biggest unaudited free for all in the history of surgery’. While the gold standard technique now for cholecys-

Proficiency-based Training Curricula The aim of a training curriculum is for an individual to acquire skills to a predetermined level of proficiency before progression to more challenging cases. It is thus not solely the simulator, but also the mode of training on the simulator, that determines the degree of transference of

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Enhanced Quality of Performance through Surgical Simulation

tectomy, anti-reflux, colorectal and bariatric surgical procedures, its introduction was less than harmonious. Reports of increased rates of bile duct injury, bowel and aortic injury engaged credentialing societies to develop guidelines for safe acquisition of laparoscopic skills, predominantly on animal models, prior to attempting procedures on patients. Despite extensive expansion of simulation-based training on animal, synthetic, and now virtual reality simulation, there remains a paucity of integration of simulation-based practice into clinical training curricula. In 2000, Scott et al. revealed that training under the guise of a 4-week laparoscopic skills curriculum on box trainers enhanced surgical performance on a laparoscopic cholecystectomy in the operating room. Further studies by Grantcharov et al. and Seymour et al. in 2004 and 2002, respectively, confirmed the ability of training on a virtual reality simulator to enhance operative speed and economy of movement, and to decrease technical error. A more recent Cochrane review of virtual reality simulation has confirmed these findings, based on 23 trials involving 622 participants. The benefits of simulation go beyond practice on a model; the trainee can practice in an educationally orientated safe environment, at progressively more challenging levels that are appropriate to the learner, leading to the development of a proficiency-based approach to skills acquisition. Our department led the development of proficiency-based training curricula in laparoscopic surgery, endovascular intervention, endoscopy, and microsurgery. This can provide a training standard that can be applied locally, regionally, or nationally.

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Image credit: Author.

Surgical TRAINING ISSUE 2.2012 MEDSIM MAGAZINE

skill to the operative setting. This constitutes knowledge-based learning, a stepwise technical skills pathway, ongoing feedback and progression toward proficiency goals, enabling transfer to the real environment. In 2009, Aggarwal et al. applied a stepwise process to the modules and metrics of the LapMentor virtual reality simulator, resulting in the development of a whole-procedure training curriculum for laparoscopic cholecystectomy (figure 1). The modules were deemed construct valid through comparison of performance across three levels of surgical experience. Furthermore, learning curve data were established to ensure that repetitive practice improved performance in novices, as measured by the simulator. The technical skills taught by training on the simulator are thus relevant for laparoscopic cholecystectomy, and should lead to a reduction in time to achieve proficiency in real patients. Training within the curriculum commences at the basic skills modules, followed by training at the two most challenging skills, evidenced by the fact that they have significant learning curves. Progression to the procedural tasks necessitates achievement of the benchmark proficiency criteria, which are based on scores derived from the performance of experienced laparoscopic surgeons. The structure of the curriculum is identical for the four procedural tasks, leading to the full-procedure module, which again has proficiency criteria for the trainee to achieve before completion of the training period. It is important to note that the curriculum adheres to the concept of ‘distributed’ rather than ‘massed’ training schedules, with a maximum of two sessions performed per day, at least one hour apart. Finally, to confirm acquisition of skill rather than attainment of a good score by chance, all benchmark levels must be achieved at two consecutive sessions. This training programme is not intended as a substitute for skills acquisition in the operating theatre, though it allows part of the learning curve to be transferred to the skills laboratory. The curriculum does not take into account previous procedural or technical knowledge, nor objectively measure this before enlisting trainees into technical practice. A cognitive skills module is essential at the front end of any training programme,

N in e B a s ic T a s k s 9 t a s k s p e r f o r m e d t w ic e o n t h e s a m e d a y in t w o s e s s i o n s, e a c h s e s si o n > 1 h o u r a p a r t

Two Basic Tasks (Clip & Grasp , and Tw o-Hand Manoeuvres) Perform ed for a maximum of two sessions per day, each session >1 h our apart C om ple on of training when all of th e following levels of skill are achie ved on two con secu ve sessions

C l ip & G r a s p ( T a s k 5 ) T im e T a k e n < 1 0 0 s e c s

T w o -H a n d e d M a n o e u v r e s ( T a s k 6 ) Total Tim e Taken < 90 se cs To t a l M o v e m e n t s < 1 0 0 Total Path Le ngth < 440cm

F o u r P r o c e d u r a l T a sk s 4 t a s k s p e r f o r m e d t w ic e o n t h e s a m e d a y in t w o s e s s i o n s, e a c h s e s si o n > 1 h o u r a p a r t

Two Procedural Tasks (Calot’s Triangle Dissec on, and Gallbladder Separa on) Perform ed for a maximum of two sessions per day, each session >1 h our apart C om ple on of training when all of th e following levels of skill are achie ved on two con secu ve sessions

Calot’s Triangle Dissec on (Task 3) T o ta l T i m e T ake n < 2 8 0 s e c s To tal M o v em e nts < 240 T o t a l C a u t e r y T im e < 1 5 s e c s

Gallbladder Se para on (Ta sk 4) T o t a l T im e T a k e n < 3 0 0 s e c s T o t a l M o ve m e n t s < 2 7 5 T o t al P at h L e n g t h < 5 0 0 c m

Full Proce dure (Laparoscopic Cholecyste ctomy) Perform ed for a maximum of two sessions per day, each session >1 h our apart C om ple on of training when all of th e following levels of skill are achie ved on two con secu ve sessions Total Tim e Taken < 540 secs; Total Movem en ts < 480; Total Path Len gth < 1000cm

Figure 1: LapMentor Virtual Reality Training Curriculum.

such as that available from the Royal College of Surgeons of England for laparoscopic cholecystectomy. Furthermore, completion of this curriculum is based on dexterity, rather than safety scores or clinical outcome measurements. This is an important aspect of research with respect to the use of technical skills rating scales and the integration of such scales into theMusic simulator software. Golf

in medicine satisfy this demand. Within the airline industry, the method of establishing the quality of a new simulator is to assess its transfer-effectiveness ratio (TER). The difference in number of trials or time taken to achieve performance criterion (in the air) between untrained and simulator-trained pilots is divided by total training time received by the simulator-trained group. It is thus possible to calculate how cost and time-effective the addition of a simulator would be in a training program. Chess Aggarwal et al. investigated the ability of an evidence-based virtual reality training curriculum for acquisition of lapRepetition aroscopic skills to transfer to improved Effort on real laparoscopic properformance cedures. They compared 20 novice surgeons, performing a series of cadaveric porcine laparoscopic cholecystectomy Immediate procedures, half of whom had undergone feedback a virtual reality training curriculum, as previously described. The virtual reality trained group performed significantly better in terms of dexterity and videobased scores at the first cholecystectomy than the control group. Further, the results reported equivalence of performance between the simulation-trained and control groups at the third and fifth sessions, respectively. Although the learning curve for the VR-trained group

How expertise is acquired in other domains?

Evidence for Transfer to Real World Performance

Focused activities The benefits of training in an educationally orientated environment that enable Deliberate review and the ability to make errors without consequences Practice are powerful KA Ericsson incentives to employ simulators within Regular the medical curriculum. Although there Over long time is ainterest in simulation-based training, especially for the high-fidelity virtual reality simulation, their presence remains within the confines of research departments, with a paucity of data to prescribe the widespread application of such tools. Although the intention is to shorten the learning curve on real procedures, few studies have objectively investigated the degree to which simulation

Golf

Chess

Focused activities

Deliberate Practice Regular Over a long time

KA Ericsson

was shorter and flatter than that for the control subjects, both groups of subjects demonstrated statistically significant learning curves over subsequent procedures. This demonstrates the fact that simulation-based training is not a substitute, but instead an adjunct to traditional modes of training. The final aim was to define how the differences between the two learning curves related to time spent on the virtual reality simulator, i.e. the TER of a simulation-based surgical training curriculum. Similar studies in the aviation industry have described a TER of 0.5, although the results of this study defined a TER of 2.28, i.e. every minute that was spent training on the simulator was equivalent to 2.28 minutes on the cadaveric porcine cholecystectomy. With this information, it is possible to accurately chart the effects of integrating simulation-based training programs into the medical curriculum. The 2-fold approach would seek to define initial outlay costs, and then to determine the time taken to recover those costs by projected reductions in time and expense spent learning laparoscopic skills in the operating theater. Only with such data can we warrant the use of simulator-based training as part of standard practice.

Experience and Expertise Effective methods to reduce errors lead to the concept of expertise, which represents a very high level of skill acquisition and is the result of a gradual improvement through extended experience in a given domain. Expert performance is not

Repetition Effort

Immediate feedback

Figure 2: Deliberate practice.

the result of extensive experience alone, but rather the consequence of engaging in specific training purposely designed to improve the current level of skill. Ericsson has proposed that individual differences in attained professional performance can be explained by differences in deliberate practice (figure 2). This framework is based on the assumption that expert performance results from engagement in activities deliberately chosen for their ability to improve performance and maintain it at the highest level. Deliberate practice calls individuals to focus their training on defined effortful tasks, or drills. It involves repeated practice with immediate feedback on performance, often delivered by teachers and coaches. The importance of deliberate practice in attainment of expert performance was first described in a study of expert musicians in Berlin. Those in the best groups spend more time in solitary practice, concentrating upon the improvement of specific aspects of the music performance, as directed by their music teachers. The best experts spent 4 hours per day on solitary practice. By the age of 20, the best expert musicians had spent over 10,000 hours. Attained level of expertise has been closely related to time devoted to deliberate practice in different domains requiring a high level of technical performance such as music, chess and sport. In a typical case of deliberate practice a coach designs a training activity to

Concluding Remarks The delivery of healthcare is undergoing a major transition across the globe. Drivers for change range from the introduction of new technologies such as primary angioplasty and robotic surgery, to restriction in work hours of trainee doctors. The dilemma of how to train doctors and allied health professionals in more specialized techniques, in a shorter period of time, together with maintenance of the highest levels of patient safety in a cost-effective manner is a difficult one. Innovation requires traditional methods to achieve higher standards, while insuring patient safety. The design, development and implementation of innovative training curricula, underpinned by objective measures of performance, has already begun. medsim

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Music

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How expertise is acquired in other domains?

improve a specific aspect of an athleteâ&#x20AC;&#x2122;s performance. These kinds of practice tasks permit athletes to stretch their performance beyond their current level through focus on improvement in a given aspect. By receiving immediate feedback and opportunities to reflect on possible refinements, competitive athletes are able to improve with repeated exposures to similar tasks, or drills, over time. In 2011, Crochet et al. performed a randomized controlled study to define whether deliberate practice could be successfully applied to training for laparoscopic cholecystectomy on a virtual reality simulator, with the intended outcome of improved quality of surgical skills. The second aim was to investigate the transfer of surgical skills from a VR simulator onto real tissues, after deliberate practice training. After training on the LapMentor virtual reality simulator, skills improved with regard to dexterity parameters in both groups. However, members of the control group completed the procedures in a shorter time and with fewer numbers of movements than the deliberate practice group, with a greater rate and final level of plateau. Conversely, the deliberate practice group achieved significantly higher scores on the video-based rating scales, which are a measure of quality rather than dexterity alone. For the 10th, 15th, and 20th LCs on the simulator, the DP group achieved global rating scores of 39%, 56%, and 50% greater than those of the control group with similar results achieved for the procedural rating scale.

Command Profile

Command Profile: PEO STRI The Orlando-based command’s Project Manager (PM) Combined Arms Tactical Trainers (CATT) with Assistant Project Manager (APM) of Medical Simulation (MEDSIM) is working “To put the power of simulations into the hands of our Warfighters.”

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he Program Executive Office (PEO) for Simulation Training and Instrumentation (STRI) is the U.S. Army’s acquisition and contracting center. Nearly all Soldiers deployed to the Overseas Contingency Operations have trained on a PEO STRI-derived device. Some of these training aids and simulations include the Counter Improvised Explosive Device, Engagement Skills Trainer 2000, Mobile Military Operations on Urban Terrain, Aviation Combined Arms Tactical Trainer, Synthetic Environment Core and Medical Simulation Training Centers.

MEDSIM MAGAZINE

M&S for Medical Operations One of the fastest growing technology areas is the modeling and simulation in support of medical operations. Medical simulation brings new technologies to a field unaccustomed to simulation or the associated tools. Project Manager (PM) Combined Arms Tactical Trainers (CATT) with Assistant Project Manager (APM) of Medical Simula-

tion (MEDSIM) is working “To put the power of simulations into the hands of our Warfighters.” MEDSIM is responsible for paving the way to provide the best medical training in the U.S Army with a standardized training platform. The MedSim program has helped saved and benefited service members, medical professionals and combatant commanders in Operation New Dawn (OND) Iraq and Operation Enduring Freedom (OEF) Afghanistan, and in all medical facilities in the U.S Army. Soldiers enter combat knowing that, if they become a casualty, they will get the very best combat medical care in the history of warfare. This knowledge enables Soldiers to accomplishing difficult missions under extraordinary circumstances. It is this battlefield capability that returns more combat-tested and experienced Soldiers to their units than any other combat multiplier on the battlefield. Treatment given in the first 10 minutes for hemorrhage, compromised airways or tension pneumo-

Above Soldiers carry a simulated battlefield casualty during a training exercise at the Fort Lewis Medical Simulation Training Center. Image credit: US Army.

thorax has the greatest impact on the soldier and typically determines their survival in combat; that period of time has become known as the “platinum 10 minutes”. Lieutenant Colonel Wilson Ariza, Assistant Product Manager for Medical Simulation, (PEO STRI), has been given the important task to manage the Army Medical Simulation Program, so before U.S. soldiers deploy to a theater of combat operations, they undergo combat casualty care training at one of the PEO STRI fielded Medical Simulation Training Centers (MSTCs). The MSTC Program focuses on the first responder and combat medic and delivers systems capable of training medical tasks to joint, multi-component, interdepartmental and even coalition partner

Accomplishments and Beyond MEDSIM’s accomplishments during 2011 alone have been phenomenal. The following list offers a few examples. • The MEDSIM program has successfully managed and sustained 24 MSTC systems, (with locations CONUS and OCONUS and employing 125 people, MSTCs have total costs of $431.4 mil-

lion). The successful deployment of six of these systems to the battlefield has helped meet priorities set in the Army Campaign Plan and support OIF/OEF; • The MEDSIM program has replaced and upgraded its fleet of simulation mannequins to each of its locations; • The MEDSIM program completed the fielding of two new MSTC sites at Ft. Benning and Camp Atterbury; • The MEDSIM program helped deployed units in Iraq and Afghanistan employ MEDSIM’s simulators across the battlefield. The deployment of sites in Kuwait, Iraq and Afghanistan, made MSTC the first fully deployed medical training platform in the history of American warfare to implement training with state of the art medical simulators; • The MEDSIM program coordinated and conducted the training and validation of more than 125,000 service members’ (Soldiers, Sailors, Marines, Airmen and foreign nationals) world-wide, providing medical units with advanced knowledge to assist the Warfighter in accomplishing difficult missions under extraordinary circumstances; and • The MSTCs have been presented with the CPL Angelo J. Vaccaro award for two consecutive years for providing the best training facility in the Army. The MSTCs offer unique and powerful learning opportunities in key competency areas, including communication, teamwork, emergent conditions and leadership, as well as tasks requiring well-practiced manual skills such as diagnostics and treatment procedures. MEDSIM believes through multi-disciplinary simulation centers and collaboration with other institutions in the military and civilian sector, quality patient care and safety will be improved for all. The future for Medical Simulation is bright and there will continue to be a growing requirement for simulation training. MEDSIM will continue to create more medical simulation training opportunities for our Soldiers. There should be no doubt that our Soldiers can provide the best care possible to our service members when properly trained; they have and will always continue to do so. MEDSIM was one of the world’s first established military simulation Program Management offices and will continue to be a global leader in the field. medsim

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ated by the best instructors available to ensure proficiency in combat lifesaver skills. In a USA TODAY article, Gregg Zoroya cited, “Troops trained in advanced trauma care could prevent up to 20 percent of combat deaths in Iraq and Afghanistan.” The Defense Health Board later said in a recommendation to the Pentagon that Enhanced Tactical Combat Casualty Care (TCCC) skills developed by military trauma specialists have already saved an estimated 1,000 lives in both OIF/OEF. The MEDSIM office supports the Army Medical Command as it develops future plans to expand simulations beyond the battlefield and into all levels of care. These simulation and training aids will specifically focus on the skills that nurses and doctors must master as a patient moves into more definitive treatments. Through partnerships with simulation leaders based in what has become known as “Medical City”, Orlando, Florida, MEDSIM has provided simulation based learning and total life cycle acquisition support to Veteran Health Affairs for clinical medical training applications. Medical City, a 7,000-acre community has drawn numerous experts to Orlando maximizing the Army’s access to the latest technology for training, research and development programs. Lake Nona's Medical City is emerging not only as Orlando's fastest-growing, most innovative master-planned community, but also as a "Project of Promise" featuring Nemours Children's Hospital, M.D. Anderson Orlando's Cancer Research Institute, Orlando VA Medical Center, University of Central Florida's new College of Medicine and Health Sciences campus, Burnham Institute for Medical Research's east coast campus, and a University of Florida research facility dotting the Lake Nona Gateway Interchange in the 600-acre Science & Technology Park.

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organizations. It allows standardized training to the Army, with added unitspecific modules based on the contemporary training environment. MEDSIM first deployed MSTCs for contingency operations in 2005 to support Operation Iraqi Freedom, and since then, has continued to combine tactical skills and technology to lead the way to an integrated training platform and deploying the most comprehensive training and educational medical system available today. MEDSIM has fielded twenty-three MSTC’s locations CONUS and OCONUS, with plans for up to 34 fixed site locations and several mobile facilities. A combination of lessons learned from current military operations and friendly engagement allows MSTCs to simulate stressors in the battlefield to test the combat medic’s ability to perform trauma management tasks under conditions they may realistically encounter on the battlefield. Through simulation technology, MSTCs create common and unique crisis scenarios using virtual controls and displays connected to virtual patient simulators to reflect physiologic changes with real-time feedback to Soldiers. Varying degrees of combat chaos are added to scenarios to increase stress levels and add to the MSTC capabilities as a powerful individual trainer and team-building tool for medical Soldiers. "When you first walk in, it's scary. It's like, 'Wow, this is real, this is training?'" said Staff Sgt. Kelly Whitesell, a medic with the 7235th Medical Support Unit in Orlando. "Then you get into the treatments, and that is like treating a real patient." Utilizing a combination of human patient simulators and part task trainers paired with live actors, MSTCs has provided specialized training to over 500,000 combat lifesavers and medics. These are cost effective solutions in low-risk, supportive environments that have become critical elements to the success of medical military training. The success of medical care is ultimately dependant on the knowledge and skill-sets of the medical provider. The ability of providers to make accurate assessments and take steps to provide prioritized interventions is critical. MedSim is saving lives by ensuring that each Soldier trained is evalu-

Simulation Center

Medical Simulation Centers Transforming International Healthcare Landscape When the Sidra Medical and Research Center’s Clinical Simulation Center opens in 2013, it will provide cutting edge training to its Doha, Qatar-based learning audience, reports Group Editor Marty Kauchak.

hen Sidra Medical and Research Center opens its doors in the first half of 2013, it will transform the healthcare landscape in that nation and the Gulf region. The center, with its initial charter to provide women’s and children’s healthcare, is being established under a $(US) 7.9 billion endowment from Her Highness Sheika Moza bint Nasser of Qatar. On the center’s horizon for later this decade is an expansion into other medical disciplines. One underpinning of Sidra’s capabilities will reside in its clinical simulation center (CSC).

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Patient Safety Sought

MEDSIM MAGAZINE

The mission of the 14,000 sq. ft. CSC will evolve as the host facility becomes operational. Renee Pyburn, the project manager for simulation at the CSC, pointed out the initial Sidra Medical and Research Center staff is being recruited from many different nations. Each member will bring different levels of academic experience, on-the-job expertise and practice models from their previous employment. Initially, the simulation center will be used to help assess and train a variety of the parent medical

Above The Sidra Medical and Research Center’s Clinical Simulation Center. Left Project Manager Renee Pyburn. Image credit: Sidra Medical & Research Center.

center’s approximate 4,000 clinical staff members. The CSC will operate with approximately 35 staff members at its peak. The scope of the CSC’s training curriculum, still under development, is expected to emphasize individual and team skills for undergraduate up through continuing education programs for practicing staff. Between 70 and 80 percent of Sidra’s assessment process will rely on simulation. The main outcome sought for simulation-based staff training is “to make certain they [the staff] can practice safely together – to

take care of the patients safely,” Pyburn emphasized. The CSC’s learning audience is expected to increase and expand in the long term. Prospective students may possibly enroll through Sidra’s affiliation with the Weill Cornell Medical Collage in Qatar, and from other institutions in the nation including the University of Calgary Nursing School, the College of the North Atlantic Allied Health School and Qatar University School of Pharmacy. “There are about 1,000 students in those schools,” Pyburn pointed out. The CSC may also be a learning resource for other medical professionals in Qatar and elsewhere in the Gulf region. Pyburn revealed her initial outreach discussions with in-nation U.S. military commands and private employers. “Many of them are interested,” she said.

Standards and Other Underpinnings

Above

The CSC is expected to use a full array of technology in its programs, including web-based learning, gaming and virtual reality, standardized patients, part-task trainers, and low, high, and medium fidelity manikins. The facility will have full-scale simulation rooms, task training rooms, standardized patient rooms, classrooms, debriefing rooms and other support areas. “There’s also a robotic surgery center in Qatar that does surgical simulation training, so we may be doing some of our surgical simulation training there at the Qatar Robotic Surgery Center,” Pyburn said. The goal is for all individuals who complete a course of instruction at the CSC to be awarded a certificate. The CSC is also taking certification to a new level in the region as it is collaborating with other simulation centers in Qatar to initiate national standards for instructor training and simulation programs. Indeed, one plan calls for the establishment of a nation-wide, instructor certification program not later than 2014. Such a program would ensure medical simulation center instructors are themselves proficient in the use of simulation-based technology in addition to having requisite teaching skills. The Sidra Medical and Research Center is seeking accreditation from the Joint Commission International (JCI), while the CSC is seeking accreditation from the American College of Surgeons and the Society for Simulation in Healthcare. “The JCI is also requiring more and more simulation for verification and

Research Center's clinical simulation

Floor plan for the Sidra Medical and center. Image credit: Sidra Medical & Research Center.

maintenance of skills, in particular for a skill that is not practiced frequently,” Pyburn pointed out.

Roadmap to Opening

Scottsdale, AZ

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Wilmington, NC

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Construction on the CSC is expected to be completed this October. With the completion of the education program later this fall, the center is expected to be operational by the end of this year. As the CSC staff equips the facility, Pyburn had several recommendations for industry vendors – its “help wanted list.” At the top of her list were surgical simulators. “There are not many realistic surgical simulators out there. The ones that are out there don’t adequately address the many areas of surgical training – so there needs to be a lot more development of that.” Pyburn continued, “And then in terms of birthing simulators there is only really one now – although others are under development.” When complete, the Sidra CSC will be one of an increasing number of such centers to operate in the region. “The number is exploding,” Pyburn remarked. Khalid Al Mohannadi, Sidra’s communications project director, emphasized that despite the increase in centers in his nation and elsewhere in the region, the centers’ staffs are ensuring each has unique capabilities to prevent duplication of investments and other inefficiencies. medsim

News & Analysis

Medical News 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.

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Medical Simulation Corporation (MSC) is offering healthcare organizations the opportunity to assess their team’s understanding of the guidelines for several clinical topics targeted for improvement by the national Partnership for Patients initiative. The complimentary knowledge assessment will help organizations determine if there is a need to implement quality improvement efforts in a particular area or evaluate the results of an ongoing or previous quality effort. The free online Quality Initiative Knowledge Assessment is available for the areas of Central Line Infection, Ventilator-Associated Pneumonia, Venous Thromboembolism, Sepsis, Stroke, Heart Failure, and more. “Organizations such as LeapFrog, Healthgrades, and CMS report that hospitals consistently fail to meet important quality standards and are not doing enough to improve the quality and safety of patient care,” says Bill Younkes, MSC President.

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First CAMLS fellowship by Simbionix – Simbionix has sponsored the first fellowship at the USF Health Center for Advanced Medical Learning and Simulation (CAMLS). The one-year University of South Florida fellowship will allow students in health professions at the graduate or postgraduate levels to focus on leadership development in healthcare simulation education and training. The fellowship, to begin July 1, 2012, will be open to students in medicine, nursing, pharmacy and public health professions. “We are proud to support this fellowship that will cultivate leaders in medical simulation education,” said Gary

Above Sensei X Robotic Catheter System. Image Credit: Hansen Medical, Inc.

Zamler, CEO of Simbionix USA Corporation. “Our company is committed to patient safety and improving outcomes for complex medical procedures. The same is true for USF. We’re a powerful combination.” “We could not be more excited about the growing relationship with Simbionix and CAMLS,” said Dr. Stephen Klasko, CEO of USF Health and dean of the Morsani College of Medicine. “Our simulation partnership will help to transform health care by making sure health professionals are competent to use advanced technology safely and most effectively.” Simbionix and USF Health have had a longstanding and productive collaboration for more than four years, and will

continue working together to achieve innovation in medical simulation. Hartford Hospital acquires Hansen vascular robotic system – Hansen Medical and the Center for Education, Simulation and Innovation (CESI) at Hartford Hospital in Hartford, Connecticut, have announced that Hartford Hospital has purchased a preclinical vascular robotic system from Hansen Medical for the purpose of conducting advanced preclinical endovascular research. “We are very pleased with the addition of a Hansen Medical vascular robotic system dedicated to preclinical vascular investigation. This solidifies our position as pioneers in medical training,” said Dr. Steven Shichman, Medical Director of Center for Simulation, Education and Innovation (CESI) and Chair of Peri-operative Services at Hartford Hospital. “It is our intention to create an institutional focus on endo-

vascular and cardiovascular robotics. Our robotic technology capability, which now includes two Sensei robots, has positioned us to become one of the leading endovascular and cardiovascular robotics programs in the world.” In January, Hansen Medical selected Hartford Hospital to be a Center of Excellence for the Sensei® X Robotic Catheter System. The Hansen Medical vascular robotic system is based upon the flexible robotic technology incorporated in the Sensei X Robotic Catheter System currently sold in the U.S. and Europe, which has been used in over 7,000 patients with cardiac arrhythmia, but includes a number of key enhancements.

trained on how to take care of a real person. Recently the college offered a life support course to teach attendees how to evaluate and treat critically ill infants and children. CMU graduate students and practicing clinicians were able to interact with the robotic mannequins. CMU Pediatric Advanced Life Support instructor Dr. Steve Vance says the goal of the course is to train physician assistant program students and practicing clinicians from mid-Michigan how to handle real emergency medical situations using state-of-the-art simulation manikins. “Our goal is to teach healthcare providers how to rapidly assess, categorize the type of illness and then treat appropriately before the child deteriorates into cardiac arrest,” Vance said. “We want to teach these people to recognize respiratory and circulatory emergencies early and intervene appropriately so that we can avoid deterioration. “We plan to use our simulation technologies to create real emergencytype experiences for clinicians and really maximize the learning potential in those cases,” Vance continued. “These technologies represent an investment by CMU that we are now utilizing to positively impact medical care in the region.”

New Simulation Centers Center for Advanced Medical Learning and Simulation (CAMLS) – The University of South Florida’s (USF) Center for Advanced Medical Learning and Simulation (CAMLS) in Tampa, Florida, held its grand opening on March 30th. The 90,000-square-foot, $38 million center was designed to train all levels of health professionals on the latest in simulation technology. The American College of Cardiology designated CAMLS as its first Center of Excellence in Education and Training It’s the only center of its kind in the world, according to Deborah Sutherland, CAMLS chief executive officer. Most medical colleges use simulators, but CAMLS brings doctors together with nurses, paramedics, biomedical engineers and others for team training and brainstorming on new medical technologies. The center includes a robotics suite, trauma operating room and roomful of surgical stations with space for more than 100 people at once. A hybrid operating room is set up to simulate a situation in which a team must switch from a relatively simple procedure to full, open surgery. CAMLS’ trauma operating room can be adjusted to simulate nearly any environment, including a battlefield unit where lights flicker, helicopters pound the air and critically wounded patients arrive one after the other.

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Central Michigan University mannequins for medical training – Central Michigan University’s College of Medicine is now utilizing Gaumard Scientific robotic mannequins in its life support course. The mannequins speak, breathe and offer real physical findings, giving students the opportunity to be

Above The University of South Florida’s Center for Advanced Medical Learning and Simulation. Image Credit: USF.

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Laerdal and Wolters Kluwer form healthcare education alliance – Laerdal Medical and Wolters Kluwer Health have announced a product and distribution alliance that they say will transform healthcare education. The “Learning for Saving Lives” alliance will initially target undergraduate programs of nursing, medicine and the health professions, and will seamlessly integrate curriculum offerings from Lippincott Williams & Wilkins (LWW), part of Wolters Kluwer Health, with simulated patient care solutions from Laerdal. Simulation labs are now an integral part of the healthcare learning curriculum and supplement the clinical hours that students spend training in hospitals. However, integrating sim lab training into the curriculum has been a challenge for faculty, and valuable and expensive simulation equipment is often underutilized. The “Learning for Saving Lives” alliance will change that. The first alliance offering, which will be introduced to the market this spring, will integrate DocuCare, a new Electronic Health Record (EHR) learning tool from LWW with Laerdal’s suite of manikin simulation offerings. As learners work with Laerdal patient scenarios, they will be able to record their patient directly into the DocuCare EHR.

News & Analysis ISSUE 2.2012

Ohio State opens Columbus medical simulation center – The latest edition to Columbus’ virtual medical world is a $13 million simulation center at the Ohio State University’s Wexner Medical Center. Ohio State has already used simulation for training, but this is a huge endeavor that in places looks like a real hospital and offers students more opportunities to hone their skills. OhioHealth has simulation labs at Riverside Methodist Hospital and Doctors Hospital. Nationwide Children’s Hospital also has a simulation center. Dr. Sheryl Pfeil, medical director of Ohio State’s 26,100-square-foot Clinical Skills Education and Assessment Center and director Carol Hasbrouck say the center’s perks include proximity to the hospital – it’s right next door – and 24-hour access for training. It was paid for with state money and medical-student tuition, and it officially opens at the end of the month, although it’s already being used by some. The center was designed to be as realistic as possible, down to working scrub sinks, Pfeil said. It will help Ohio State with its emphasis on team training, in which workers from multiple disciplines treat the same virtual patient, said Hasbrouck, assistant dean of clinical skills and medical education. UT Center for Advanced Medical Simulation opens – The University of Tennessee Graduate School of Medicine recently opened a new medical simulation center that’s expected to enhance the quality of patient care and improve outcomes by advancing the medical skills of physicians and other healthcare professionals. Physicians and staff said the new facility stands alongside the nation’s best simulation centers for meeting the needs of practicing and aspiring medical professionals. The new center is 6,500 square feet, significantly larger than the 400-squarefoot original simulation center that opened on the Knoxville campus of The University of Tennessee Medical Center in 2008.

MEDSIM MAGAZINE

New Products Epic releases Unreal gaming engine for medical, other training applications – Epic games has recently agreed to have its Unreal

Above Polhemus’ latest motion tracking product – G4. Image Credit: Polhemus.

University, the Sirius program funded by IARPA which helps participants “recognize and mitigate” their own biases, and a HumanSim platform for medical training.

Engine 3 (UE3) gaming engine licensed to various departments and agencies of the U.S. government for a variety of training applications, including medical. Epic has entered into this agreement with the US government through Virtual Heroes, part of Applied Research Associates. Virtual Heroes will transfer UE3 to the various agencies, and will support government developers by establishing the Unreal Government Network. Virtual Heroes says it will support the deployment of the Unreal Engine via browser over secure government networks, as well as support UE3 on platforms like iOS, Android, Flash, current gaming consoles, PC and Mac Virtual Heroes produces “serious games,” and is behind the Army training game/recruitment tool America’s Army, which utilized the Unreal Engine 2 when it came out in 2002. Epic Games is the game developer behind Gears of War and Infinity Blade, and it’s Unreal Engine is used in numerous games including Borderlands, Arkham City and Mass Effect. While the US government already has UE3 for its Army game, some of the projects Virtual Heroes is planning on developing using the engine include: an FBI Academy “multiplayer crime scene training simulation,” an “anesthesiology training application” for Army physicians in collaboration with Duke

Motion Tracking Breakthrough – Polhemus has made a breakthrough in motion tracking innovation with its latest product, G4™. It’s a wearable, compact, wireless tracker. Designed with rehabilitation, human factors biomechanics and other purposes in mind, G4 is completely tetherless, yet still provides 6DOF (degree-of-freedom) high fidelity tracking with the level of accuracy magnetic tracking is known for. The system sets up in minutes and the G4 hub is compact and mobile - the size of a cell phone. Because of its versatility, G4 paves the way for many new applications. “Now someone can put sensors on their body and they are not connected to an electronic box - they are free to move around,” Neil Schell, the company’s director of business development in its Research and Technology division, said. G4 is the latest edition to the company’s line-up of motion tracking products. Polhemus has a unique product line for the medical simulation market, as their proprietary electromagnetic technology allows for sensors to be completely embedded, tracking through objects, walls, and people. G4 is scalable and allows the user to expand capabilities, adding additional hubs or sensors to increase the tracking range or the number of points being tracked. There is no cross-talk interference, meaning multiple simulators can

Mimic announces new daVinci performance assessment system – A new assessment system has been developed by a team of researchers to more reliably predict whether surgeons are ready to operate on patients using the da Vinci robotic surgical system. The new technology, called MScore, provides more precise analysis of actual surgical performance, which has been shown to be difficult to accomplish using common training approaches. Mimic Technologies, the simulation company that built the da Vinci simulation platform, is developing

Sensable haptic devices enhance medical simulations – Sensable recently showcased its hapticallyenabled surgical, medical simulation, rehabilitation and robotic applications developed using the company’s Phantom® force feedback haptic devices. Studies have shown that adding tactile feedback into image-guided surgical and simulation solutions can enhance proficiency, accuracy and dexterity for better prepared surgeons and better surgical outcomes. As a result, force feedback haptics technology has increasingly gained adoption in immersive training and simulation applications, and is now moving into diagnostics, patient-specific surgical planning, stroke rehabilitation and in robotically-controlled, minimally invasive procedures. the company said that adding the sense of touch is changing the way surgeons are trained in fundamental skills, learn advanced subspecialty skills, perform minimally invasive

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ISSUE 2.2012

Stanford develops new sepsis teaching tool – Stanford Hospital ICU chief Norman Rizk is a strong believer in the value of a new Web-based medical game called Septris. The game trains physicians to treat the deadly complications from an infection known as sepsis. Septris is a new, first-of-its-kind, Web-based medical game developed by a team of Stanford University Medical Center team of Stanford physicians, researchers and education technology experts. Septris can be played on a mobile phone, a tablet such as an iPad, or a computer, and it represents a promising new approach to medical education. The idea is to plug knowledge about treating sepsis into the brains of clinicians who might find learning by digital game more appealing than a lecture, especially if they grew up with Nintendo, Playstation and Xbox. The name of this medical training tool is inspired by one of the world’s most popular computer games, Tetris. The game begins with the cartoon image of two patients on the left side of the screen. On the right side are their vital signs – those cues that can tip off sepsis’ presence. Along the bottom of the screen are diagnostic tests and treatment options. As every second passes, the patients’ images sink down the screen, their vitals deteriorating. It takes less than two minutes for a Septris patient to die, which means observations and decisions must be made quickly. The game’s objective is not just to keep the patients alive, but to cure them.

MScore, utilizing performance data collected from more than 100 experienced surgeons and academics who have completed at least 75 separate cases. This performance data is being collected from seven leading academic medical centers worldwide, including University of Southern California, U.C. Irvine, and Columbia University. MScore compares a novice surgeon performance to that of experienced surgeons in order to give an objective assessment of a surgeon’s skills. Such an evaluation can help hospitals decide whether a new da Vinci surgeon is proficient enough to conduct surgery on patients. The MScore system encourages continued training long after proficiency has been established, and performance is monitored over time to inspire a surgeon to continually advance their level of skill. The MScore system allows every movement and action the surgeon makes to be tracked and evaluated within a virtual reality training environment. A surgeon’s proficiency and score is established by utilizing a wide variety of performance metrics, such as task time, efficiency of instrument motion, blood loss and the force applied to tissue. Performance baselines are derived from the data collected from experienced surgeons.

MEdSim Magazine

operate independently in the same area. G4 is available for shipping now.

News & Analysis

surgery, and achieve proficiency even in geographies where training facilities or access to cadavers are lacking. Some Sensable applications include the Virtual Basic Laparoscopic Skill Trainer (VBLaST), a touch-enabled virtual reality platform from Rensselaer Polytechnic Institute, that is designed to train and test future surgeons, and is the cornerstone of the university’s “Virtual OR” initiative.

ISSUE 2.2012

B-Line Medical’s SimCapture Central Control Module – The Central Control module allows users to monitor and control the recording and assessment activities of their entire center from a single web-based interface. The center-wide dashboard can be configured for automated workflows and recordings in advance of events, or sessions can be started manually on the fly. The Central Control module supports multiple layout views for centers with various configurations, including the ability to identify multiple floors and discrete simulation suites. The Central Control module is built on B-Line Medical’s proven Clinical Skills technology, affording users outstanding versatility and reliability.

MEDSIM MAGAZINE

Med360 Data Capture/Integration Platform – B-Line Medical has created another powerful and innovative technology for the most widely used platform in the simulation center management industry today: SimCapture® now has the ability to capture data from virtually any device. In addition to integrating with a wider variety of simulators than any other product on the market, SimCapture®’s MED360® data recording engine can now read, store and report on data in real-time from any device... regardless of network connectivity, software version, or device type. MED360® can even record from devices that do not typically output data - imagine having the ability to trend patient monitor data, ultrasound readings, electronic medical record information or data from any simulator directly from the screen. All captured MED360® data is dynamic and interactive, allowing users to jump to key points in the session by clicking data points on trend lines, log fi les or a multitude of reports. Training and feedback can now be extended

Above Anatomage’s The Table. Image Credit: Norbert von der Groeben/ Stanford Medical Center.

to include almost any piece of equipment thanks to SimCapture’s ability to operate seamlessly in any environment, simulated or clinical. Explore the potential for education and research without limitations. MED360® - Integrate with Anything. Enhancing The Table – Anatomage’s The Table is a life-size, interactive anatomy visualization table for the medical community. The product offers high fidelity visualization of 3-D anatomy and interactivity. The user may load in his or her DCM data sets, providing unlimited teaching material. The Table, which also allows for virtual dissections, ultimately provides for a range of anatomy training at the undergraduate level, in medical school courses and during residency. Currently in service at three medical training institutions, the product has rapidly evolved to also support the training of the radiology community and other health care professionals. Kris Thomson, the project manager for The Table, outlined several enhancements for the product through 2012. “The company is also working with Stanford Medical Center, one user of The Table, to develop a digital anatomy library. This is another thing that we’ll be constantly updating and building on - to build the library with other universi-

ties as they get involved.” The Table is also expected to be updated with models of surgical tools. “This would allow animations to go through and simulate different surgical procedures,” Thomson concluded. The company also offers other software solutions that can be tailored to individual institution needs. Simposia Community and ARTHRO Mentor VR – At a community conference in January, Simbionix USA Corporation demonstrated the Simposia communities for physicians. The networked communities are designed to allow physicians to share and discuss, clinical procedures, videos and other content in a 24/7 environment. “The first Simposia community, for Women’s Health, is a place where doctors can go and post like they can on LinkedIn Groups and create user-generated content,” Marc Schwachter, M.D., the company’s physician community manager in its medical education division, said. “We make it easy to upload cases and videos, and to teach with case vignettes so doctors can share their surgical videos with one another, post documents and share them, and ask their colleagues about them and have discussions – all the standard things you can do on a social network you can do here,” he added. Simbionix recently launched a LAP Mentor/MentorLearn Simposia community to support this line of simulators. This allows LAP Mentor users to share best practices and curricula.

The CAE ProMIS simulator is presently configured as version 3.0. “We have given it a lot more space to support the growing need for bariatric surgery to allow one to work in a larger space with larger instrumentation. That has been accommodated along with a more ruggedized design and other hardware improvements,” Fried said. When Fried met with MEdSim, his company was completing its 2012 product roadmap for hardware and software improvements.

ProMIS Simulator Evolves – Last October, CAE Healthcare announced it acquired Haptica’s ProMIS minimally invasive surgical simulation product and tool tracking and augmented reality technologies. Haptica’s ProMIS minimally invasive surgical simulator, now part of CAE Healthcare’s surgical simulation line of products, continues to be enhanced to increase its ability to deliver high fidelity training for learning audiences. The CAE ProMIS simulator allows learners to train with their preferred

Above ProMIS minimally invasive surgical simulator. Image Credit: CAE Healthcare.

surgical instrumentation while watching their work on a screen. Several of the procedural modules take it one step further by enhancing the learning experience with an augmented reality perspective. “It bring the concept of a basic task trainer to the next level by offering an integrated learning management system, video and virtual video debriefing and a series of objectively measured metrics to help track learner progress as they graduate from learning the basic skills to their application in surgical scenarios,” Howard Fried, CAE’s product manager for surgical simulation solutions, said. When compared to legacy training devices that help teach and refresh laparoscopic surgery skills, CAE uses a variety of positioned cameras that track tools in a virtual space and other enhancements, Fried said. “This helps you to interact with your environment either in a full, virtual, immersed environment, practicing camera navigation or practicing certain tasks on physical models.”

Surgical Simulator for Microsurgery – Immersive Touch has introduced a surgical simulator to teach and enhance microsurgery skills. Patrick Kania, a company spokesperson, pointed out that one significant capability provided with this device is haptic feedback. “When you are touching tissue you actually get the sense that you are touching a specific tissue.” When MEdSim completed a scenario on the simulator, strong force and torque were transmitted through the stylus when medical instruments were intentionally placed on incorrect tissue. Visual cues noting the errors provided additional feedback. The company’s latest microsurgery simulator has been delivered to the King Khalid Eye Specialist Hospital in Saudi Arabia for advanced training to their opthamology residents. LumbarPunctureBaby and Nerve Block Training System – Simulab has introduced its LumbarPunctureBaby. Stephanie Ginger, the company’s marketing director, said what is different about this product as compared to other legacy models on the market is the articulating spine, the presence of venous plexus, and the ability the monitor and change the pressure of the CSF. “The articulating spine is important to the procedure because flexing the body form opens up the spinous process which is very small in an infant. The other significant component is the presence of the epidural venous plexus. If the user receives a response of red fluid, it indicates that the needle has been inserted too far, missing the CSF.” The Seattle-based company has also developed the Interscalene/Supraclavicular Nerve Block Training System.

ISSUE 2.2012

Multi-Player Game for Mass Casualty Management Training – BreakAway is developing CBRNE Game – an incident management in a hospital, mass casualty incident multiplayer game for the Telemedicine and Advanced Technology Research Center. While the product’s initial customer is the military hospital sector, BreakAway expects to make the serious game available to the commercial market next year. “This takes the game that they (civilian and military hospital staff) often play as a table top exercise and places it in a web-based game,” Doug Whatley, BreakAway’s president, said of his TATRC-sponsored project. The company will deliver its fully playable version of the game to TATRC in June for testing and validation. Distribution of CBRNE Game is expected early next year within U.S. DoD hospitals. “And then we’ll really look to commercialize it for civilian hospitals,” Whatley added. The product is expected to have a different title when fielded. The new BreakAway product is envisioned to enhance hospital training within the civil sector. Those facilities must complete two exercises (one tabletop and one live) per year to conform with Joint Commission protocols. Whatley emphasized the product is entirely web-based to permit operation from a secure desktop or other platform.

33 MEdSim Magazine

Also in January, Simbionix purchased the ARTHRO Mentor, a virtual reality arthroscopic training simulator line, from GMV, Spain. The training simulator supports training for complex arthroscopic shoulder and knee surgery techniques.

News & Analysis

The system is ultrasound compatible and includes a simulated nerve simulator. Ginger explained that the system is unique as the user can use both real time ultrasound and the nerve stimulator to confirm that the needle is proximal to the nerve. Simulab is developing additional products using their Patented SmarTissue™ technology to expand the Nerve Block Training System to include: Sciatic, Popliteal and Femoral Nerve Block Trainers.

ISSUE 2.2012

Laparoscopic Training Advancements – One of the more innovative and collaborative training systems in the community is the Laparoscopic Training Progression. The best-ofbreed, integrated curriculum framework includes Red Llama’s SimPraxis Cognitive Training platform, 3-Dmed’s Minimally Invasive Training System, Box Trainer and Surgical Science’s LapSim® Virtual Reality Training System. Layne Shapiro, a sales and implementation specialist at Surgical Science, told MEdSim that the curriculum framework is applicable for surgical skill development as well as training for particular procedures. Laparsocopic cholecystectomy and hysterectomy are just a couple examples procedures utilizing the Laparoscopic Training Progression curriculum.

MEDSIM MAGAZINE

The Laparoscopic Surgery Training System (LASTS) developed by Charles River Research through office of Naval Research (ONR) will help military surgeons returning from deployment refresh their laparoscopic surgery (LS) skills, Charles River is modeling these surgical skills to develop training systems and refresher courses that improve the efficiency and maximize retention of acquired skills. To improve battlefield first-aid skills, PROMPTER (Pictorial Representations of Medical Procedures to Train for Effective Recall) was developed for the US Army. These memorization aids are presented to Soldiers through adaptive microgames, available through smartphone apps and web browsers so soldiers can log-in and play from any location. Charles River is incorporating haptics, into its simulation-based medical training solutions with HAMS

(Haptics in Medical Simulation). HAMS produces improved haptics for virtual medical simulations can enable trainees to practice medical procedures using advanced physical simulations of human anatomy.

Community Newsmakers New Polhemus Leadership – Polhemus owners, Al Rodgers and Ken Jedrzejewski, announced a leadership change at the company. The high-tech motion tracking company confirmed that Skip Rodgers will take the helm as president of Polhemus. In addition, Francine Roy will take over as chief financial officer at the company.

Corporate Transactions Geomagic completed an acquisition of Sensable Technology Inc.’s 3-D design and haptics businesses. Sensable will remain a developer of volumetric CAD/CAM solutions, and the inventor of Phantom force-feedback haptic devices that simulate the physical sensation of touch in the virtual world. This acquisition expands Geomagic’s vision to advance and apply 3-D technology. Geomagic is also acquiring the majority of Sensable’s considerable patent portfolio, which extends across haptic device designs and applications and voxel-based modeling. Sensable’s dental products are not included in this acquisition.. medsim

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Calendar 23-25 May NPSF Congress National Harbor, Washington, DC www.NPSF2012Congress.org 29-30 May Global Alliance for Medical Education (GAME) Toronto, Canada www.game-cme.org 3-6 June ASPE San Diego, CA www.aspe.org 4 June OCHU Annual Conference Toronto, Canada www.OCHU.gov 12-14 June Games for Health Boston, MA. www.gamesforhealth.org 14-16 June SESAM Stavanger, Norway www.sesam2012.net 19-20 June UK Simulation in Nursing Conference Leeds, England www.HPSN/Events.com 20-23 June INACSL Nurse Education San Antonio, TX www.inacsl.org 13-16 August ATACCC 2012 Ft. Lauderdale, Fl www.ATACCC2012.org 5-8 September SLS Annual Meeting & Endo Expo Boston, MA. www.SLS.org

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