MEdSim Magazine - Issue 3/2013 by Halldale Group

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Issue 3.2013

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Simulation Centers

Focus on ROIs Simulation Centers

Fill Your Simulation Funnel: How to Maximize Your Center’s Usage

Interview

Interview with Richard M. Satava, MD FACS

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ISSUE 3.2013

Editorial comment

Editor's Comment

" It has been estimated that 80% of avoidable errors in healthcare are due to failures of communication within and across the teams..."

All aspects of healthcare are changing. Patient safety is a global priority and when we hear that the mortality rate due to error equates to five jumbo jets crashing once a week there is no hue and cry from the public or the government as there would be if it were airliner crashes. World train crashes warrant more coverage! Why is this the case? No healthcare professional goes into medicine to kill patients! They enter the profession to give care and save lives. Given how complicated our bodies and brains are, it is not surprising medical science does not understand all the intricate workings of either. Forty years of research has been done to cure cancer but the reduction in cancer rates occurred more from smoking cessation than all research. The healthcare profession is well aware of the problems and have for the last 20 years made changes in education, training and embraced technology to rectify the problem. However, with all the changes in the educational system and in the reduction of work hours and new technologies the problem still exists. In the US in the early 2000s the ACGME limited working hours for resident staff from 100 hours to 80 hours per week (still the highest in the world with Sweden the lowest at 35) citing patient safety and resident burnout as the reason. In reality, pressure from organizations and politicians because of media coverage of error and mistakes influenced the decision. Advocates for the change felt care of patients and learning would both improve. Ironically in a recent study in Journal of General Internal Medicine that looked at the difference in mortality rates pre- and post reduced work hours there was no significant change in mortality. However, there was a perception that hand-off of patients post reduced work hours was not as efficient. There have been tremendous technological advances that help doctors diagnose (ultra sound, advanced MRI) and treat disease and enhanced surgical procedures (minimally invasive surgery and now robotic surgery) that are less invasive for the patient. However, the problem still exists. Great strides have been made in team training and inter-professional training from the medical school, nursing school level to hospital teams working as units and in robotic surgery where every team member has a role to play and must communicate efficiently and effectively with all

team members. Communication among and between healthcare teams, doctors, nurses, pharmacist, anesthesiologist is a top priority in current training and the problem still exist. It has been estimated that 80% of avoidable errors in healthcare are due to failures of communication within and across the teams of people charged with the care of patients. The cost in lives and money of these errors is, by any calculation, unacceptable. Reports also highlight the fact that Healthcare is now the most dangerous occupation for its workforce with over 650,000 workplace injuries a year (2010 figures). "We remain concerned that more workers are injured in the health care and social assistance industry sector than in any other, including construction and manufacturing, and this group of workers had one of the highest rates of injuries and illness at 5.2 cases for every 100 workers," Labor Secretary Hilda L. Solis said in October, 2011. And this is down from each of the prior year reports. If we are to improve ‘patient safety,’ the watchword of our sector, as well as ‘workplace safety’ then we must improve the education and training of people working in healthcare. Other high risk industries such as Nuclear Power and Airlines, whose existence depends on an exemplary safety record and which are held up to public scrutiny at a level not (yet) seen in Healthcare, have developed safety management systems and tools including robust training methods to equip their personnel to succeed. They did so via a rigorous study of their processes and practices leading to a raft of standard operating procedures then standardized training and assessment of their personnel to ensure the successful implementation of those new, safe, work practices. The demand from patient groups, government, learned bodies and the professions themselves is for Healthcare to now do the same. As in the industries mentioned above, this fundamental change to our sector must be initiated by those who work within it; the broader Healthcare community. Judith Riess Editor in Chief, MEdSim Magazine

e judith@halldale.com MEDSIM MAGAZINE 3.2013

Contents

ISSUE 3.2013

Editorial Editor in Chief Judith Riess, Ph.D. e. judith@halldale.com Group Editor Marty Kauchak e. marty@halldale.com US & Overseas Affairs Chuck Weirauch e. chuck@halldale.com US News Editor Lori Ponoroff e. lori@halldale.com RoW News Editor Fiona Greenyer e. fiona@halldale.com

Advertising Director of Sales Jeremy Humphreys & Marketing t. +44 (0)1252 532009 e. jeremy@halldale.com Sales Representative Justin Grooms USA & Canada t. 407 322 5605 e. justin@halldale.com Sales Representative Chris Richman Europe, Middle East t. +44 (0)1252 532007 & Africa e. chrisrichman@halldale.com Sales & Marketing Karen Kettle Co-ordinator t. +44 (0)1252 532002 e. karen@halldale.com Marketing Manager Ian Macholl t. +44 (0)1252 532008 e. ian@halldale.com

03 Editor's Comment. Editor in Chief Judith Riess suggests the successful implementation of new, safe, work practices must be initiated by those who work within the healthcare sector. 06 Focus on ROIs. Marty Kauchak describes the expanding interest in returns on investment for medical simulation centers. 10 Fill Your Simulation Funnel: How to Maximize Your Center’s Usage. Jennifer Calzada, MA, provides insights on medical simulation center management from a corporate sales support perspective. 14 Interview. Interview with Richard M. Satava, MD FACS, Professor Emeritus of Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington. 20 HealthCare Simulation of South Carolina: A Functional Statewide Collaborative (Part 2). John J. Schaefer, III, MD discusses the educational and operational methodologies underlying HealthCare Simulation of South Carolina. 23 A Wireless Gadget for Simulation of Partial Seizures in a Child. Rahul Panesar, MD, Sean Cavanaugh, BS and Christopher Gallagher, MD, provide details on building a cost-effective, wireless mechanism simulating a partial seizure for a child-sized mannequin.

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 Artworker Daryl Horwell t. +44 (0)1252 532011 e. daryl@halldale.com Halldale Media Group Publisher & Andy Smith CEO e. andy@halldale.com

On the cover: The Mayo Clinic's medical simulation center. Image credit: Mayo Clinic.

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$55 t. +1 407 322 5605 t. +44 (0)1252 532000 e. medsim@halldale.com

www.halldale.com/medsim 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.

26 Conference Report. MEdSim continued its presence at international conferences through July.

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

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

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.

MEDSIM MAGAZINE 3.2013

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

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

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Simulation Centers

Focus on ROIs

In the fourth in a series of articles on medical simulation centers, Group Editor Marty Kauchak examines community stakeholders’ expanding interest in returns on investment for these facilities.

uring one random four week period this spring, the Halldale Group’s website, halldale.com, reported the opening or upgrade of four healthcare simulation facilities in the US or overseas. Not to be lost on the quickening pace of new facility openings serving the healthcare community’s global learning audiences is the associated cost of these sites. A survey of the same website revealed recent, high-end investments for some new simulation centers on the order of $18 million. More common opening costs were about $7-8 million. Investments of this magnitude during this era of increasing healthcare costs and expenditures are certain to raise the eyebrows of stakeholders of these magnificent facilities. Indeed, leaders in medical facilities’ “C-Suites” (for CEOs, CFOs and others), much like their counterparts in other high-risk sectors who invest in high-end simulation systems and centers, increasingly want to know the quantitative and qualitative returns on investment (ROI) for these appropriated funds.

ROIs One of the newest, large, private sector US medical simulation centers is at Mayo Clinic in Jacksonville, Florida. The hospital’s initial healthcare simulation program was launched in 2011 in a 2,700-sq.ft., temporary facility. This January the hospital 06

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opened the doors to a new, 9,600-sq.ft. center. The Mayo Clinic executive leadership team and other in-house groups are aware of the broader benefits of healthcare simulation and closely monitor ROIs and associated activities – many of which are routinely recorded at their facility. When Gene Richie, RN, the Operations Manager of the Jacksonville Simulation Center, spoke with MEdSim this May, he had just finished familiarizing one of his institution’s cardiology fellows with the function of a new endovascular simulator. The simulation subject matter expert recalled that when they were reviewing the proposed case load, the doctor identified on the simulator’s list of modules a new procedure that is being introduced at Mayo Clinic. “They had been in the planning phases for several months in preparation to perform cases

Lt. Patricia Butler, Program Director for PPH at Naval Hospital Bremerton gives training to Interns and other Medical Residence at the Simulation Lab. Image Credit: James Evans Coyle/ US Navy.

of this nature,” Richie said, and continued, “The cardiology fellow stated, ‘this is almost real in terms of the way it feels when I have to move through the blood vessels and manipulate wires.’ The provider can now come over to this safe environment and practice multiple procedures without any risk to the patient.” Mayo Clinic (with campuses in Jacksonville, Phoenix and Rochester, Minnesota) is looking beyond using simulation for building and enhancing individual skills, as reported for this cardiologist, and team skills – to the much broader challenge of gaining other ROIs from its Commitment to Safety Initiative. The program, which promotes a culture of patient safety while enhancing inter-professional communication, enables the three hospitals’ staffs to recognize a deteriorating patient and then communicate that development among team members. Richie explained one outcome. “Using key verbal queues allows staff members to focus attention to critical communication needs in a stressful environment. We’ve addressed this from many different angles including a multi-disciplinary group, which we brought into the simulation center. We were able to quantify a significant value of improving the overall competence of staff relating to listening and communication, and building confidence for moving into a real life situation.” Mayo Clinic in Jacksonville also recorded a significant reduction in center line infection rates through the use of a simulationenabled training course – yielding another quantifiable ROI. The training course is part of a broader effort throughout the three Mayo Clinic facilities to have newly reporting physicians follow a proficiency checklist when performing a procedure on patients. “It’s very much like flight simulation where you have to go through the checklist to make sure you hit those appropriate key points before you actually take off,” Richie wryly noted. Ann Mullen, MSN, ACCNS-AG, CHSE, the Program Manager at Shipley Medical Simulation Center, Newton-Wellesley Hospital, placed ROIs for her institution in perspective as she quantified the supported learning audiences. The Newton, Massachusetts-based community expert reported that in conjunction with CRICO (a provider of medical professional liability coverage, claims management and patient safety resources to its members) and their generous grants, team training programs for the Emergency Department and the Operating Room are offered for hundreds of interdisciplinary staff. “Advanced clinical skills and team training are underway for staff obstetricians and midwives. All of these programs formerly required staff to go off-site for tuition-based classes and were attended only by a fortunate few. Not only is the on-site simulation center providing opportunities to greater numbers of staff, it is more convenient, and now the entire clinical team can be included in the training for a richer experience,” she explained. ROIs also have the attention of stakeholders of simulation centers at academic institutions, including community colleges. The Allied Health Simulation Center at Ozarks Technical Community College is a multi-disciplinary, inter-professional Center that provides high-fidelity education experience to 12 different Allied Health Programs. The facility became operational this February. The 2,000 square foot Center provides multiple learning environments including a medical-surgical suite, a trauma and

intensive care suite, a labor and delivery suite, a residential suite, and a debriefing space. The Simulation Center also partners with local hospitals and the Missouri National Guard to deliver continuing education experiences. Joel Doepker, the College’s Director of Communications and Marketing, told MEdSim the Simulation Center operates independently through student tuition and grant resources. The Ozarks Technical Community College is expecting a mix of qualitative and quantitative ROIs from the investments in the Center. “Although our Allied Health programs are already in high demand within the community, the Center provides an additional learning experience that students may not be able to receive at other colleges or universities within the state. The return on investment is anticipated to come from additional students desiring to complete their healthcare education at Ozarks Technical Community College thus increasing general education enrollment and more qualified applicants for each program. The Simulation Center can be used as a purposeful clinical site, thus alleviating the burden of securing high demand areas for student experiences and lowering the student to teacher ratio,” Doepker said. Of particular note, the Center has recently developed a fee-for-usage strategy that will provide another ROI.

Shipley Medical Simulation Center and CRICO offers team training programs for the Emergency Department and the Operating Room. Image Credit: Shipley Medical Simulation Center, NewtonWellesley Hospital.

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Simulation Centers Returns on investment are not the exclusive domain of the private sector. The Naval Hospital Bremerton (NHB) (Washington)’s Simulation Center is capable of simulating most facets of Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support, Neonatal Resuscitation Program, Advanced Trauma Life Support, and Childbirth, Preand Post-Partum conditions. NHB training that utilizes simulations range from American Hospital Association-certified ACLS and Basic Life Support courses, to training on how to identify myocardial infarcts (heart attacks) or the proper placement of tourniquets. “We can even do certain procedures such as broncoscopies and endoscopies,” Douglas Stutz the hospital's Public Affairs Officer explained. In a much broader context, the Simulation Center delivers a wide range of training. Some skills that are often sought after include: suturing, birthing drills, intubations, inserting nasogastric tubes, central line insertions using sonosites, and many more. Even in this era of constrained Department of Defense resources NHB continues to invest in learning technologies. Stutz noted, “We have recently added three of the most advanced simulators on the market; these pediatric, neonatal and adult simulators are now (or will be soon) installed and ready for training.” These investments support NHB's Simulation Center's mission, keeping it on course to develop and maintain the skills of it's healthcare staff and become the go-to source of skills development for regionally based military personnel. The naval hospital’s rich mix of simulation devices help deliver diverse ROIs. Stutz’s short list of cost-savings and other quantitative advantages, and qualitative benefits is familiar to MEdSim’s readers in the private sector: streamlining training for doctors, nurses, Navy corpsman and medical/nursing students; providing medical personnel with the ability to practice, and then practice some more, and see the physiological results without risking real-life patients; verifying and validating student retention of material taught during certification programs and providing realistic training to test certification requirements. 08

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NHB’s Stutz noted the greatest cost savings in terms of ROIs would be that of time – closely mirroring the insights of Shipley Medical Simulation Center’s Mullen. Stutz pointed out that training time at the NHB Simulation Center is more efficient. “Training periods are compressed to the actual training event and time is not spent on scenario development, travel, setup, and/or cleanup. Trainees have a quicker return in that the Simulation Center has training scenarios set up so that clinicians can show up ready to train and then return immediately to normal patient care duties upon completion of training,” he said. And finally, travel is mitigated in that the simulators are located in centralized areas and also have the capability to be mobile so that training can take place in work center of providers.

Senior Leadership Interest in ROIs Other qualitative and quantitative ROIs monitored by community leaders include learner hours, volume of activity at the center and the departments that use the center. Mayo’s Richie noted that his CEO “Dr. [William] Rupp remains abreast of department utilization. He wants to make certain staff are availing themselves in the use of the center because he understands the value of practicing in a safe environment and improving the quality of their skills prior to transferring them to the hospital environment,” Richie added Richie said that as Mayo’s leaders are “monitoring our metrics and activities – returns on investment – and as we feel compressed for space, we can go back and talk about expanding to a commitment of 18,000 sq. ft. in total.” Shipley Medical Simulation Center’s Mullen said her center has been open for just over two years and it has been fortunate to receive significant foundation and grant monies for development, construction and initial operations. Early on, Mullen and her staff have established a culture of accountability and transparency for their leadership about the center’s activities. “From the beginning, we have provided hospital leaders with information about our contribution to the hospital’s goals. We collect the following data to illustrate the program's success: class attendance, number of instructors trained, and hours of instruction. We also conduct post-course evaluations asking Simulation Center

Shipley Medical Simulation Center, Newton-Wellesley Hospital. Image Credit: Shipley Medical Simulation Center, NewtonWellesley Hospital.

participants to share a behavior or practice that they intend to change based on the learning, in addition to standard survey questions,” Mullen explained. Of special note, to date, the Simulation Center has not expended any operational dollars. In its current state of rapid growth in programs, sessions, faculty and attendance, accurate cost analysis is not yet possible. Mullen did point out that her office has been able to provide educational opportunities specific to simulation that greatly benefit the Hospital’s clinical programs and provide possible liability insurance discounts for some clinician groups. That simulation activity may offer ROIs to the insurance sector and its policy holders is a powerful notion – one that is often discreetly mentioned and always off-the-record, on conference exhibition floors and in break-out sessions, and in other community settings. MEdSim attempted to engage several healthcare practitioner insurance providers on the record for this article. Mary G. Gregg, MD, FACS, MHA, the

Chief Medical Officer, SVP, at MagMutual Insurance Company, was the only leader in this sector who accepted our invitation to discuss the topic. For its part, MagMutual Insurance Company is a mutually physician owned, medical liability company covering 17,500 physicians. The Atlanta-based corporate leader and her company fully understand the opportunities offered by simulation. Some of the company’s expectations from ROIs in medical simulation centers include improvements in safety, decreased risk and, as significant, decreased claims and liabilities. “Simulation can be used in almost every segment of the health care field including the practice of medicine as well as the creation of safe healthcare systems and design of ongoing assessments,” Gregg emphasized. And while MagMutual Insurance Company has not yet made any investments in medical simulation centers, “plans are in the works,” Gregg told MEdSim. She continued, “We see simulation

as a means to improve safety and change the culture of medical education.”

On the Horizon The Naval Hospital Bremerton is also taking its entire ROI construct to a higher plateau. In one instance, the naval facility’s Simulation Center is in the process of developing a system for the collection of training metrics. The collection of this performance data will be used for trend analysis and improvement of the training system and curriculum to address areas identified through trend analysis. Continuous “Needs Assessment” in the form of training critiques has been developed in order to continuously assess and improve the Simulator Center. Stutz added “The program TEAMSTEPPS, which is a teamwork system that offers a powerful solution to improving collaboration and communication within the institution, is being incorporated into scenarios in order to enhance communication between team members.” medsim

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Simulation Centers

Fill Your Simulation Funnel: How to Maximize Your Center’s Usage Jennifer Calzada, MA, provides insights on medical simulation center management from a corporate sales support perspective.

our institution has spent a year and millions of dollars planning and building a state-of-the-art medical simulation center. But just because you build it, doesn’t necessarily mean people will come. How do you ensure that administration feels they are getting their money’s worth and that your center is maximizing usage? Here at the Tulane University School of Medicine, we borrow strategies from the corporate sales world, which is where I came from prior to becoming the Director for the Tulane Center for Advanced Medical Simulation & Team Training, which officially opened in January 2009. That means we are constantly filling the funnel.

Filling Your Usage Funnel So what does that mean? The funnel analogy is common in sales. It demonstrates that sales is a process and you are constantly working with multiple clients at multiple stages of that process. At the top of the funnel are your targets and you should have many of them at once, as not all will become clients. As targets move down through the funnel, they become a more likely prospect to become a client. One way of looking at it is there are four stages – targets, prospects, clients and repeat clients. The world of simulation training is not unlike this sales process with the same targets, prospects, clients and hopefully repeat clients. Even if your center only works with your institution’s internal learners, you will still have people at various levels 10

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of acceptance of simulation as a training method. Initially when you open, every department at your institution should be a target. You should continually be going through this process – identify a target, sell them on the benefits of medical simulation and turn them into a valid prospect, work with them to create and run their course, and hopefully repeat. Some will rapidly move to being a client on their own. You will also have some you need to present how simulation can enhance their current method of student education or staff training. Supply them with articles on how simulation training has been done at other centers, and walk them step-by-step through writing a curriculum. If all goes well on their first simulation course, hopefully they’ll come back and become a repeat client. Whether a group is part of your institution or is external and would have to pay a fee, the process should be the same. Target, present, support, execute, and repeat. This is a simplistic view of

Anesthesiology residents work through a critical airway case before debriefing with department faculty and an educator. All images: Tulane Center for Advanced Medical Simulation & Team Training/Bethanie Dardant

usage funnel process to build simulation business in your center.

Tulane Sim Center, in the Beginning The Tulane Center for Advanced Medical Simulation & Team Training opened the doors in January 2009. While the opening was slightly ahead of the curve for the rapid rise in simulation activities in medical colleges, simulation was certainly long established at many institutions across the US. That means that there existed many different models of how to run and operate a simulation center. During the planning phase prior to opening the center and the first year after opening, Tulane faculty and staff visited dozens of centers and attended an equal number of meetings that all had a different example of “here’s how we do simulation.” The question we had for ourselves was “what do we want to be when we grow up? How do we want the Tulane Sim Center to be known?” The answer to these questions came from this methodi-

cal process that relies as much on the corporate business world as it does on education and healthcare. The first step was to establish a strong leadership team, who could work as a unit, but each member had strengths in their own domain to create a whole and solid team. The Tulane Sim Center is run by a group of three Directors. Jennifer Calzada, MA, is the main center Director and

Anesthesiology resident preparing for neonatal airway management.

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Simulation Centers runs day-to-day operations and planning. Jennifer’s background is from the corporate world with a 20-year history from the communications and media industries and experience in marketing, research and corporate sales support. While probably seen by some as an unusual hire choice, that sales support mentality would later become important. Jim Korndorffer, MD, MHPE, FACS, is the Medical Director, as well as Program Director for Surgery and Assistant Dean for GME (Graduate Medical Education). His primarily responsibility is for the efficacy of curricula at the Sim Center and supporting faculty in their curriculum creation. Surgery has been one of the specialties on the forefront of utilization of simulation. As former head of the Tulane Minimally Invasive Training Center, he was a natural fit for the Sim Center. Kevin Krane, MD, is the Director of Team Training, as well as Vice Dean for Academic Affairs and Professor of Medicine. His role and responsibility at the Sim Center is developing the strategy for team training curriculums at Tulane. Dr. Krane has been a TeamSTEPPS Master trainer since 2008 and was instrumental in Tulane becoming one of five national TeamSTEPPS Training Centers for AHRQ’s National Implementation Program. The second step was to determine our mission, to plant our flag in the ground for what the center should accomplish. The Tulane center was established with the mission to develop training to improve the quality and efficacy of healthcare, improve education, reduce medical error to improve patient safety, allow for multidisciplinary research, provide an environment for healthcare development and set a standard for national education, training and certification. Yes, it is bold and audacious and reaches high, as a mission statement should. If it were easy and quickly achieved it would not have been much of a journey to accomplish our mission. Lastly, and it’s what we live day in and day out, is how would we operate? How would we work with faculty? Establish new courses? Train learners? The answer, in short, any way and every way they wanted. And this is where 12

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Tulane departs from some other simulation centers. From the very beginning we acknowledged that we, the Sim Center, were not the experts. Yes, we are the simulation experts at Tulane, but simulation is not the goal. Simulation is the tool to teach specific content, but simulation is not what learners come to the center to practice. Therefore, the mentality of sales support and service became important. The Sim Center was set up as a service that supported educational and training objectives, primarily for the Tulane School of Medicine, but increasingly more, even for external partners and clients.

The Simulation Process at Tulane We support Course Directors, from both Tulane and elsewhere, in their goal to achieve learning objectives. We do recommend a clear and proven path for successful attainment of the objectives – including: • Written curriculum plan; • Didactic course materials; • Facilitator and debriefing training for faculty and instructors; • Familiarity with simulation equipment; • Advance scheduling of training time; • Sessions that include didactic, small group simulation and effective debriefing; • Course evaluations from learners, faculty and simulation staff. We encourage all these steps, but do not mandate. Our list of simulation activities fit the funnel image, with a larger number doing only a few of these steps and a smaller number accomplishing all steps. We have found it’s better to let a course director take short cuts and fail to meet objectives and help them understand what steps would help overcome gaps, than to mandate every step from the beginning and end up with departments and faculty who simply choose to not use simulation at all. Sometimes failure is the best lesson. We have always considered ourselves the open source version of simulation. We provide the structure, the support and the tools; you tweak them to work how you want to meet educational

goals. But after four and a half years, how has this manifested itself? Initially, much of our activity came at the GME level and to this day continues at a steady level. The opportunity, for interns especially, to be able to do repetitive practice for cases that are rarely seen is one of the hallmarks of patient safety. Additionally, it is ideal for interns to have their first encounter with equipment and hospital specific protocols in simulation, rather than in-patient care areas. Undergraduate medical education and especially the pre-clinical years, has been our biggest growth area in recent years. Based on faculty feedback, we determined that Clerkship Directors felt they were wasting time in simulation teaching procedures that they felt were too basic, but couldn’t be skipped. Therefore, in the last two years, we have worked with faculty to push the acquisition of certain basic skills down to the beginning of medical education. We determined procedures that were valuable across many specialties and started holding simulation sessions starting within the first two months of medical school. These procedural sessions are timed with the appropriate medical knowledge, as much as possible, during Anatomy, Pharmacology, Foundations in Medicine

• Our Lady of the Lake of Baton Rouge, LA; • Ochsner Hospital of New Orleans; • Cardiovascular Institute of the South for cath lab training; • Gastroenterology Associates and North Valley Health Center of ND for endoscopic training; • Louisiana Organ Procurement Agency for organ packing and transport; • Wasit University of Iraq for FLS training and testing.

IJ and subclavian central line placement are important procedures for interns to master.

and the Mechanisms of Disease courses. While the simulation sessions are not teaching a procedure to proficiency, they play an important role in engaging students early in their education and help students truly learn and interact with the content, rather than faculty teaching at them.

Some of these clients, such as Aureus Research and Remote Medical Education, came to us with their curricula fully developed and with experienced instructors, we simply provided the space, equipment and simulation tech support. Others came to us with just an idea and we supported them from curriculum development through instruction and sometimes testing. During the four and half years since the Tulane Sim Center opened, the field of medical simulation has grown tremendously. Some would say the industry has exploded and with this growth has also come rapid change and advancements. There are as many different ways to manage a simulation center and conduct a simulation course, as there are centers. So if you are new to the field, how do you start? We say you start with a funnel. Get a lot of instructors to do a few things and work your way through them to have a few who accomplish everything and use them as your star examples. Then to add some more, target, present, support, execute and repeat. medsim MS1307

Tulane Sim Center is Open to All Just as we have with Tulane residents, fellows and medical students, we work with external clients in any way that fits their goals and objectives. A benefit of being a private institution is that at the Tulane Sim Center, we are able to fill in our time with unaffiliated, paying clients. This is also a benefit to the region, bringing medical simulation opportunities to institutions that would never consider building their own center. During the four and half years since our opening, we have held courses from a few hours up to a week long for a wide variety of institutions, including: • Franklin Medical Center Emergency Department of Winnsboro, LA; • Aureus Research for clinical trial coordinator training; • Remote Medical Education for remote paramedic training; ME D S IM MA G A Z INE 3 . 2 0 1 3

Interview

Interview with Richard M. Satava, MD FACS Professor Emeritus of Surgery, Department of Surgery, University of Washington Medical Center, Seattle. Richard M. Satava, MD FACS Image credit: University of Washington.

r. Satava has held numerous leadership and management positions in the medical community. Prior assignments and positions include Professor of Surgery at Yale University and a military appointment Professor of Surgery (USUHS) in the Army Medical Corps assigned to General Surgery at Walter Reed Army Medical Center and Program Manager of Advanced Biomedical Technology at the Defense Advanced Research Projects Agency (DARPA). He has also served on the White House Office of Science and Technology Policy Committee on Health, Food and Safety. His previous positions of leadership and influence in medical societies include membership of the Emerging Technologies and Resident Education, and Informatics committees of the American College of Surgeons (ACS) and now the Accredited Educational Institutes committee. Group editor Marty Kauchak conducted a wide ranging interview on topics of interest to our community with Dr. Satava on July 22, 2013. MEdSim: Given your scope and breadth of experience and accomplishments in the community you have certainly “seen the future.” Your insights on how medical simulation has evolved. Dr. Richard M. Satava: The real change began in 1987 when I started building the first virtual reality simulator. After submitting for publication a number of times to multiple different journals, I finally had the paper accepted and it was titled “Virtual

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Reality Surgical Simulation – the First Steps”. In 1992 when I was still on active duty, and because of the work I had done both on simulation and virtual reality mainly, and robotics – I was on the team that developed the first surgical robot – I received orders to report to DARPA. It was a “detailed” duty assignment where I was also assigned to the [now closed] Walter Reed Army Medical Center where I could keep my surgical practice going. I was a program manager at DARPA. That gave me the opportunity to craft solicitations and provide sufficient amounts of funding in robotics and surgical simulation, and in other areas as well. In the 14 years I was at DARPA the program comprised $(US) 10s of millions in surgical and medical simulation – mainly surgical skills and basic technical skills training, because both virtual reality and medical simulation were totally new fundamental sciences for healthcare I worked extensively with some of the pioneers in simulation. Jeff Cooper, Phd, at Massachusetts General Hospital, was one early expert in team training and communication skills. And then there was the pioneer in simulation, Dave Gaba, MD, at Stanford University-VA Clinic. He completed all of his simulation on a mannequin whereas the DARPA projects focused on virtual reality. MEdSim: Reflecting on DARPA’s significant, early investments in these technologies, was there an adequate return on investment for the US taxpayer and, as important, the military stakeholder? Dr. RS: No – with a small yes. And that was because it was very difficult to get the surgical community to pay attention to simulation and training. A fair amount of that was my fault. We had developed simulators initially and discovered about five to six years into the overall program that it wasn’t about the simulator at all, it was about the curriculum. We finally got very heavily into the critical piece – curriculum development and validation. The problem we discovered, at least in the first few years, is that every company that was funded found their favorite doctor and did what that doctor said. It

turns out the education community and, in particular, those responsible for certification – the boards of surgery, urology and others – didn’t care how fast people operated. Time was the main metric that nearly everyone used. Because we did not focus on patient safety, we were not able to get these appropriate surgical authorities to accept the simulator and its curriculum, let alone to mandate the use of simulation. Medical educators were rightfully skeptical because if simulation was not required by the certification authorities (Boards), it was reasoned, why should they exert a significant effort in simulation? MEdSim: I imagine that during your DARPA assignment you also worked closely with the US Army’s PEO STRI in Orlando? Dr. RS: Yes. I had the opportunity to be closely in touch with PEO STRI which was the command that was funding all of the other non-healthcare simulation for our service and other military commands. I learned from them not only the

components of simulators but also the essence of simulation from the program management and curriculum development standpoints. MEdSim: You have also collaborated with behavioral psychologists and nonmedical learning professionals during your career. Dr. RS: During my assignment at Yale University’s Department of Surgery and concurrently at the NASA Commercial Space Center, I continued to support DARPA. I had a Fulbright Scholar, Tony Gallagher, who spent two years with us, who was a behavioral psychologist and I learned an enormous amount from him and gained a great amount of respect for his occupation. Through Dr. Gallagher’s efforts, as well as the medical educators, psychometricians and statisticians, it was possible to prove the effectiveness of the curriculum and simulators. In 2002, the VR to OR validation study was accepted by the American Surgical Society. After that was accepted, the American Board of Surgery soon required that simulation become part of surgical

training. That was the major step forward for simulation becoming accepted. MEdSim: And today’s healthcare community requires a rigorous curriculum with outcomes? Dr. RS: Yes, they require a well-constructed curriculum with the appropriate outcomes that has validation proving that they are effective in training the learner. Without that validation it doesn’t matter how famous your surgeon is, or how important your company is, the authorities are not going to approve it [the simulator or simulation]. MEdSim: So how is the community doing to validate the technologies we see in medical simulation centers and in conference exhibition halls? Dr. RS: It’s been a very, very long struggle. There are some simulation-based curricula, that have been accepted, but by-and-large it’s been very, very slow. Part of the reason is the medical education community does not accept any of the simulations and training curricula until they have been unequivocally proven to be effective. There is not a lot

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interview of experience in the medical community on the rigors of curriculum development and on validation and implementation. This is slowly becoming adopted by more and more professionals in the medical profession who are finally beginning to understand the rigors necessary in order to make a curriculum acceptable and a required part of training. Most surgeons do not have the time to spend to understand the stringent requirements to get his or her curriculum developed. The number one problem we have today for procedural-based training, where you use a lot of simulation, is that clinicians will say, “I have a great idea for training as a procedure.” They find a company and together build a simulator to their own specifications – as a health care provider and physician. In essence, this approach is one in which the clinician says “This is the way you should do it because this is the way I do it”. And then the clinician and company cannot understand why no one will buy their simulator because – the obvious explanation is that the developers frequently do not spend the time conducting the validation trial. In some cases, when the developers do attempt to validate the simulator, they try to do it themselves without the proper inputs of the educational and behavioral psychology community - and they miss their mark. There is currently a small community of medical simulation experts (which is beginning to grow), of 40 or 50 people, perhaps a bit larger, that truly understand how to develop a curriculum, how to create a supporting simulator, how to conduct a rigorous validation study and then how to design a high-stake test that will be accepted by the certification bodies – this is referred to as the full life cycle development of curriculum - it’s a very rigorous process that takes at least two to three years to move forward. MEdSim: And the cost? Dr. RS: It costs a lot of money. $100s of thousands in order to actually design a curriculum, incorporate it into a simulator and then validate the study and design the high-stakes test that accompanies it. All of that process must be completed before applying to the certification authority (such as a Board), to 16

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consider requiring the curriculum to be a required part of surgical training. MEdSim: Can you contrast that with the military simulator or simulation procurement model? Dr. RS: Well the irony of this is I have known about this since the early 2000s because of my association with the military simulation community. That community does not expect to build a simulator for a couple hundred thousand dollars and to have the curriculum implemented. They understand that it is not possible to perform the full life cycle development of a curriculum for less than a few million dollars. And once completed, it is necessary to spend a year or two validating it for nearly a million dollars in order to have a curriculum that is unequivocally, rigorously tested so it can demonstrate to the users that it is effective. This order of magnitude effort is sometimes difficult for the medical community to understand. MEdSim: So is one solution to reduce medical community procurement costs, to accept as the military does, in many of its training devices, the “80 percent solution?” Dr. RS: There is the issue of technology. We are experts in basic skills, team training and the like. For advanced procedures the medical community does not currently have the money to invest in order to make a simulator that allows you to practice not a skill but on the full surgical procedure for an operation, that is on the order of a high fidelity flight simulator, or tank or driving simulator. Such a medical simulator would be very, very expensive, and extremely technically challenging, and cost on the order of $10s to $100s of millions of dollars for one that is biologically correct and not just physically correct.

"It becomes very difficult for the simulation centers to have enough funding and manage at a level they should have," Dr. Satava. Image credit: University of Washington.

The only good news is now we have a number of accredited simulation centers that have this rigorous understanding and we are beginning to get curricula developed which meets the standards necessary to be accepted by those who really count – the certification boards. MEdSim: It also sounds like there’s a compelling need to bring others from outside the healthcare community into this process: educators, technicians to refine medical simulation center course content and other subject matter experts. Dr. RS: Yes, that is absolutely true. To develop a medical education curriculum is a multi-disciplinary task: clinicians who know what is necessary and also behavioral psychologists to help them design what the curriculum will be, and to literally extract from them what are the critical outcome measures. My experience is there are very, very few surgeons or physicians who truly understand how to design curriculum, beginning with the outcomes measures and metrics that are required. They haven’t gone through the task analysis and all the other essential details that are required. In addition, they are reticent to reach out to those who can – the behavioral psychologists, statisticians and others. You cannot develop a high stakes curriculum that will result in certification if you do not have a multi-disciplinary team. MEdSim: You noted the importance of the American College of Surgeons (ACS) in advancing the state of the art in medical simulation. Dr. RS: I did. Back in 2003 or so Dr. Ajit Sachdeva [Director, Division of Education, ACS] made a very profound statement: There is not an available source of funding to invest in such a high fidelity simulator. All the money that is being put into simulators is for very simple simulators. Trying to get to the next level is expensive and difficult, and there’s not enough people working in this area because there is no return on investment. It is really, really hard to take that next step – to produce a biologicallybased simulator for a specific procedure. With respect to the 80 percent solution, you do not have an 80 percent solution for a flight simulator, do you? MEdSim: For the full flight simulators, no. Dr. RS: When peoples’ lives are not at stake the 80 percent solution would be fabulous. But right now we are at the 20-30 percent solution in healthcare. We need a major, huge step forward to get there. We have hit the “technology wall”. MEdSim: What are the impediments that prevent the medical community from embracing a more military-like procurement or life cycle business model for simulators? Dr. RS: There are a number of educational and behavioral issues. The vast majority of the people do not truly understand the rigor required in medical education. The problem is the clinicians, who are absolutely critical in order to determine what training needs to be developed (i.e., the outcomes measures) have no clue how to do it. Some clinicians claim that they know exactly how to do a particular procedure and therefore, they will claim “This is the way you do it – you watch me and we’ll have a curriculum”. They do not understand the principles that are required for developing the outcome measures before you develop the curriculum, nor do they understand the full life cycle development.

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interview “It is not about the simulator, it is about the curriculum”. That was the “Ah Ha!” moment for the simulator community. Dr. Sachdeva, when he made that statement, also said the other major problem facing the medical education community is that, even as simulation is beginning to become accepted and required, there is no quality assurance on the quality of the training - the simulation centers that were being built at that time were so random that there was no assurance that the training which was being performed had merit. Under his direction and the impetus of the ACS Board of Regents under Dr. Carlos Pellegrini, and others, the ACS declared that although they believed in simulation-in-healthcare they were not certain that the process for managing a simulation (medical education) center was rigorous enough to develop confidence in the training for patient safety. Therefore they set up an ACS accreditation process that would guarantee the quality of education at a simulation center. They initiated the ACS Accredited Educational Institute (ACS-AEI) process for certification of simulation centers. This was every bit as rigorous as the process which hospitals go through for certification, and resident training programs were required to meet by their Residency Review Committees. By 2006 The ACS-AEI had piloted a study, modified it and tested over again,

and that year they began to certify simulation centers to train surgeons in technical skills using simulation. There are now 77 certified centers, 14 are international. All have gone through the rigorous ACS-AEI process, which includes not only specific skills training, but also multi-disciplinary and inter professional team training. MEdSim: Team training is one topic of increasing interest in agendas and on the exhibit floors of recent conferences. Dr. RS: What the ACS has done to greatly facilitate that perception is the ACSAEI has emphasized the importance of patient safety with the sub-header “Improving patient safety through surgical education and training.” Several things have happened because of ACS: 1. The focus on training and education of the healthcare provider has become a secondary (supporting) issue. The primary issue is patient safety; and 2. Simulation as a technology gave us opportunities to train to quantitative measurements that must be met in order to train to proficiency. MEdSim: We talked off line about the airlines. While it appears the medical community is lagging behind the airline industry in effectively embracing learning technologies, the medical is belatedly making progress. Dr. RS: There is no doubt, but there are a lot of issues facing the medical commu-

nity both technical and non-technical, the least of which is financial. There is a fundamental problem in healthcare – adequately funding medical education at the resident level. Quite literally there is no funding for resident medical education at the national level. A small percentage has come out of the graduate medical education budget (which is mainly intended for medical students). My understanding is that there are no specific dedicated teaching funds for structured resident education, and any such “educational funding” is usually used to pay for faculty time and residents salaries So it is difficult for simulation centers to survive because education is expensive and it is not profit making. It becomes very difficult for the simulation centers to have enough funding and manage at a level they should have. MEdSim: So the medical simulation centers turn to alternate funding sources – foundation grants and the like to pay for infrastructure. Dr. RS: That is so true. The problem is nobody wants to invest in infrastructure. Everyone who is willing to invest will donate to create a simulation center, but there is rarely any sustainment money to run it – to hire the necessary, qualified people to take care of it over time. Benefactors can put their name on a simulation center, but cannot put their name on paying for electricity and for

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the faculty to come and teach. This is a huge problem. MEdSim: Getting back to education and patient safety, it appears simulation, as part of the learning process, has an opportunity to make a huge impact – much as did the Flexner Report which changed medical training from follow me around as a medical apprentice, to a structured scientific educational training program. Dr. RS: Until now, there has not been a method to measure technical performance. All performance assessment was by the attending surgeon observing the resident, and the faculty deciding when they “were ready.” Simulation has permitted the establishment of objective measurements and to train to a benchmark level of proficiency (which is determined as the mean of experienced surgeons’ performance). We’re moving the technical skills from a time-based educational system (i.e., a strict 5-year training program) to a proficiency-based one – you have to continue training until you meet all the established milestones. Another important change is that with simulators, as we previously discussed, it is possible to implement multiprofessional education through interprofessional team training. The above factors are why this is a fundamental revolution in medical education – it is made possible by the technology of performance metrics through

simulation and the process of objective structured assessment. MEdSim: Let’s finally follow up and address your interest in robotics and share with us the state of that technology with regards to simulation. Dr. RS: Yes, you are referring to the fundamentals of robotic surgery (FRS) curriculum. It was decided to develop FRS curriculum from first principles. As compared to the fundamentals of laparoscopic surgery (FLS), which was developed principally as a high stakes test, the FRS is being developed for the full spectrum of outcomes measures through high stakes testing and certification. The enormous value of the FLS is that it was the very first high stakes test for simulation skills training, which is now a required minimal invasive surgery component for a surgeon who wants to be certified in general surgery. The FRS is a very accurately defined study. Based upon 19 years of experience in non-healthcare simulation the outcomes measures were defined and the appropriate metrics were chosen. Then the task analysis was conducted to determine what skills are required in the curriculum to meet the outcomes and measurements and metrics. This is a huge project, requiring multiple consensus conferences of subject matter experts. Then the validation study design had to be constructed to have enough learners in it to produce an unequivocal

validation as well as meeting the conditions of an evidence-based scientific study. And now the validation process is in place. One other final accomplishment is that through the ACS-AEI and some industry support, the Alliance of Surgical Specialties for Education and Training (ASSET) has been established. This is 14 surgical specialty societies (including the Department of Defense and the Veterans Administration Hospitals) which perform robotic surgery who have participated in developing the FRS curriculum. This is the first time that multiple specialties have ever collaborated in developing a single common curriculum for training. When completed, the individual specialty societies review the curriculum and consider adopting it for their specialty; in addition it will be considered for adoption by the ACS’s accredited institutes – all 77 of them. It is hoped that this will become a national and then a global curriculum that provides a common set of robotic surgery skills that all surgeons, regardless of specialty or nation, will be trained and assessed. Personally, it is unclear to me why two surgeons in different parts of the nation or the globe, would be trained to do the identical operation differently, perhaps this could be the first step to breaking down the silos that separate the medical education and training community. medsim

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HealthCare Simulation of South Carolina: A Functional Statewide Collaborative (Part 2)

In this second of two invited articles, John J. Schaefer, III, MD describes the operational and educational approach of HealthCare Simulation of South Carolina.

his is the second of an invited two-part series about the simulation collaborative that has developed in South Carolina. In 2006 South Carolina’s three state Universities established a collaborative and endowed chair to increase the utilization of simulation for the benefit of South Carolinian patients, students and healthcare workers. As of 2012, HealthCare Simulation of South Carolina has grown to include 10 collaborative and 20 affiliated partners, with a 20-fold increase use of simulation (about 50,000 sims/yr.). The first article (MEdSim 4/2012) focused on the origin, development and infrastructure of the collaborative and its statewide office. Part two will focus on the specific educational and operational methodologies underlying the high volume, low cost simulation that has been a significant key to the success of the organization.

Defining “Practical Simulation” There are three “Practical Simulation” elements supporting our organizational model: simulation as a teaching methodology that takes advantage of simulator tools where diverse and large numbers of Healthcare students and practitioners have individual and group access to training; Healthcare teachers with reasonable training can adopt simulation training methodologies rapidly and the “value” of using simulation justifies the capital, operating and indirect costs associated with it.

How to Make Simulation Practical? At the heart of our approach is shifting the complexity from 20

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needing an expert operator running a simulator manually and expert instructor teaching the course towards an approach where any teacher can run the simulator using simple to run pre-programmed scenarios (that were complex to develop) and running the course using an “expert” curricula. By decreasing the complexity of teaching the course and running the simulator, the utilization can be increased. In some appropriate instances, one teacher can supervise multiple simulation stations where students are working in small groups running the simulators themselves. We call this approach an “Expert Curriculum-Competent Facilitator Model”. (Figure 1)

Elements of a HCSSC “Practical Simulation Course” 1) Internet-based “Participant Curricula” To minimize dedicated instructor time away from clinical revenue generating activities, this self-paced discrete component is reviewed by motivated, responsible, adult learners prior to dedicated simulation training component of training.

Basic Emergency Airway Management course for medical students with one facilitator, 12 students using four simulators with students running simulator scenarios after five minutes of training (graded course).

Figure 1 Expert Curriculum-Competent Facilitator Model. All images: John J. Schaefer, III, MD.

2) Internet-based “Facilitator Curricula” This component is required to provide critical standardization of delivered educational objectives (for any given educational topic, different instructors will teach different things without structure) and lower the threshold for training of instructors (most clinician teachers are not formally trained as educators). (Figure 2) 3) Standardized, objective driven, highly automated simulator scenarios The simulation exercise uses a well designed, pre-programmed simulation scenario run by the facilitator (teacher). This scenario incorporates semi-automated evaluation of key educational objectives embedded in the scenario that are automatically flagged for focused feedback specific to the individual or group's performance and additionally provides standardization of the whole evaluation/feedback process. (Figure 3) 4) Automated grading incorporated in simulator “Debriefing Log” The simulation exercise uses a well designed, pre-programmed simulation scenario run by the facilitator (teacher). This scenario incorporates semi-automated evaluation of key educational objectives embedded in the scenario that are automatically flagged for focused feedback specific to the individual or group's performance and additionally provides standardization of the whole evaluation/feedback process. The facilitator then uses this debriefing file as an educational diagnosis that when coupled with a standardized "reflection" process leads to a focused, standardized (yet individually specific) learning encounter with the student. The facilitator uses the flagged performance point in the debriefing log and guides the student through reflection to determine whether the lapse identified was secondary to a "knowledge", "skill" or "judgment" flaw. At this point the facilitator guides the student to the better or correct way to perform. During this process the facilitator also reinforces positive performance points identified automatically in the scenario and presented in the debriefing log. (Figure 4) Depending on the equipment used, a video record is available and specifically tagged to each evaluation point for use as needed in the debriefing process.

Figure 2

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5) Documented “Value Statement” The saved debriefing files can later act as an objective record that with some administrative support can be used for creating a summary of the learning across multiple students or for research. With some of the additional technology available (i.e., B-Line Medical SimBridge), trainee and faculty portfolios can be made available over the Intranet for additional reflection.

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Figure 5 Operationally this approach is significantly cheaper to run in that one simulation specialist can support up to eight independent rooms where traditional approaches require an expert simulator operator for each simulator. As part of services available within the collaborative, support for training the trainer as it applies to: loading and running scenarios; accessing and using curricula; and a primer on debriefing with objective driven scenario logs is available. Within the statewide collaborative, approximately 30 courses/modules and 1,000 scenarios are supported for use within the collaborative applying these methodologies. The operational and educational approach (Figure 5) described in this article, is an applied example of commoditization of previously complex, costly approaches to simulation education and operation by making available broadly, at a lower cost, what previously only experts in simulation could offer at a much more expensive price. It is the mission of HealthCare Simulation of South Carolina to facilitate access to simulation based educational methods for healthcare educators throughout the state of South Carolina. medsim 22

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Simulation

A Wireless Gadget for Simulation of Partial Seizures in a Child Rahul Panesar, MD, Sean Cavanaugh, BS, and Christopher Gallagher, MD describe their efforts to build an inexpensive, wireless partial seizure mechanism for pediatric status epilepticus simulation scenarios.

he most common neurologic disorder in children is seizures, with up to 6% of all children having at least one episode by the age of 16. Seizures can be non-convulsive (i.e., absence, complex-partial) or convulsive (partial or generalized), presenting in a wide array of settings, including infection, fever, electrolyte abnormalities, stroke, trauma, intoxication, tumor formation or neurocutaneous syndromes. Convulsive seizures lasting for longer than 30 minutes or two or more discrete seizures without a return to baseline mental status are defined as convulsive status epilepticus (CSE). The annual incidence of CSE is reported to be 10 to 73 episodes/100,000 children and the mortality reported to be between 2.7% and 8% with an overall morbidity between 10 and 20%. Therefore, early recognition of CSE is paramount to timely intervention and subsequent resuscitation and treatment. The need for rapid administration of medications, securing the airway and assessing the cardiac, respiratory and neurologic function of the patient requires a coordinated effort of the resuscitating team, which is amenable to high-fidelity simulation. Currently, several high-fidelity pediatric mannequin models are available commercially that provide multiple functionalities including breathing, palpable pulsation, heart sounds, phonation and pupillary responses. At our institution, we have employed the pediatric Laerdal SimJunior速 mannequin, which has an additional feature of head movement to simulate seizure activity.

However, if bag mask ventilation techniques are applied, movement of the head can be subdued, resulting in lack of recognition of CSE. Therefore, we explored new techniques to provide a more explicit indication that seizure activity was present. Current devices simulating seizure activity include inflating/deflating bags to replicate generalized seizures and those that move the head as well as a recentlydescribed mechanical device that can simulate partial seizures in an infant mannequin. However, a cost-effective, wireless mechanism simulating a partial seizure for a child-sized mannequin has not been described. Our goal was to build an inexpensive, wireless partial seizure mechanism for our pediatric status epilepticus simulation scenario to move either a leg or arm of the SimJunior mannequin. We set out to construct a simple vibratory, remote-controlled circuit using off-the shelf technology that could be readily reproduced with toy parts available at most retail stores.

Figure 5 The finished gadget attached to the left foot with a Velcro strap (A). The receiver motor circuit embedded into the gurney and covered with a hospital sheet, red transmitter wiring showing (B). All images: Stony Brook Long Island Children's Hospital

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SIMULATION Methods We searched local retail stores to find vibratory children’s toys that housed motorized devices powerful enough to feasibly move the mannequin limb. Additionally, we searched for remote-controlled devices that could provide the transmitter and receiver components of the circuit to turn the motor on and off. During this process, we were determined to design and build the entire device as simply and inexpensively as possible to allow easy reproducibility and replacement of parts, while providing the optimal amount of movement to simulate seizure-like movements. After construction of a prototype, we would implement it in a high-fidelity simulation of pediatric status epilepticus.

Circuit: Motor The motorized device we found to be adequate to our need was in an infant toy musical bouncing ball (Fisher Price® Bounce and Giggle Pig™), though a variety of other vibratory and bouncing toys are available for approximately US$30. After testing toy functionality, we removed the batteries (3 AA batteries), opened the casing and disconnected the motor from the wiring to the circuit and the speaker, and detached the battery casing (Figure 1). The motor drives an eccentric gear transmission causing a vibration effect. Now isolated, the motor was ready for connection to the receiver circuit.

Circuit: Transmitter and Receiver The transmitter and receiver components of the circuit were found in a remote-controlled toy car (New Bright© RC, New Bright Industrial Co., Ltd, model #4310) that operated at the 49 MHz frequency signal for approximately $10. The transmitter unit was powered by 2 AA batteries supplying 3.0 volts DC to a circuit of several surface mounted capacitors, load resistors and a packages 48.3877 MHz can-crystal radio frequency (RF) transmitter, with a 22 gauge 8-inch copper wire for an antenna. The movement of either the thumb knob controller switch caused an RF transmission frequency which activated two different channels (forward/backward, right/left) on the receiver circuit. Each knob allowed a slightly different carrier frequency to allow distinct signaling of the receiver channels. The receiver (Figure 2) embedded in the car was powered by 2 AAA batteries, supplying 3.0 volts DC. The antenna is a 22 gauge 8-inch copper wire. The receiver power supply had a 2-pole on/off switch. With the receiver power switch in the “on” position, Figure 1 Motor isolated from vibratory toy. The eccentric gear transmission is housed in a plastic case providing vibration (A). The leads from the motor (B) were soldered to 2 wires (C) that connected to the receiver.

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and either of the transmitter thumb knobs moved, the receiver activated several field effect transistors to saturate, causing the closing of the 3.0 volt power circuit connected to the DC motor, thereby activating the motor and causing the vibratory effect. After testing functionality of the remote and car, the car was stripped down to the receiver component which sat on the battery casing. The wiring from the car’s circuit connected two wires to the front motor to move the front wheels to the left and right. Two additional wires connected to the rear motor to move the rear wheels forward, thereby propelling the car. These wires were cut and the front wires were soldered to the motor end plates to turn it on or off (Figure 3). The motor was activated with the 3.0 volts from the receiver circuit when the transmitter knobs were pushed, giving the vibratory motion desired. The receiver circuit was then secured to the motor with adhesive glue and electrical tape (Figure 4). To avoid altering the mannequin, a small 4 x 2 inch compartment was cut 2 inches into the foam cushion of the gurney where the mannequin calf and heel region would normally rest (Figure 5). The seizure gadget was placed inside with the extension of the motor compartment right side up. A solid piece of plastic was placed on the bottom to avoid dampening of the vibration and foam was placed around the gadget to dampen any noise emanating from the motor. The leg was placed on top of the motor and secured with Velcro® straps to the gurney to avoid displacement by simulation participants. The leg was draped with a hospital sheet which accentuated the movement of the limb, allowing participants to more easily recognize the simulated partial seizures. This device was incorporated into the Pediatric Simulation Program at our institution for the status epilepticus scenario in an 8-year old boy with severe pneumonia, hypoxia and hyponatremia. During the simulation scenario, the facilitator in the simulation suite would observe the session and, while wirelessly communicating with the control room behind a two-way mirror, was able to activate the movement of the mannequin limb at his or her discretion by moving the back/forward switch on the remote controller. Thus, the facilitator could discretely control the duration and frequency of movement from up to 15 feet away, depending on the interventions by the participants and the progression of the scenario. After the simulation, the seizure gadget would be removed from the compartment, batteries removed and all components stored safely in the control room, all without the mannequin having been altered.

Left: Figure 2 The receiver circuit from the RC car. The circuit was isolated from the motors to the wheels. Leads that activated the front wheels (A and B) were cut and connected to the wires from the motor terminals.

Right: Figure 3 The connected vibratory motor (A) to the receiver circuit (B) with antenna (C).

quency in the simulation lab. We discovered that the technician in the control room could not use the remote control since the glass and wall separating the simulation suite and control room obstructed the signal. Therefore, the facilitator in the simulation suite handled the controller. However, this was not a hindrance to fidelity; rather, the facilitator had acute control over how long and often the partial seizure would manifest. Additionally, interference from other electronic devices in the simulation suite that would alter the signal from the remote controller was not observed. Finally, the device is not completely concealed; though it was embedded into the gurney, participants could see it under the leg if the removed the hospital sheet. However, the Velcro strap hid most of the gadget and this did not seem to affect their overall response from participants.

Conclusion

Results

A wireless, inexpensive, easily reproducible and compact seizure gadget can be built from commercial toy circuits to enhance the fidelity of medical simulations involving partial complex seizures in a pediatric mannequin.

To date, we have used the seizure gadget in two simulations in the high-fidelity suite as well as one in-situ simulation in the general pediatric ward. In each session, the gadget was able to achieve the intended effect of simulating seizure activity and the participants acknowledged the movement as such. The facilitator was able to covertly control the seizure activity at his or her discretion, depending on the actions of the participants. The device did not affect the mannequin, was easily placed into position, did not interfere with other wireless devices and was safely stored afterwards with battery removal. The small amount of noise produced by the motor was eclipsed by the commotion of the room and ambient noises of the code.

About the Authors Rahul Panesar, MD, is an Assistant Clinical Professor in the Division of Pediatric Critical Care Medicine, Department of Pediatrics at Stony Brook Long Island Childrenâ&#x20AC;&#x2122;s Hospital, Stony Brook New York. Co-author Sean Cavanaugh, BS, is Senior Simulation Technician at the Clinical Skills Center, Stony Brook University Medical Center and co-author Christopher Gallagher, MD, is Professor in the Department of Anesthesia at Stony Brook University Hospital. Dr. Panesar acknowledges the contributions of Bill Giangarra, Senior Biomedical Engineering Technician in Biomedical Engineering at Stony Brook University Hospital. medsim

Discussion The literature shows high simulator validity is crucial to enhance the realism of a simulation session and subsequently education for participants, improving their skills and responses to critical events, and ultimately, will lead to greater patient safety. High-fidelity mannequins and a variety of tools and techniques to improve the realistic features of simulation are being investigated in academic and commercial sectors to address this aspect of simulation-based education. We have demonstrated that a simple wireless seizure gadget can be readily constructed from commercially available toy parts and effectively incorporated into a simulation scenario depicting partial complex seizures in a pediatric mannequin. To the best of our knowledge, this the first wireless pediatric partial seizure device reported in the literature. Implications from this work include using other cost-effective remote controlled gadgets to improve the fidelity and realism of simulation, such as building remote-controlled LEDs to change skin color or motors to initiate bleeding. Additionally, we have begun to build circuits with more than one motor per wireless controller; as in our case, so as to allow multiple limbs to vibrate independently or in unison. Lastly, this portable seizure gadget can be adapted to various-sized mannequins, including infants, in a variety of environments and scenarios, for similar effects. Limitations to this device include obstruction to the radio fre-

Figure 4: The finished gadget. The receiver circuit (A) mounted to the back of the motor (B). The gadget was activated remotely by the RC car transmitter (inset, C).

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Conference Report MEdSim continued its presence at international conferences through July. Publisher & CEO Andy Smith, Editor Judith Riess, US Sales Representative Justin Grooms and Group Editor Marty Kauchak provide recurring themes from select conferences’ keynote addresses, breakout sessions and the exhibition floors.

ur editorial team continued to see common themes and challenges facing the healthcare community. All conferences highlighted patient safety and addressed ways to improve education and training through rigorous curriculum development and the use of simulation. While still faced with technological barriers, lack of resources and other challenges, they looked for solutions to the problems. International Simulation Center Directors talked about sharing curriculum across nations and surgeons around the globe highlighted the need to have international skills certification and standardization of medical procedures. New Orleans was the venue for the May 8-10, 2013 15th Annual National Patient Safety Foundation (NPSF) Congress. The key theme that resonated throughout the three-day event was simulation can advance the patient safety mission. But the road leading to improved levels of patient safety using simulation is often winding, with occasional hazards and roadblocks. Wednesday morning and afternoon’s sessions on Advancing the Patient Safety Mission Through the Use of Simulation, provided insights on a number of foundational skills and knowledge sets needed to get simulation programs and processes up and running, and maintain their effectiveness. Not lost on the attending delegates at these sessions was the compelling need to get things right the first time, during the layout and design of simulation centers and in other activities. “Do overs” in adjusting simulation systems and processes are often costly in terms of resource expenditures, and may adversely impact patient safety. Another impression from the three days of NPSF events is the increasing importance of team training and activities in simulation centers and other training venues. And while the S&T sector is providing simulation labs, and their enabling equipment and systems to allow teams to learn, refresh and rehearse their hands-on skills, there are also “soft skills” – communications, onthe-job behaviors and the like which if not mastered – may be distractors, or worse, among team members. The Thursday Keynote Session: Bedside Manners focused on 26

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the effects of ineffective soft skills in hospital venues and served as a wake-up call for the healthcare community to build these capabilities. Another trend in team training gleaned from the conference’s proceedings is the inclusion of expanded healthcare providers in scenarios and events. While training sessions continue to focus on surgeons and nurses, the addition of other staff, like pharmacist to validate medicine dosages, and scenarios with patients and family members to understand procedures and follow-up care are being used in many medical schools and hospitals. A final, emerging topic of interest was the case for simulation center staff and faculty development. This requirement is frequently forgotten but is obviously crucial and often not covered in budgets. Despite government missteps in funding and sequestration in the military, the VA and DoD continue to acquire training systems and devices. So while contract awards may “move to the right” by one or two quarters, government healthcare providers are still looking to buy technology enablers for their learning programs. NPSF and this June’s SESAM (Society in Europe for Simulation Applied to Medicine) both raised the issue of “just” or “no fault found” reporting of incidents/accidents – which the sector as a whole might not appreciate but the airline industry’s “no fault found” has improved airline procedures and safety, and is mandated reporting. Our viewpoint is that even if limited to a single hospital or group of hospitals, a “just” reporting system would highlight problems/shortfalls that could be addressed through education and training and could be embedded into medical education curricula. Funding and obtaining other resources for curriculum development and education courses using simulation is a challenge around the globe. SESAM, which convened this year in Paris, brought simulation directors, medical educators and healthcare providers together to brainstorm and come up with solutions to recurring problems. In the case of simulation centers in the EU, for example, although initial government funding for five years of

NPSF Congress. Image credit: David Aleman, f-Stop Photography.

Conferences

operations can be achieved, what it can be used for is restricted. No commercial activity can be started by the center in those five years and there is no funding for curriculum development, maintenance and updates after that initial grant. Centers have a unique problem: sustainment! Sessions with EU nations’ simulation center directors highlighted each countries successes and problems and sought solutions for how they could collaborate on curriculum development, assessment, sustainment and return on investment strategies. Listening to presentations throughout the conference season, the subject of patient safety was front and center with the crystal clear implication that better and ongoing training will improve patient safety. There was an elusive and critical “third link” that many presenters did not address – returns on investment, in particular those that lead to lower costs. The 2nd SURGICON Conference held in Gothenburg, Sweden gave us a global perspective of medical education and training through the use of simulation throughout a surgeon’s training. Other items of interest discussed at SURGICON were to use simulation to address critical errors during actual procedures. Conceptually, three months after an “event” a group would run an exercise in the ward or OR, closely modeled on the event, as a way of seeing if there were skills or other gaps that could be addressed to prevent a recurrence of “negative events” from that incident. A second area was developing international standards and procedures and certifications so that medical doctors trained in one area of the world could perform procedures in a different world location. Ireland’s surgical program which incorporates simulation throughout a doctors training was discussed and they wanted to find other similar programs that could be used as models in other countries. Australia and Ireland have very effective rural health programs through the use of traveling health coaches. In fact, Australia borrowed the idea from Ireland and both are quite effective in delivering health care to rural populations. At this June’s 12th Annual International Nursing Association for Clinical Simulation and Learning conference in Las Vegas, evidence-based practice was a major theme throughout the sessions. One presentation highlighted the Patient Outcomes in Simulation-Based Medical Education: A Systematic Review (Zendejas et al, 2013). The academic endeavor noted the simulation community’s failure to provide adequate, timely, quality studies to document the benefits of using learning technology to prepare for actual medical procedures. Of 10,903 articles screened, 50 reported patient outcomes for 3,221 trainees and 16,742 patients. The presentation noted, “Simulation-based education was associated with small to moderate patient benefits in comparison with no intervention and non-simulation instruction, although the latter did not reach statistical significance.” Clearly the S&T sector has an opportunity and challenge to respond to the question: why simulation? Interprofessional skills development was discussed in a number of sessions dealing with different levels of nurse training. Many schools are incorporating team training with medical students, nursing students and others at the beginning of their educational programs.

Patient safety was an implied and/or explicit theme through many of the breakout sessions at this conference. During discussions with delegates on the conference floor, we were impressed by their awareness of products which operate well in a standalone mode as well as networked, especially in a medical simulation center environment. The Hamlyn Symposium on Medical Robotics conference held in London, delivered content ranging from keynote addresses by Intuitive Surgical’s CEO and Titan Medical’s CEO on robotic surgical advancements to surgical robots retrieving foreign bodies from a beating heart. Hamlyn grew from Imperial’s Cross Faculty Workshops to an international forum for clinicians, engineers and researchers to exchange ideas and explore new challenges in healthcare technologies. Presentation topics ranged from training and clinical outcomes, image guidance in robotic surgery, as mentioned above, to new clinical approaches and pilot studies on evaluations in the control of a flexible surgical robot. The number of countries involved in robotic surgical advancements was impressive.

Michael Bernstein, President, CAE Healthcare. Image credit: CAE Healthcare.

At HPSN World, convened June 30-July 2 in San Francisco, Michael Bernstein, the President of CAE Healthcare, in his opening address, encouraged companies to form an alliance to improve healthcare much as the airlines did. He discussed the fact that medical error accounts for as many deaths as five jumbo jets crashing each week. The conference keynoter gave an impressive presentation on the importance of team training. Presenters from around the globe highlighted best practices and new simulation technologies including a sneak peek at the CAE Childbirth Simulator that is due out in 2014. A number of sessions talked about the art of debriefing and how important it was in simulation. Throughout the conference simulations were conducted on the show floor as they were at NPSF. Mobile rural healthcare simulation and training was a key issue that many US states have to deal with and developing realistic scenarios that meet the needs of a rural, almost all volunteer EMS team and limited hospital facilities, was a topic of interest as were the sessions on scenario development, team training, core skills training and effective evaluation. medsim M E D S I M M A G A Z I NE 3 . 2 0 1 3

World News & Analysis

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

$1.9 Billion Healthcare/Medical Simulation Market by 2017 – Markets and Markets, a global market research and consulting company based in the U.S., released a report that says the Healthcare/Medical Simulation Market will be worth $1.9 billion by 2017. The "Healthcare/Medical Simulation Market - By Products (Patient Simulator, Surgical Simulator, Imaging Simulation, Task Trainer), Technology (Haptic, Virtual Reality), End-Users (Academics, Hospitals, Military) & Services - Trends & Global Forecasts To 2017" analyzes and studies the major market drivers, restraints, and opportunities in North America, Europe, Asia, and rest of the world. This report studies the Global Healthcare/Medical Simulation Market with forecasts to 2017 and says the Healthcare/Medical Simulation Market has experienced extensive growth over the past few years, mainly attributed to advancements in technologies. The increasing focus on training of medical practitioners, rising healthcare costs, growing focus on patient safety, and availability of funds has helped increase the purchasing power of academic institutes, thereby driving the growth of the market. Mount Sinai Proves Simulation Helps Anesthesiologists Re-enter Practice – Results of a 10-year study on retraining anesthesiologists in a simulation program at the Icahn School of Medicine at The Mount Sinai Medical Center in New York show that 70 percent of participants returned to active practice within a year of completing the program. 28

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AUA/Mimic Robotic Surgery Courses to be Offered With CME Credits – The success of the hands-on robotic surgery simulation courses offered at this year’s American Urological Association (AUA) event in San Diego were so successful that Mimic Technologies, the creator of the dV-Trainer, plans to hold future robotic simulation training courses at the following upcoming annual meetings this year: Society of Laparoendoscopic Surgeons, American Association of Gynecologic Laparoscopists, Clinical Robotics Surgery Association, and Society of Robotic Surgeons. The presence of experienced faculty and three different forms of simulation in one course was unique and offered training that could be individualized to each trainee’s specific requirements, said Dr. Chandru Sundaram, Professor of Urology at Indiana University School of Medicine, who led one of the hands-on courses at AUA, which focused on a Robotic Partial Nephrectomy.

The study is an analysis of the simulation program used to retrain and assess anesthesiologists’ skills between 2002 and 2012. The Icahn School of Medicine at Mount Sinai’s Simulation Lab was one of the first simulation labs of its kind, launched in 1994 under Adam I. Levine, MD., the study’s senior author.

The study's findings are available online and appeared in the July print edition of the journal Anesthesiology. Levine said that reentry programs for anesthesiologists are urgently needed and are of great interest to the American Society of Anesthesiologists and The American Board of Anesthesiology.

ACCP and Simbionix Collaborate On Bronchoscopy Education – Simbionix and the American College of Chest Physicians (ACCP), are collaborating to promote bronchoscopy education in a partnership that reinforces the goals of both organizations to improve patient safety and outcomes through advanced medical education. This commitment follows several years of Simbionix BRONCH Mentor use during ACCP's professional and diversified educational delivery in its courses and workshops where the simulator is integrated with instruction to teach and train basic to advanced bronchoscopic procedures. The goal is to develop curricula for bronchoscopy instruction and hands-ontraining. Work will continue to enhance and grow through the use of the BRONCH Mentor simulators that will be located in the new ACCP Innovation and Simulation Center scheduled to open in 2014. Training for Blood Gas Testing Improves Patient Safety & Satisfaction – A team at Bath Academy in the UK developed a simulated teaching package to help improve the ability of undergraduate medical students to perform arterial blood gas (ABG) testing. The Bath Academy trains Bristol University Medical School undergraduates at the Royal United Hospital (RUH). The simulated ABG teaching package at the RUH incorporates a mannequin ABG puncture arm and a specially adapted blood gas analyzer that teaches undergraduate medical students how to take ABG samples and interpret results in the context of a realistic simulated clinical scenario. The blood gas analyzer donated by Roche was altered so it could be used in a simulated environment, but is designed to replicate the Roche blood gas analyzers located in the emergency department, neonatal unit, medical admissions unit and biochemistry department at the hospital. Mimic Medical Education & Development (MimicMed) offer one-day Simulation-Based Robotic Surgical Training Courses at its Training Center at the Florida Hospital Nicholson Center in Orlando, Florida. Attendees may earn CME credits. Many surgeons have been exposed to virtual reality simulation through the da Vinci Skills Simulator and

the dV-Trainer at various surgical conferences and have requested that formal robotic simulation courses be provided, said Todd Larson, Director of Mimic Medical Education & Development at Florida Hospital. Brigham and Womens Hospital Installs Full-size Robotic Surgery Simulator – The new simulator is a fully operational da Vinci Surgical System console, identical to the actual units currently used in BWH’s operating rooms. The simulator is available for surgeons to use in the hospital’s STRATUS Center for Medical Simulation 24 hours a day, 365 days a year giving BWH surgeons the opportunity to hone their skills and raising the bar of safety for robotic-assisted surgery. Safe robotic surgeons must become one with their operative console, so that the patient-side robot truly functions as an extension of their own body, said Antonio Rosario Gargiulo, MD, the medical director of the Center for Robotic Surgery at BWH. This state-of-the-art simulator should give our patients confidence that their surgeon is always a technically competent robotic surgeon. Data suggests that complications from robotic surgery are less common beyond the early adoption phase by surgical teams. Memorial Hermann Katy Hospital Gets da Vinci Simulator Surgical System – Memorial Hermann Katy Hospital in Texas acquired a new da Vinci Si Surgical System, a third generation robot that offers technological advancements, including unparalleled precision, dexterity and control that lets physicians take a minimally invasive approach for many complex surgical procedures, such as removal of the uterus, uterine fibroids and the prostate gland. These new advancements benefit patients by enabling smaller incisions and less blood loss, thus reducing the patient’s length of stay and recovery time. The hospital is the first in the area to acquire the da Vinci Skills simulator. UK Children’s Hospital Trust Fund Buys Paediatric Surgical Robot – The Children’s Hospital Trust Fund purchased the UK’s first surgical robot, the da Vinci robotic system, to be used solely for surgery on babies and children. The trust donated the robot to Chelsea

and Westminster Hospital, which sees 85,000 babies and children from all over South East England each year. The £1 million robot was purchased with funds raised through the charity’s Pluto Appeal fundraising campaign.

Eye Surgery SHACRA Develops Cataract Surgery Training Sim – Research scientists from the SHACRA (Simulation in Healthcare Using Computer Research Advances) team with INRIA (Institut National de Recherche en Informatique et en Automatique) in Lille, France have developed a simulator prototype for cataract surgical training. The key feature of this simulator is that it relies on a very realistic biomechanical model of the eye, thanks to the technologies of InSimo. HelpMeSee is now leading a project to develop a high-fidelity virtual reality surgical simulator and courseware modeled on flight simulators. HelpMeSee founder Al Ueltschi was a pioneer in aviation safety and simulator based training of pilots. James Ueltschi, chairman and co-founder of HelpMeSee, remarked, "We proved through FlightSafety International that simulators can be used to train thousands of pilots every year. We strongly believe that this principle can apply to cataract surgeons as well. We are very confident we can solve this problem." HelpMeSee Selects Moog to Develop Eye Surgery Simulator – HelpMeSee has successfully tested virtual reality surgical training simulators as a proof of concept and went on to select Moog for a joint development contract to design and produce a high-fidelity virtual reality eye surgery simulator and courseware model to train cataract surgeons to perform high quality, high volume surgeries to save the sight of millions of blind people worldwide. The simulator design will include contributions from InSimo and SenseGraphics, companies acting as subcontractors to Moog on this project. The eye surgery simulator aims to provide students with a realistic environment to practice and achieve proficiency in any number of scenarios. M EDSI M M A G A Z I N E 3 . 2 0 1 3

World News & Analysis Eye Surgeon Develops New Training Device – The Jarstad cataract surgery trainer, a new cataract surgical device was unveiled this May at the American Society of Cataract and Refractive Surgeons symposium in San Francisco. John S. Jarstad, MD., F.A.A.O., Adjunct Associate Professor, Pacific Northwest University C.O.M. and Medical Director of Evergreen Eye Centers, in Federal Way, Washington developed the device that provides surgical training that enhances skills reinforcing fine motor skills and muscle-memory to help optimize surgical procedures in the operating room.

Hospital S&T Houston VA Medical Center Improving Health Care through Clinical Simulation – The Michael E. DeBakey VA Medical Center (MEDVAMC) in Houston, Texas, opened a new clinical simulation lab to help improve the quality and efficiency of Veterans health care through realistic simulations of normal and routine processes and to train the center’s clinical staff to respond to emergency situations with more knowledge and confidence. MEDVAMC plans to increase the use of medical simulation training for clinicians so they can learn how to conduct complex procedures in a setting that imitates real-life situations without putting patients at risk. Adventist Health in California Opens New Sim Lab – The Adventist Health / Central Valley Network Clinical Education Department in Hanford, California, opened a new simulation lab that lets staff and nursing students train in realistic situations by performing standard practices with mannequins in a simulated hospital environment. The lab, in one of the units of the former Hanford Community Medical Center building, now Adventist Health/Support Services, was funded by a $75,000 grant in 2011 as a part the Adventist Health Corporate Innovation campaign. Helen DeVos Children’s Hospital Opens Pediatric Simulation Suite – Helen DeVos Children’s Hospital in Grand Rapids, Michigan in the US opened a new pediatric simulation suite that mocks 30

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actual medical scenarios for training and education purposes. The simulation suite designed to support the hospital’s goal of being the safest children’s hospital in the country, and is designed to improve the technical expertise of clinicians, strengthening multidisciplinary teamwork and enhancing communication among physicians, nurses, paramedics and other health care providers. Jump Trading Simulation & Education Center Opens – OSF HealthCare and the University of Illinois College of Medicine official opened the new Jump Trading Simulation & Education Center. The Jump Center is a virtual hospital that combines medical equipment and the latest simulation technology for better education, performance training and research.

Academic Centers UVA Simulation Center Gets $3 Million Upgrade – The University of Virginia’s School of Nursing invested $3 million to outfit its Mary Morton Parsons Clinical Simulation Learning Center with 25 point-of-learning stations and the latest in high tech equipment. The 9,200 square-foot facility has seven high-fidelity patients that are programmable with a host of ailments, 21 high-tech beds including a birthing bed, and a mock isolation unit to practice infection control procedures common in hospitals today. University of Nebraska Dedicates New Surgical Simulation Suite – The University of Nebraska Medical Center dedicated its new Dr. Wayne and Eileen Ryan Surgical Simulation Suite that is modeled after the simulation center at the Mayo Clinic. The simulation suite was made possible by a $1 million gift from Wayne Ryan, PhD and his late wife Eileen, and will allow UNMC to become a regional training and testing site for medical students. University of Windsor Equips New Simulation Lab – The University of Windsor renovated an entire floor of its Medical Education Building with $4.2 million of funding from the Ontario government. The floor is dedicated to simulation training and research for the university’s nursing program and

to complement the Schulich School of Medicine and Dentistry. Eight high fidelity medical mannequins including a postpartum woman and an infant housed in the floor’s nursing simulation lab along with a 56-seat classroom and group instruction areas. University of Buffalo to Build New School of Medicine & Biomedical Sciences – The University of Buffalo (UB) unveiled plans for the new $375 million School of Medicine and Biomedical Sciences it will break ground on this fall. The new medical school will comprise more than a half-million square feet and will be one of the largest buildings constructed in Buffalo in decades, bringing some 2,000 faculty, staff and students to the medical campus, UB officials said. CMU College of Medicine Welcomes Inaugural Class – Central Michigan University’s College of Medicine seated its inaugural class of 64 students, who will begin their studies August 4. Their training will include an emphasis on diseases and medical conditions often seen across central and northern Michigan. As the only medical school in Michigan training doctors to address the needs of residents and families living in more rural regions, we selected students with a passion for medically underserved communities, said Ernie Yoder, dean of CMU’s College of Medicine.

Nursing University of Minnesota Opens New Nursing Simulation Center – The University of Minnesota’s School of Nursing has opened a new, stateof-the art education center for nursing and other health professional students. The center will provide students with opportunities to engage in complex simulated health scenarios in interprofessional teams, use sophisticated telehealth technology and learn emerging health records technology. The 11,000 square foot simulation center features 38 remotely controlled video cameras; interactive video conferencing capability; a medication-dispensing technology room; and simulated intensive care, hospital, nursing home, clinic and home care environments.

World News & Analysis Central Virginia Nursing Simulation Lab Dedicated – The Central Virginia Center for Simulation and Virtual Learning, a Central facility operated jointly with Lynchburg College was recently dedicated, and will open to students in the fall. The first phase of the 15,221-square-foot center is complete and consists of five acute care inpatient rooms, one critical care inpatient room, one labor and delivery birthing suite, two primary care exam rooms, one home health apartment, and an ambulance venue. The second phase of the simulation center will create a virtual hospital environment. Kaplan University-Augusta Opens Nursing Simulation Lab – Kaplan University’s Augusta, Maine campus officially opened its new simulation nursing lab that features sophisticated technology, including simulation mannequins VitalSim and SimMan3G. With lungs that breathe spontaneously, heart and lung sounds comparative to real life, eyes that move, and the capability to recognize over 180 different, the lifelike mannequins enhance the nursing students training with realistic medical scenarios. Loma Linda University Medical Center Using Simulation Center for Housekeeping Training – Since a clean and disinfected hospital contributes to patient safety, the department of environmental services at Loma Linda University (LLU) Medical Center in California elevated its annual training of housekeeping staff to a new level in the health care field. This year’s training took place at the LLU Medical Simulation Center, a fully outfitted mini-hospital in which students and staff practice with high-tech mannequins where the controlled environment allowed for more comprehensive learning than hectic onthe-floor training. UCOL New Zealand Nursing Lab Gets Laerdal SimView – The Universal College of Learning’s nursing simulation lab is the first school in New Zealand to get Laerdal’s SimView, a new hi-tech audiovisual system. The Universal College of Learning’s (UCOL) Palmerston Northcampus nursing simulation lab is the first school in New Zealand to get Laerdal’s SimView, a new hi-tech 32

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Code Yellow Matures – MEdSim and its sister publication MS&T have monitored BreakAway’s progress with its CBRNE GAME product through the last several years. The product is being commercially branded as CodeYellow. Walter Cheek, a company spokesperson, noted CodeYellow is now being used in studies with both civilian and military hospitals. “The product is fully mature for military scenarios and we are expanding the library of scenarios to address many of the top priorities of civilian hospitals and healthcare systems.” The community expert further noted the attributes that make the product attractive include the ability singly or in groups to practice responses any time and any place. “Also, to easily be able to customize the hospital attributes so that local issues and timely topics can be addressed in the exercises. They also like that CodeYellow can be used for 'onboarding' so that new employees can be quickly familiarized with local protocols,” he added.

audiovisual system. The installation will allow for full integration of patient voice, vital signs, hi-definition video recording and debrief, and network access to activities within the school’s two simulation labs.

International News Singapore General Hospital Opens New Training Facility – The Singapore General Hospital (SGH) campus is opening a training facility in The Academia that is designed to give medical, nursing and allied health staff hands-on training. The mini-hospital is a simulated working environment with an operating theatre, an intensive care unit and specialist outpatient clinics. The training facility will be the base for education and training institutions such as the SGH Division of Surgery, Institute for Medical Simulation and Education and SingHealth Alice Lee Institute of Advanced Nursing where trainee surgeons and students will undergo surgical training at a wet skills

laboratory. It will also offer training for cardiopulmonary resuscitation, bedside resuscitation and proper drip care for patients and house SGH's pathology services, research laboratories and education facilities. Dubai Healthcare City Opens New Simulation Center – Dubai Healthcare City (DHCC) opened the Khalaf Ahmad Al Habtoor Medical Simulation Center , the first comprehensive training facility of its kind in the region and part of the center's expanding medical education portfolio. It has to two operating rooms, equipped with high-fidelity mannequins, intensive care and post-anesthesia units, operating rooms, patient care rooms, a ward environment and a maternity room. India’s JIPMER Opens New Simulation Centre – The Jawaharlal Institute of Postgraduate Medical Education and Research’s Department of Surgical Gastroenterology (JIPMER) in India inaugurated its new surgical technology learning center. The Rs. 3.8 crore (about US$ 800,000) lab will simulate various

procedures in the field of gastroenterology, urology, gynaecology and even bronchoscopies. There are nine simulation devices to test the skill of students at three different levels. Gregory University Pioneers Medical Simulation in Nigeria – Gregory University in Uturu, Abia State, Nigeria is working on introducing simulation as a way of training medical students when it starts offering medicine by the end of the year. Gregory University would be the first of Nigeria's 123 universities to pioneer this method of teaching in that country. University Chancellor Dr. Gregory Ibe told the National Universities Commission that the university is in talks with universities in the United States to pilot the program. "We have 30 medical colleges in Nigeria,” he said, but the best of our universities can only admit a maximum of 150 students every year so the only way to increase the capacity is through medical simulation. If you go into piloting, the whole training is done through simulation. It is a new idea that is being used in the United States and we want to bring it to Nigeria." Medical Simulation Training Centre Opens in Saskatchewan – The Cypress Health Region and Dr. Noble Irwin Regional Healthcare Foundation joint project officially opened The Lee/ Irwin Simulation Centre and Cenovus Energy Inc. Control Room in the Medical/Surgical department at Cypress Regional Hospital in Swift Current, Saskatchewan, Canada. The project was supported by a $100,000 donation from the Lee/Irwin and $35,000 from Cenovus Energy Inc., and its goal was to provide three mannequins to train health professionals in the use of new equipment and for them to practice techniques on simulated patients. UK Bone Densitometry Training for Health Professionals – Healthcare professionals can improve their skills in bone strength and density at the Bone Densitometry in Osteoporosis Assessment and Management course September 30 and October1, 2013 in Birmingham, UK. The course is run every two years by the National Osteoporosis Society, and is the only one of its kind of the UK. The class is relevant to all health

professionals with an interest in osteoporosis and fragility fractures, e.g. physicians, nurses, radiographers, technologists and clinical scientists, and aims to improve standards in bone densitometry practice across the UK.

New Curricula New RCSA Curriculum Uses Simbionix ANGIO Mentor Simulator – The Registry of Cardiovascular Specialists and Assistants (RCSA) is using the Simbionix ANGIO Mentor simulator in its Cardiovascular Medical Simulation Training Course and Certification program. The program teaches cardiovascular care skills and procedural knowledge using the multidisciplinary surgical simulator that gives participants a realistic hands-on practice of endovascular procedures typically performed under fluoroscopy in the cath lab, interventional suite or an OR. Learners include cardiovascular medical specialists, vascular medical specialists, cardiovascular assistants, medical simulation educators and others.

New Products and Developments VA Extends Partnership with Decision Simulation for SimLEARN – The Department of Veterans Affairs (VA) has extended its enterprise license with Decision Simulation LLC to support their SimLEARN (Simulation, Learning, Education and Research Network) initiative. In 2011, the VA launched a pilot program using the DecisionSim platform to advance its efforts with SimLEARN, a national program furthering the advancement of simulation training and education. In 2012, the VA signed a five-year, enterprise-wide contract with Decision Simulation to extend access to all VA employees. The VA has now exercised the first option year of the 2012 contract. The VA's investment in DecisionSim could exceed $10 million if all of the options are exercised. Medic Vision Uses Haptic Devices for Surgical Drilling Training – Medic Vision of Melbourne, Australia, incorporated SensAble Technologies,

Inc.’s haptic devices in its Mediseus Surgical Drilling Simulator for improved surgical training. By haptically enabling its simulator, Medic Vision created a realistic virtual environment where otolaryngology surgical residents (earnose-throat specialists) can practice to perfection on high-risk procedures reducing risk to patients, improving surgical outcomes, and eliminating the use of costly, sometimes prohibited cadaver samples. SonaCare Launches Sonatherm HIFU Surgical Ablation System – SonaCare Medical, a provider of minimally invasive high intensity focused ultrasound (HIFU) technology, has launched the FDA-Cleared Sonatherm HIFU Surgical Ablation System. A laparoscopic HIFU surgical ablation system, Sonatherm is the only HIFU system 510(k) cleared for the laparoscopic or intraoperative ablation of soft tissue. Sonatherm uses HIFU energy to ablate a wide variety of soft tissues from the ultrasound focal point back to the surface of the targeted tissue. Lumenis Unveils New Simulator for Urologists on HoLEP Procedures – Lumenis Ltd. has unveiled a new surgical teaching simulator for Holmium Laser Enucleation of the Prostate (HoLEP) at the American Urological Association (AUA) Conference. The HoLEP is designed to shorten the surgical learning curve for urologists to practice this gold standard treatment for Benign Prostatic Hyperplasia (BPH). Fusion IP's Medaphor Targets China with ultrasound simulators – Fusion IP portfolio company MedaPhor has signed an agreement with Tellyes Scientific to sell its range of ultrasound simulators into mainland China. Tellyes Scientific, a $40m medical simulation manufacturer, based in Tianjin, China will buy 10 of MedaPhor’s ScanTrainer systems for its five regional offices in China. Tellyes will target China's 3,000 nursing schools, medical colleges and universities for ScanTrainer, a simulator that helps trainees learn key ultrasound scanning skills. Simbionix's PROcedure Rehearsal Studio Gets U.S. Patent – Simbionix USA Corporation, a provider of medical education and simulation training, M EDSI M M A G A Z I N E 3 . 2 0 1 3

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Simbionix U/S Mentor Introduced in Europe – Simbionix USA Corporation exhibited its new U/S Mentor simulator for the first time in Europe at this June’s SESAM (Society in Europe for Simulation Applied to Medicine) exhibition in Paris. In correspondence with the rapidly growing utilization of ultrasound technology by various medical specialties, the Simbionix U/S Mentor provides a unique training opportunity, allowing healthcare professionals and clinical practitioners to independently acquire sonography skills in their field of practice.

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received a U.S patent for its patient specific simulation product, the PROcedure Rehearsal Studio (PRS).The PRS is a first in industry products with a new technology that allow physicians to rehearse a complete endovascular procedure on a virtual 3-D anatomical model based on a specific patient’s CT data. This is the first such patent ever granted in the United States and follows a similar patent granted in the United Kingdom. Spectranetics' Cardiac Lead Extraction Simulator Goes Mobile – The Spectranetics Corporation introduced the only laser-assisted lead extraction simulator two years ago that is a virtual, hands-on environment to train physicians in the removal of leads, the insulated wires that connect pacemakers and defibrillator devices to the heart. A year later, the company followed up with a comparable system designed to

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