MEdSim Magazine - Issue 3/2014 by Halldale Group

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Issue 3.2014

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Virtual Patients

Using Web-based Virtual Patients to Enhance Case-based Learning

SIMULATion Acceptance

Why is Simulation So Slow in Gaining Acceptance in Medical Education? Nursing

Fixing the Nursing Shortage SHOW Preview

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HEATT 2014 – Breaking Down the Silos in Healthcare

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ISSUE 3.2014

Editorial comment

Editor's Comment Having attended the National Patient Safety Foundation (NPSF) annual meeting this month as well as HPSN and AUA and having listened to many excellent speakers and dedicated professionals discuss what is happening in medicine as well as daily readings of journals, blogs and other media sources it is evident there is a great deal going on worldwide to “fix” medicine; initiatives ranging from the 20 year old patient safety movement to the documented shortage of trained healthcare providers; to how to better train medical students. The following will highlight what seem to be the most promising ventures and initiatives. In a global study published in 2013 in BMJ Quality & Safety, Dr Ashish K. Jha, Department of Health Policy & Management, Harvard School of Public Health, and others, reviewed literature published worldwide since 1976 and found that an estimated 421 million hospitalizations occur annually, and approximately 42.7 million adverse events. These adverse events result in 23 million disability-adjusted life years (DALYs) lost per year. Approximately two-thirds of all adverse events, and the DALYs lost from them, occurred in low-income and middle-income countries. However, these findings suggest the importance of critically evaluating the quality and safety of the care provided once a person accesses health services. The data should be a call to global health policymakers to make patient safety an international priority. WHO’s prominent initiatives include the ‘Safer Surgery Saves Lives’ campaign, which documented the global volume of surgery and gaps in operating room supply and pioneered a simple checklist to improve intraoperative safety. Other efforts include tools for patient safety research and quality improvement and a consensus conference to develop international core competencies for patient safety research. The global problem of inadequate health care and the set of causes that underlie it, motivated Dr. Jha and others at Harvard to start an online course to focus on global healthcare quality and safety. The MOOC (Massive Open Online Course) uses data as a key cornerstone for the project. They were able to assemble a world-class faculty and because it was a new course they had the freedom to write a fresh syllabus specifically for online learners, consisting of conversations on pressing topics; interactive sessions where students create content and experts dialoging, answering questions and discussing issues. Through this course they will “crowd source the first global ‘atlas’ on healthcare quality and have a resource that will map the world’s journey toward a safe patient centered healthcare system,” Dr. Jha predicts. The Association of American Medical Colleges

estimates that the United States will face a shortage of 130,000 physicians during the coming decade. This projected shortage, coupled with the nursing shortage, which has been recognized by governments, academia and health organizations, could mean limited access to care for many worldwide. In a study conducted by Rand, a non-profit research organization in the United States, they suggested using different models of care to lessen the effects of the doctor shortage. One model uses nurse practitioners and physician assistants to provide primary care and the other was patient centered medical homes. Both models are being used in the US but account for less than 20% of providers. For these models to grow there will have to be widespread changes in policy, state licensing laws as well as fee structures and payment and reimbursement regulations. Shiv M. Gaglani and Ryan Haynes wrote a fascinating article in the Annals of Internal Medicine entitled ‘What Can Medical Education Learn from Facebook and Netflix?’ The medical students chose the title because they realized the algorithms they were using in medical school were much less sophisticated than the ones being used by Amazon, Netflix and Facebook. They hypothesized that if the same tools being used by these social media sites, such as machine learning-based recommendations, intuitive interfaces, etc. were used in medical education they could transform how medical students and other healthcare providers are educated. An example they used was how Amazon recommends products based on prior purchases. They felt supplementary resources in medical education such as videos, references, images, mnemonics and even patient cases could be used to supplement what students are learning in the classroom or clinic. That is the premise behind Osmosis, Shiv and Ryan’s start-up company. Osmosis uses data analytics and machine learning to deliver the best medical content to those trying to learn it, as efficiently as possible. Since its launch the company has delivered over two million questions to more than 10,000 medical students around the world using a novel push notification system that syncs to student curricular schedules. The program uses adaptive algorithms and an intuitive interface to provide the best, most useful customized content to those trying to learn.

Judith Riess Editor in Chief, MEdSim Magazine

e judith@halldale.com MEDSIM MAGAZINE 3.2014

Contents

ISSUE 3.2014

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

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

Editor's Comment. Editor Judith Riess examines using new ideas and existing data to improve patient safety.

Why is Simulation So Slow in Gaining Acceptance in Medical Education? Dr. Howard Champion and Dr. Jan Cannon Bowers look at issues to be addressed to make simulation an integral part of experiential medical training.

Emergency Department Innovation with Simulation: It Takes a Village. Allen J. Giannakopoulos, PhD, and Matthew Kadrie share the simulation model they used in the redesign of an Emergency Department.

Fixing the Nursing Shortage Staff writer Lori Ponoroff addresses the worldwide nursing shortage by highlighting strategies being used by associations, universities and governments to combat the problem.

Using Web-based Virtual Patients to Enhance Case-based Learning. Jim Carlson, PhD, discusses a program his school uses to enhance clinical reasoning competency.

Developing Educational Military Veteran Patient Simulations. Chuck Weirauch talks to Maureen Tremel, Seminole State and Sharon Hackney, Florida Blue Foundation about the benefits of developing educational scenarios and simulations to treat war veterans.

HEATT 2014. The Healthcare Education Assessment Training and Technology conference and exhibition will be taking place August 22-24 in Orlando, USA.

HSPN 2014. Highlights from HPSN 2014 held in Florida.

Simulation Centers and Training Programs in the Ukraine. Staff writer Lesya Hoover reports on the international collaboration taking place to open simulation centers in Ukraine.

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

MEDSIM MAGAZINE 3.2014

On the cover: i-Human is a web-based virtual patient platform. Image credit: i-Human Patients, Inc.

Artworker Daryl Horwell

t. +44 (0)1252 532011 e. daryl@halldale.com

Halldale Media Group Publisher & Andy Smith CEO e. andy@halldale.com

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Simulation Acceptance

Why is Simulation So Slow in Gaining Acceptance in Medical Education? Howard Champion MD, FRCS (Edin), FRCS (Eng), DMCC, FACS and Jan Cannon-Bowers PhD highlight and discuss the business model, medical education and simulator issues that need to be addressed to make simulation an integral part of medical education.

here are huge pressures to reform medical education at this time. The shorter work week for resident training reduces the scope and volume of patient exposure. Increasing demands to reduce patient risk associated with the traditional mentored development of clinical and technical proficiencies are mounting, as is public demand for increasing objectivity and transparency of competence before trainees practice on their own. Many residents qualifying from training programs do not feel adequately prepared for autonomous practice. This, among other factors, accounts for the fact that 80% of surgeons graduating from general surgical training programs go on to fellowship training. The escalating costs of training - both direct costs and also those due to extending time in the operating room (and other clinical environments) - are of great concern to hospital and clinic administrators. They are also of concern to the federal government, which provides huge support for medical training through Medicare reimbursement to hospitals and Veterans Administration support of faculty. Given these pressures, it is somewhat surprising that medical educators and administrators have not more fully embraced 06

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simulation as at least a partial solution. Not only have simulators been shown to enhance performance in the operating room (OR) and improve patient outcome, they reduce the need for mentorship and OR time during technical skill acquisition, thus lowering training costs. It is not that the leadership in the medical professions has been slow to embrace simulation. The Accreditation Council for Graduate Medical Education (ACGME) long ago dictated that surgical training programs must have simulation capability, and the American College of Surgeons (ACS) has certified 76 simulation centers as Accredited Education Institutes (AEIs). It would seem, therefore that the ground is fertile for simulators to gain a viable and important place in the preparation of patient

Practising skills with computer feedback. Image credit: SimQuest

care providers of all levels and in facilitating an objective process of graded autonomy. Despite these efforts, the adoption rate continues to be slow, even with increased demand and burgeoning scope of medical practice, procedures, and technologies. There are two main reasons for this: (1) the business model that supports surgical simulation and (2) the simulators themselves.

The Business Model â&#x20AC;&#x201D; Who Pays? Simulators can be expensive to create, particularly those that incorporate technologies such as virtual reality (VR), augmented reality (AR), or haptics. There has been much debate as to the value of some of these technologies compared to lower-fidelity solutions such as box trainers or other devices that provide the capability for multiple repetitions. However, it is becoming more accepted in the scientific literature that the development of muscle memory improves with the degree of objective measurement and relevance to actual procedures. VR and

AR technologies represent the cutting edge of capabilities that are available to supplement patient-based experiential training. But, who will pay the $1.5 million necessary to develop a prototype simulator and then productize it for a partial task trainer with 6-7 degree-of-freedom (DOF) haptics? And once they are developed, who will purchase them for $100,000 â&#x20AC;&#x201C; $300,000 apiece? Simulation centers are unlikely to do so, as they are more reliant on donations of such equipment (with at least a 1:3 or 1:2 ratio of donations to discounted purchases). Who will bear the lifecycle costs of such equipment and provide the necessary updates? Why would Johnson & Johnson spend $1â&#x20AC;&#x201C;2 million developing a simulator for its Ethicon Inc. surgical training centers if that simulator would facilitate the use of equipment purchased from a competing manufacturer such as Covidien? Until these questions can be answered, development of high-end

simulators will suffer. A potential business model may exist when new equipment or techniques require a skill set to be attained before use on patients or for credentialing. In these cases, an equipment developer could co-release the new device along with a training simulator that documents the level of skill achieved. This strategy will also promote product acceleration into the market space, thus increasing access and sales. This approach has been used in simulation-based training for robotics-assisted and minimally invasive surgery, albeit with inappropriate timing and risk to patient safety. Another innovation will be the soonto-be available open-source technology platforms on which learning content can be placed. By adopting open-source models, the cost of creating VR and AR simulators can be reduced by 50% or more, thus providing greater opportunities for value-added market penetration in medical education. Notwithstanding the lack of financial horsepower, the medical community is

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Simulation Acceptance beginning to respond to the huge demand for technology to augment the process of training. Recent initiatives can be found in the orthopedic surgical community and others that have begun to adopt simulation and make curricular changes that can fully accommodate, respond to, and benefit from available and pending technologies. For the most part, however, even simulation centers that are populated with millions of dollars of equipment, have not adequately integrated the simulators into curriculum development or performance assessment, and thus fail to maximize their capabilities. One of the main problems is that training in such environments is not paid for per se, so there are no economic incentives for medical educators to make optimal use of these technologies. Moreover, faculty are rarely paid or incentivized for teaching in the simulation center - highly skilled medical practitioners are seen as having more value billing for patient care. Ultimately, new business models must be created to respond to the need, the customer, and the consumer.

Wound closure arm tool. Image credit: SimQuest

ing degrees of fidelity and with or without anatomic/tissue material properties or relevant pathological/physiological capabilities. Physical models and augmented physical models rarely provide the integrated capability for objective performance assessment or exhibit the anatomic or pathophysiological variations encountered in clinical practice. Further, simulator design and construction are often driven by engineers remote from the end users. Although end users lack instructional design knowledge and may not understand the role of muscle memory/repetition in cognitive processes, skill acquisition, complex decision making, and adult learning, they do provide valuable insights to the design process.

Simulators, their Manufacturers, and the Claims they Make Approximately 30 companies, often very small ones, make a variety of products that fall within the rubric of medical simulation. These include simple box trainers or physical models with vary-

Thus, current simulators as a group fail to be responsive both to trainers and trainees. They provide a costly platform for certain knowledge acquisition (usually for a single, very circumscribed pathology) with some limitation on repetitions and no access to the variability that is encountered during experientially gained clinical knowledge acquisition. Clearly the paradigm must flip to end user and learning sciences as the donor. Members of the medical training leadership agree that technology will play a vital role in the future of medical training, and that the following are essentially nonexistent: • True multidisciplinary involvement in cognitive/procedural task analysis and analysis of training solutions to achieve specific training goals. • Surveillance of evidence-based practice prior to the development of training objectives, training systems, and metrics design. • Incorporation of the above into a plan of embedded learning strategies and scaffolded guided practice for adult learning. • Completion of the steps from preprototype iteration to implementation and evaluation before launching into an appropriately modified curriculum and training environment. Also lacking in current simulators is significantly rigorous validation. The term is used with abandon as a market-

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ing tool without the support of appropriately scrupulous and robust science. One reason for this is that the conduct of transfer-of-training validation exercises is inordinately expensive and does not necessarily provide the scientist or consumer with the level of answer that is appropriate for the training environment and goals. There are other ways of proving value. These issues must be addressed before simulators will take their rightful place as a critical adjunct to experiential medical training. Carefully designed and validated next-generation simulators will enable exposure to a variety of pathologies, increase the cognitive pathways that the practitioner has experienced prior to patient care, and create healthcare professionals who can expertly perform procedures before they have ever entered an operating room. This not only benefits patients, who will be more comfortable if a surgeon has that déjà vu feeling during surgery rather than a feeling of surprise, but also benefits accrue to society at large in terms of fewer errors, safer surgery, and reduced costs. In summary, the deficiencies of technology-assisted adjuncts to medical training are manifest and multiple. As the thought leaders in healthcare move to appreciate the importance of valuebased healthcare education to attain and sustain safe practice for the population,

quality simulation-based solutions will become the norm, and market-sustainable business practices will be developed. How long this takes remains to be seen. But from the patient’s point of view, the sooner the better. medsim About the Authors Howard Champion MD, FRCS (Edin), FRCS (Eng), DMCC, FACS, has a 35+ year history as a trauma surgeon, leader in civilian and military surgical education, and driving force behind the development of trauma scoring, centers, and systems. He was instrumental in developing technical trauma surgery training courses, i.e., the Definitive Surgical Trauma Skills (DSTS) propagated by the International Association for Trauma Surgery and Intensive Care (IATSIC) and the Definitive Surgery for Trauma Care Course (a joint offering of the Uniformed Services University of the Health Sciences [USUHS], the Royal Defence Medical College, and the Royal College of Surgeons in London), which he co-convened and taught for 10 years (1997−2007). Dr. Champion was a founding member of the American Trauma Society and the Committee on Tactical Combat Casualty Care, and founder and president of IATSIC, the Eastern Association for the Surgery of Trauma, and the Coalition for American Trauma Care. Throughout his career, he has led the effort to introduce objectivity and

standardization to surgical education, both as a clinician and as President and CEO of SimQuest, a pioneer in developing simulation-based training systems for emergency and non-laparoscopic procedures such as hemorrhage control, open surgery, microsurgery, and burr hole drilling. Jan Cannon-Bowers, PhD, holds MA and PhD degrees in Industrial/Organizational Psychology from USF. She served as Assistant Director of Simulation-Based Surgical Education for the Department of Education at the American College of Surgeons from 2009 -2011. Previously, Dr. Cannon-Bowers served as the US Navy’s Senior Scientist for Training Systems where she was involved in a number of large-scale R&D projects directed toward improving performance in complex environments. In this capacity she earned a reputation as an international leader in the area of simulation and game-based training, team training, training evaluation, human systems integration and applying the science of learning to real-world problems. Since joining academia, Dr. Cannon-Bowers has continued her work in technology-enabled learning and synthetic learning environments by applying principles from the science of learning to the design of instructional systems in education, healthcare, the military, and other high performance environments.

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Process Planning

Emergency Department Innovation with Simulation: It Takes a Village Allen J. Giannakopoulos, PhD and Matthew Kadrie built a model of an Emergency Department that clearly defined and thoroughly tested each process.

ospital Emergency Departments are constantly faced with possible gridlock due to an unexpected increase in the number of patients that arrive. This can be further aggravated by an absence of processes to improve patient flow. What change can be made to improve the process? How will that change affect the patient’s length of stay? Will that change affect the door to doctor time? These are all questions that have been asked by Emergency Departments. Their patient flow process is not performing up to standards, so how do we improve it? Well, there is always the option of making the change in real life and “hoping for the best”. Or, a more rational and cost effective way is to simulate the processes. With the help of a large number of staff from diverse areas, a computer simulation model was designed that mimics a real life, real time Emergency Department (ED). The amount of work involved with the development indeed took a “village”, realizing that no single area alone can accomplish such a task. An ED with separate silos for patients means possible gridlock for patient flow. The leadership team of the ED realized this problem and was searching for a solution, when computer simulation was brought to their attention. This is a tool that helps simulate their patient flow processes, saving them both time and money. So how did we create a computer simulation for one of the busiest, most hectic areas of a hospital?

Getting Started While building a model for this ED, the team discovered that it is vital to clearly define the exact issue being addressed. Since a computer simulation model will be a perpetual function, it is necessary to have a target in place to get accurate results. During our initial build of the ED, we had a vague idea of a few different problems that were 10

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in need of a solution, but had to target each one individually. How to expedite the lower acuity patients, nurse staffing hours, and accelerating the patient admit process are examples of some of the pain points brought to our attention. Process flows of the area were created to gain an understanding of how the ED operates. After multiple meetings with various staff members of the ED, we determined what processes were required. The processes mapped out were based on the different acuity levels of a patient. The higher acuity patients require more diagnostic testing as well as higher priority over lower acuity patients. We also included the staff member(s) assigned to each activity in the process flows. The remaining data points were researched throughout the model building phase. The data collected for each step in the process was obtained from multiple sources; we started with the arrival rates of the patients so we could accurately represent the patient input during a busy day in the ED. Physicians, nurses, technicians, phlebotomists, and many other areas within the ED provided the amount of time each step takes in the

Above Model with floor plan. Image credit: Author.

process. We also collected data on the staffing schedules, when staff went on break, and when they took a lunch. Every factor that may interrupt a staff member from direct patient care had to be recognized and documented in the processes. Next, we needed to determine what elements to measure against or compare the simulation to. When it was time to validate the simulation, we needed specific metrics to serve as a baseline. These metrics would be what the department, in this case the ED, uses to measure their results. Length of stay, door to doctor, door to nurse, and disposition to departure are some sample metrics that we used in our ED simulation. In performing this part of the project, it indeed took a “village” to accurately identify the elements and gather the data, while working through the team differences in approaching the decisions of what data to use - which is a crucial point.

Building the Model As preliminary data gathering wrapped up, model construction started. By uti-

lizing the floor plan of the ED we were able to start building the main structures. The ED’s floor plan provided us with the infrastructure (location of the walls, nurse stations, bathrooms, etc.). Once the walls and other structures were built into the model, we made several in-person walkthroughs of the multiple areas located within the ED. The walkthroughs supplied a thorough look at the areas, providing the locations of certain items, such as medical equipment, computers, and patient beds. After the walkthroughs were concluded and were built into the model, we had a visual representation that mimicked the ED. With this representation of the ED as a foundation, we started making it functional by inputting the numerous processes. We entered what was going to happen, when it was going to happen, how long it was going to happen, and who was going to make it happen. After frequent meetings with ED staff, we were able to detail the processes and include as many of the “what if” scenarios as possible. For example, if a patient

arrives and there is an empty bed, they will be escorted directly to that empty bed to be triaged. If a bed is not available, the patient will wait in the waiting room until the dedicated triage room becomes available. All of the processes built into the model were “as is” or what was currently happening. As in any simulation, we began by simulating real life rather than what should be happening. This is another aspect of “it takes a village” as now we were dealing with multiple processes with dozens of data elements and staff from every facet of ED life. While sounding simple, it is far more complex performing team initiatives and coming to consensus on the various process decision points than one realizes. Real life data was added into the processes to make them functionally accurate. The most crucial part of any computer simulation is data accuracy; it drives the simulation and allows us to see an accurate depiction of real-time events. One can build a picture-perfect model that mimics reality, but running the model is useless if the data is flawed.

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Process Planning Gathering data was the most essential and prolonged phase. Data was extracted from several applications utilized in the ED. While some would assume the data was accurate but in fact the data we received was only as good as the data entered. We encountered several issues with data that may have resulted from either improper data entry, data being entered at the wrong time, or staff members documenting differently. Management became aware of the discrepancies and they are working on standardizing documenting procedures. As a result, the corrupt data could not be utilized and the team determined the best fit statistical distribution based on staff experience. The processing times for all activities used in the ED simulation were based on a statistical distribution curve. The use of statistics was a vital component in providing a variation in the process, just as each process varies in real life. A nurse exam does not always take five minutes and not every patient will have the same experience. The simulation tool can actually calculate the statistical distribution. By inputting the data set, the tool will provide the best fitting statistical distribution based on that data. This is an enormous asset with the tool as it improves the accuracy of the simulation, removing the laborious task of trial and error in using some of the 100+ distribution models built into the tool. For data points that we could not obtain a valid set of numbers, we used a triangular distribution. The triangular distribution takes into account the maximum, minimum, and the mode to distribute the probability accordingly. Note that it is still possible to change these types of distribution after the simulation has been completed in order to measure the changes that the final data sets show. Some data could not be obtained from an application, so we used our next best option, “expert estimation”. What is “expert estimation”? This is when the process owners, or the ones who are actually performing the process, told us how long the process takes. They provided the best case scenario, the worst case scenario, and the average. However, there were times when we would get mixed responses, for example, management reporting that an activity only took 12

Above Sample data collected. Image credit: Author. Left Data points with statistical distribution. Image credit: Author.

five minutes; when in fact, after talking to a nurse, it actually took fifteen minutes. The information provided by the process owners, rather than management, was more likely to be reliable since they were the ones actually performing the process. Building the simulation required numerous model builds. After presenting the model to the ED staff, we performed several recommended changes. Some changes were as simple as the color of their scrubs but others were major process changes, such as, where a patient would go after receiving treatment in a certain area. While accurate, a perfect solution is not realistic due to the amount of variation in an ED.

Validation Once again, the “village” of staff united and assembled a simulation that combined all of the dynamic processes involved in the ED with agreement to the data inputs. Next, we had to validate that the simulation was producing data comparable to real life. The model was set up to display length of stay times, door to doctor times, door to nurse times, and many other metrics that the ED uses as a benchmark. A customized dashboard displays the metrics used to analyze data produced by the simulation. Next, we ran the simulation for 30 replications and viewed the output data in the dashboard. The metrics were compared to data that the ED produces in real life, to confirm that the simulation is behaving in a manner aligned with reality. The first run presented an issue with the lower acuity patients; the length of

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Process Planning stay in the simulation for these patients well exceeded reality. We went back to the “village” and the problem was identified in the patient registration process. The simulation naturally treats the higher acuity patients with priority, since they are in a more serious condition and typically require precedence. This continued to postpone the registration of the lower acuity patients, something that was not actually happening in the ED. After confirming this with the ED staff, we modified the registration process in the simulation. It turns out that in most cases, a lower acuity patient is seen faster than a higher acuity patient with the intent of speeding up their discharge. We ran the simulation again for 30 replications. This time the performance data numbers were more precise, validating that we built a working model mimicking a real life ED.

Experiment and Analyze Innovation provided a functioning model similar to a real ED, but what would we do with it? This was the prime motive for building the simulation model, having the ability to make changes in the model, and analyzing the results that are produced. By running different scenarios using computer simulation, we were able to forecast possible outcomes, prevent adverse patient outcomes, and be fiscally responsible by staying within the department’s budget. The computer simulation tool allows us to experiment with different scenarios. We modified only one variable per scenario, since modifying many variables could impact each scenarios’ results. Then, we performed an experiment that ran each scenario many times. The data produced from each scenario was presented on the dashboard, allowing us to compare and analyze the results. The ED staff clearly identified the issues that needed to be addressed. One example involved the hours an area within the ED was open for patient care. At the start of building this simulation, the ED was operating this area from 11:00 am to 11:00 pm, their busiest hours. But, what would happen if these beds were available 24 hours? How would that affect the patient’s length of stay and the time that it takes a patient to see a physician? This was a perfect scenario to run 14

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in the simulation. The appropriate variables were modified in the model to keep the area open for 24 hours rather that only 12 hours. We ran this scenario 30 times along with the original “as is” scenario. The two were compared and, as a result of keeping this area open 24 hours, the length of stay for all patients decreased considerably. The results were presented to the ED management team and it was left in their hands to decide whether or not to change the hours of this area. Computer simulation made a decision less complicated, with a greater chance of success. The ED simulation is a perpetual function, utilized by the staff on an as-needed basis. Changes are typically led by the front line of the ED with the “village” of nurses, technicians, and physicians. Management provides support for these decisions and helps align them into place. Until now, our ED was on their own for making their decision based on “what if” scenarios only. Now, they have an innovative tool that can help support or oppose a “what if” scenario. This is the future of reengineering healthcare processes. And, it takes a “village”. medsim About the Authors Allen J. Giannakopoulos, PhD is the Corporate Director for Reengineering and Redesign at Baptist Health South Florida in Miami. His duties include process reengineering and computer simulation of processes in clinical and business departments; knowledge reports development; auditing for ePHI and HIPAA; and the management of processes for Role Based Security. Dr. Giannakopoulos earned his academic credentials from the State University of New York in Brockport, BS in Business; University of Rochester, MBA in Business and Marketing; and his PhD in Health Administration from Kennedy - Western University. Dr. Giannakopoulos been published in over 50 health care journals and publications and has been a featured speaker and presenter over the past 25 years in health care, quality improvement and process simulation. Matthew Kadrie is a Process Management Engineer at Baptist Health South Florida (BHSF). His tasks include process analysis, process simulation, and performing and presenting research for current Information Technology trends. Matthew holds a Bachelors of Computer Science from St. John Fisher College and a Masters of Business Administration from Florida International University (FIU). A special thank you to Gary May for his support on the article.

Above Dashboard with metrics. Image credit: Author.

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Nursing

Fixing the Nursing Shortage Lori Ponoroff discusses one strategy being used to eliminate the worldwide nursing shortage.

hey’ll need a million in Europe, a million in the United States, two million in India, five million in China... and the list goes on. Throwing numbers like these around almost sounds like playing with Monopoly money... but these are real numbers for the critical nursing shortage the world is facing now, in the next several years – and likely, way beyond. The nursing shortage isn’t breaking news; the world has been dealing with an ever-increasing shortage of nurses for close to 20 years. The problem is that nursing shortage forecasts seem to get exponentially bigger with each new prediction. In July 2002, the US Department of Health and Human Services released a report saying the nursing shortage it previously projected would start in 2007, was already evident by 2000 when the national supply of full-time employed (FTE) registered nurses (RN) was about 1.89 million, while demand was estimated at two million – a shortage of 111,000 or six percent. It also predicted the shortage would grow relatively slowly until 2010, by which time it would have reached a workforce of 2.3 million, or a shortage of 12 percent. In reality, RN employment in the US in 2009 was already more than 2.5 million, according to the US Department of Labor Bureau of Labor Statistics (BLS). By 2012, RN employment grew to 2.74 million, according to the BLS’ Employment Projections 2010-2020 report released in February 2012. That same report projected from 2012 to 2022, the number of new RN jobs would grow 19 percent, with 526,800 new jobs; add to that the projected need for 525,000 replacement nurses in the workforce, and the total number of job 16

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openings for nurses by 2022 will be 1.05 million – out of a total of almost 3.4 million jobs. Many believe there won’t be nearly enough nurses available to fill those jobs, like the “United States Registered Nurse Workforce Report Card and Shortage Forecast”, also published in 2012, which predicts a shortage of 300,000 to one million nurses in 2020. So why the need for so many nurses? There are almost as many reasons as there are countries trying to hire them. Besides the current issues of an aging population and job dissatisfaction among nurses, China plans to build 20,000 new hospitals in the next 10 years and is going to need millions of nurses to staff them. In some countries – like India, the Philippines, Jamaica, Nigeria, Russia and Canada – the hunt for higher pay, more sophisticated facilities and better chances for advancement lead nurses to migrate to other countries. The US is one of those countries importing nurses to fill many more vacancies than there are natives available to fill them. This country shares some of the same issues others are facing, like

Above Nurses learn skills from practicing with mannequins. Image credit: Laerdal Medical. Opposite Practical skills training for monitoring babies. Image credit: National League for Nursing.

a steep population growth resulting in a growing need for health care services, but it faces some unique ones, too, like an aging nursing workforce getting ready to retire, not enough students in the pipeline, and a shortage of professors curbing the already stretched capacity of nursing schools and their ability to crank out new nurses. The new Affordable Healthcare Act calls for nurses to have more roles as team members and leaders, the US baby boom generation is requiring more healthcare services and with improved technology and managed-care issues, only the sickest patients require hospital stays and intense treatment – requiring more skilled and specialized nurses in hospitals and home-health organizations. Finally, even though they are available and anxious to work, many new nursing graduates are unable to find jobs because so many hospitals require up to two years experience. It’s clear we need strategies to deal with the nursing shortage that will address all these issues, and many ideas have been presented by the World Health Organization; individual governments; universities; and medical, surgical and nursing organizations – like the National League for Nursing (NLN). The NLN sees its job as making sure it is bringing new nurses into the faculty arena, according to its CEO, Dr. Beverly Malone, who says that too many qualified applicants are turned away from nursing schools each year because they don’t have the clinical space or the teachers to teach them. So the NLN is “encouraging nurses to continue their education”, she says, and “helping to sustain them once they get into teaching, so that we have enough faculty members. We help faculty learn how to use the newest equipment and the newest technology – we help keep them at the top of their game, because they are the ones who are teaching the students to become nurses – and getting them ready for the new world of healthcare.” It’s that new world that makes the shortage much more than just a nursing issue, so many of the strategies call for a collaborative effort among nursing leaders, practitioners, health care executives, governments and the media. For our part, MEdSim will begin by focusing on strategies developed by nursing organi-

education, practice and community stakeholders. Other states pursue different strategies; awarding colleges grants, offering loan repayment or forgiveness programs for nurse educators and loans to students that can be paid back through service to the state.

Partnerships and Grant-funded Initiatives

zations such as the American Association of Colleges of Nursing (AACN), the NLN, and the Tri-Council members for Nursing (made up of the AANC, the American Nurses Association (ANA) and the American Organization of Nurse Executives (AONE). We’ll give an overview and feature individual strategies in upcoming issues.

State Legislative Initiatives Resolving the US nursing shortage will require the collective effort of stakeholders at the national, state and local levels. Federal legislators are demonstrating a commitment by funding Nursing Workforce Development programs like Title VIII of the Public Health Service Act, and many states have initiatives underway to increase the number of new nurses entering the workforce and pursuing faculty careers. These efforts generally center on the creation of new legislation to remove financial barriers to pursuing a nursing degree, mostly at the graduate level, and often result from a collaborative push by representatives from both the education and practice communities. The number of statewide legislative initiatives are multiplying – some enact legislation to address the shortage of Registered Nurses (RNs) and nurse educators; others focus efforts on the shortage of nurse educators, the primary obstacle facing nursing schools looking to expand student capacity; and still others are working to launch programs involving strong collaborations between

Corporate foundations, non-profit agencies and government programs offer a host of grants to students, teachers and universities to help fund tuition, research, scholar programs, fellowships, interprofessional education and more. The Association for Prevention Teaching and Research (APTR) 2014 Paul Ambrose Scholars Program (PASP) is an example of a grant that exposes health professions students to influential public health professionals and prepares them to be leaders in addressing population health challenges at the national and community level. It provides minigrant funds for students to implement a Healthy People 2020 Leading Health Indicators-focused project within a student's community or at his or her academic institution. A different example is Cape Fear Community College using a $60,000 grant received from the Cape Fear Memorial Foundation (a private, non-operating foundation) to help fund the salary of a Simulation Hospital/Lab Coordinator, a position that serves both the Associate Degree Nursing (ADN) and Practical Nursing (PN) programs. CFCC’s ADN and PN programs currently rotate 205 students through simulation experiences, using its newly expanded nursing lab. The addition of a dedicated simulation coordinator means the nursing programs now have the ability to maintain open lab hours and structured clinical practice environments. “The ability to use our simulated hospital as a clinical site will assist in graduating a greater number of nurses to serve the community and enhance the comfort level and expertise of these nurses,” said Brenda Holland, ADN program director. “Without a qualified faculty member to run the simulation equipment and simulated hospital unit, this additional clinical space could not be used to its full potential. M E D SI M M A G A Z I N E 3 . 2 0 1 4

Nursing Strategic Partnerships Nursing colleges and universities are searching for creative solutions to increase the number of registered nurses to help offset barriers to expanding student capacity and meeting the projected demand for nursing care such as budgetary constraints, a limited pool of nursing faculty, insufficient clinical sites and a lack of scholarship monies. One solution is for nursing institutions to collaborate with clinical partners and other stakeholders to build student capacity and satisfy mutual needs. These partnerships take many forms and serve various functions – some schools use expert practitioners to augment the nursing faculty supply, some create collaborative arrangements to increase student enrollments, while others form partnerships to provide tuition forgiveness to students in exchange for work commitments. Some service partners share physical resources and infrastructure with schools to help overcome limitations in clinical, classroom and research space.

Accelerated Programs Nursing schools are looking for ways to increase student capacity and reach new student populations without sacrificing the integrity and quality of the nursing education. One approach is the accelerated degree program for non-nursing graduates that builds on previous learning experiences and transitions individuals with undergraduate degrees in other disciplines into nursing – in 12-18 months. The typical second-degree nursing student is motivated, older and has higher academic expectations than high school-entry baccalaureate students. Accelerated students typically excel in class, are eager to gain clinical experiences – and faculty find them to be excellent learners who aren’t afraid to challenge their instructors.

Increasing Diversity Another strategy is to attract more men and minority students. Although nursing schools enroll more diverse students than medical or dental colleges, the majority of students in today's baccalaureate nursing programs are female from non-minority backgrounds. Studies point to many reasons why 18

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men and minority groups do not pursue nursing: role stereotypes, economic barriers, few mentors, gender biases, lack of direction from early authority figures, misunderstanding about the practice of nursing and increased opportunities in other fields. Compounding the lack of student diversity and further impacting minority recruitment efforts is the fact that nursing school deans and faculty also comprise a gender-skewed, racially homogenous group. Schools are using a combination of traditional marketing methods, targeted outreach campaigns, and strategic planning to recruit more men and minority students into their degree programs. Central to any outreach campaign is a marketing message with visual cues that speak to a target audience, so schools are using updated brochures, promotional messages and images of diverse groups of nurses to appeal to underrepresented groups. They are also working to reach middle- and high-school students to develop a pool of future nursing students from diverse backgrounds. Some schools are helping prospective students better understand what is involved in a nursing degree to help lower attrition rates, while others are making direct one-on-one contact and providing more support during the application process.

Boosting Enrollment and Capacity Recognizing the critical need for a larger pool of nursing professionals, nursing schools are focusing on ways to boost enrollment and capacity. Before schools can think about adding more students to their programs, they first have to deal with faculty shortages, state-mandated enrollment caps on baccalaureate programs, a limited supply of clinical training sites, or other resource constraints. Luckily, state governments are helping with these issues with new legislation, creative partnerships and financial aid programs. Proactive efforts include recruiting from within by encouraging nursing graduates to continue their education – from associate degrees to bachelor degrees to master’s programs and offering tuition assistance if they go straight

from one program to another. They’re finding creative ways to improve financial aid and enhance distance learning; they’re using television, radio and newspaper ads and service announcements; and they’re targeting young people early to stimulate interest now, that nursing is a rewarding career choice, which hopefully will pay off later. Some offer college-credit courses on their campuses to high-school students in areas such as medical terminology and introduction to health careers and others offer summer nursing camps for interested high-school students.

National Image Campaign Nurses for a Healthier Tomorrow (NHT) is a coalition of 43 nursing and health care organizations working with a communications campaign to attract people to the nursing profession and to heighten awareness of the shortage and the excellent opportunities available to those who choose a nursing career. NHT’s website offers nurses and those interested in becoming nurses a variety of resources on careers – with descriptions of the many kinds of nursing positions and specialties available, job profiles and recruitment campaigns; education – including different types of nursing programs, nursing schools and financial aid; links to other points of interest such as corporate programs, choosing a career in nursing, and higher education possibilities; and communications notices from the Nurses for a Healthier Tomorrow coalition.

Focus on the Workplace Working off the premise that constant change in the health system challenges the notion that one nurse can be all things to all people, Tri-Council members for Nursing say nurses with varied education and practice competencies bring different skills to patient care, and they must be able to practice to the fullest potential their capabilities. To compete as attractive professional destinations, practice environments should consider recognizing and rewarding these differences by defining nurses' roles, using and compensating nurses according to their educational preparation and competencies, providing more manageable workloads and creating happier and healthier work environments. medsim

Virtual Patients

Use of a Web-based Virtual Patient to Enhance Case-based Learning in Health Professions Training Jim Carlson, PhD, PA-C, describes Rosalind Franklinâ&#x20AC;&#x2122;s use of a web-based virtual patient simulator to enhance case-based learning in teaching clinical reasoning.

linical reasoning is complex, requiring significant time and experience to master. Traditionally, this competency is acquired through didactic coursework followed by an apprenticeship phase where learners are mentored by experienced clinicians.1 Case-based learning (CBL) is frequently used to teach clinical reasoning.2 This paper describes the use of i-Human, a web-based virtual patient encounter simulator, to enhance CBL in both physician assistant and medical school curricula. CBL is an instructional approach that uses patient vignettes to prepare students for clinical training, linking theory to practice.2 CBL uses an inquiry-based method where learners work independently or in groups participating in clinical reasoning by collecting clinical data (H&P), determining differential diagnoses, ordering and interpreting clinical tests, and constructing a management plan. Case vignettes are selected to meet specific clinical reasoning learning objectives, guided by faculty. CBL is similar to Problem Based Learning (PBL) and even bedside teaching with actual patients. However, CBL is generally more structured, relying on a guided inquiry model where learners are directed through a series of steps that model clinical practice while receiving feedback to hone decision-making accuracy. CBL patient vignettes may be text-, computer-, or videobased, or use other forms of simulation based training (SBT). 20

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Standardized patients (SP) or mannequinbased cases are frequently used to mirror realistic encounters, reliably assess learner performance, and provide highly specific individualized feedback. However, SP and mannequin-based simulations are often resource intensive. Faculty time is required to write case objectives and scripts. SPs need to be trained by qualified educators. Quality assurance should be performed regularly to assure appropriate case portrayal, calibration to the script and rating tools devised. High fidelity mannequins require "animation" by trained simulation technicians and faculty presence is required to guide the flow of case simulations, as well as to review and assess student performance. While high in face validity and effective for teaching and assessment, the complexities associated with such simulations create scalability challenges that can prevent regular implementation, especially for programs with large class sizes.

Figure 1 i-Human Patient Interface. All Images: James Carlson, RFUMS.

Virtual Patients Virtual patients (VP) provide an opportunity to engage students in CBL with greater frequency and fewer resources than other forms of simulation. Cook and Triola define a VP as a “specific type of computer program that simulates real-life clinical scenarios; learners emulate the roles of healthcare providers to obtain a Nasco Division history, conduct a physical exam, HealthCare and make diagnostic and therapeutic decisions”.3,4 Assessment may be automated and case MedSim debriefing can be individualized as with SP or mannequin-based June 2014 simulation, but delivered with fewer faculty resources. Once MS1406 developed, a VP can be disseminated to an unlimited number of users and offer a solution to the scalability problems associated with other forms of SBT. Based on these advantages, our institution decided to adopt and integrate i-Human Patients® or “i-Human”, www.i-human.com, a web-based virtual patient platform, to provide greater access to CBL and complement our existing mannequin and SP-based activities. The i-Human case player simulates a wide range of clinical conditions and reasoning activities. Users interact with a patient avatar to perform discrete clinical reasoning elements; conducting comprehensive or problem focused H&Ps, determining differential diagnoses, ordering and interpreting tests, and determining final diagnoses and management plans. Instructors can draw from an existing bank of cases or create their own using an authoring tool. Patients are highly customizable including presentations of male, female, adult, pediatric, and varied cultural backgrounds. Case authors have the option to customize the case flow to include strategies that provoke specific clinical reasoning behaviors such as identifying pertinent findings, linking findings to diagnoses, ranking diagnostic hypotheses, and linking each test ordered to the differential diagnosis selected. Figure 1 demonstrates the i-Human user interface. i-Human case play follows a guided inquiry approach where students ask questions and make decisions as the case player advances sequentially through the patient encounter vignette, mirroring the clinical reasoning process for the learner. Students have the freedom to collect clinical information and commit to clinical decisions, but feedback can be given at each step to teach optimal decision making and prevent learners from straying too far from the appropriate decision making process. Conversely, feedback can also be withheld at any or all points to allow learners the opportunity to make decision errors and learn from those mistakes. This flexibility allows instructors to calibrate case difficulty to learner skill level, a feature shown to promote effective learning.5,6 To strengthen our clinical reasoning instruction and assessment, and to explore how a virtual case player might be effective, used within a larger curriculum, our faculty decided to pilot the i-Human in four specific ways: 1. Engage and assess individual Physician Assistant (PA) student clinical reasoning in a CBL course. 2. Promote collaborative learning in small group CBL within the medical curriculum. 3. Improve interactive learning in larger group case studies in PA and medical training. 4. Study diagnostic reasoning behavior, cognitive bias, and diagnostic error

Engaging and assessing individual student clinical reasoning i-Human was incorporated into the redesign of a clinical reasoning course within our Physician Assistant (PA) curriculum. Clinical Decision Making (CDM), is a required didactic course for all first year PA students during their pre-clinical training. Course objectives include learning how to perform comprehensive and focused history and physical examinations (H&P), development of differential diagnoses and treatment plans, and documentation of clinical encounters. Content is delivered using CBL, allowing students to actively engage in and receive feedback on the clinical reasoning process. Prior to the redesign, the course was largely delivered using a classroom format where students collected the case H&P verbally in a "round robin" format, playing the role of a patient and answering questions as the class asked them. Students were then tasked with determining a differential diagnosis, linking the H&P findings to support the diagnostic hypotheses suggested, and ordering initial testing. After class, students received the results of the tests they ordered, determined a final diagnosis, and submitted a case write up detailing the pathophysiology of the disease diagnosed. Since the H&P was taken as a class, this format did not allow for individualized engagement and assessment of these skills. In recent years, standardized patient and mannequin-based simulations were introduced to allow students more immersive experiences. These additions provided an MS1406

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Virtual Patients opportunity to better assess individual student reasoning proficiency but use of mannequin-based and standardized patient cases was sporadic due to resource and time limitations. Case studies typically delivered by faculty during in-class face to face sessions were developed into i-Human cases for individualized case play. Students now perform a focused H&P, determine a differential diagnosis, select diagnostic tests, review the returned diagnostic tests, determine a management plan, and document the case in a SOAP note format all within i-Human. This format allows for case play in a â&#x20AC;&#x153;flippedâ&#x20AC;? classroom design where students experience the case prior to class sessions and come prepared to discuss case findings rather than spending precious class time collecting clinical information. Course surveys demonstrate that 100% of students agree or strongly agree that virtual case play was a valuable addition to the course and that individual case play was helpful to learning. Specifically, students said i-Human cases brought a greater sense of realism, allowing them to feel engaged in authentic clinical reasoning. Faculty were pleased with greater access to individual student data for grading and debriefing purposes. SP and mannequin-based case studies are still used to assess psychomotor constructs such as interpersonal communication and direct physical examination. However, reasoning is now more regularly reviewed using i-Human, allowing faculty the opportunity to provide feedback specific to individuals and the class overall. i-Human continues to be used in conjunction with SP and mannequin-based cases to engage and assess PA student clinical reasoning behaviors in this CBL course.

Promoting collaborative learning in small group CBL We also implemented i-Human to augment small group casebased learning within the medical school curriculum. Our M2 Clinical Skills Course, a two-week immersive session offered prior to transitioning to M3 clinical rotations. Objectives include reinforcement of clinical reasoning skills learned during pre-clinical didactic course work. Content is operationalized to specific disciplines including surgery, internal medicine, women's health, pediatrics, and other core clinical rotations in order to help students apply their developing clinical skill set to the specialties and environments they will be practicing during the third year. Course content is delivered using a CBL format where small groups of 7-8 students are asked to engage patient case studies or solve clinical problems under the guidance of two senior level (M4) students participating in a teaching elective. i-Human is used on an interactive SMART board. Cases are scripted to deliberately engage small group collaboration using several tools embedded in the i-Human platform. Students perform a focused H&P, answer basic science and clinical questions relevant to the case topics, determine a differential diagnosis, and develop initial plans for management. Ambiguous clinical information is included to promote discussion and debate between learners, an exercise that strengthens critical thinking and reasoning. For example, if the case has abnormal heart or lung sounds, the group is asked to come to a consensus on what the finding is (e.g. wheezing vs. crackles) and the significance of the finding to the case presentation. Additionally, quizzing features and break22

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out exercises (e.g. acid base calculations, anatomy review, etc.) built into i-Human can be completed on the SMART board to link basic science with clinical concepts presented in the case. Student surveys and faculty feedback highlight that using a virtual platform enhances collaborative learning that helps students. Prior course versions relied on paper case studies presented in larger group sessions offering limited realism and interaction between learners. i-Human appears to provide strong face validity in that learners report feeling engaged in authentic decision making. M4 facilitators, all whom took prior iterations of the course without the use of i-Human, found the virtual patient format to be engaging and effective at promoting small group discussion and collaboration and helpful in structuring their teaching and keeping the group on task, since it modeled the clinical decision making sequence and provided learning exercises that could be used to promote group discussion and consensus building.

Promoting collaborative learning in larger groups As noted, utilization of virtual patient technology in a small group format engaging students in CBL-based clinical reasoning was effective and well received. Not surprising since studies show that CBL is often most effective when promoting social learning and collaboration.2 However, recruiting small group facilitators and identifying space for many small groups can be a challenge to implement

Figure 2 i-Human Patient used with large group case studies.

on a regular basis. Additionally, scripting highly immersive detailed case studies for individualized student case play is resource intensive. CBL has been informally and formally used during large group faculty-led sessions at our institution for decades. Classroom-based faculty-led case studies are efficient and well received by students and faculty due to their ability to efficiently model the clinical reasoning process. Traditionally, this has been done through paper cases or PowerPoint cases presented during lecture-oriented sessions, which was limited in terms of student interaction and the inability to place students in learning activities that let them feel they are making authentic clinical decisions (suspension of disbelief). We use i-Human to bring greater collaboration and realism to traditional case studies. Using a large room with tables seating eight students, up to 300 students can be accommodated. A central computer is utilized to “play” i-Human while the case output is replicated on monitors at each table, allowing students to view and experience the case. See Figure 2. Thus, a single faculty can provide a guided small group CBL experience for 300 students. Case play is frequently paused to encourage students to discuss and come to consensus on the meaning of H&P findings, laboratory values, and final diagnostic hypotheses. As with the small group sessions used with the M2 skills course, the facilitated i-Human case player enable larger groups to realistically and collaboratively proceed through a variety of case studies and more fully experience the clinical reasoning pro-

cess. Student and faculty feedback has been positive, resulting in students more regularly using i-Human in small groups and individually. Faculty feedback notes i-Human case player brings an element of realism and student engagement that was difficult to attain with paper or PowerPoint case studies.

Studying diagnostic reasoning behavior, cognitive bias, and diagnostic error Missed or delayed diagnoses occur in approximetly 15% of patient cases and efforts are underway to better understand how to train providers to avoid errors and improve accuracy.7,8 Cognitive reasoning failures are frequently associated with diagnostic error and most experts use a dual process (type 1 and type 2 reasoning) model to explain how clinicians make diagnostic decisions and understand how these errors might occur. Experts tend to make decisions while relying on pattern recognition learned from experience (type 1 reasoning) while novices tend to make decisions using a more thorough but cumbersome deductive approach (type 2 reasoning).Understanding, studying and measuring the decision making process is challenging. Virtual patient technology offers a powerful platform to study and address this need. i-Human has the ability to engage clinicians in authentic patient vignettes while capturing information about the H&P they perform, the tests they order, and the diagnoses they consider. Authors can construct cases of varying levels of difficulty to study how this variable affects accuracy. Similarly, case

studies can be presented to both novice and experienced clinicians or different types, (physician assistants, physicians, nurse practitioners, etc.) in an effort to better understand how each group uses clinical information when making diagnostic decisions. We currently are putting protocols in place to study these variables using the i-Human case player in an effort to inform both teaching and practice.

Conclusion Within our curricula, the i-Human virtual case player has been well received by faculty and students participating in CBL. It has allowed more frequent assessment and feedback on individual student clinical reasoning and greater collaboration in small and large group case studies. It serves as a method to study clinical reasoning behaviors and patterns. Our programs continue to rely heavily on mannequin and SP-based simulation, but adding a virtual case platform has been a valuable efficient way to more regularly engage students in meaningful learning activities focused on clinical reasoning. medsim About the Author James (Jim) Carlson, PhD, PA-C is the Vice Dean, College of Health Professions and Associate Vice President for Healthcare Simulation at Rosalind Franklin University of Medicine and Science (RFUMS). He has over 12 years of teaching and experience in health professions simulation and assessment. His research interests involve simulation-based assessment, interprofessional education, and clinical reasoning evaluation.

REFERENCES 1 Bowen JL. Educational strategies to promote clinical diagnostic reasoning. NEngJMed.2006;355(21):2217-2225. doi:10.1056/ NEJMra054782. 2 Thistlethwaite JE, Davies D, Ekeocha S, et al. The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Med Teach. 2012;34(6):e421-e444. doi:10.3109/0142159X.2012.680939. 3 Cook DA, Triola MM. Virtual patients: a critical literature review and proposed next steps. Med Educ. 2009;43(4):303-311 doi:10.1111/j. 1365-2923.2008.03286.x. 4 Cook DA, Erwin PJ, Triola MM. Computerized Virtual Patients in Health Professions Education: A Systematic Review and Meta- Analysis: Acad Med. 2010;85(10):15895 Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005;27(1):10-28. doi:10.1080/01421590500046924. 6 McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research: 2003–2009. Med Educ. 2010;44(1):50-63. doi:10.1111/j.1365-2923.2009.03547.x. 7 Berner ES, Graber ML. Overconfidence as a Cause of Diagnostic Error in Medicine. Am J Med. 2008;121(5):S2-S23. doi:10.1016/j. amjmed.2008.01.001. 8 Graber ML. Educational strategies to reduce diagnostic error: can you teach this stuff? Adv Health Sci Educ. 2009;14(1):63-69. doi:10.1007/s10459-009-9178-y. MEDSIM MAGAZINE 3.2014

Nursing

Developing Educational Military Veteran Patient Simulations US & Overseas Affairs Editor Chuck Weirauch discusses the Seminole State Nursing Centerâ&#x20AC;&#x2122;s Grant to develop educational scenarios and simulations to train nurses in treatment of war veterans.

o the EMS and nursing students removing a young man from a car involved in an accident, there was no visible trauma that could explain his high degree of agitation. Little did they know that he was an Iraqi war veteran, suffering from a post-traumatic stress disorder (PTSD) triggered by the accident. Once at the hospital, the emergency medical staff was at somewhat of a loss as to how to treat the patient as well.

Fostering better care for veterans It's a scenario that could play out many times in Florida because of the high number of military veterans, more than 1.6 million, that reside in the state. That is why the leadership at Seminole State College's Ann Wiggins Moore Center for Nursing and Healthcare Professionals wanted a way to educate its nursing students in how to medically treat such veterans, but to also understand the psychological, emotional and environmental elements present in treating afflicted veterans. The Center's educators felt the need to provide such educational scenarios for the College's EMS and Police Academy departments as well, since they will also be involved in the 24

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care of veterans during their careers. They feel that if students have a better understanding of these patients' lives and take them into consideration when treating those veterans, it will lead to better outcomes for those patients. The goal is to not just develop such live, scripted role-playing simulations as the one described above and integrate them into the college's curricula, but to make such tools available to other Florida medical educational institutions, as well as nationally through the National League for Nursing (NLN). Starting with a pilot project last year in conjunction with the NLN, the effort has led to a joint grant this year from the Florida Healthcare Simulation Alliance and the Florida Blue Foundation that will help the educators reach this goal.

Seminole State College nursing students take part in the college's "Joining Forces" pilot veteran's simulation program. Image Credit: Seminole State College.

According to Maureen Tremel, MSN, ARNP, CNE, CHSE-A, ANEF; Nursing Professor and Director of Experiential Learning/Simulation at Seminole State and the Nursing Center's lead on the pilot and mini-grant projects, the effort started in 2013 as a pilot seminar with the NLN. Tremel was awarded the Certified Healthcare Simulation EducatorAdvanced certification at the Society for Simulation in Healthcare (SSH)'s International Meeting on Simulation in Healthcare earlier this year.

NLN Joining Forces Campaign

Simulation Grant Underway "At the end of the two-day pilot, we had become immersed in this veteran culture," Tremel said. "So we felt that it was such a powerful project that we wanted to continue it. We also felt that nursing educators are not knowledgeable enough to be able to start to implement some of those scenarios with their students. We also learned that we were not competent enough yet to do these scenarios and be content experts in simulations and experts in military medical problems. So, we as a group, decided to write a minigrant through the Florida Healthcare

Simulation Alliance that is partnered with the Florida Blue Foundation." The same team members who developed the pilot program are also involved with the Foundation and Alliance minigrant. Along with Tremel, they are Nursing Professor Marguerite Abel, MSN, RN; Adjunct Nursing Professor Sharon Saidi, MSN, RN, CNE; and Adjunct Nursing Professor Rita Swanson, CDR, USN, Ret., BSN, RN. Swanson is also Training Manager for the Alliance. Under the three-year joint Foundation and Alliance grant, which went into effect this January, the team of Seminole

In 2012, the NLN began a campaign to encourage nursing schools to educate their students in how to care for patients, and in particular veterans, with PTSD and traumatic brain injury (TBI). The NLN had launched this campaign in conjunction with a national effort coordinated by the US Department of Veteran Affairs (VA) and the Department of Defense (DoD). Also partnered in this White Housesponsored "Joining Forces" initiative were the American Nurses Association (ANA); American Academy of Nurse Practitioners (AANP); and the American Association of Colleges of Nursing (AACN); along with hundreds of the nation's nursing schools and organizations. The joint goal is to further educate the nation's nurses so they are better able to meet the needs of service members, veterans and their families. One of the primary areas of concern is veterans with PTSD and or TBI.

Seminole College Pilot Program In April 2013, Seminole State conducted its two-day pilot â&#x20AC;&#x153;Joining Forces and National League for Nursing Simulations: Advancing Care Excellence for Veterans" role-playing nursing student education seminar, featuring four simulation scenarios developed by the NLN. Each scenario focused on one of four physically and/or mentally impaired veterans played by college theater students; two injured in Iraq, one Vietnam veteran and one Korean War veteran. Each patient presented unique conditions for the Seminole College nursing, physical therapist and EMT students to learn how to treat them from a physical, psychological and emotional point of view. M E D SI M M A G A Z I N E 3 . 2 0 1 4

Nursing College nursing educators will pursue several goals, Tremel explained. The first part of the effort will be to learn how they can effectively integrate at least two simulated veterans featured in scripted educational role-playing scenarios into their nursing curriculum. One of the veterans played by theater students will be the younger Iraqi veteran who was in the car accident who has PTSD. The other staged veteran is a Vietnam War veteran who is homeless, like many of those in Florida. A second goal for the grant team is to develop standardized patients and to properly train actors to play the roles of the two veterans. A third goal is to look at the scenarios and see how they can be expanded beyond the nursing community and involve local health and community services personnel. "These scenarios are too powerful just to keep in the nursing curriculum," Tremel said."We will be partnering with the Seminole College EMS and Police Academy, as well as our other health partners to see how we can look at this as the big picture. We want these other professionals to be involved in these scenarios with us to improve the use of the scenarios." During the course of the grant, the Seminole College team will be sharing what they have learned about integrating the scenarios into their curriculum across the state through the Florida Healthcare Simulation Alliance network. They also plan to provide this information to the NLN so that this organization can disseminate it as well. "While our original goal was to have these scenarios developed and written for our nursing students, our overall goal is to show how well they can become a catalyst for getting the different programs involved in healthcare to work together, and then share this with the NLN, the Florida Healthcare Simulation Alliance, the Florida Blue Foundation and other Florida health education colleges and schools across the state," Tremel summed up.

Florida Simulation Partnership The Florida Healthcare Simulation Alliance is a statewide organization with the mission of advancing, coordinating, and expanding the use of all forms of simulation in academic settings, healthcare institutions, and agencies across the state to advance healthcare education and foster patient safety. The Alliance Board of Directors is made up of representatives of several Florida healthcare organizations and educational institutions. The Florida Blue Foundation is a separate philanthropic affiliate of Florida Blue, Florida’s Blue Cross and Blue Shield company. A grant from the Foundation provided the initial funding for the start-up of the now-independent Florida Healthcare Alliance organization. According to Sharon Hackney, Senior Programs Manager for the Florida Blue Foundation, the Seminole College mini-grant is one of eight of the eleven awarded by the Foundation that relate to medical simulation. The mini-grant program is a collaboration between the Foundation and the Alliance, with a total of $526,000 awarded in 2014. "The simulation mini-grants support our Foundation's commitment to nursing simulation and education," Hackney said. "It is also a grant program that we feel will provide access to quality patient care. We look at these as a way to continue the education 26

M E D SI M M A G A Z I N E 3 . 2 0 1 4

Image Credit: Seminole State College.

of the nursing workforce and provide the type of education and training where nurses will be even better at their jobs. This grant will also help the Blue Foundation, which already had an interest in the support of a diverse and well-trained nursing workforce. We also saw what was happening in simulation, and saw that it was an important area to begin to fund."

Wider Applications Alliance Board member Mary Lou Brunell, who is the Executive Director for the Florida Center for Nursing, said that the Alliance has a strong emphasis towards nursing because there is such a high volume of simulation use in the profession. However, the organization is not limited to nursing and actually is a strong proponent of inter-professional education,” she added. "As with the Seminole State grant, our hope is to have demonstrations and projects that allow others to see the benefits of incorporating simulation into their academic programs," Brunell said. "We also hope that medical simulation can be a benefit, not to just a student, but also to the recipients of the future care delivery and perhaps it will allow us to improve the quality and the preparation level of the student graduates towards the completion of their programs." “Out of several applications received for Foundation minigrant applications, the Seminole State College application was appealing because it addressed issues related to military veterans,” Brunell noted. “In particular, it also was concerned with healthcare student and personnel awareness of the symptoms of conditions such as PTSD and TBI in veterans, who may be perhaps an underserved population.” "This is a chance to demonstrate that this kind of educational opportunity and learning can be accomplished through simulation," Brunell summed up. "So this mini-grant did two things. One is that it opened up an opportunity for an education program that could then be shared with others that is a simulation program that is designed to help nursing students. But this also could be applied to nurses or other professionals who work with veteran populations. That is because they most likely did not receive this exact type of training towards these type of syndromes in their education program. So this is something that could be applied broadly to multiple types of populations." medsim

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Improving Education and Training to Enhance Safety, Efficiency, Capacity and Performance A multidisciplinary conference and tradeshow for the healthcare sector. August 22-24 2014 Rosen Shingle Creek Resort Orlando, Florida, USA

Conference and Exhibition Preview

Conference by:

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toward establishing a safety culture in healthcare a

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learn from experts and peers about the critical roles that training and education play to improve patient outcomes and workforce safety. HEATT is designed for educators, hospital managers, surgeons, nurses, anesthesiologists,

HEATT 2014 will look at how we achieve this education

technicians, device manufactuers, simulation providers,

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Preliminary Conference Program

Conference by:

Opening Remarks and Keynote Addresses • John Armstrong, MD, FACS, State Surgeon General, will provide

successfully; and how simulation can be used in your training program

a Florida healthcare perspective and discuss the use of simulation as a

as an effective assessment tool.

tool to enhance medical education and training.

• Robert M. Sweet, MD, University of Minnesota will focus on

What Healthcare Can Learn from High Risk Industries • Chris Lehman, Editor-in-Chief, Civil Aviation Training Magazine will chair a panel that will discuss practices and procedures adapted

simulation projects including the development of a human tissue property database, advanced real time and predictive modeling of human tissue and tool interactions.

by other high risk business like aviation, nuclear, and military.

Technology Advancement

Speakers include: James Blake, PhD, retired PEO STRI, Brian

• John Vozenilek, MD FACEP, Chief Medical Officer for

J. Dunkin, MD, FACS, Medical Director, Methodist Institute for

Simulation, Jump Trading Simulation and Education Center, OSF

Technology, Innovation and Education (MITIE), and Dr. Sunjoo

Healthcare will highlight healthcare innovation through simulation and

Advani, President, International Development of Technology B.V.

engineering in his Intersections presentation.

(IDT), Breda, The Netherlands.

• Richard Boyd, Chief Executive Officer, Metaversial, LLC will

Curricula Development and Impact • Donald Combs, PhD, Vice President, Dean of Health Professions, EVMS will lead a panel on the curricula revolution. Daniel

chair a session on technology advancement in healthcare which will showcase how technology enhances diagnostic procedures and how it is being used to enhance patient care and safety.

Clinchot, MD, Vice Dean for Education, Ohio State University,

Robotic Training

discusses how Lead, Serve, Inspire affects their medical curriculum,

• Martin Martino, MD, Lehigh Valley Health Network will describe

John A. Rock, MD, MSPH, Florida International University, Herbert

the vision of the Robotic Training Network (RTN) to standardize the

Wertheim College of Medicine discuss the curricula developed for

robotic surgical curriculum and education for residents/fellows-in-

their new medical school, and Jerry R. Youkey, MD, Dean, South

training (OBGYN and SURGERY) through the development of a

Carolina School of Medicine Greenville shares how they developed

collaborative network.

their curricula to foster knowledge and learning environment for

• Jeffrey Levy, MD, Chief Executive Officer, Case Networks, Inc.

enhanced patient safety.

will discuss standardizing education for improved outcomes for the

• Karl Schweitzer, MD, Ortho Carolina will lead a panel of Fellows in

fundamentals of robotic surgery curricula.

a discussion about their education, and why they felt it was important to continue their training before starting independent practice. Panelists

Faculty Development

include: Mireille Truong, MD, Florida Hospital Nicholson Center and

• Gwendolyn D. Franklin. PhD, CRNA, Florida Association of

University of Minnesota.

Nurse Anesthetists, will describe the work she has done and is doing

• Dr. Rita D'Aoust, Associate Dean for Academic Affairs and

in faculty development.

Director of Inter-professional Initiatives, University of South

• Lori Lioce, DNP, FNP-BC, NP-C, CHSE, FAANP Simulation

Florida, will highlight simulation initiatives for enhanced practice and

Coordinator, Alabama State Nurses Association will share their

skills assessment and team training curricula in nursing schools that

development of a nurse practitioner resident program.

impacts the training and hospital environment. She will be joined by Carol Fowler Durham, EdD, RN, ANEF, Clinical Professor & Director, CERC, University of North Carolina and more. • Deborah Sutherland, PhD, Chief Executive Officer, CAMLS, University South Florida will discuss the importance of competency based training across healthcare domains.

Working Groups and Break-out Sessions The five groups that were formed at the February CAMLS Forum will be joined by a sixth group; “Is it time for a Federal Advisory Committee for Clinical Simulation?” An opportunity to coordinate the education, research, and innovative promise of simulation at a national level led by Paul Pribaz, OSF Healthcare. The five original groups will report

Surgical Education

on their progress and continue their workshops at the conference

• Howard Champion, MD, Chief Executive Officer and Founder,

which include: Assessment of Technical and Non-technical Skills,

SimQuest LLC will highlight advances in surgical education and the

Robin Wooten, Chair; Breaking Down the Silos, Competency

steps being taken to implement ACGME requirements.

Based Education and Practice; Laura Gonzalez, Chair; Faculty

• Robert Pedowitz, MD, UCLA, will share how the orthopaedic

Development and Retention; Thomas Doyle, Chair; Hospital

community worked together from Board to medical school to make

Administration, Connie Lopez, Chair. Conference participants may

simulation a part of their curricula and advances that have been made.

join the workshop of their choice. Each chair will give a brief summary

• Dimitrios Stefanidis, MD, PhD, FACS, FAMBS, will offer examples

of the group’s activities during the conference and the groups will have

and studies of simulation programs that have been implemented

working sessions during the conference to develop a product.

The Exhibition HEATT 2014 will highlight the critical roles education and training play in the business of healthcare. These two central factors have made this event a must-attend for all disciplines throughout the healthcare industry. This yearâ&#x20AC;&#x2122;s conference is expected to draw over 30 vendors and 500 attendees, and will address the rapidly-changing world of technology and training and how the healthcare industry must adjust.

100

102

104

103 Pocket Nurse

106

Mimic

Limbs & Things

MockMeds

108

110

114

118

Smooth-on

105

120

122

119

121

218

Objectivity Plus

124

117

Laerdal

Moulage

204

202

116

Sciences & Training

216

107

219

Main conference room Central Seating & Dining Area

To additional conference rooms and Hotel

Cardionics

205

203

302

OtoSim

221

207

304

CAE

HeartWorks

SSIH

306

217

Buffet Tables

Registration

319

To conference rooms

* Booth and room sizes are not to scale

Exhibit your company at HEATT For sponsorship and exhibiting opportunities please contact your regional representative: USA & Canada: Justin Grooms +1 (407) 322-5605 justin@halldale.com

Rest of the World: Chris Richman +44 1252 532007 chrisrichman@halldale.com

Organised by:

Conference Report

HPSN 2014 Editor in Chief Judith Riess reports from the Human Patient Simulation Network (HPSN) event which took place at the end of April. Above Dr. Robert Amyot, President, CAE Healthcare. Image credit: CAE Healthcare.

PSN 2014 was held in Sarasota, Florida, which gave the participants of the conference the opportunity to visit the simulator plant and meet the employees where the mannequins are developed. The conference theme was ‘The Simulation Sandbox’. It was chosen because former conference participants requested more time to network, interact with instructors and teachers and learn the nuts and bolts of the simulations and the exercises. Dr. Robert Amyot, President of CAE Healthcare opened HPSN by telling his story. He was a cardiologist practicing in a university teaching hospital in Montreal when a patient was brought to the lab for a test. She had a life threatening heart condition and the test was high risk but he was an expert and had done 1000s of these tests. When he did the test she died on the table. She was rushed to surgery and is fine. The experience, however, led him to develop the Vimedix Ultrasound Simulator because he could no longer train students by the old method of ‘see one, do one, teach one’. After three years of development when they started commercial production of the simulator, CAE came knocking. They bought his company and he became part of CAE Healthcare. He said HPSN was a forum to improve patient safety. He noted that CAE Healthcare was recognized for their simulators but had sold more cameras than simulators. The company introduced a new product at the conference which he likened to an aviation black box on steroids. The product, Replay, is a web-based streamlined audio visual system to support debriefing for clinical encounters. Replay is a room with an integrated memory that records continuously in HD. It can be used as a teaching tool, for debriefing, for learning and practice.

Dr. JoDee Anderson is an Associate Professor and the Medical Director of the Neonatal Intensive Care Unit at Oregon Health & Science University. She gave the keynote address and talked about the importance of team training. She discussed her experiences in neo natal resuscitation and the importance of identifying performance gaps. In their simulation development they identify the problem, perform a needs assessment, and choose the correct educational strategy to achieve their goals. She said you have to evaluate students and instructors to make sure you can achieve learning outcomes. She emphasized that leadership of a team requires collaboration and listening skills and taking cues from the babies you are treating. They use simulation in their training to discover what is causing errors and then go through the process to eliminate the errors and teach students to make good decisions through guided deliberate practice. HPSN had many workshops for hands-on learning and many sessions covering how-to training and step by step presentations on successful programs. Amar Patel from WakeMed, conducted a session on the nuts and bolts of producing an ROI for your simulation center. He laid out step by step metrics that needed to be produced and how you showed the value. Lori Lioce talked about their nurse practitioner resident program and went through the steps they took in developing the program, the role of each instructor and the materials covered. The Ohio State team of Stephanie Justice and Lisa Rohrig showed how they developed the inter professional team training simulation for their nursing school curricula to meet the nursing school requirements. Many other sessions were conducted covering in situ, debriefing, identifying safety threats, collaborative care and changing the healthcare culture. The 2014 conference offered more technical training courses, more one on one opportunities to interact with CAE educators, technicians and engineers and more practical tutorial sessions than at past HPSNs. medsim M E D S I M M A G A Z I NE 3 . 2 0 1 4

Interview

Developing Simulation Centers and Training Programs in Ukraine Lesya Hoover interviews Ukrainian-Swiss Mother and Child Health Programme representatives, Natalia Riabtseva and Grigory Naumovets.

n May 30, 2013, the first Ukrainian medical simulation center was officially opened in the Crimean Perinatal Center, Simferopol city, Ukraine. The goal of this new training center is to improve the teamwork of all specialists involved in the process of delivery and neonatal intensive care. Similar medical simulation centers were opened in the second half of 2013 in three more regions of Ukraine: Volyn, Vinnytsia, and Ivano-Frankivsk. The four medical simulation training centers were opened under the Ukrainian-Swiss Mother and Child Health Programme, which started in the area of perinatology. All four centers acquired high-tech simulators SimMom and SimNewB manufactured by Norwegian company Laerdal. The money spent on the simulators in the four centers totaled 400,000 CHF (more than US $ 450,000). It all became possible due to a longstanding successful Ukrainian-Swiss partnership, which started in 1997. Broad and active collaboration with European partners and world health organizations

M E D S I M M A G A Z I NE 3 . 2 0 1 4

are essential for establishment of medical simulation centers in Ukraine within the scope of ongoing health-sector reforms. Although some other CIS states started their medical simulation programs earlier than Ukraine, for instance, Kazakhstan, where state-of-the-art medical simulation training centers with high fidelity equipment were opened in Astana and several other cities, the accomplishments that we see in Ukraine are of the utmost importance for the country. They will pave the way for the establishment of more simulation centers with sophisticated equipment throughout Ukraine. Upon the opening of the first four centers, national and international specialists in medical simulation began the process of sharing their expertise on the organization of routine training process and the use of manikins. For instance, Ana Reinolds, MD, the head of CESIMED Simulation Center in Porto (Portugal), conducted training for four regional simulation teams on scenario development and assessment of SimLab performance. The program effectively collaborates with various national and international projects, such as WHO, UNICEF, UNFPA, WB, on implementation of a number of joint initiatives. MEdSim met with representatives of the Ukrainian-Swiss Mother and Child Health Programme, Natalia Riabtseva and Grigory Naumovets in Kyiv, Ukraine, and they answered the following questions about the project. MEdSim: What were the biggest challenges during the implementation of the simulation part of Ukrainian-Swiss Mother and Child Programme in Ukraine?

Above Rehearsal of a simulation training on neonatal resuscitation in Ivano-Frankivsk, Ukraine. Image credit: Grigory Naumovets.

We think the most serious challenges are related to: • Establishing a team and ensuring further support by the hospital administration; it was particularly difficult to involve an IT specialist as a member of the team; • Infrastructural aspects: allocating facilities with adequate room space and layout, furnished with appropriate medical equipment and consumables; • Introducing a completely new educational methodology/ approach: it requires capacity building, advocacy, explanations to authorities and management, etc. MEdSim: What advancements do you see in Ukrainian hospitals as the result of team training offered in the recently opened centers? It’s probably too early to analyze this, as the teams have only recently started regular training and thus far conducted not enough of them to make definite conclusions. However, the trainers note that their colleagues who have already taken simulation training now behave in a different way and are actually improving their practices. MEdSim: What medical simulation issues need to be addressed before the completion of the programme? What are your tasks for the near future? In general, we try to focus the efforts of the simulation centers on the topics of most urgent importance for their regions. As a project, we want to complete the following tasks before the completion of the programme. Preparing a basic manual for the teams; intensifying the training process; and organizing in Ukraine the first conference devoted to simulation training in medicine.

A D V A N C I N G

P A T I E N T

S A F E T Y

MEdSim: Do you co-operate with Ukrainian medical schools and Universities, if so in what areas? Yes, we involve people from Universities as trainers and authors of the manual. MEdSim: Do you have a part of your programme devoted to neonatal nursing? Not specifically. We have training courses (such as primary resuscitation, breathing disorders, etc.) developed for neonatal teams that involve both doctors and nurses. MEdSim: What can you say about the Ukrainian medical simulation market in general, its main tasks, problems and challenges? We would say it is rather weak and fragmented for the time being; manikins are mainly of low fidelity, and methodology is not clearly defined. But it should further develop in the near future. Medical simulation training is becoming an accepted method for medical education in Ukraine. There is obviously a growing need for simulation centers and their services in this country, but there are also lots of challenges, problems and vital tasks that undoubtedly the Ukrainian medical simulation industry will face in the future. It cannot be accomplished without heavy investment in the development of the systems, training and equipment purchases. The complex strategic approach with the participation of the government institutions in cooperation across the whole Ukrainian medical community as well as participation of world’s best medical simulation specialists is needed to make simulation an integral part of medical education in Ukraine. medsim

T H R O U G H

E D U C A T I O N

A N D

T R A I N I N G

Advertise in MEdSim magazine to reach healthcare simulation and training professionals. MEdSim is the world’s only magazine for news, information and commentary on healthcare education, simulation and training. It is now circulated in printed and electronic format to over 39,000 healthcare training professionals in hospitals, universities, the military and veterans’ organizations. A d vA n c i n g

The next issue of MEdSim magazine will be published on 14 August with extra circulation at HEATT in Orlando (22-24 August)

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World News & Analysis

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

ROBOTICS

NEW PRODUCTS & DEVELOPMENTS

EBUS-TBNA Training

3D Augmented Reality Software

Simbionix and the American College of Chest Physicians (CHEST) have entered the second phase of their collaboration to promote bronchoscopy education with the BRONCH Express, a simulator the two organizations co-developed for EBUS-TBNA training. Endobronchial Ultrasound – Transbronchial Needle Aspiration (EBUSTBNA) is an advanced diagnostic method with a steep learning curve that is rapidly gaining popularity and is effective in the diagnosis and staging of lung cancer, as well as the diagnosis of benign causes of mediastinal and hilar lymphadenopathy. The increasing demand for EBUS among pulmonologists and thoracic surgeons means they need hands-on training to gain proficiency in performing the procedure safely and efficiently. The

BRONCH Express was developed to provide a solution for the growing demand for that training and qualification. The desktop simulator offers virtual patient cases in a realistic anatomical environment, and the cases are based on actual data and are immersed in a controlled training environment.

ACADEMIC

Nursing Scholar-in-Residence Program Excelsior College is funding a five-year sponsorship of the National League for Nursing’s (NLN) Scholar-in-Residence program that will facilitate career advancement for nurse educators with doctoral degrees. The program is managed by the NLN Center for Innovation in Simulation and Technology, one of seven new centers that comprise the NLN Home for Transformative Excellence in Nursing Education. The new simulation scholar-in-residence will provide direction to ongoing NLN simulation activities; collaborate with NLN leadership to develop and execute simulation research; increase the NLN faculty development simulation and technology offerings; expand the Simulation Innovation Resource Center website and simulation activities; support participants in NLN's Leadership Development Program for Simulation Educators; and provide guidance to NLN's Advancing Care Excellence for Seniors Project. The scholar will also plan simulation events at the NLN Education Summit, Technology Conference and other professional development programs; and collaborate with companies involved with simulation to provide resources and updates of simulation research studies and advances. 34

M EDSI M M A G A Z I N E 3 . 2 0 1 4

Mimic Technologies has launched Maestro AR, a new augmented reality software module that is only available on the dV-Trainer® robotic surgery simulator. Mimic says Maestro AR is the first robotic surgery simulation technology that provides 3D virtual instruments for interaction with anatomy in a 3D video environment. Maestro AR is available as a multispecialty package, including partial nephrectomy with hysterectomy, prostatectomy and general surgery modules in development for future delivery. Using the dV-Trainer, partial nephrectomy trainees interact with anatomical regions using virtual robotic instruments within augmented 3D video. Maestro AR for partial nephrectomy (partial removal of a kidney) was developed in collaboration with Inderbir S. Gill, MD (Chairman and Professor of the Catherine and Joseph Aresty Department of Urology, Founding Executive Director of the USC Institute of Urology and Associate Dean for Clinical Innovation, Keck School of Medicine of USC) and Andrew J. Hung, MD (Clinical Fellow, Advanced Robotics and Laparoscopy, Keck School of Medicine of USC). The module features a partial nephrectomy video from an actual case performed by Dr. Gill and audio to guide trainees through five procedure steps – and as they progress through the module, trainees identify anatomy, anticipate tissue retractions, predict regions for dissection and refine surgical skills.

ACADEMIC

NEW PRODUCTS & DEVELOPMENTS

University of Toledo Opens New Simulation Center

ASA Simulation Education Network Endorsement

MedaPhor Announces Landmark 100th System Sale

The University of Toledo in Ohio has opened a 65,000-square-foot Interprofessional Immersive Simulation Center with simulation equipment for medical training and other colleges that use modeling and simulation. The facility brings together three concepts in training: • The Virtual Immersive Reality Center features a five-sided LED iSpace – a seamless curved interactive 3D wall and two smaller 3D walls that offer virtual immersive experiences such as letting a user stream through HD images of the human body from cells to organs. • The Advanced Clinical Simulation Center includes simulated hospital rooms for intensive care, trauma, operating, labor and delivery, pediatrics and ambulatory care. • The Progressive Anatomy and Surgical Skills Center features surgical skills suites with advanced procedural skills training labs. The Center also works with several global industry collaborators, the US military and other health-care organizations.

The University of Wisconsin School of Medicine and Public Health’s Department of Anesthesiology received endorsement from the American Society of Anesthesiologists' (ASA) Simulation Education Network. Now the department and the UW Health Clinical Simulation Program can offer immersive simulation education courses for American Board of Anesthesiology diplomats to fulfill their simulation Maintenance of Certification in Anesthesiology.

MedaPhor has sold its 100th ScanTrainer system to Palm Beach State College in Florida. The virtual reality ultrasound simulator lets trainees feel what they see on the computer screen to develop the complex mix of cognitive skills and eyehand movement coordination required to learn ultrasound scanning skills. It uses real patient scans to teach core and advanced skills – without the need for an ultrasound machine or a patient, with considerably reduced supervision.

ROBOTICS

Developing Pediatric Sepsis Training Engineering & Computer Simulations (ECS) will use its Emergency Management Staff Training to develop training for doctors and nurses in recognizing sepsis in infants for the Children's National Medical Center (CNMC), in Washington, D.C. ECS is working with CNMC to develop the Pediatric Exercise Training System (PETS) to help train medical providers to identify the early signs of sepsis from subtle and chronic diseases, according to Jeff Sestokas, the CNMC Instructional Systems Technologist. “Early recognition requires an appreciation for hidden symptoms and cognitive and behavioral changes that can evolve over a period of hours or days,” said Sestokas. PETS will allow providers to develop individual and team-based decision-making skills required to have a shared mental model of a patient's evolving status through communication between medical care providers at shifts, inter-professional teams, and with patient's families.

FIRST RESPONDER

Training Responders to Control Bleeding Among Mass-Casualty Victims Surgeons and first responder organizations started an initiative about a year ago to increase the number of survivors of an active shooter or mass casualty incident. The initiative requires law enforcement officers to get medical training and equipment to control bleeding, a goal set forth by the Hartford Consensus; a collaborative group of trauma surgeons, federal law enforcement, and emergency responders; and driven by the ACS, the Federal Bureau of Investigation (FBI), Major Cities Chiefs Association and Prehospital Trauma Life Support program. The principle of more training and equipment is central to the findings of the Hartford Consensus, according to an article published in the March issue of the Journal of the American College of Surgeons: “The Hartford Consensus: THREAT,

A Medical Disaster Preparedness Concept”. A companion piece published in the March issue (“Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events: Hartford Consensus II”), calls for an educational strategy and evaluation of THREAT’s implementation to quantify its benefits in managing active shooter or mass casualty events, where victims often bleed to death before medically trained emergency responders can reach the scene. THREAT is an acronym for the needed response to mass shootings developed by the Consensus: T-Threat suppression, H–Hemorrhage control, RE–Rapid Extrication to safety, A–Assessment by medical providers, and T–Transport to definitive care. Law enforcement officers are typically the first to the scene, but they lack the

medical training and equipment to treat the victims, and filling that critical need is one of the Hartford Consensus’ calls to action that is already having an impact. In concert with ACS and the Major Cities Chiefs Association, more than 36,000 police officers in Los Angeles, Philadelphia, Houston, Phoenix, Dallas, New Orleans, Tampa, and Washington, DC will receive bleeding control kits and training this year. Another key call-to-action is to educate and equip the public to respond to victims, even though sometimes these people may be victims themselves. Activating that type of response effort means equipment needs to be available in schools, shopping centers and other public places. It also means developing – and delivering – education and training programs for the general public. M EDSI M M A G A Z I N E 3 . 2 0 1 4

World News & Analysis NEW PRODUCTS & DEVELOPMENTS

Conquer Mobile & VRcade Partner on Medical Simulation the potential for multi-player simulations, and it will allow Conquer Mobile to create a fully immersive operating room (OR) experience. VRcade uses a mix of proprietary and off-the-shelf hardware and software and integrates with game engines such as Unity. Because of the system’s modular design, components can be upgraded as technology grows, resulting in an evolving platform that won’t become obsolete.

Conquer Mobile, a mobile solutions specialist, and VRcade, creator of the outof-home VRcade VR platform, are partnering to produce medical simulation solutions for medical education. Conquer Mobile is developing medical simulation products for iPad and home VR systems such as Oculus Rift, and was searching for a fully immersive open walking environment. The company says VRcade met the criteria, with

no wires, no controllers, no motion sickness, completely intuitive movements,

INTERNATIONAL

ACADEMIC

Diabetes Training Toolkit

Master of Science in Medical and Healthcare Simulation

Three diabetes specialist nurses at Peninsula Community Health (PCH) created a simulation-based hypoglycaemia training tool that was so successful it is now being used throughout the hospital in Cornwall, UK. Amanda Veall, Kim Bull and Amanda Davis developed the training programme after seeing how the hospital used simulation in other training situations. Hypoglycaemia is a potentially lifethreatening condition in diabetic patients that occurs when their blood sugar dramatically falls. The training teaches how to treat patients with hypoglycaemia on mannequins in a real hospital ward to the entire multi-disciplinary team (nurses, health-care support workers, and junior and senior doctors), and after each session participants go through a de-brief to determine how well the team responded, communicated with each other and found the equipment needed.

The Drexel University College of Medicine Graduate School of Biomedical Sciences and Professional Studies launched a graduate program offering a Master of Science Degree in Medical and Healthcare Simulation that prepares healthcare professionals to teach others how to care for patients in simulation environments. The two-year, part-time program provides individuals with prior training and/or experience in healthcare with a broader education in simulation-based medical education, specifically those: • with healthcare experience, such as nurses, physicians and paramedics looking for professional development in simulation education; • currently working in healthcare education looking to advance their careers; • looking to transition into a new educational career in simulation. The majority of courses are delivered online and in three, one-week intensive simulation practicums on site at the university in Philadelphia, Pennsylvania. The degree provides students with a core, detailed focus on the many facets of simulation-based healthcare education and will give them multiple options to pursue upon graduation.

NEW PRODUCTS & DEVELOPMENTS

Chamberlain Group Launches Infant Surgical Trainer The Chamberlain Group has announced the birth of Surgical Sam, the first fully operable, high-fidelity infant surgical team trainer. Developed with Boston Children’s Hospital for team-training initiatives in pediatric cardiothoracic and general surgery, Surgical Sam allows important steps of surgery to really happen – letting operating-room teams fully immerse in simulations to optimize performance, safety and outcomes for children. 36

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NEW PRODUCTS & DEVELOPMENTS

ACADEMIC

Oesophageal Doppler Simulator

Univ. of Tennessee Opens Simulation Lab

Deltex Medical Group, a provider of oesophageal Doppler monitoring (ODM), has released its new training aide, an oesophageal Doppler patient simulator. The simulator is inside an upper, halfbody mannequin that allows probe insertion through the mouth or nose, correct identification of aortic blood flow and probe focus. It is compatible with the company’s CardioQ-ODM and the CardioQ-ODM+ monitors. The simulator helps users develop competence and confidence in placing a probe before doing it on a real patient, significantly reduces the learning curve and will increase the productivity of the company’s clinical support staff, according to Ewan Phillips, chief executive of Deltex Medical.

The University of Tennessee, Knoxville’s Nursing and Engineering Colleges has created a Health Information Technology and Simulation Lab with spaces identical to a variety of care facilities – and patients in the form of actors and manikins. The lab features a range of medical settings with cameras that send live video feeds to a control room, letting teachers change patient manikin’s conditions without disrupting the aura of a working medical facility. Pairing up is great for both colleges, said College of Engineering Dean Wayne Davis, it helps speed design and computing for the healthcare students and means instant data and real-world testing for engineering students.

Ultrasound Meets Patient Simulator Finally with HeartWorks TTE Mobile, Ultrasound Simulation can now be incorporated into patient simulations within your centre, allowing image acquisition and accurate decision-making all within a mobile, versatile and easy to use product. Never before has a product been available to enhance your current training models like this. To find out more please contact:

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World News & Analysis ROBOTICS

Training for FAST Arthroscopy Curriculum Simbionix USA Corporation, a provider of medical simulation, training and education products, has released a virtual reality training module for the Fundamentals of Arthroscopic Surgery Training, known as FAST. The American Association of Nurse Anesthetists (AANA), American Academy of Orthopaedic Surgeons (AAOS) and American Board of Orthopaedic Surgery (ABOS) collaborated to create the FAST program - a structured curriculum for sequential development of basic knowledge and arthroscopic motor skills. Less invasive and easier on patients than orthopaedic open surgery techniques, arthroscopic procedures have become more common for surgeons to visualize, diagnose and treat problems inside a joint. But these procedures are challenging, as they require ambidextrous

triangulation in three dimensions, guided by a two-dimensional video display. The new FAST module offered on the Simbionix ARTHRO Mentor™ complements the FAST program with didactic content alongside hands-on training of arthroscopic skills that help facilitate mastery of the basics, so students learn arthroscopic skills sequentially before the full surgical procedure.

INTERNATIONAL

UBC Okanagan Nursing and Med Students Train Together The University of British Columbia’s Faculty of Medicine and the Okanagan School of Nursing have collaborated to bring medical and nursing students together for joint emergency-medicine training at the Pritchard Simulation Centre at the Clinical Academic Campus at Kelowna General Hospital. Using patient simulators for emergency treatment case scenarios, Code Blue teams were assembled to assess health crises in life-like patients that breathe, speak, cough, groan and display the same symptoms that mimic the unpredictable events that routinely occur in a hospital emergency room, and beeping monitors displayed faltering or improving life signs, depending on the patient’s medical condition. Its critical team members understand their roles and how to work together, according to Dr. Cheryl Holmes, clinical associate professor and Year 3 education lead for the Southern Medical Program at Kelowna General Hospital. There are instant decisions to be made about treatments and medications, with team members relying on each other’s expertise 38

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and quick assessments of the patient’s condition, but “often in an emergency setting, doctors and nurses are called in to deal with life-threatening situations and they may not even have met one another, let alone worked together before," said Holmes. Simulations like this one point out simple and important routines so everybody is aware of what’s going on, commented Holmes, like looking each other in the eye while explaining what they are doing, and not assuming everyone in the room heard and understands. The participating students had high praise for the joint exercise, saying it offered a safe way to prepare, before coming together for the first time in a live situation. Medical student Donovan Duncan said the collaborative nature gives doctors and nurses a chance to rethink how they approach problems so they can provide the best patient assessment and care. The joint training was so successful, the two faculties plan to repeat it and expect to collaborate in other areas of joint clinical training, too.

SURGICAL IMPROVEMENT INITIATIVES

ACS and Safe Surgery 2015 Surgical Safety Checklist Initiative The American College of Surgeons (ACS), Safe Surgery 2015 and the South Carolina Hospital Association hosted the ACS Surgical Health Care Quality Forum South Carolina, bringing together health care leaders to discuss the successes and challenges of implementing the World Health Organization’s (WHO) Surgical Safety Checklist in every operating room in the state. Based on results of the South Carolina Surgical Safety Checklist implementation still being evaluated, Safe Surgery 2015’s leadership estimates if the checklist is used for every patient undergoing surgery in the state, it could save at least 500 lives per year, prevent 2,000 complications and save $28 million in health care costs. The Safe Surgery 2015 initiative was launched in 2011 to measurably reduce surgical infections, major complications and death through effective populationwide implementation of a modified version of the WHO Surgical Safety Checklist. “The Safe Surgery 2015 program and the efforts in South Carolina are perfect examples of how we can use existing tools and resources to effectively advance patient care and benefit the entire health care system,” said David B. Hoyt, MD, FACS, Executive Director of ACS. INTERNATIONAL

University of Guam Upgrades Sim Lab The University of Guam School of Nursing and Health Sciences has used a $100,000 donation from TakeCare Insurance Company to upgrade its Learning Resource Center Simulation Lab; provide scholarships for Nursing and Health Science students, graduate education and continued professional development for faculty; and fund computer lab support and recruitment and retention initiatives. The upgraded lab features new lab equipment including wall units for oxygen and suction systems to simulate the hospital environment, and equipment for recording simulations.

World News & Analysis ACADEMIC

HOSPITAL

Indiana University Hospital Opens New Learning Center

Conemaugh Memorial Simulation Lab Earns ACS Reaccreditation

Indiana University Health Ball Memorial Hospital has opened a 10,000 square-foot simulation facility for hospital staff, physicians, residents, medical students and the community. The Janice B. Fisher Learning Center features high-fidelity simulator manikins that let students and staff practice procedures such as chest tube and tracheotomy management, defibrillation and urinary catheter insertion. The simulators are programmed to provide realistic patient responses and outcome – helping to hone critical thinking, communication and teamwork skills as users learn to manage the care of a simulated patient that responds to their interventions. The center has emergency department trauma, critical care, exam and operating rooms; a skills lab; computer labs; and classrooms – and will offer community education classes such as CPR.

The Medical Skills Learning Center (MSLC) at Conemaugh Memorial Medical Center in Johnstown, Pennsylvania was reaccredited as a Comprehensive-Accredited Education Institute (AEI) by the ACS. The AEI accreditation program is a voluntary peer-review process and institutions that successfully complete it are accredited for three years. Conemaugh's MSLC is one of only 68 ACS-accredited simulation labs. An ACS-AEI addresses the educational needs of a broad spectrum of learners and advances the science of simulationbased education, with the goals of enhancing patient safety, supporting maintenance of certification requirements, addressing competencies all surgeons and surgical residents need to achieve and demonstrate, and enhancing access to contemporary surgical education.

ACADEMIC

Jump ARCHES - A New Medical/Engineering Research Partnership A $25 million gift is helping create a new partnership between medical clinicians and engineers that will revolutionize clinical simulation, education and health care, according to Jump Trading Simulation & Education Center (Jump). The Jump Applied Research for Community Health through Engineering and Simu-

lation (Jump ARCHES) is a $50-millionplus project that will create joint research projects between the Jump Center at OSF HealthCare in Peoria, Illinois and the University of Illinois at Urbana-Champaign’ College of Engineering. Jump ARCHES will create new tools and technologies using imaging, health

information technology, novel materials and human factors to enhance medical simulation and education – along with new tools, techniques and devices for clinical use and treatment – with a fundamental goal of improving the quality of care and outcomes for patients and to reduce health care costs.

INTERNATIONAL

New Computer Technique Simulates How Medicine Affects the Liver What happens when chemicals flow through the blood stream into the liver and react with the organ? What if parts of the liver are damaged and medicine cannot be properly metabolized? A new computer simulation developed primarily by experts at the Fraunhofer Institute for Medical Image Computing MEVIS in Bremen, Germany, can now answer questions such as these in greater detail. Fraunhofer was a primary partner in the team developing a program to simulate realistic blood streams and metabolic processes, whose results are being published in the PLOS Computational Biology scientific journal. The liver removes toxic matter from the blood, produces important proteins and stores vitamins, with about 90 liters of blood flowing through the human liver every hour. The researchers used a highresolution 3D image of a liver to provide a detailed simulation of how blood flows through and reacts with the liver. Based on this image data, they reconstructed 40

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the exact structure of the fine branches of the vessel system and then split the organ into 50,000 small blocks, in contrast to most of today's pharmacokinetic simulations, which simply treat the liver as a single 'black box'. To keep computation time in check, they combined the procedure for the thousands of cells in each block, and to make sure their results were realistic, they relied on a large database of medical research that describes the metabolic characteristics of liver cells. The results of the simulation showed blood flow and metabolic reactions can be tracked in detail on the computer screen. For example, the computer monitor could be used to observe how quickly a contrast agent reached the various sections of the liver and how it gradually decayed. However, the procedure, developed as part of the Virtual Liver Network with the Department for Experimental Molecular Imaging at the RWTH Aachen University and Bayer Technology Services in Leverkusen, can do even more. Researchers performed a

simulation to show areas of the liver with steatosis, a widespread illness also known as fatty liver disease, which showed the steatotic sections of the liver absorbed lipophilic contrast agents more effectively than healthy tissue. Metabolic reactions of other medications could also be simulated for both healthy livers and those that are diseased or damaged. "Currently available computer models only consider the liver as a whole," explained project leader Tobias Preusser. "Our technique is the first to simulate what actually happens inside the organ," and has the potential to become a useful research tool for the pharmaceutical industry. The new simulation software will be able to answer questions such as “how does a new medication affect a patient suffering from steatosis or other liver diseases?” and in the future, could be used in clinical practice to decide if a specific liver medication should be used for a specific patient.

NEW PRODUCTS & DEVELOPMENTS

ArthroS FAST Module VirtaMed has released a virtual reality training module for FAST (Fundamentals of Arthroscopic Surgery Training) into its ArthroS™ simulator. FAST is the program created by the major American orthopaedic associations – ABOS (American Board of Orthopaedic Surgery), AAOS (American Academy of Orthopaedic Surgeons) and AANA (Arthroscopy Association of North America) – in response to the mandate they implemented last year to improve and standardize surgical education of arthroscopy. The virtual reality module is based on the Sawbones FAST workstation developed by a team led by Robert Pedowitz, MD, PhD. The fusion of the Sawbones

ACS Surgical Collaborative in Florida Results in Statewide Improvement

FAST dome in ArthroS lets surgeons practice basic skills before performing complex arthroscopies. The workstation’s basic motor skill training tasks helps guide trainees through the first steps of arthroscopy – and helps hospitals and training centers comply with the mandate.

ACADEMIC

A GLIMPSE into Effective Medical Communication Researchers at the University of Texas (UT) at Arlington College of Nursing, Baylor Scott & White Health and UT Dallas have developed a video-game simulation they say can teach doctors and nurses to work more collaboratively by playing out tense situations in a virtual world. The federally funded project received two national awards at the 4th Annual Serious Games and Virtual Environments Arcade & Showcase during the 2014 International Meeting on Simulation in Healthcare in San Francisco, including Best-in-Show for the Academic Faculty Category and 4th place in the Technology Innovations division. “Our hope is that this project will enhance patient safety and, ultimately, improve patient outcomes,” said Beth Mancini, a UT Arlington nursing professor and Associate Dean of the College of Nursing. Mancini is principal investigator for a nearly $1 million grant from the US Agency for Healthcare and Research Quality that funds GLIMPSE, or a “Game to Learn Important Communications Methods for Patient Safety Enhancement”. Her partners in the research were Baylor Scott & White Health’s Dr. Yan Xiao, director of patient safety research; Susan Houston, director of nursing research at the hospital; and Marjorie Zielke, director of the UT Dallas Arts and Technology program’s Virtual Humans and Synthetic Societies Lab.

A surgical collaborative of Florida hospitals resulted in broad improvements, helping most hospitals significantly improve quality and reduce costs of surgical care, according to a new study published in the Journal of the American College of Surgeons. The results were so positive, the researchers argue the results support the case for the ACS National Surgical Quality Improvement Program (NSQIP®) collaborative as a systems approach to population-based improvement in surgical care. Using the ACS NSQIP, the Florida Surgical Care Initiative (FSCI) reduced complications by 14.5 percent. The study estimates the program averted 165 complications, saved 89 lives and avoided more than $6.6 million in health-care expenses during the 15-months from March 2011 to July 2012. FSCI is a joint project between the Florida Hospital Association and ACS that focuses on four ACS NSQIP measures: surgical site infections, catheter-associated urinary tract infections, colorectal infections and surgery in elderly patients. The research team set out to assess if FSCI’s significantly improved results were due to a few outperformers or broad-based improvement. They found most of the 54 participating hospitals improved, some significantly, and the level of improvement for each measure differed from hospital to hospital.

NEW PRODUCTS & DEVELOPMENTS

Droiders Surgical Application Pairs Google Glass and Augmented Reality Droiders, an official Google Glass applications development start-up, has launched MedicAR, a new application that combines augmented reality and Google Glass™ to improve the simulation and teaching of certain procedures in surgery and patient care. The MedicAR application also represents a potential new aid to improve safety issues in surgical interventions for common procedures among junior surgeons – and even for uncommon ones among experts. During a recent demonstration, Dr. Homero Rivas, assistant professor of sur-

gery and director of innovative surgery at Stanford University, connected the wearable device from Google to Droiders’ MedicAR application, and used an anatomical human model to perform an open reduction and internal fixation of a left complex clavicular fracture. The MedicAR application requires a target to be temporarily tattooed on the patient’s skin. The surgeon and his assistant then direct their Glass to the target, which reveals the augmented reality on their screen, showing all aspects of a given

surgery, and then displays procedures step-by- step. The project was the next logical step in the company’s collaborative efforts with Dr. Rivas, according to Julián Beltrán, founder of Droiders. He said the two teamed up last summer to perform a livestreamed transatlantic operation through Glass, a first in telemedicine at the time, using Droiders’ own streaming solution, and shortly after, were among the first Glass developers to introduce augmented reality into its Glassware. M EDSI M M A G A Z I N E 3 . 2 0 1 4

World News & Analysis ACADEMIC

Surgical Innovation and Simulation The Grainger Foundation committed $5 million to NorthShore University HealthSystem (NorthShore) that will support research and professional training in leading-edge surgical techniques, and significant funding for the newly renamed Grainger Center for Simulation and Innovation. The Grainger Center offers courses in medical and surgical disciplines to physicians and surgeons that are led by senior fellow practitioners and backed by the latest research and technological innovations. The courses are an integral part of NorthShore’s surgical residency program with the University of Chicago Pritzker School of Medicine, especially since the American College of Surgeons recently made the study of surgical simulation a mandatory track in surgical residencies nationwide. NorthShore surgeons will also partner in the development and testing of new surgical instruments and simulators with industry providers, engineering faculty and senior surgeons around the region. The Foundation’s commitment will support NorthShore surgeons in developing new applications of minimally invasive surgery – and the simulation laboratory’s extensive array of simulators will help surgeons acquire the increased dexterity and skills necessary to develop and rehearse complex new operations before they are used in the operating room. The center also received a large donation from the Jane R. Perlman Trust that is being used to establish an Advanced Practice Provider (APP) residency program to teach nurse practitioners and physician assistants how to further improve patient care and clinical outcomes, while reducing healthcare costs. ROBOTICS

Simulation Training Gives Surgeons “Expert Status” Surgeons who follow a rigorous training protocol on a simulator have a significant performance advantage on the da Vinci robot, according to a study by The Icahn School of Medicine at Mount Sinai and Morristown Medical Center in New Jersey. Board-certified laparoscopic surgeons with no previous robotic surgery experience were able to meet or exceed the rigorous requirements set by a team of robotic surgeons with anywhere from eight to 40 hours of simulation training. The study found surgeons can become skilled much faster by using the simulator, potentially saving time, blood loss, and costs for each hospital robotic program. “This landmark study has been used to establish a new training protocol, which is available through MShare, Mimic’s curriculum sharing portal,” said Jeff Berkley, founder and CEO of Mimic Technologies. The simulator’s software was developed by Mimic Technologies for the da Vinci robot and is sold by both Mimic and Intuitive Surgical. 42

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