Simulation technology in critical care: 1000 deaths for medical education Technology for teaching and evaluating critical care knowledge, skills and attitudes Randy S. Wax, MD, FRCP(C) Technology Application Unit and Critical Care Unit, Department of Medicine, Mount Sinai Hospital Lecturer, Department of Medicine, University of Toronto

Learning objectives Why simulation? Features of a simulator Apply simulation technology Limitations and resource requirements

A traditional approach to learning

Problem #1 Just because students learn a task in the classroom doesnt mean they can demonstrate successful performance during a crisis.

Problem #2 Some clinical experiences are so life threatening that students are not going to be involved in the management.

Problem #3 Some are so rare that the student may not ever experience the situation until they are in the midst of caring for the patient.

Different simulation formats Patient management problems (paper/pen) Computerized simulation – Internet-based Role playing/standardized patients Mannequin-based (e.g., CPR BCLS trainer) Virtual reality

Why simulation? Used in many high reliability fields – Aviation – Nuclear power – Military flight operations

Why simulation? No risk to patients Many scenarios can be presented, including uncommon but critical situations in which a rapid response is needed – E.g. malignant hyperthermia 1:40,000 cases Participants can see the results of their decisions and actions; errors can be allowed to occur and reach their conclusions

Why simulation? Identical scenarios can be presented to different clinicians or teams The underlying causes of the situation are known With mannequin based simulators clinicians can use actual medical equipment – examine limitations in the human-machine interface

Why simulation? Re-create clinical environments – Assess interpersonal interactions with other clinical staff – Evaluate and improve teamwork, leadership, and communication skills

Why simulation? Intensive and intrusive recording of the simulation session is feasible – Audiotape – Videotape – Physiological monitoring of participants (EEG, ECG, etc.)

Why simulation? There are no issues of patient confidentiality Recordings can be preserved for research, performance assessment, or accreditation

How can we use simulation? Skills training Evaluation Epidemiology and modification of errors (and their consequences) Crisis resource management

What can you teach/evaluate? Specific skills – Intubation – Bronchoscopy – Defibrillation Integration of knowledge, skills and decision making – Resuscitation – Refractory hypoxemia

Level 1Level 2Level 3 SkillIntegrateHigh-fidelity Medical Student Bag ventilation Hypoxemic patient Ward team ResidentIntubateHypoxemic patient ER/ICU RN, RT Fellow/ Staff LMA, surgical airway Difficult airway management Full ER/ICU team CME

Evaluation of the evaluation tool Type of simulator – Low to high fidelity Type of simulation – Full theatre environment or real location – Training device for specific tasks Efficacy of assessment – Valid – Reliable

SIM MAN

Life-size mannequin

Computer Controlled

Teach airway management

Use airway devices

Fibreoptic intubation

Difficult airway – Decreased cervical range of motion – Tongue edema – Pharyngeal edema – Laryngospasm – Trismus – Fiberoptic intubation/bronchoscopy – Surgical airway – Detectable carbon dioxide

Breath sounds

Check pulse & blood pressure

Obtain peripheral IV access

Mask ventilation

Decompress tension pneumothorax

Monitor cardiac rhythm

Shock unstable rhythms

Additional features Chest tube insertion Invasive hemodynamics Ventilator management (including HFOV)

Control crisis situations

Give feedback

Assessment instruments Specific – Debriefing (oral or written…good for factual) – Observation and scoring system (checklist or score sheet or palm pilot) – Time to performance of specific task Global – Simulated mortality as end-point – Time to solve problem

How can we use simulation? Skills training Evaluation Epidemiology and modification of errors (and their consequences) Crisis resource management

Epidemiology of Medical Error Types of errors made during anaesthesia simulation Schwid and ODonnell Anesthesiology 1992

Crisis Resource Management Using all available resources during a crisis to achieve safety and efficiency – Information – Equipment – People

Crisis Resource Management Error countermeasures – Reduce the frequency of errors – Correct errors – Limit the impact of errors

Resources Simulator PLUS operational budget Competency standards – Who/what are you testing? Content experts – Set objectives and clinical setting Simulation experts – Translate objectives and clinical setting into functional simulation scenarios AV equipment (debriefing)

Limitations of simulation Difficult to demonstrate improved outcome from use of simulation – Adverse events are unusual – Extreme number of potential confounders Forced to use simulation performance as surrogate outcome

Initiatives at MSH

Mock cardiac arrests – ACLS protocols – Use of equipment – Systems issues (elevators, cancel arrest) – Crisis resource management – Feedback/debriefing

Initiatives at MSH Life-saving delegated medical acts – ICU/CCU nurses – Use of epinephrine/atropine – Defibrillation Pre-ACLS interventions – Bag-valve-mask ventilation – Understanding respiratory failure and shock

Initiatives at MSH Medical and Critical Care Residents Continuing education courses – Difficult airway management – Advanced ARDS strategies Technology evaluation – OCCIN Project Multidisciplinary approach Portable

Parting comments Simulation is fun for students and teachers You can use simulation technology as an evaluation tool Choose the most appropriate tool for achieving educational goals Remember basics of education, otherwise simulator is an expensive toy