Practical Simulation: Key Principles & Methodologies: “—making the rubber meet the road” by John J. Schaefer, III, MD, Professor Anesthesia and Perioperative Medicine Assistant Dean MUSC College of Medicine, Lewis Blackman Endowed Chair South Director: HealthCare Simulation of South Carolina

Charleston, SC and the Medical University of South Carolina

Established 1824 Colleges Medicine, Nursing, Dentistry, Pharmacy, Health Professions MUSC Medical Center is comprised of four separate hospitals (the University Hospital, the Institute of Psychiatry, the Children's Hospital, and the Ashley River Tower). The Medical Center includes centers for specialized care (Heart Center, Transplantation Center, Hollings Cancer Center, Digestive Diseases Center).

Objectives: “Practical Simulation Methods in HealthCare Education” Practical Simulation Defined Why “Practical Simulation” is critical to your success The operational concept to achieve it Practical Simulation Demonstrations across range of “Simulation types” – Task training: NG tube objective assessment (interactive demo) – Task Training: Orthopedic Surgery (video demo) – Student run multi-simulator, single instructor interactive demo – Individual assessment----Nursing student med administration (video demo) – Individual assessment----Pediatric Resident NRP Individual assessment (video demo) – Team Training: Team Leader Focus: Pediatric ER emergencies (video demo) Interdisciplinary Focus: SIRE (video demo) Specialty Team Focus: Neonatal LBW Team (video demo) – Research using Simulation Summary

Objectives: “Practical Simulation Methods in HealthCare Education” Practical Simulation Defined Why “Practical Simulation” is critical to your success The operational concept to achieve it Practical Simulation Demonstrations across range of “Simulation types” – Task training: NG tube objective assessment (interactive demo) – Task Training: Orthopedic Surgery (video demo) – Student run multi-simulator, single instructor interactive demo – Individual assessment----Nursing student med administration (video demo) – Individual assessment----Pediatric Resident NRP Individual assessment (video demo) – Team Training: Team Leader Focus: Pediatric ER emergencies (video demo) Interdisciplinary Focus: SIRE (video demo) Specialty Team Focus: Neonatal LBW Team (video demo) Summary

Practical Simulation Pyramid of Success Communicate Value Establish Value Create/Deliver Quality Courses Create a Functional Center/Lab Develop a Realistic Plan Focus will be on simulation methodology critical to achieving success!

What is meant by “practical” simulation in Healthcare? 1.Simulation as a teaching methodology that takes advantage of simulator tools where diverse and large numbers of Healthcare students and practitioners have individual and group access to training. 2.Healthcare teachers with reasonable training can adopt simulation training methodologies rapidly. 3.The “value” of using simulation justifies the capital, operating and indirect costs associated with it.

Objectives: “Practical Simulation Methods in HealthCare Education” Practical Simulation Defined Why “Practical Simulation” is critical to your success The operational concept to achieve it Practical Simulation Demonstrations across range of “Simulation types” – Task training: NG tube objective assessment (interactive demo) – Task Training: Orthopedic Surgery (video demo) – Student run multi-simulator, single instructor interactive demo – Individual assessment----Nursing student med administration (video demo) – Individual assessment----Pediatric Resident NRP Individual assessment (video demo) – Team Training: Team Leader Focus: Pediatric ER emergencies (video demo) Interdisciplinary Focus: SIRE (video demo) Specialty Team Focus: Neonatal LBW Team (video demo) – Research using Simulation Summary

MUSC Healthcare Simulation Center 11,000 sq ft training space, 15 available training rms. Stake holders: All Colleges & Medical Center Opened June 2008 Activities : – 70 course – 9,000 student encounters – 6,000 full scale simulations – 2,000 task trainer simulations – 70 faculty involved in simulation Focus will be on simulation methodology critical to achieving success!

Simulation Center Capital Costs Example: Large Center: Size: 11,000 sq ft facility Capital Costs: Renovation ~ $1,566,353 Simulation equip.~ $810,000 AV equipment ~ $300,638 Computers ~ $206,500 Other~ $25,000 Total: ~ $2,908,491 Average capital cost / sq. ft ~ $250

Simulation Center Costs/yr. Examples: Large Center: Staff: 30% Med. Director, 2 Admin., 2 Sim., Spec., 1 IT Operational Costs: Salaries ~ $303,027 Rent~ $208,847 Other~ $61,250 subtotal: ~ $573,124 Recapitalization Costs:~$117,250 Total Costs per year:~$690,374

Typical busy week’s schedule Focus will be on simulation methodology critical to achieving success!

Advocacy vs. Value based funding: Advocacy based funding: “The concept seems valuable-- so I’ll pay” Generates “enthusiasm” but is harder to translate into $ Difficult to sustain “Fickle/Vulnerable” to change Value based funding: “The results of training— are valuable--- so I’ll pay” “The training cost $ you save us is worth what we pay you--- so I’ll pay” “The malpractice cost $ you save us is worth what we pay you--- so I’ll pay” Focus will be on simulation methodology critical to achieving value!

Value Model (which is the basis of what a stakeholder is paying for): Value from the viewpoint of those funding medical simulation commonly falls into at least four forms: 1.Utilization:  # students trained  # courses delivered  # faculty involved 2.Measured Educational Value:  Subjective evaluations  Objective evaluations  Peer reviewed publications  Non-peer reviewed publications  Grant dollars generated 3.Financial Educational Value:  Indirect dollar savings (Malpractice Costs)  Direct dollar generation or savings (Save direct training dollars) 4.Public Relations Value:  Recruitment  Referrals to Health System  Fund Raisers  Others

Communicate Value (to Stakeholders)

Objectives: “Practical Simulation Methods in HealthCare Education” Practical Simulation Defined Why “Practical Simulation” is critical to your success The operational concept to achieve it Practical Simulation Demonstrations across range of “Simulation types” – Task training: NG tube objective assessment (interactive demo) – Task Training: Orthopedic Surgery (video demo) – Student run multi-simulator, single instructor interactive demo – Individual assessment----Nursing student med administration (video demo) – Individual assessment----Pediatric Resident NRP Individual assessment (video demo) – Team Training: Team Leader Focus: Pediatric ER emergencies (video demo) Interdisciplinary Focus: SIRE (video demo) Specialty Team Focus: Neonatal LBW Team (video demo) – Research using Simulation Summary

Complexity of operating simulator & Teaching Expert Instructor, Expert Simulator Operator High Costs per student Competent Facilitator (runs own simulator) Lower cost per student Student self training or 1 facilitator with multiple sim. activities Low cost Utilization of Simulation-based Education Methods Range of HealthCare Simulation Operational Use: Most Users are here--- This is what we have been doing since We do some of this now too--

Simulator predominantly in manual mode or scenario (3G) is modified on the fly Limited “Objective” educational outcomes Utilization is severely limited by limited # of “Expert” Instructors and “Expert” simulator operators Simulator only running a scenario with a specific set of objectives with grading and feedback Extensive “Objective” educational outcomes Utilization is significantly increased because competent Facilitator training threshold is lowered Expert Curriculum/Scenario, Competent Facilitator Model Practical Simulation Expert Instructor Small grp. exercises Expert Sim. Operator Current “Expert” Instructor/Sim Operator approach Competent Facilitator

And in some cases Competent Supervisor Student independent learning Simulator only running a scenario with a specific set of objectives with grading and feedback and operated by trainees Extensive “Objective” educational outcomes Utilization is maximized because complexity of operation threshold is lowered to the point that trainees can learn to run a scenario in minutes. Note: until this level is achieved, using simulation requires more “Instructors” than traditional educational methods though many believe simulation decreases the need.

What does not work well-- Manually adjusting the simulator “on the fly” to create a case that tracks with training objectives can only be done by a highly trained operator (even with a script). Simultaneous paper and pencil or electronic evaluation with some type of evaluation form while you are also running a simulator (this requires concentration) is generally impractical. “Non-structured Debriefing”. While some people have been formally trained as educators, most Healthcare providers that teach are not.

With “manual” operation of the simulator, you have to teach a teacher to competently run this GUI with enough expertise to create “Human Reactions” in real time while watching the trainees:

What does work pretty well-- 1.Pre-course participant preparation through studying online curricula based on “adult learning” principles. 2.With just about any simulation training exercise, the facilitator has immediately available well designed curricula to support standardization (usually web-based) with less time in training of the trainer. 3.The simulation exercise uses a well designed, pre-programmed simulation scenario run by the facilitator (teacher). This scenario incorporates semi- automated evaluation of key educational objectives embedded in the scenario that are automatically flagged for focused feedback specific to the individual or group’s performance and additionally supports standardization of the whole evaluation/feedback process. 4.The facilitator then uses this debriefing file as a preliminary educational diagnosis that when coupled with a standardized “reflection” process leads to a focused, standardized (yet individually specific) learning encounter with the student.

With a well programmed scenario, a teacher (or student) only has to accurately run this- Bag-Mask competency skill scenario LMA skill competency scenario BP assessment practice skill scenario Nursing Critical Care Assessment Training scenario Anesthesia Difficult Airway Management Competency scenario Nursing Med Surg Training scenario Trauma Assessment Demo scenario

With a well programmed scenario, physiology, pathophysiology, pharmacodynamics, seizures, airway obstruction, etc. are pre-programmed With selection of “Standard induction of general anesthesia”, apnea, airway obstruction, hypoxic physiology automatically occur

Multimedia can be embedded in a programmed scenario to: Present simulation “case stem”

Multimedia can be embedded in a programmed scenario to: Diagnostic information: labs, EKGs, X-rays, videos— ECHO, ultrasounds Choosing a menu item here returns a set of Physician orders on the monitor

Multimedia can be embedded in a programmed scenario to: Clinical signs & symptoms (as a picture, sound, movie or document that is presented on the monitor) that the actual simulator can’t otherwise emulate.

Multimedia can be embedded in a programmed scenario to: Standardized debriefing cues during the simulation that automatically appear on the monitor.

Multimedia can be embedded in a programmed scenario to: Scenario support info.: i.e. equipment list, equipment layout & QA, instructions, etc.

Nursing Aspiration Prevention & Rx ”Semi-Automated, Standardized Guide for “Diagnostic Educational Objectives based Reflection”

Well designed/programmed scenarios that are simple to run coupled with “Semi-Automated Objective Driven Reflection Process” ⁺ ₌

Objectives: “Practical Simulation Methods in HealthCare Education” Practical Simulation Defined Why “Practical Simulation” is critical to your success The operational concept to achieve it Practical Simulation Demonstrations across range of “Simulation types” – Task training: NG tube objective assessment (interactive demo) – Task Training: Orthopedic Surgery (video demo) – Student run multi-simulator, single instructor interactive demo – Individual assessment----Nursing student med administration (video demo) – Individual assessment----Pediatric Resident NRP Individual assessment (video demo) – Team Training: Team Leader Focus: Pediatric ER emergencies (video demo) Interdisciplinary Focus: SIRE (video demo) Specialty Team Focus: Neonatal LBW Team (video demo) – Research using Simulation Summary

Task training: NG tube objective assessment (interactive demo)

Good “Theater” does not equal “Learning”! =

Task training: NG tube objective assessment (interactive demo)

Key Points to observe: – Using SimMan or SimBaby or VitalSim Advanced software with a “dumb” task trainer to enhance simulation – Specific educational objectives driven – Simplified menus – Use of multimedia to support standardization – Debriefing log documents performance of specific educational objectives – Performance is automatically scored!

Lets do it--- Need a volunteer to run scenario (familiar with a nasogastric tube) Minimal experience with SimMan NOTE: I will be the

Vital Signs Training Competent Supervisor Student independent learning

Vital Signs Training ALS (Vital Sim Advanced) & SimMan Simulators 1 student runs simulator, 1 student measures RR, 1 student measures HR, 1 student measures BP then switch & practice again, & again---etc. Call facilitator for help as needed, when confident take summative version.

Student run multi-simulator, single instructor interactive demo Competent Supervisor Student independent learning Simulator only running a scenario with a specific set of objectives with grading and feedback and operated by trainees Extensive “Objective” educational outcomes Utilization is maximized because complexity of operation threshold is lowered to the point that trainees can learn to run a scenario in minutes. Note: until this level is achieved, using simulation requires more “Instructors” than traditional educational methods though many believe simulation decreases the need.

Student run multi-simulator, single instructor interactive demo Key Points – Specific educational objectives driven – Simplified menus – Use of multimedia to support standardization – Performance is automatically scored and shows on monitor! – Debriefing log documents performance of specific educational objectives

Lets do it--- Need 8 volunteers to run scenario (familiar with measuring HR, BP, RR) Minimal experience with SimMan

Practical Model used in following examples: Expert Curriculum/Scenario, Competent Facilitator Model Simulator only running a scenario with a specific set of objectives with grading and feedback Extensive “Objective” educational outcomes Utilization is significantly increased because competent Facilitator training threshold is lowered Competent Facilitator

Team Leader Focus: Pediatric ER emergencies (video demo)

Individual assessment----Nursing student med administration (video demo)

Interdisciplinary Focus: SIRE (video demo)

Research using Simulation

Individual assessment----Pediatric Resident NRP Individual assessment (video demo)

Specialty Team Focus: Neonatal LBW Team (video demo)

Task Training: Orthopedic Surgery (video demo)

Objectives: “Practical Simulation Methods in HealthCare Education” Practical Simulation Defined Why “Practical Simulation” is critical to your success The operational concept to achieve it Practical Simulation Demonstrations across range of “Simulation types” – Task training: NG tube objective assessment (interactive demo) – Task Training: Orthopedic Surgery (video demo) – Student run multi-simulator, single instructor interactive demo – Individual assessment----Nursing student med administration (video demo) – Individual assessment----Pediatric Resident NRP Individual assessment (video demo) – Team Training: Team Leader Focus: Pediatric ER emergencies (video demo) Interdisciplinary Focus: SIRE (video demo) Specialty Team Focus: Neonatal LBW Team (video demo) – Research using Simulation Summary

Complexity of operating simulator & Teaching Expert Instructor, Expert Simulator Operator High Costs per student Competent Facilitator (runs own simulator) Lower cost per student Student self training or 1 facilitator with multiple sim. activities Low cost Utilization of Simulation-based Education Methods Range of HealthCare Simulation Operational Use: Focus on the methods to work in towards this quadrant

Specific Focus Areas: Focus on complex scenarios that run simply Take advantage of multimedia fx. to support simplification & standardization Whatever grading paradigm you prefer, maximize the opportunity for simplification & value through automation Focus on designing intuitive menus It’s all about removing barriers & creating value statements at the individual & stakeholder level

Hope this was inspiring---