The Integrated Simulation Center: Lessons Learned Tony Errichetti, Patty Myers, Tom Scandalis American Association of Colleges of Osteopathic Medicine 4 th Annual Meeting – “Challenges and Opportunities” Baltimore, MD - June 24, 2006

2 Objectives Describe the state-of-the-art simulation center Discuss curricular, political and logistical issues in setting up a simulation center What are the key issues, decisions? Review major simulations technologies, and their integration

3 Simulation = reality substitution

4 Increased use of simulations because…. Shrinking patient base, shorter stays Shrinking patient base, shorter stays COMLEX-PE, USMLE-CS COMLEX-PE, USMLE-CS DO School Sim Center Program Surveys DO School Sim Center Program Surveys  SP Programs: 62% - No robotic sim programs (JAOA) - No robotic sim programs (JAOA)  SP programs: 82%, 8% under development - Robotic sim programs: 57% - Robotic sim programs: 57% (submitted to JAOA) (submitted to JAOA)

5 Increased use of simulations because…. Simulation industry (SPs, patient simulators, virtual reality) Simulation industry (SPs, patient simulators, virtual reality) High medical error rates, lawsuits and public demands for higher quality - High medical error rates, lawsuits and public demands for higher quality - Patient safety! Patient safety!

6 Classroom Work How do simulations “work”?

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9 Practice / repetition in a patient- and trainee- safe environment (sim center) “Confidence builds competence” Arousal, increase of productive anxiety, “nightmare” scenarios Feedback / debriefing – the essential element

10 Simulations …. …solve training logistical problems …solve training logistical problems “We prescribe illnesses” “We prescribe illnesses” …provide control of the clinical training and skills assessment …provide control of the clinical training and skills assessment …do not harm or leave patients untreated as a bi-product of medical education …do not harm or leave patients untreated as a bi-product of medical education

Simulation Center Elements Simulation Technologies Simulation Connectivity System

Simulation Technologies Simulation Triad

Simulated and standardized patients: What’s the difference? Simulated Standardized More realistic More standardized Less standardized Less realistic Training Assessment

14 Early Mechanical Simulator

s “Venus Médica” La Specola Collection, Firenze

s “Venus Médica” La Specola Collection, Firenze

17 Gross Anatomy Animal Models e.g Suturing Practice

18 Part-task / Part body trainers  Basic concepts  Psychomotor skills training

19 Patient simulators (manikins)  Teamwork, procedures e.g. codes, ACLS Procedure simulators  Psychomotor skills, e.g. laproscopic surgery

Virtual Reality and Computer-Based Programs  PC/Mac – Patient “in the computer” (DxR)  Haptic – Feel and touch  Full immersion – Haptic plus virtual environment

Full-Immersion Virtual Reality Diana – University of Florida

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23 Easy storage Users (trainees, faculty) retrieve videos through the web SP / Sim training / quality assurance Debriefing / precepting / feedback – locally and remotely Digital AV

24 Paperless PC / PDA data collection - ROI: saves time and human resources Data analysis / scoring / score reporting Evaluation of trainees, faculty Longitudinal studies of competency acquisition Data Collection

25 Managing schedules (e.g. students, SPs) - ROI: saves time and human resources Exam management Automated announcements Automated DV camera movements Program Management

Planning / Financial Issues

27 Training areas (rooms) Permanent Mobile Simulators, equipment (stuff) Faculty Staff (people) Curriculum SPs, trainers,techs, coordinators $ im Center Element $

28 # 1 Problem Building first, then planning

29 Problems Budgeting and purchasing out of synch with planning and operations. Users aren’t consulted in design process.

30 Lesson Learned Planning = Really good planning =

31 # 2 Problem Buying more manikin than what’s needed, and / or not budgeting for other simulation equipment

32 Lesson Learned Manikin just one of hundreds of pieces of equipment needed Develop a program first (planning again) before committing to a manikin

33 Lesson Learned Sim Centers are expensive! “We’re in a medical education arms race!” - Ken Veit, D.O. - PCOM  Collaborate when possible  Establish regional sim centers  Sell your services

34 # 3 Problem Decentralized management of simulation services

Administrative Problem Family Medicine Surgery / ED MIS

36 Lesson Learned Centralized management of all sim services, under a dean (vs. e.g. family medicine), to maximize efficiency, and program integration

37 Lesson Learned Program director = an expert in performance test development (usually a Ph.D.) who can work with and develop clinical faculty to:  create formative and summative assessment  set pass-fail standards  design research Have a consultation line in your budget to bring in experts

How Simulations Are Changing Clinical Learning

39 From Learning Silos…

40 To integrated curriculum Basic Sciences / Clinical Knowledge / Skills Because the work requires integration of knowledge, skills, attitudes

41 …and integrated health care delivery DOCTORS NURSES, PAs PTs …because healthcare requires team work

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43 “Cardiology” Scenario Students encounter a cardiology complaint (manikin) and discuss physiology / pharmacology issues with a science teacher

44 “Gross anatomy - SP” Scenario Students in gross anatomy dissect the abdomen and then watch a video, in the lab, of a patient (SP) presenting with abdominal complaints.

45 “Suturing” Scenario Students practice suturing (p/task trainer) attached to a “conscious patient” (SP)

46 “Conscious - Comatose” Scenario Students encounter a hospital patient (SP), then that same patient in a comatose state (manikin)

47 “Pre-Encounter” Scenario Students prepare for a sim encounter by meeting a web-patient (PC-VR), then meet the “actual patient” (manikin) in an ED setting, and / or live patient (SP)

48 “Patient Management” Scenario Students encounter a patient (SP), then that same patient in a acute state (manikin), then manage the patient’s treatment post-discharge (PC-VR)

49 “Simulator-Audience Response” Program Students encounter a patient in an acute state (manikin), and through a live DV feed, an audience participates via an audience response system

50 “Death and dying” Scenario Students encounter “dying patient” (manikin), then counsel “grieving family member” (SP)

51 Death and Dying Scenatio: Objectives Combine clinical training and behavioral medicine Verisimilitude: Using the manikin to get students (MS1) into the “death and dying” scenario, to practice couseling Integrate PA, DO and psychology faculty

52 Steps Developed manikin case Developed 5 SP cases, i.e. 5 SPs representing 5 different grief reactions Trained SPs Ran the program Debriefed the students

53 Videos

Summary: State-of-the-Art Sim Center Integrates the Simulation Triad Integrates knowledge and skills Simulation connectivity system that integrates everything together Plan before you build - Consult the users! Faculty development – the hardest job

For Information Tony Errichetti, Ph.D. Chief of Virtual Medicine Director, Institute For Clinical Competence