Advancements in Medical Training
Written by Dr. Haru Okuda and Dr. Lygia Arcaro
MMT 2011 Volume: 15 Issue: 8 (December)
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The military is no stranger to skill acquisition when preparing their warfighters and other personnel. Training exercises customized towards potential real-world threats are a familiar way in which the men and women of the armed forces obtain mastery in routine and hazardous tasks and missions. Thanks to the efforts of leading VA clinicians and technicians, health care is no longer different.
A 1999 report by the Institute of Medicine entitled “To Err is Human,” found that between 44,000 and 98,000 people die each year in the U.S. as a result of preventable medical errors. Simulation is a credible teaching tool for both military and civilian populations to practice their skills in a safe, immersive environment in order to be mission ready and save lives. Just as the military uses simulations to train troops the way they would fight in hostile territory, VA uses simulation techniques to train clinicians the way they would practice in the clinical arena.
Where did health care simulation get its start? In the 1980s, a young man named David Gaba completed medical school and, through his interest in the space program, became aware of how pilots and soldiers trained. Dr. David Gaba is now director, Patient Simulation Center of Innovation at the VA Palo Alto Healthcare System and associate dean for Immersive and Simulation-based Learning at Stanford University. He is considered one of the founders of health care simulation and defines simulation as a “technique—not a technology—to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner.”
Extent of Training:
How In-Depth Does it Go?
Typically, simulation is divided into four categories based on different modalities: standardized patients, screen-based simulation, partial-task simulation and high-fidelity mannequin simulation.
Standardized patients have been traditionally used in the medical and nursing school environment to teach history-taking, assessment and physical exam skills using trained actors. Some standardized patients are also trained as “gynecological teaching associates” and are skilled in the art of providing feedback to the student examiner while undergoing a physical examination.
Screen-based simulation ranges from online virtual patients that allow for the learner to read case histories and select from a variety of possible clinical responses, to avatar- based virtual worlds that enable providers to work as teams in a real-time web-based environment.
Partial task simulation is often divided into two subcategories depending on the technology of the equipment. Task trainers are used in many instances, which are anatomical body part mannequins used for student practice. Simple task trainers enable learners to practice skills such as the placement of an intravenous line or chest tube. More complex task trainers simulate highrisk procedures, such as colonoscopy or laparoscopic surgery, using haptic technology that gives the learner a sense of physical resistance and touch feedback similar to what they will experience when performing the procedure in a real patient.
High-fidelity mannequin simulation, sometimes called “simulation theater,” reproduces a real clinical environment such as an operating room using lifelike mannequins that are capable of breathing, sweating, seizing, blinking, speaking, and reproducing heart and lung sounds.
Recently, the field of simulation has begun focusing research on where these modalities can best be applied in the health care setting. One area is in the application of simulation for education. Schools are using simulation labs to provide opportunities for health-professions students to become familiar with procedures, evoke critical thinking skills, and work with colleagues as a team when interacting with patients.
Surgical programs are requiring the use of simulation to teach laparoscopic skills prior to having the resident perform on a patient. Other programs, such as anesthesiology, are using simulation to train residents to use anesthesia machines and troubleshoot equipment. Emergency medicine and internal medicine programs are teaching skills like lumbar puncture on task trainers, and code team management on mannequins. The days of “see one, do one, teach one” are increasingly falling out of favor.
The field of patient safety and quality improvement is researching ways of using simulation to improve patient care. In obstetrics, simulation is used to allow teams of clinical providers to practice managing high-risk, low-frequency events such as post-partum hemorrhage and shoulder dystocia. Studies have demonstrated a significant reduction in neonatal injury after simulation team training. Other hospital systems are training their physicians and nurses in the placement and management of central lines and demonstrating a reduction in central line associated bloodstream infections.
This past year, at their annual meeting, the National Patient Safety Foundation dedicated a plenary session on simulation to showcase how it can be used to disclose errors.
Apart from provider training, simulation is being used to test units and workflow within medical facilities. Testing entire systems in a health care organization can lead to the identification of latent safety threats. Prior to the opening of a new hospital or clinic, simulation experts can provide common scenarios to the staff of a certain ward or floor. For example, simulating a transfer from a patient room to other clinical environments, such as radiology, may reinforce a smooth process or expose hazards that need mitigation. A simulation test performed by the armed forces global emerging infections surveillance and response system (GEIS) in a new satellite hospital found 37 latent safety threats involving equipment, personnel and resources. Because GEIS used simulation to test the new facility prior to opening, they were able to address most of these potential threats prior to the arrival of patients.
A popular attraction and well-known simulation event called “SimWars” has been featured at meetings like the International Meeting on Simulation in Healthcare, and American College for Emergency Physicians. These team competitions use both low- and high-fidelity mannequins in patient scenarios where competitors must work through the clinical problem in a fixed amount of time. Each team is evaluated against predetermined criteria that encompass the entire simulation process. There are “SimWars” played by accomplished health care professionals and students alike (www.vimeo.com/11084119), and scenarios may have components of team training and communication principles.
The applications described above are only a few ways simulation is being used in health care. Studies are increasingly demonstrating the effectiveness of simulation.
What is the Future of Simulation in Health Care?
As technology continues to advance, simulation will continue to provide an opportunity for the health care provider to practice procedures and become familiar with the equipment. Answers to questions about the functioning of the equipment, techniques or approaches to common and not-so-common surgical procedures, and the ability to fill in knowledge gaps if an error is made can be accomplished through the use of simulation well in advance of encountering a live patient.
Boards controlling re-licensure of health care professionals are talking about using simulation in their decisions to define what procedures will need to be demonstrated prior to renewal. Percentages of time students can use simulated patient care activities in lieu of actual demonstrated live practice is being mandated by some licensing bodies. Standards and guidelines will continue to emerge from simulation associations.
A compendium of broad categories of simulation modalities can be found on the Department of Veterans Affairs SimLEARN Internet website, www.simlearn.va.gov/lib.asp. SimLEARN, an acronym for the Simulation Learning Education and Research Network, is a national program under the Veterans Health Administration for advancing clinical simulation training, education and research across VHA. The program is a collaborative effort of the Employee Education System, Office of Patient Care Services and Office of Nursing Services program offices. For more information, go to www.simlearn.va.gov. ♦
Dr. Haru Okuda is SimLEARN National Medical Director, Department of Veterans Affairs, and Dr. Lygia Arcaro is SimLEARN National Director, Nursing Programs, Department of Veterans Affairs.