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SIMULATION CENTERS
Medical Simulation Center Fundamentals TRAINING DEVICE DESIGN
Haptics in Medical Simulation LEARNING TECHNOLOGY
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Issue 4/2012
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Editorial Comment
in medical education provides the ability to practice, practice, and practice in a safe environment..."
On the cover: HumanSim is a software simulation platform developed to provide medical education for individual and team training. Image credit: Applied Research Associates, Inc.
training. The findings were published in The Annals of Surgery and compared University of Toronto surgical residents who completed a five month simulation training module to residents who received conventional surgical training. Their research proves that surgeons who train using simulation technology perform significantly better in the operating room than those who train using conventional methods. Now, as Medical Director of St Michael’s Patient Simulation Centre, he takes a leading role in training the next generation of surgeons. Similar advancements are taking place in medical simulation centers throughout the world. These centers are training nurses, doctors, pharmacists and other healthcare professionals to equip them with the skills necessary to assure competency in their chosen fields. In a study by Yasuharu Okuda, M.D. and others in 2009 a MEDLINE search of original articles and review articles related to simulation in education with key words such as simulation, mannequin simulator, partial task simulator, graduate medical education, undergraduate medical education and continuing medical education found 113 articles which they included in their review. The articles demonstrated that simulation training lead to improved medical knowledge, comfort in procedures and improvements in performance during retesting and simulated scenarios. As stated by Dr. Okuda, simulation, in all its incarnations, is a tremendous tool for healthcare educators that allows students to achieve goals without patients being put at risk. Simulation has also been shown to be a reliable tool for assessing learners and for teaching topics such as teamwork and communication. Dimitrios Stefanidis, M.D, Carolina Medical Center, in his article that appeared in MEdSim 1/2012, discussed the application of motor learning theory to simulator learning, important curricular elements for skill acquisition, and methods of simulator performance assessment that maximize learning and clinical skill transfer. Using simulation in medical education provides the ability to practice, practice, and practice in a safe environment, alters the degree of difficulty in the scenario, provides instant feedback and allows individuals to achieve competency as individuals or team members and provides tangible measurable outcomes. Judith Riess Editor in Chief MEdSim Magazine judith@halldale.com
03 MEdSim Magazine
" ...simulation
In this first year of MEdSim we have highlighted changes in medical school curriculum; discussed best practices in hospitals to reduce cost and reduce infections; highlighted association goals gleaned from conferences and articles for transforming healthcare; discussed how to measure competency and the use of simulation as an evaluation as well as teaching tool for all healthcare professionals; shared ideas for measuring effective training through the use of simulation and the rapid growth of simulation centers across the world and how to get return on investment for these centers. We have interviewed key healthcare professionals to understand the rapidly changing face of medicine and to discuss state of the art practices in their fields. Our goal is to highlight best practices in medical education and training through the use of simulation and other tools to reduce cost and improve patient safety. From our attendance at recent meetings we have learned that some doctors are taking bold steps to ensure that medical professionals are equipped to meet the future demands of a burgeoning population while having contact hours of training reduced. Richard Reznick, M.D., the dean of Queen’s Faculty of Health Sciences, is recognized for his commitment to surgical education, simulation, research and academia. Dr. Reznick’s research has focused on performancebased assessment, technical skill acquisition and simulation, all with the aim of improving practice. His work in surgical assessment and simulation also led to the creation of a unique competency-based curriculum to train surgeons. Dr. Reznick is a fellow of both the Royal College of Physicians and Surgeons of Canada and the American College of Surgeons. A checklist to reduce surgical complications, he participated in developing is now being used around the world. At the Minimally Invasive Surgical week in Boston during his presentation he announced that in January he will be accepting highly qualified high school students in his medical education program. This has been a long accepted practice in much of the world, but not in the US or Canada. Another physician, practicing in Canada, Dr. Teodor Grantcharov, an associate professor of medicine at the University of Toronto and a surgeon specializing in minimally invasive surgery, is improving surgical outcomes through education. He and Vanessa Palter, a surgical resident and Ph.D., candidate recently published a study showing that surgical residents who train first in a simulation lab significantly outperform colleagues who receive only standard surgical
ISSUE 4.2012
Editor's Comment
CONTENTS
MEdSim Magazine The Journal for Healthcare Education, Simulation and Training 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
Halldale Media Group Publisher & Andy Smith CEO e. andy@halldale.com
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Editorial Comment Editor in Chief Judith Riess reflects on MEdSim’s first year of publication and ‘best practices’ in education, training and curriculum development from articles.
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SIMULATION CENTERS Medical Simulation Center Fundamentals. Group Editor Marty Kauchak provides the first in a series of articles on medical simulation centers.
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SIMULATION CENTERS HealthCare Simulation of South Carolina: A Functional Statewide Collaborative. John J. Schaefer, III, M.D., the Director of Medical University of South Carolina (MUSC) Simulation, describes the members’ successes in increasing simulation usage in that state.
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TRAINING PROGRAM Improving Patient Safety and Reducing Hospital Costs: The University of Washington Central Venous Catheter Project. Edgar J. Figueredo M.D., Mika N. Sinanan M.D., Ph.D., Vanessa Makarewicz RN, MN, Sara Kim, Ph.D., and Andrew S. Wright M.D. describe their program to change the culture and practice of care in Central Venous Catheter procedures through simulation.
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TRAINING DEVICE DESIGN Haptics in Medical Simulation – Some Best Use Cases. Adrian Hendrickse, B.M., FRCA and Karl Reinig, Ph.D., provide a compelling case for the inclusion of haptic functioning in medical training devices.
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Simulation Intricate, Innovative and Inexpensive... DIY Surgical Simulators. Staff writer Lori Ponoroff describes the healthcare learning community’s efforts to integrate do-it-yourself simulators in its programs.
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LEARNING TECHNOLOGY Gaming Technology Holds Promise of Advancing Medical Education. Chuck Weirauch examines the role of serious game development for health care sector learning programs.
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Medical Curricula Medical Student Skills Simulation in 2012. Robert Acton, M.D., FACS describes the plan by the American College of Surgeons and The Association for Surgical Education to release a joint curriculum for teaching medical students patient skills.
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PATIENT SAFETY Do Bar Code Administration Systems Improve Patient Safety? A Nurse’s Perspective. B.F Ingelson, RN, MHA and T. Natalini-Whitmore, RN, MS, discuss the barriers to the adoption of the Bar Code Medical Administration and its receptivity among nurse staffs.
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News Medical News. Updates from the medical community. Compiled and edited by the Halldale editorial staff.
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All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise – especially translating into other languages – without prior written permission of the publisher. All rights also reserved for restitution in lectures, broadcasts, televisions, magnetic tape and methods of similar means. Each copy produced by a commercial enterprise serves a commercial purpose and is thus subject to remuneration. MEdSim Magazine, printed January 2012, is published 4 times per annum by Halldale Media, Inc., 115 Timberlachen Circle, Ste 2009, Lake Mary, FL 32746, USA at a subscription rate of $25 per year. MEdSim is distributed in the USA by SPP 75 Aberdeen Road, Emigsville PA 17318-0437. Periodicals postage paid at Emigsville PA. POSTMASTER: send address changes to: Halldale Media Inc., 115 Timberlachen Circle, Ste 2009, Lake Mary, FL 32746, USA.
ISSUE 4.2012
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05 MEdSim Magazine
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Simulation Centers
Medical Simulation Center Fundamentals In the first of a series of articles on medical simulation centers, Group Editor Marty Kauchak reports the quest for patient safety and other requirements are fueling the community’s demand for these facilities.
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imulation allows healthcare profession members to learn and enhance many skills for individual and team procedures before they step into the operating room. The rapidly evolving simulation market provides doctors, nurses and other healthcare professionals with cost-effective and high-fidelity part-task trainers to complement the array of more expensive, heritage full-task training devices prevalent throughout the community. At the same time, cutting edge Web-based instruction, virtual worlds and other forwardleaning technologies are being intro-
duced into the continuum of academic and professional learning. Hospitals, medical schools and other institutions in the private and public sectors allow their professionals to learn and rehearse an increasing list of procedures in the virtual domain – not on an actual patient – at medical simulation centers. These venues typically have classrooms, virtual operating rooms, after-action review (debrief) stations and other facilities to allow learners to use technologies throughout their continuum of instruction. In an accompanying feature article in this issue, John Schaefer, M.D., further
explores the realm of possibility with networked simulation, discussing HealthCare Simulation of South Carolina. In a series of building block-type articles, MEdSim will highlight the latest developments in medical simulation centers. This initial story looks at how the burgeoning, underlying demands for simulation are fueling the requirements for these facilities to serve as brick-andmortar venues for learning. In follow on articles we’ll look at returns on investment (ROI) and the business case for these facilities, the technologies that populate the centers and other topics.
The Primacy of Patient Safety Simulation centers and their enabling technologies are an important investment for any size host institution. Three data points on the cost of these facilities may be gleaned from facility openings through this summer. This July, CHRISTUS St. Michael Health System unveiled its new 5,200 square-foot, $1.2 million Simulation Center in Texarkana, Texas. Earlier in June, the University of Texas in San Antonio opened a new $3.9 million Simulation Center and Clinical Learning Lab for its School of Nursing, and in Australia a $1.3 million mobile simulation center is expected to revolutionize the way clinical training is delivered in regional and remote areas of New South Wales. Even in an era of increasing medical costs and competition for resources, medical sector decision makers are investing in simulation centers – and with compelling reasons. In medical simulation, the training imitates reality, offers almost limitless opportunities to have things “go wrong”, allows practitioners to safely demonstrate how to “do things right”, and
ISSUE 4.2012
The Clinical Simulation Laboratory (CSL), jointly supported by the University of Vermont Colleges of Medicine, and Nursing and Health Sciences, and Fletcher Allen Health Care. Image credit: Raj Chawla/UVM Medical Photography.
The healthcare profession, in relation to the military, civil aviation and other highrisk communities, is belatedly embracing simulation. The other sectors have used part-task trainers, full mission simulators and other devices for decades to help its members learn and enhance their ability to operate aircraft, vehicles and ships, and perform other skills – prior to conducting the task. In a positive development, simulation is becoming a foundation of healthcare providers’ culture of learning. The majority of this activity is occurring at simulation centers. These facilities are built and equipped to allow individuals and teams to be immersed in increasingly rigorous training scenarios – without using live patients. These venues are being built at a quickening pace. During a one week period this September, MEdSim’s sister editorial resource www.halldale.com reported the opening of two centers and the donation of $7.1 million to open another facility in 2013. The surging interest in medical simulation centers is a global phenomenon. Indeed, the embryonic Sidra Medical and Research Center’s Clinical Simulation Center in Qatar, promises to be one of the leading facilities in the world [Medical Simulation Centers Transforming International Healthcare Landscape MEdSim issue 2.2012]. Two center leaders described their state-of-the-art facilities. Cate Nicholas, Ed.D., MS, PA, the Director of Simulation Education and Director of the Standardized Patient Program at the Clinical Simulation Laboratory, University of Vermont/Fletcher Allen Health Care, told MEdSim, that her simulation laboratory is built on a distributed model with more than one physical location. Part of the laboratory’s infrastructure includes a virtual hospital. “This has six inpatient rooms, one with an attached bathroom; a multipurpose room which can be transformed into an OR/ER/MICU [medical intensive care unit]/ PICU [pediatric intensive care unit] or SICU [surgical intensive care unit] based on the needs of the faculty; two debrief rooms – one small and one large which accommodates up to 35 people; a task-trainer room which holds 16 people or more; and a virtual reality room which has a num-
ber of devices – a simulator for robotic training, a colonoscopy/ endoscopy machine and arthroscopic machine.” Another attention getter is the diverse learning audiences served by this center, providing another indication of the interest by the private and public healthcare sectors in the technology. Nicholas, who is also a physician’s assistant, pointed out the Clinical Simulation Laboratory (CSL) is jointly supported by the University of Vermont Colleges of Medicine, and Nursing and Health Sciences, and Fletcher Allen Health Care, and serves multiple learning audiences. A partial list of the more than 20,000 healthcare professionals who will annually use the laboratory includes aspiring doctors, nurses and allied healthcare professionals at UVM colleges; faculty staff at the university; and staff doctors, nurses and other community professionals, as the EMT programs. The CSL also provides educational support for the Vermont Air and Army National Guard. The Burlington, Vermont-based simulation community leader noted her learners’ particular interest in part-task trainers is to develop specific clinical skills. “These devices are getting an incredible amount of use across the continuum of medical school training and across the health care continuum – they are being used quite extensively. Also of note, the Clinical Simulation Laboratory’s has a video capture system that supports the recording, replaying and debriefing of simulation scenarios. One of the community’s newest simulation centers is the Simulation Lab at Kishwaukee (Illinois) Community Hospital, part of KishHealth System. The lab is outfitted with a computer control room and a mock patient room that houses iStan, a wireless simulated patient equipped with fully operational functions including bleeding, tears, and other fluids “iStan also has realistic physiology and responses including EKG rhythms,” DurRay Sanchez-Torres RN, BSN, the Clinical Development Coordinator of the Simulation Lab, pointed out. Healthcare providers are able to run scenarios, making decisions in real time, communicating with and treating iStan as an actual patient. Medications are given through IVs, oxygen is delivered through the nose and mouth, and catheters are inserted, creating a training environment like no other, as iStan speaks and reacts as a human being would to whatever stimulus is presented,” Sanchez-Torres added.
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Understanding Simulation Centers
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provides corrective feedback as a guide to future action, Connie Lopez, MSN, CNS, RNC-OB, CPHRM, the National Leader for Simulation-based Education & Training in the National Risk Management and Patient Safety section at Kaiser Permanente, observed. She added, “Simulation-based education provides an opportunity to practice a variety of clinical situations where error is more likely to occur. At Kaiser Permanente, medical simulation-based training effectively targets commonly elusive educational objectives: practice without risk, curricular standardization, and pedagogic efficiency.” The Kaiser Permanente investment strategy in simulation at all eight of its regions also helps illustrate the surging interest in simulation across healthcare specialties. Simulation-based programs at Kaiser Permanente are now offered in: labor and delivery, anesthesia, operating rooms, neonatal/ pediatric intensive care units, medical/surgical units, general and interventional radiology, adult and pediatric procedural sedation, ambulatory surgery and procedural centers, clinics and emergency departments. “These programs are constantly evolving and we are looking at other high-risk areas where simulation can be utilized,” Lopez pointed out. At the association level, the American College of Surgeons’ Division of Education has embraced simulation across the spectrum of education and training programs and has established an accreditation program for simulation centers. . Following up on Lopez’s theme, Ajit Sachdeva, M.D., FRCSC, FACS, the director of the ACS division, told MEdSim that patient safety was at the top of his list of requirements for using simulation. “There are things that we need to do to train people in simulated environments so they can perform in a much more effective way in real environments and provide safe care of the highest quality,” Sachdeva said. Sachdeva noted the ACS views simulation as a way to promote excellence and expertise in surgery. “That comes through the repeated, deliberate practice, which requires a fair amount of training in simulated environments. We can change the slope of the learning curve by doing this.” He emphasized learning tasks may be completed in a more concentrated manner through simulation while it takes considerable time to gain expertise in the real operating room environment, Additionally, Sachdeva said the achievement of cognitive, judgment and technical skills may be effectively assessed and documented against pre-established standards in a simulated environment. “We also can expose our learners to diseases and conditions that are unique and uncommon, so they are prepared for and can deal with the unexpected,” he remarked. The National Patient Safety Foundation (NPSF) views simulation through the prism of its very- focused mission: improving the safety of the healthcare system. To support the mission, the foundation has become a unique proponent of simulation – recognizing its value as an educational tool to assist healthcare professionals as they learn and apply patient safety techniques. The NPSF’s efforts in this sector have been led by Jeff Cooper, Ph.D., a long-time advocate of medical simulation and a community subject matter expert. “Jeff and our board have made us quite familiar with the value of simulation as
a learning tool and the place that it has in improving safety practices,” Diane Pinakiewicz, the foundation’s president, told MEdSim. At an early point in the foundation’s existence, it also believed that simulation had tremendous value as a safety enabler – allowing the health care professional to practice a procedure before performing the steps in real time. “The discipline of anesthesia was able to improve its safety profile through the use of simulation,” Pinakiewicz recalled. “What we realized was that simulation had broader application to safety across disciplines.” The Lucian Leape Institute, a think tank based at NPSF, also endorsed simulation in its report Unmet Needs: Teaching Physicians to Provide Safe Patient Care. Pinakiewicz pointed out that the report framed simulation as a “critical component of medical school training.” The NPSF’s president also noted that the healthcare community’s awareness and understanding of the value of simulation to support individual and team training has been shaped, in part, by the experience of aviation and other highrisk industries that have used simulation for decades. “Using simulation to practice new procedures while presenting no risk to patients is invaluable to improving patient safety. If you have the capability to learn in a scenario where you are safe and protected from potentially hurting someone, and are able to learn from trial and error without affecting a patient, that has value,” she said. And while some of the returns on investment or other outcomes of simulation use may be hard to quantify, using this technology to learn and rehearse, and learn experientially and not just didactically, result in more effective skills and teamwork to get the job done.
Team Building and Beyond Much like their counterparts in the military and civil aviation sectors, medical professionals can also build team skills in a simulated environment. Kaiser Permanente’s Lopez noted that her colleagues have used medical simulation to support our "teams of experts becoming an expert team." She continued, “Through the use of simulation in the medical training environment any health care provider or medical center team has the potential to improve and maintain collaborative teamwork and communications skills in
From top: Dr. Ajit Sachdeva, American College of Surgeons; Cate Nicholas, University of Vermont/Fletcher Allen Health Care; Connie Lopez, Kaiser Permanente. Image credit: American College of Surgeons; Raj Chawla/UVM Medical Photography; Kaiser Permanente.
One of the community's newest simulation centers is the Simulation Lab at Kishwaukee (Illinois) Community Hospital. Image credit: KishHealth System.
ISSUE 4.2012
sive care unit. At the most recent follow-up they had zero central line infections with insertion related to those learners coming in – and that’s in one year.” As part of the system review, the laboratory has also contributed to lower infection rates through collateral improvements in hand washing and other sterilization procedures, electronic health record documentation, and other actions. “I don’t think the simple task of having the learners come in and learn how to put a central line in a simulator made the difference. I think it’s because we got involved with a process review of how do we improve and lower central line infection rates from A- Z, and we took that system and replicated the process in the simulation lab,” Nicholas reflected. [Editor’s note: See related University of Washington central line study in this issue.] The simulation laboratory is helping improve two other internal processes; skin surveys to avoid bed ulcers in hospitalized patients and preventing patient falls. In what promises to be a watershed development in healthcare’s use of simulation, providers of malpractice insurance for healthcare professionals are reducing their rates for members who demonstrate levels of competency through simulation. While several insurance providers in this sector declined MEdSim’s invitation to provide on-the-record or on background insights on the impact of these technologies on their rates, the ACS’s Sachdeva corroborated anecdotal evidence we have received on the topic at conferences and other venues. “The insurance companies have been watching the advances in the field of simulation. They have realized that validated and effective methods for teaching and assessment can be very useful to ensure that individuals acquire and demonstrate specific levels of competence, proficiency and expertise. In some cases, they have started offering small reductions in insurance malpractice premiums, which is a very positive trend,” Sachdeva said. medsim
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addition to improving patient safety and clinical outcomes.” Indeed, MEdSim has noted the buzz at recent conferences – on the exhibition floor and in break-out sessions – about systems and strategies designed to replicate the successes of institutions such as Kaiser Permanente that build and enhance team performance through simulation. Sachdeva, too has noted this development, but added a hint of caution for his colleagues. “People sometimes get so focused on team training that they do not sufficiently address the needs of the individual. If the individual does not have the requisite skills, no amount of teamwork is going to cut it – people on the team can only compensate for so much. Our approach has been to focus on excellence at the individual level, excellence at the team level, and excellence at the systems level. All three domains must be addressed effectively through simulation.” At the end of the day, medical simulation centers are a business and must remain financially viable. Roger Smith, Ph.D,, examined this topic in greater depth in his MEdSim feature article Surgical Education, Research and Business Design, Issue 1.2012. At a more elementary level, CEOs and other “shareholders” of organizations that invest in simulation labs, look for ROIs from their expenditures. MEdSim readers gained insights into ROI in a groundbreaking article on the topic ROI: What is it and does it really matter? by Don Combs, Ph.D., Issue 2.2012. While ROI will be discussed in more detail in follow-on articles, the concept is included in this discussion because of its linkage to patient safety. The Clinical Simulation Laboratory is achieving an impressive ROI by improving processes, in addition to teaching and enhancing individual skills. In one instance, Fletcher Allen Health Care, the University of Vermont’s teaching hospital, is dramatically reducing the infection rate for central line insertion procedures. “We were invited into the discussion because we have central line insertion mannequins,” Nicholas said, and continued, “The key here was a total system review. Simulation had something to contribute – it was a piece of the pie. We were able to become part of a new, required training for first-year residents prior to them entering the medical inten-
Simulation Centers
HealthCare Simulation of South Carolina: A Functional Statewide Collaborative
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The partners of HealthCare Simulation of South Carolina have increased the annual rate of simulation usage 20-fold in that state, reports John J. Schaefer, III, M.D., in his first of a two part article on the collaborative.
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his is an invited two-part series about the simulation collaborative that has developed in South Carolina. In 2006 South Carolina’s three state universities established a collaborative and endowed chair to increase the utilization of simulation for the benefit of South Carolinian patients, students and healthcare workers. As of 2012, HealthCare Simulation of South Carolina has grown to include 10 collaborative and 20 affiliated partners. The ten collaborating partners in the past six years have provided over 80,000 student encounters involving over 200 faculty throughout the state and have developed over 300 active courses, conducted over 100,000 simulations to included over 60,000 center utilization hours. Through this collaborative the annual rate of simulation usage has increased twenty fold.
The first article will focus on the origin, development and infrastructure of the collaborative and its statewide office. Part two will focus on the specific educational and operational methodologies underlying the high volume, low cost simulation that has been a significant key to the success of the organization.
History In the late 1990s and at the urging of state business leaders, state delegations visited the campuses and leaders at The University of Texas at Austin and
Above Simulation Center map with partners. Image credit: HealthCare Simulation of South Carolina.
Communicate Value Establish Value Deliver Quality Courses
Create Functional Center
Strategic Planning
complex. John Schaefer, M.D., was recruited from the University of Pittsburgh, Peter M. Winter Institute for Education and Research (WISER) where he served as the founding director. The initial collaborative consisted of four sites including Medical University of South Carolina, Greenville Technical College and the Greenville Health System of which only the Greenville Technical College had an established simulation program.
Figure 1. Practical Simulation Pyramid of Success. Credit: HealthCare Simulation of South Carolina.
Collaboratives might originate for any number of reasons. In this case, the leadership at the various organizations interested in simulation realized that they lacked the internal expertise to build a successful simulation program and that there were “economy of scale” opportunities in accessing a central source of expertise in simulation. HealthCare Simulation of South Carolina (HCSSC), through the endowed chair program was established in 2006 at MUSC as two distinct divisions including the statewide collaborative office with its own staff and the MUSC HealthCare Simulation Center which is a 12,000 sq. ft. facility that serves MUSC. The center opened in 2008. Dr. Schaefer holds the Lewis Blackman Endowed Chair for Patient Simulation and Research and serves as the director for both divisions of HCSSC. It is through access to the products and services of the statewide office and by working with local thought leaders, to develop a successful simulation program to grow to serve their local missions using simulation. The statewide collaborative office includes a staff of twelve people with simulation based expertise in the areas of administration, operations, course and scenario development, information technology, center design and project management. Organizationally HCSSC is divided into two service lines: the Collaborative Partner Services service line and the Collaborative Course and Scenario Development service line. Products and services offered to collaborative partners are based on a proven set of applied educational, operational and financial concepts collectively known as “Practical Simulation” methods. Practical Simulation is defined as the simulation process used (design, infrastructure, operations etc.) that allows large numbers of students to experience individual and group simulation exercises and to allow large numbers of teachers (facilitators) to be able to practically operate and use the wide range of simulator tools
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Organization, Services and Products
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the North Carolina Research Triangle in order to see the enormous positive economic impact that results from building a state’s knowledge base. These two trips resulted in the passage of the Research Centers of Economic Excellence Act by the South Carolina General Assembly in 2002 and the creation of the SmartState Program. The SmartState Program creates the opportunity for our state’s three senior research institutions to recruit dozens of world-class scientists and engineers to the state and to work collaboratively in ways truly unprecedented. Rather than competing for resources, as is the national norm, South Carolina’s research institutions now work together to strengthen the state’s economy. Since 2003, $180 million has been appropriated from the State Education Lottery to establish unique Centers of Economic Excellence at the state’s three research institutions: Clemson, University of South Carolina (USC), and the Medical University of South Carolina (MUSC). The Review Board has awarded 49 Centers and 87 SmartState Endowed Chair positions. Each Center specializes in knowledge-based research fields such as engineering, nanotechnology, biomedicine, cancer research, and energy science. The SmartState Endowed Chairs secure private sector and federal grants to increase the state’s knowledge base and stimulate the economy. The SmartState Program is responsible for $1.2 billion in external investment in the state economy – a sixto-one return on the state’s investment of lottery proceeds (not tax dollars). The program also has resulted in the creation of nearly 7,000 jobs. The Clinical Effectiveness and Patient Safety Center of Excellence (CEPSC) was established in 2006 to promote and increase the use of simulation education and training in South Carolina as part of the Health Sciences of South Carolina Centers of Economic Excellence Endowed Chairs Program. Healthcare Simulation South Carolina (HCSSC) is one of three endowed chair programs within the CEPSC. This program and endowed chair was located at the Medical University of South Carolina and began operations in the spring of 2006. Its offices are located in the MUSC Harborview office
Simulation Centers
with limited technical training. Practical Simulation outlines the components to creating a value-based simulation center that includes quality standards for developing and delivering simulation activities, data collection and reporting. Each Practical Simulation component includes steps deliberately designed to economize and improve the efficiency and effectiveness of delivering simulation education.
HCSSC Collaborative Partner Development Roadmap
Marketing
The elements within the PS categories include: • Strategic Planning - Stakeholder education is required to support realistic planning decisions for simulation education use • Create a Functional Center - Facility Design and Development - Staff Training and Development - Information Technology Infrastructure and Support - Simulation Equipment Support - Economy of Scale • Deliver Quality Courses - General Support - Faculty Development - Simulation Activities • Establish Value - Data Collection - Intellectual Property; and • Communicate Value - Research Collaboration and Support
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Realizing that one of the significant barriers to having a successful simulation program is access to quality simulation curricula and scenarios; early on HCSSC surveyed its constituent partners as to desired training products in the domains of nursing and medical students, residency programs and hospital patient safety needs. As resources allowed, a range of courses and scenarios were developed based on practical simulation methods and offered to collaborative partners as part of the benefits of participation in the collaborative. Currently this includes access to over 800 scenarios accessed through the SimStore and over twenty Sharable Content Object Reference Model (SCORM)formatted Internet curricula sets accessed through a password controlled Moodle delivery system. A process for working with a potential partner from initial contact through established success was developed and is known as the “Early Success Program”. The components of the “Early Success Program’ program include a complete process for strategic planning, center design, curriculum integration, technology support, staffing plans, training and data collection for reporting value.
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Economics The statewide collaborative office was initially funded through grant support as one of the Smart State programs, and funding through two of the initial collaborative partners. It has moved towards a sustainability model based on internal revenue composed of endowment revenue and fees from all collaborative partners in return for valued products and services and external revenue composed variably of grants and licensing revenue. Currently about 70% of the annual costs are from internal revenue with 30% generated from external revenue. To support this economic model, a number of processes were put
Site Visit
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in place with the help of MUSC including; the formation of an LLC “SimTunes” to act as a commercial outlet for copyrighted simulation related curricula and scenarios; a standardized alternative copyright pathway within MUSC for copyrightable simulation materials; an inter-institutional agreement process to support collaborative partners participation in co-development and licensing; and a conflict of interest management program to protect the integrity of the institution and individuals. In addition to the products and services provided to the collaborative partners from HCSSC, significant discounted costs for capital purchases and warranties were obtained and passed on to collaborative partners. Transparency of all costs and services are annually reported to all collaborative partners. Reported value, versus collaborative membership costs, to date has been quite favorable with over $3 million saved in direct costs to date. As part of the operational model offered to collaborative partners, ii
Figure 2. Early Success Program. Credit: HealthCare Simulation of South Carolina.
includes the opportunity to provide services at a low unit cost (i.e., $60/hr/simulation room at MUSC simulation center). HCSSC has also played a central role in obtaining over $2 million in research related grants with its collaborative partners. Participation in the collaborative is renewed annually. To date no contracted collaborative member has withdrawn from the collaborative.
cial disclosures. The products, services and processes of HCSSC did not appear over night. Personnel had to be hired and trained from scratch over a twoyear period before a stable level of products and services was achieved and new development is continuous. Not all simulation programs in South Carolina participate in this collaborative though the collaborative is growing yearly. The next article in this two part series will focus on the specific educational and operational principles that are generalized throughout the collaborative to help support high volume, high value, and low cost “practical simulation”.
Lessons Learned & Future Directions Simulation in healthcare is an immature market characterized by: limited general knowledge on how to develop successful local programs, lack of available simulation educational content and limited value statements and business models to support ongoing costs of operation. HealthCare Simulation of South Carolina and its collaborative of 10 partners and 20 affiliates have had some significant success in making simulation based education available for a wide range of users in South Carolina. The keys to this success have been: 1) high level leadership vision and support of the founding partners; 2) access to “practical simulation” exper-
Author, Dr. John J. Schaefer, Professor, Department of Anesthesia and Perioperative Medicine, MUSC. Credit: HealthCare Simulation of South Carolina.
tise through the endowed chair program; 3) vision in establishing methods for external revenue to offset internal costs; 4) relatively rapid development of products and services; and 5) trust and transparency in pricing and finan-
About the Author Dr. Schaefer has been involved in human simulation with mannequin-based simulators since their introduction into medical education in the United States in the early 1990’s. He is a Professor in the Department of Anesthesia and Perioperative Medicine at the Medical University of South Carolina. He received a B.A. in Chemistry, B.S. in Chemical Engineering and a Doctorate of Medicine from West Virginia University from 1981 – 1988 respectively. medsim
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Training Program
Improving Patient Safety and Reducing Hospital Costs: The University of Washington Central Venous Catheter Project
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Edgar J. Figueredo M.D., Mika N. Sinanan M.D., Ph.D., Vanessa Makarewicz RN, MN, Sara Kim, Ph.D., and Andrew S. Wright M.D., discuss a three-part plan to improve patient safety surrounding Central Venous Catheterization at the Institute for Simulation and Interprofessional Studies (ISIS), University of Washington.
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C
entral Venous Catheterization (CVC) is one of the most common invasive procedures performed in modern hospitals. Up to 48% of patients in the Intensive Care Unit have a catheter placed, with 15 million CVCs inserted every year. Catheters are also frequently placed in the Emergency Department, the Operating Room, and in Interventional Radiology. Unfortunately, the rate of complications from CVC is quite high, with studies demonstrating a complication rate between 5% to 29% (1). Mechanical complications associated with this procedure include failure to place the catheter, pneumothorax, arterial puncture, pulmonary embolism, air embolism, dysrhythmia, and death. Each year in the United States there are around 80,000 Central Line Associated Blood Stream Infections
(CLABSI). These infections are common, costly, and potentially lethal, resulting in up to 28,000 deaths among patients in ICUs . According to the National Nosocomial Infection Surveillance System of the Centers for Disease Control and Prevention, the median rate of CLABSI in ICUs of all types ranges from 1.8 to 5.2 per 1000 catheter-days . A CLABSI increases ICU and hospital length of stay by 5 and 7 days, respectively. The average cost of care for a CLABSI is $45,000, with an annual cost in the United States estimated between $296 million to $2.3 bil-
Figure 3. Full procedural simulation. Image credit: Authors.
MD/Provider Module Supplies and Setup - Sterile Technique - Barrier Precautions - Patient Preparation - Patient Positioning - Local Analgesia Anatomy Ultrasound Manometry US-guided Technique Catheter Exchange Complications - Air Embolism - Arterial Cannulation - Bleeding - Arrhythmia - Loss of Consciousness - Hypotension - Hypoxia - Inability to advance or remove guidewire - Inability to Achieve Blood Return - Pneumothorax
RN Module Line types CVC Bundle - Daily review of line necessity - Hand hygiene - Chlorhexidine scrub Dressings Maintenance of IV tubing and supplies Documentation Blood draws Drug/IV administration Blood cultures Bathing
such as indications, technique, or error recognition and management. Additionally, because most faculty physicians and senior residents had learned a landmarked-based approach rather than the safer, ultrasound-guided technique, this deficit was typically passed down to junior trainees. For nurses, onthe-job training led to a lack of standardization and variance between clinical units. We committed ourselves to change the culture and practice of care in CVC through an approach of intensive simulationbased education combined with a system-wide quality improvement process. This required careful consensus building around best practices and agreement on a standardized process of care, followed by the development of training modules, a plan for implementation, and changes to clinical practice. Based on the concept that this was a system-wide issue, we determined (with the full backing of health system administration) to require compliance by all departments, all physicians (including senior faculty physicians), physician assistants, and advanced practice nurses who place central lines. It rapidly became clear that nursing staff, patients, and their families also needed specific and targeted education. We engaged our academic training hospitals to modify the medical staff credentialing process to explicitly include satisfactory completion of the simulation-based curriculum for CVC placement, and included all relevant Department Chairs in our work. We feel that these were critical steps in attaining system-wide culture change and compliance with best practices. In order to reach consensus on best practices and standardization, we built a team of experts including physicians from multiple departments (surgery, critical care, and anesthesiology), nursing staff, hospital administration, infection control, risk management, and a Ph.D. medical educator. Curricula was exhaustively reviewed and put on a regular update schedule and mounted on our enterprise learning management system
Table 1: Key Topics for CVC Cognitive Training Modules. Credit: Authors.
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MD/RN Module Indications Contraindications Alternatives Risks Team Approach - MD/RN roles - Pre-procedure huddle - Time-Out process - RN Cross-Monitoring - Checklists - “Stop-the-line” criteria - “Two Challenge” rule Standard Protocols for: - Care after insertion - Daily review of line necessity - Line Removal - Catheter Exchange
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lion . In 2008 the Center for Medicare and Medicaid Services (CMS) declared that CLABSIs are a “never event” and will no longer pay for care related to CLABSIs. A number of interventions have been suggested to reduce the rate of catheter-related complications. Routine use of ultrasound guidance during line insertion significantly reduces the risk of pneumothorax and arterial injury. Luminal pressure monitoring (manometry) may further reduce arterial injury. In order to reduce the infection rate, the Institute for Healthcare Improvement (IHI) has developed a central line bundle of hand hygiene, chlorhexidine skin antisepsis, maximal barrier precautions upon insertion, optimal catheter site selection, and daily review of line necessity with prompt removal of unnecessary lines. Compliance with this bundle has been shown to significantly reduce the incidence of CLABSI. At the University of Washington we recognized that compliance was less than optimal in standards, with significant variation in care. Internal review revealed that this variation in care was due to several issues including 1) lack of knowledge in modern concepts in CVC such as maximal barrier precautions, lack of training in ultrasound-guided CVC placement, and 2) lack of standard technique and equipment. A materials management issue accompanied this, as equipment such as ultrasound machines, barrier drapes, sterile gowns, and standard CVC kits were not always available at the bedside. Training in CVC catheterization prior to this initiative depended on the clinical service and had not been standardized. For trainees, introduction to CVC followed the typical Halstedian education model with learning occurring during performance of the procedure (under supervision) on actual patients. The limitations of this approach are well established. For example, in one study, successful first cannulation occurred in 37% of the residents trained under the Halstedian model, with a CVC insertion success of 67%, compared to 51% and 78% respectively of the residents trained with simulation. At the University of Washington, while some departments did use the simulation lab to practice CVC placement, this did not follow an established curriculum and often did not include didactic training in topics
Training Program
for systemic tracking for credentialing purposes. Our three-part plan to improve patient safety surrounding CVC included: 1) a cognitive trainer for didactic education, 2) a technical skills simulation for both training and evaluation of proficiency, and 3) a system-wide quality improvement process.
Design and Implementation of the Cognitive Trainer The first step in design of the cognitive trainer was developing content. When it became clear that some information was needed by both physicians and nurses, we split the program into three modules: one for all trainees (focused on indications, scheduling, and patient preparation), one for physicians and other providers who place lines (focused on technical issues around positioning, sterile barrier use, ultrasound, vein access, wire and catheter insertion, and fixation), and one for nurses alone (focused on monitoring, documentation, and maintenance of CVCs). A patient and family education module was also developed. Ultimately the key topics were agreed upon, as seen in Table 1. In order to make the program as engaging as possible, it was designed to be an online module with interactive anatomy demonstrations and copious use of video. Screenshots from the trainer are seen in Figures 1 and 2. At completion of the online training comprehension is assessed with a multiple-choice examination. An important aspect of the training is the team component. In the past, physicians typically placed CVCs without participation by nursing staff. This led to poor team coordination, safety issues with inconsistent patient monitoring, and limited compliance with documentation of standard processes of care. As described further below, part of the QI process involved requiring nursing presence during line placement and use of a standardized checklist. This culture shift required special attention in our training. Because our hospital is also in the process of adopting the TeamSTEPPS program (which is an evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and teamwork skills among health care professionals), language and skills from this program were incorporated into the CVC training, including concepts such as “stop-the-line” criteria and the “two-challenge” rule.
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Design and Implementation of the Technical Skills Simulation
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The first step in designing the technical skills simulation was to agree on a standard process for line insertion for clinical practice. This required consensus building between physicians from multiple departments, as well as input from hospital administration. We then aligned the technical skills simulation with the agreedupon standardized process. A key feature of the technical skills simulation is that it is a “full-procedural” simulation (Figure 3) carried out at various sites of the UW Medicine Institute for Simulation and Interprofessional Studies (ISIS), our enterprise simulation center. In the past CVC training in the simulation lab was often limited to just the needle and guidewire insertion, which many physicians viewed as the most difficult and most technical portion of the procedure. We felt that it was important to include the entire procedure from patient consent to final verification of proper line positioning in order to ensure that all learners are comfortable
Figure 1 (top). Interactive demonstration of relevant anatomy. Figure 2. Video demonstration of Ultrasound-guided CVC insertion. Image credit: Authors.
with the entire standardized process for line placement. During training and certification, the simulation takes place at four stations: • Patient Preparation, • Internal Jugular Needle and Guidewire insertion, • Subclavian Needle and Guidewire Insertion, and • Catheter Advancement and Completion. We have found that the use of multiple stations has some practical benefits. First, the flow allows for multiple examiners and examinees to work in an assembly-line fashion, improving throughout when training or certifying large numbers of physicians. Second, a common problem in CVC simulation is rapid degradation of simulated tissue. We have tried ultrasound-compatible simulators from a number of third party suppliers, and currently use the CentraLineMan System® (Simulab, Seattle,
Washington). Once the simulated tissue has been dilated for catheter insertion, leakage makes it unusable for additional training sessions. By using multiple stations we can cycle the simulated tissue from the most pristine (setup) to the less damaging (needle and guidewire insertion). Typically a simulated tissue can withstand 10-20 training sessions at the second and third stations, as long as the tissue is not dilated. Once the tissue is no longer suitable for needle insertion it is cycled to the final station, where a guidewire is left permanently in place. It can then be used for multiple dilations and catheter placements before being discarded. The technical skills simulation is used as an educational tool and then as an evaluation of basic proficiency. We therefore developed an assessment tool consisting of a checklist and global rating. The simulation checklist includes all elements of the clinical checklist developed as part of the system-wide Quality Improvement (QI) process (see below) with additional elements to assess technical skill. This tool has subsequently been validated in a singlecenter study. Multi-institutional and multi-specialty validation is underway. Every trainee is required to complete every step of the procedure properly to be “certified” for proctored clinical CVC placement.
placed into documentation and tracking of all lines. Our electronic medical record was modified to allow structured charting of line insertion, routine line care, and line removal. “Structured” data in these notes can be extracted for Quality Assurance (QA) purposes. Each line is now tracked throughout its hospital course by dedicated nursing staff, and a daily list of all lines is generated for nursing leadership. The list includes the patient identifiers and unit, the length of time the line has been in place, and the reason for the line. This list is then reviewed to assess the indications for and necessity of the line. The third component of the QI pro-
cess was to improve the availability and accessibility of equipment. We standardized the CVC disposable kits with our vendor and worked extensively with materials management to develop and stock line carts that contain all necessary supplies, including spare guidewire, sterile gowns, gloves, and barrier drapes. Ultrasound machines were also purchased and sited throughout the hospital. A line cart and US machine are now available in every unit where lines are placed.
Challenges Perhaps surprisingly, there has been relatively little conflict in developing
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Design and Implementation of System-Wide QI Process
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Encourages surgeon adoption of da Vinci ® system; frees up clinical robot for revenue-generating procedures
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Mimic, dV-Trainer, MSim, and Mscore, are trademarks of Mimic Technologies, Inc. Intuitive Surgical and da Vinci are registered trademarks of Intuitive Surgical, Inc. dV-Trainer is not a product manufactured, sold or distributed by Intuitive Surgical, Inc.
ISSUE 4.2012
Proven, Highly Realistic Simulation Training for the da Vinci® Surgical System
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In parallel with our efforts to develop and implement our enhanced educational process, we also began a comprehensive system-wide quality improvement process. The full backing of hospital administration and the leadership of key clinical departments supported this effort. A key component of this QI process is the establishment of, and requirement for a clinical checklist for CVC insertion. This mandates and documents compliance with key elements of our standardized protocol such as patient preparation, hand hygiene, use of ultrasound, and more recently arterial pressure monitoring (manometry) for CVC lines, as well as patient monitoring. It also reinforces the team components of the procedure, including specific callouts for a team preprocedure huddle and identification of “stop-the-line” criteria. A major additional effort has been
Training Program
a consensus regarding a standardized CVC insertion process. The major challenge in this process has been the intense manpower effort required to implement and sustain the move to standard training, credentialing, and tracking. The initial investment in developing the standardized clinical process and the educational initiative has been followed by ongoing work to track results and maintain the ongoing quality improvement process. This has been a major initiative by hospital administration, and the team involves more than 20 people from different clinical and administrative departments. We currently meet twice monthly to discuss cases, address ongoing issues, and plan future revisions. An additional challenge has been the costs associated with implementation of the educational curriculum. Initial funding for development of the online training modules and the technical skills simulation came from internal funding sources, and cost an estimated $70,000 to $100,000 per year, plus the support costs for dedicated nursing staff. Additionally, this cost does not account for all of the faculty time and FTE (fulltime equivalent) spent in development. Additional costs are accrued annually for maintenance and updates to the curriculum. The training/evaluation costs of the technical skills simulation are estimated to be $66.48/person. Costs are minimized through reuse of simulated tissue (as noted above) and use of outdated and vendor-donated, nonsterile CVC kits for the simulation lab (ISIS), which drives costs down to $22.48/person. While the ISIS bears the costs of materials, equipment, and technician FTE, each department is responsible for providing their
own faculty for training and evaluation sessions. There was some initial resistance regarding the requirement for certification from faculty long used to placing CVCs. Departmental and divisional presentations, information about the training program, and an efficient process for credentialing contributed to effective consensus building. Many faculty noted value to their own practice from reviewing the state of current practice and our training program. Essential to our program was certification for every provider including all faculty who place or supervise CVC placement. Some faculty did decide to stop placing or supervising line placement, helping to maintain volume for others that serve to help maintenance of skills for the rest. In addition, we have noted a progressive decline in the number of CVCs (33% reduction) as more standard indications reduce the rate of CVC placement, including reductions in our CVC placement in the ICU.
Results and Current Directions To date we have now certified more than 1,150 physicians through the combined didactic and technical skills simulation. We have performed several evaluations of the effectiveness of our training platform. Pre/Post testing on the multiple choice examination shows improved knowledge after completion of the training. More importantly, completion of the technical skills simulation dramatically improves compliance with the checklist (from an average of 22 checklist errors before training down to 3 after training). Having now trained and certified all faculty physicians and trained active
nursing staff, we are now moving into a mode of maintenance of certification. We are currently developing an annual refresher/update module for nursing staff, residents, and currently credentialed faculty. It is unclear how often demonstration of proficiency in the simulation lab should be required, and whether or not this should be impacted by clinical volume. It may be that physicians who place less then a certain number of lines per year should be required to demonstrate continued proficiency on a more frequent basis. Clinically we have seen improved compliance with and documentation of the central line bundle, from 0% documentation in January 2008 to near 100% currently. The rate of CLABSI at the two hospitals involved in this project has progressively reduced over the course of our training since 2008, decreased by roughly 200% to a rate that is consistently below 0.9 CLA-BSI/1000 catheter days. Although there were significant costs involved in development of this program, based on our internal surveillance data we estimate that it prevents 35 line complications per year, saving $30,000 dollars per complication, for a total savings of $1,050,000 annually. We have also realized savings from materials management as we have standardized our equipment and reducing the number and types of line being stocked. Therefore we conclude that the investment in time, personnel, and money has been more than recouped in improved patient safety and reduced hospital costs. We feel that this program of a combined educational and quality improvement initiative can serve as a model for other clinical scenarios. medsim
REFERENCES
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1. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. [Research Support, U.S. Gov't, Non-P.H.S.
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Review]. 2003 Mar 20;348(12):1123-33. 2. Klevens RM, Edwards JR, Richards CL, Jr., Horan TC, Gaynes RP, Pollock DA, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007 Mar-Apr;122(2):160-6. 3. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. [Research Support, U.S. Gov't, P.H.S.]. 2004 Dec;32(8):470-85. 4. O'Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep. [Guideline Practice Guideline]. 2002 Aug 9;51(RR-10):1-29. 5. Institute for Healthcare Improvement. Cambridge M. How-to Guide: Prevent Central Line-Associated Bloodstream Infections. . (Available at wwwihiorg) [serial on the Internet]. 2012. 6. Evans LV, Dodge KL, Shah TD, Kaplan LJ, Siegel MD, Moore CL, et al. Simulation training in central venous catheter insertion: improved performance in clinical practice. Acad Med. [Randomized Controlled Trial Research Support, U.S. Gov't, P.H.S.]. 2010 Sep;85(9):1462-9.
TRAINING DEVICE DESIGN
Haptics in Medical Simulation – Some Best Use Cases
F
or hundreds of years, medical professionals were trained the same way – see one, do one, and then soon thereafter, do more, independently. Cadavers offered some ability to practice, but a doctor’s skills were largely honed on live patients – initially under supervision, and then in live surgical situations. The few simulators available were mechanical, and only offered crude approximations for skills training. Today’s training methods provide the opportunity for doctors to practice until proficient, using a new generation of surgical simulators. In today’s environment, where initiatives to improve patient outcomes predominate many medical subspecialties have embraced technology as a better and safer way. Students are looking for new ways to learn. Most clinicians involved in training learners – seek different ways of fostering
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Above OSC Virtual Temporal Bone Drilling Simulator, using two Phantom haptic devices Image credit: Ohio Supercomputer Center.
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Calling attention to the use of haptic feedback in training devices used in other domains, Adrian Hendrickse, B.M., FRCA and Karl Reinig, Ph.D., assert that for effective training on appropriate procedures, medical simulators should include haptic functioning.
TRAINING DEVICE DESIGN
learning, for two reasons: students respond to different learning styles and learning that's fun or experiential seems to work best. Indeed the game-like factor cannot be overlooked. A generational change led to today’s students arriving at medical school with a natural sophisticated ability to play screen-based games and manipulate 3-D objects. Today medical simulators vary from low to high end in both cost and fidelity from; • fake tissue on which to practice suturing • simple 3-D textbooks that visualize the learning experience • Virtual Reality (VR) trainers akin to video games teaching small core skills but without haptics to • VR simulators with kinesthetic or haptic feedback for discrete procedural training and eventually for certification on various surgical specialties.
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Feeling, as well as Seeing: Research Update
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The question of whether haptic feedback in simulators is required has interested researchers across various domains. Often, seeing anatomy in 3-D space and in readily manipulated ways is only part of achieving proficiency and competency at a quantifiable and clinical level. This is particularly true when learning a blind procedure, or one where the unseen and unobservable anatomy is key to successful performance and proficiency. The authors assert that for effective training on appropriate procedures, simulators should include haptic functioning. The literature reflects that many colleagues across other medical specialties agree, including M. Zhou, et al in a 2012 study in laparoscopic surgical skill acquisition, S. Liang et al. in a 2009 study in ophthalmology, and A.F. Abate et al. in a 2010 study in obstetrics. It’s only logical that to achieve finger memory and/or dexterous manual proficiency with the sizes and kinds of instruments used today, we must practice so that our senses of touch, sight and hearing are activated. The oft-presented argument for haptics is its use in other training domains: aviation, space exploration, military and the nuclear industry. Pilots don't simulate attributes of flight without it feeling right in their hands. For instance, the controls stiffen the angle of the flight deck changes. These simulators are expensive, and in aviation no one complains; it “feels right” and that is what matters. Furthermore, instances such as the “Miracle on the Hudson” where a pilot with extensive simulator experience could perform the near miraculous, smooth landing intuitively reaffirm the role of ultra-realistic simulation as a training vehicle. Quantitatively proving where and when haptics make a difference, however, becomes trickier. In a 2011 literature review of simulation and quality improvement in anesthesiology, C.S. Park summarized that simulation has a proven relationship to improving the effectiveness of education (T1 training), and to improve how skills are transferred to clinical performance (T2 training). Simulation’s effect on clinical outcomes – T3 training – was evidenced in a more limited extent, particularly in elucidating latent conditions, for which simulation interventions later can be designed. Tasks that require spatial awareness may benefit from the experience of force feedback, but are probably not as great a fit for haptics as, say, the need to develop tissue feel. In the domain of anesthesia, when learning to perform a femoral block, it’s actually the identification of fascial boundaries – which one cannot see unless using ultrasound techniques – that
helps the trainee find the right location. Palpation over the femoral artery helps them to predict the location of structures within the inguinal region and hence the location of needle insertion but the femoral nerve will only be found by using a mixture of nerve stimulation and tissue feel. Kulcsar, et al. in 2011 characterized eight tactile elements associated with successful performance of spinal anesthesia, from touching skin and bone, to the “pop” sensations of skin and dura mater, to the sensations associated with advancement of spinal needle through three different tissue types. The study’s focus was to determine if haptically enabled simulation could distinguish between novices and experts, and thus if haptically enabled simulators represent a viable means to certify competency in spinal anesthesia. It did, however, with considerable inter-rater variation when experts were presented with the same haptic rendering on more than one occasion for bone surfaces, skin pops, dura pops and subcutaneous tissue sensations. This finding suggests that it is indeed possible for simulators to “feel real”. Experts agreed that the structures they were feeling virtually, felt real and that there was a wide range of real. The Kulcsar et al. study discussed
Surgical Theater’s Surgery Rehearsal Platform (SRP) uses haptic devices and patients’ own CT and MRI images to enable surgeons to practice and warm-up on the patient’s unique anatomical variations in advance. Image credit: Surgical Theater, LLC.
the role of explicit knowledge – learning that is formal and easily specified – vs. tacit knowledge – learning that is less easily defined and measured. Tacit knowledge is difficult to transfer to trainees in a clinical setting under traditional apprenticeship models and is primarily acquired through experience – exactly the kind of knowledge that simulators seek to provide. Simulators may be vital in providing experience with anatomic variation – something a surgical resident only really begins to appreciate with experience. Offering a simulator experience that feels real over a variety of situations greatly assists in this context. Ideally the simulator can then vary parameters to make distances and feedback slightly different but still real to provide a wealth of experience.
Haptically-Enabled Simulation – Best-Fit Scenarios The above studies and our own sentiment bear out the belief that there are procedures where haptics provide a clear benefit to the simulation experience, so that haptically enabling the simulation is a must.
A d v A n c i n g
P A t i e n t
1. Bone/Tissue distortion and feel. The Ohio Supercomputer Center (OSC), a publicly-funded research partner to Ohio universities and industries, has won national recognition for its Virtual Temporal Bone Project, which utilizes a Phantom® haptic device (made by Geomagic, Morrisville NC). Developed in partnership with Nationwide Children’s Hospital and The Ohio State University Department of Otolaryngology, OSC’s simulator presents a true-to-life experience encountered in ear surgery. The temporal bone contains the structures for hearing and balance, and the simulator allows future surgeons to practice delicate surgical drilling techniques on a computer-based teaching system instead of cadavers or as apprentices in operating rooms. The use of haptics in OSC’s simulator allows surgeons to “feel” the surgery they are performing, as well as see and hear it. The haptic device and accompanying software employ force-feedback technology to literally push back on the trainee’s hand as they look through a 3-D stereo view that replicates what a surgeon would see through a microscope
S A f e t y
t h r o u g h
during surgery. Drilling sounds are then modulated based upon the pressures and area of bone being removed. In this context, haptics enhances the realism and hence the teaching value of the simulator OSC’s temporal bone simulator is presently being used at 10 sites around the US and has even assisted in the training of surgical residents in Nicaragua, where access to cadaveric temporal bone samples is extremely limited. The group is currently conducting a multi-institutional study to define objective assessments for integration into an automated assessment tool for resident evaluations. Study participants are Duke University, Stanford University, University of California Irvine, University of Mississippi, University of Iowa, University of Cincinnati, Baylor College of Medicine, Albert Einstein College of Medicine, University of Texas, Southwestern, Henry Ford Medical Center and The Ohio State University. 2. Blind procedures. Touch of Life Technologies (ToLTech), in collaboration with the University of Colorado Center for Human Simulation, has developed a virtual environment to practice multiple medical procedures. The
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t r A i n i n g
The next MEdSim magazine will be published on 21 January, featuring: • Techniques and training to reduce MRSA infections • Technologies used in simulation centers: their effectiveness and what to expect in 2013 • London’s award winning Simulation and Technology-enhanced Learning Initiative (STeLI)
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ISSUE 4.2012
Tackling poor communication across inpatient, outpatient and ancillary services The Royal College of Surgeons Ireland Professional Development Programme Setting up a simulation center: the basic steps in management, design and developing curricula A special report on the simulation and training industry in Florida
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Common Platform Medical Skills Trainer (CPMST)1 collocates 3-D stereo graphics with high-fidelity haptic devices to create a totally immersive bi-manual environment in which to train and prove proficiency. Initial applications include diagnosis and treatment of compartment syndrome, regional anesthesia, joint injection, and ophthalmic procedures. An associated Mentor program eavesdrops on the state variables of the simulations to guide, critique and score the users, providing an autonomous experience that replicates the apprenticeship method, but on demand and without risk. In the CPMST’s femoral nerve block application, the trainee initially experiences blind needle advancement, utilizing palpation of bony landmarks, pulse, and the feel of various structures as the needle advances, to determine the proximity of the needle tip to the femoral nerve. This training would simply not work without the simulator’s ability to display the associated haptic forces. Follow on lessons include stimulation through the needle and ultrasound guidance as clinically useful methods to confirm the needle path. 3. Surgical rehearsal. Simulators can also be made into surgical rehearsal platforms where the marriage of patient CT and MRI files allow the ultimate in personalized rehearsal. Traditionally clinicians would look at CT scans before an operation and have to translate the flat, black-and-white image into a realistic picture in their heads. Working this way can add time during a critical operation, when of course the goal is to reduce time in surgery without sacrificing accuracy. Surgical Theater’s Surgery Rehearsal Platform (SRP) is the first simulator on the market to use patients’ own CT and MRI images, enabling surgeons to practice and warm-up in advance on the patient’s unique anatomical variations. The SRP reconstructs CT and MRI images/ scans and transforms those images into dynamic, interactive 3-D models with life-like tissue reaction and accurate modeling of surgery tools that allows surgeons to plan and rehearse a specific patient’s case before entering the operating room. The initial offering has been developed for brain aneurysm surgery, one of the most technically complex procedures a neurosurgeon performs. A cerebral
The Common Platform Medical Skills Trainer, from Touch of Life Technologies. Image credit: ToLTech.
aneurysm is a ballooning of a blood vessel in the brain that is often treated by microsurgical techniques involving the placement of a small titanium clip across the neck of the aneurysm. Development of complicated brain surgeries that involve a complex approach in delicate areas of the brain such as pituitary and meningioma tumors is underway. By holding a Phantom haptic stylus designed to operate as if he/she was holding a surgical instrument, the surgeon can “feel” the virtual tissues, note their reaction to different shaped surgical clips, feel the results of more or less pressure on the aneurysm, and practice different angles of insertion. Providing a realistic environment, allows the surgeon to make critical decisions in advance, on an exact replica of the patient, in a “risk free” virtual rehearsal environment, hence, to “pre-live the future” of a specific patient case.
Cost – The Bottom Line, or is it? Another factor considered by both simulation purchaser and creators, is cost – as assessed by Thompson et al in 2011 specifically for laparoscopic cholecystectomy. Virtual reality simulators are more than just a PC and off-the-shelf software. Haptically enabling the training means
the simulator system will require the addition of a haptic device and associated software/ programming development costs. The system price tag will reflect these, although with affordable PCs and off the shelf components haptically-enabled simulators exist on the market today starting at $15,000. However when the simulator is itself a platform for delivering more than one kind of training, to be used by more than one medical school or hospital department, the purchasing decision is easier to costjustify. Beyond cost, there are “If/Then” scenarios that may extend far beyond cost-benefit analyses in the decision as to whether a haptically-enabled training experience leads to better training for specific procedures. As CMS-driven penalties for being the bottom quartile of hospital readmissions loom – and as penalties when adverse reactions are deemed avoidable also loom – the cost of a simulator may be minor in the light of the risk of reputation or financial damage arising from perceived gaps in training. As resident training hours are limited while procedures become more complex – simulation fills a vital role in medical training. When the right tasks are haptically-enabled, simulation is a powerful adjunct to both training and certification. medsim About the Authors Adrian Hendrickse, BM, FRCA is associate professor of anesthesiology at University of Colorado Medical School and practices at the University of Colorado Hospital. He also is the director of the department of Anesthesiology’s simulation education program and is a consultant with the School of Medicine’s Center for Human Simulation. Karl Reinig, Ph.D. is assistant professor of Cell and Developmental Biology at the University of Colorado School of Medicine, and co-founder and director of engineering at Touch of Life Technologies. He also has over 20 years of experience creating realistic 3-D display of complex scenes to lead the development of virtual environments in which to gain, maintain, and prove medical skills. Funding for the CPMST has come from the Telemedicine and advanced Technology Research Center of the US Army Medical Research and Materiel Command. 1
Lori Ponoroff, MEdSim Staff Writer, provides insights on the fielding of do-it-yourself simulators as instructional devices.
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udget cuts, time constraints and the peace of mind that comes with practicing by simulation instead of on patients is driving surgeons, students and instructors alike to make their own simulators. From the simplest applications – like citrus fruits and soda cans – to more involved devices like a vascular simulator made from a laundry basket, wood and copper tubing, DIY (do-it-yourself) simulators are popping up on You Tube, in medical journals and at surgical conferences. The cost of commercial simulation equipment often presents financial barriers to institutions interested in holding procedural or examination skills workshops, according to Ted Warren, Manager of Education and Career Development at the American College of Physicians (ACP) in Philadelphia, Pennsylvania and at the ACP's Herbert S. Waxman Clinical Skills Center that takes place at the ACP's annual scientific meeting. “Depending on the skill being taught,
homemade or do-it-yourself simulation can remove those barriers and allow participants to get the valuable hands-on practice proven to change behavior – at a fraction of the cost,” Warren said. “A program can then make these skills workshops available to more participants, broadening the reach of the educational experience.” Take, for example, the ACP center’s simulated abscess model developed by ACP from an idea by Thomas Rebbecchi, M.D., an associate professor of emergency medicine at Cooper University Hospital in Camden, New Jersey. Using a suturing pad, a balloon, toothpaste, rubber cement and some clamps, the mock abscess model is easy and inexpensive to make – and provides a realistic model that helps teach the motor skills and steps necessary to properly incise, drain and dress an abscess, Warren explained. “At the annual ACP Internal Medicine scientific meeting, we can cycle over a hundred individuals through our Incision
Sharing Simulation Ideas On-line journals, papers and videos make sharing low-cost alternatives simple and sweeping, as do education conferences like Surgery Education Week, where Sexton presented his invention. Surgery Education Week is sponsored by the Association of Program Directors in Surgery and the Association for Surgical Education. The meeting provides a forum for those involved in surgical education to seek new approaches and creative solutions to medical education issues. Similarly, SimGHOSTS – The Gathering Of Healthcare Simulation Technology Specialists, is an independent
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Intricate, Innovative and Inexpensive...DIY Surgical Simulators
and Drainage of Abscesses workshops, while saving thousands of dollars by using a homemade simulation – rather than a commercial option.” Equally simple to make is the vascular surgery simulator designed by general surgery Resident Kevin Sexton, M.D., at Vanderbilt University in Nashville, Tennessee. In one weekend trip to the hardware store, Sexton and his wife designed a $5 vascular simulator that is now being used by residents to easily and effectively practice intricate vascular surgical techniques and vessel repair. Using nothing more than copper tubing, plastic bird guards (often used to block dryer vents), a drain and some miscellaneous items such as wood screws and two-by-fours, Sexton produced 18 vascular simulators for a residency workshop. In the first two-hour workshop, 24 first-year surgery residents practiced multiple vascular techniques at various anatomically challenging positions and were then asked for their feedback. The results were overwhelmingly positive – all of the respondents said they would like to have the simulator for personal use. “It’s not uncommon to come up with non-traditional solutions to medical training. Residents do this all the time,” said Sexton. “I practiced vascular anastomoses in a coffee can because that is what my chief resident said worked. What makes our design useful is we can share it with other residents and institutions who want cost-effective simulation. That’s the win.”
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Simulation
The ACP uses low-cost mock abscess drainage models at its annual Incision and Drainage of Abscesses workshop. Image credit: American College of Physicians.
Simulation
training meeting dedicated to supporting healthcare simulation technicians by developing online resources and handson training events. At SimGHOSTS 2012, Laerdal sponsored a DIY Video contest where simulation techs could share DIY tips and tricks for increasing efficiency or realism in their medical simulation labs. Fritz Sticht from the Behling Simulation Center at the State University of New York at Buffalo won an iPad for his video that demonstrates an affordable and easy-to-build Cervix/Uterus Model, and Brian Florek from Northwestern University’s Feinberg School of Medicine Simulation Technology & Immersive Learning (STIL) program won a GoPro2 for his video on Increasing Mechanical Ventilation Fidelity on the Laerdal Simman 3G. After the winners presented their ideas, an impromptu sharing session ensued, according to Lance Baily, Executive Director of SimGHOSTS.Org. “We spent another 45 minutes with other attendees sharing their own successful DIY ideas – with some incredible results,” said Baily. The winners’ DIY concepts, and those of other contestants, are available on the SimGHOSTS website at www.simghosts.org/got-sim-2012/ diy-video-contest/#entries. In October, a recording of the extemporaneous session will be posted on SimGHOSTS’ subscription-based web forum. “We have had some amazing ideas come out of our online group – it’s a great resource for folks looking to engage with a global community that is trying to create affordable solutions,” Baily said.
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Snacks as Simulators
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Many more DIY simulation ideas can easily be found with a simple Web search – everything from multi-component devices like homemade laparoscopic simulators to the single-piece, knot-tying tool made from an empty soda can devised by Neville Dastur, M.D., a Senior Clinical Researcher at King’s College London. Dastur’s paper published in the Annals of The Royal College of Surgeons of England, explains a simple DIY technique that allows trainee surgeons to practice knot tying while not applying too much force to the structure being sutured, something that can’t be practiced on a traditional, fixed hook simulator. How does it work? Simply place an empty soda can with the ring pull positioned upright on a piece of paper and draw a circle around the side
of the can. Trainees practice tying knots on the ring pull without moving the can outside of the circle or lifting the can from the surface. Simulators don’t get much cheaper, simpler or more readily available than an empty soda can. But some are just as simple, like a box of beans or a piece of fruit. The University of Florida College of Medicine’s Center for Simulation Education and Safety Research (CSESaR) has full laparoscopic towers and surgical simulators, but during interviews for surgical residents, the staff evaluate their manual skills with some very simple devices, according to the center’s director, Bruce Nappi. He said that without anatomical features, any delays caused by anatomical confusion are eliminated, and this is the approach used for the Fundamentals of Laparoscopic Surgery testing. The devices are made with cardboard boxes, paper coffee cups and dried beans – and “the objective is to measure an applicant’s ability to move slippery beans from one cup to another in a set time interval,” Nappi explained. “Different box and cup placements force appropriate hand and arm positioning. The key functional elements of the system are forcing the lap tools to go through a hole cut in the rim of the box, and cutting an appropriate window in the box top to constrain vision. The cost is minimal to construct many identical units for parallel testing.” Pamela Andreatta, EdD, Founding Director of the Simulation Center at the University of Michigan, developed a way to use a clementine to teach the skills crucial for laparoscopic surgery. Andre-
Objective Structured Assessment of Technical Skills (OSATS) exam. Image credit: University of Toronto Surgical Skills Centre at Mount Sinai Hospital.
atta got the idea after R. Kevin Reynolds, a gynecologic oncology professor, asked her to devise a simulation to teach the delicate task of removing lymph nodes as part of surgical procedures used to minimize the spread of cancer. Andreatta realized “a clementine has tissue variability that reflects the same variation between organs, vessels, nerves and other anatomical tissues within the pelvis,” she said, “a sturdy external cover, with spongy and delicate flesh and connective fibers on the inside.” She came up with an exercise where students insert a camera, scissors and a grasper into holes on top of an opaque box that has a clementine inside. They have to take off the peel in as few pieces as possible, remove the pith, separate the segments – and then put the segments and peel back together again. Grapefruit – another citrus fruit – was used this summer to simulate brain tissue at a neurosurgery rookie camp. The camp brought together medical school graduates from across Canada who were starting their neurosurgery residency programs to focus on critical neurosurgery skills, according to David Clarke, M.D., interim chief of neurosurgery and medical school professor at Dalhousie University in Nova Scotia, Canada. “An important skill to teach trainees in using a bipolar (surgical instrument) is that you have to leave the bipolar on and the ends together for a fixed amount of
Using left-over materials; home repair products and a grocery list of meat, fruits, and vegetables has been a way of life for Lisa Satterthwaite and her team at the University of Toronto Surgical Skills Centre (SSC) at Mount Sinai Hospital since it opened in 1998. “When we opened this skills lab, simulation was in its infancy and there was really no one to talk to – simulation wasn’t really popular,” said Satterthwaite, manager of the center in Toronto, Canada.
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ISSUE 4.2012
A Shopping List for Supplies
“Toronto only had one medical school with a lot of medical students and residents coming through, and not a lot of money to spend on technical skill training,” she said. “So to train the residents we started developing our own (simulation) models based on readily available materials and meats from slaughter houses and local butchers to accommodate our large number of students, but small budgets. That’s what propelled us into the DIY model making.” They knew other schools were facing the same issues, too – all starting from scratch and struggling to substantiate their labs, so the SSC decided to share its DIY approach and created the Surgical Skills Centre’s Model Procedures webpage (http://www.utoronto.ca/ssc/ procedures.htm) that lists and describes some of the lab’s DIY simulation models. Since then, the SSC center has taken its DIY simulations to new heights – continuously developing new models in collaboration with other departments – and then sharing new developments with the medical community. Most recently, the staff went to Chicago for a colorectal objective structured assessment of technical skills examination project. It’s an exam they hosted and created the models for – all of which were tested and verified by experts in Toronto and the United States. “We have built a culture of model creation and we’re known here at the skills lab for our low-fidelity models and creativity,” Satterthwaite said. “It’s a collective endeavor – we’re using a lot of creativity and mind-building from faculty and our staff here at the skills lab. Residents have a say in our models – and we get experts in to trial them. “We use everything from shoe laces to wood to tennis balls to recreate technical skills training models – you name it, and we use it,” she said. They use spaghetti squash and green peppers as models for hysteroscopy and repurpose old or expired pieces of medical equipment for new uses, like using an old Jackson Pratt bulb (used as a drain in surgery) for suprapubic catheterization models. “You really get a different vision when you go shopping now – we look at things and think, you know what, that would make a really good artery,” Satterthwaite said. “The amount of models we can make based on products from supermarkets, craft shops and hardware stores is endless.” medsim
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time so that it coagulates the blood vessel; but if you leave it on too long, then the ends of the bipolar become stuck to the tissue,” he said. “If that happens and you take it out, you can rip the blood vessel and cause bleeding.” The grapefruit is great, Clarke said, “because if you use a bipolar as you should, then the juicy part just peels away from the fibrous part that goes from the center to the outside; but if you leave it on too long, the grapefruit – just like brain tissue – will become sticky and you have to rip it out when you remove the bipolar. This is a very important skill and concept for someone operating on the brain to understand and a grapefruit does a great job of illustrating that.” The camp teachers used a wide range of simulation techniques – from the advanced and expensive NeuroTouch simulator to other inexpensive tools like the grapefruit. For example, a simple system of tubes and beakers simulate how shunts and drains work, Clarke said. “Another skill residents have to learn is how to manage hydrocephalus – which is a blockage of normal fluid circulation in the brain,” he explained. “Sometimes we have to drill a hole in the skull and put in a tube to drain the fluid. If a patient needs a permanent drain, we put in a tube that goes from the cavity of the brain, under the skin and into the belly. To illustrate how the different kinds of shunt systems work, we used a beaker of colored water hooked up to IV tubing – and then went through different shunt valve systems so the residents could see how the system performs when they change the position of the patient or the kind of valve used. “Real valves cost hundreds or thousands of dollars,” Clarke said, “but this way we can put something together with left-over materials and use it to illustrate how these things work.”
LEARNING TECHNOLOGY
Gaming Technology Holds Promise of Advancing Medical Education Staff writer Chuck Weirauch reports on developments in the rapidly evolving serious games for healthcare learning sector.
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lthough simulation technology has become a leading tool for the advancement of medical education and training, gaming technology has still not gained an equal level of acceptance with medical educators as its counterpart. While the pioneering game-based Pulse!! Virtual Clinical Learning Lab developed by Texas A&M University-Corpus Christi and Breakaway, Inc., has proven to be a major success, most medical colleges and teaching hospitals have focused more on the use of human patient simulators, or mannequins, as their primary initial teaching tool.
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Duke's Virtual Environment That may change once the results are in concerning the training effectiveness of the gaming technology-based Immersive Learning Environments at Duke (ILE@D) being developed at the Duke University Human Simulator and Patient Safety Center at Duke University Medical Center in Durham, NC. The gaming platform for this Web-based and avatar-driven medical education system, which employs the Unreal gaming engine, is provided by the HumanSim platform developed by Virtual Heroes. Applied Research Associates, Inc., is the parent com-
pany for both HumanSim and Virtual Heroes. According to John Taekman, MD., Director of the Human Simulator and Patient Safety Center, the ILE@D is to be a kind of cross-collaborative, multidisciplinary platform where Duke medical faculty members can interact and communicate with their students while sharing resources with both students and other faculty members. Individually and in teams, students will be presented various virtual patient care scenarios in which they must diagnose the HumanSim-modeled patients, communicate with team members and perform the proper medical procedures in a variety of health care environments through their avatars. The ILE@D system is currently undergoing development in partnership
HumanSim is a software simulation platform developed to provide medical education for individual and team training. Image credit: Applied Research Associates, Inc.
effort was funded by the US Army's Telemedicine and Advanced Technology Research Center (TATRC) as a training program for deployed Army physicians who had no previous education in that field. Now Duke is considering that module for its applicability for its resident training, Taekman said. "No one has ever done this before on the scale that we are trying to create," Heneghan said in reference to the development and the future commercialization of the ILE@D and HumanSim learning modules. "This is a transformational change, because before everything has been mannequin-based."
Jerry Heneghan, the Director of Product Support for HumanSim, describes this process as similar to commercial and military aviation pilot training, where the student first takes online familiarization courses and then learns and practices on flight training procedural trainers in the schoolhouse before being exposed to full-flight simulator training. A former military pilot himself, he has encouraged Duke University to take this approach to medical training.
Accurate Models But the real key to the success of the ILE@D program is the accuracy of the virtual patient models incorporated in the system, Heneghan pointed out. That's why his company is drawing from Duke medical SME data to establish requirements for algorithmic models for virtual patient physiological characteristics and symptoms, down to accurate representations of the electrical activity of the cardiovascular system, for example. That accurate data representation is crucial not only for ILE@D, but for the future intended commercialization of the learning modules that HumanSim hopes to offer through commercial agreements with Duke to the medical education community, Heneghan remarked. HumanSim and Duke have partnered in such agreements before, one example being the game-based Pre-deployment Anesthesia Training Module. That
With the advent of such gaming technologies as those demonstrated in Pulse!! and HumanSim, the medical education community has begun to show more interest in gaming in its curricula. However, at this point no one seems to have a measure as to what extent. To help answer that question, for the first time, the Association of American Medical Colleges (AAMC) initiated a survey amongst its membership this October as to the extent of the application of gaming technology as a part of its annual survey on the use of simulation for medical education. According to Carol Aschenbrener, MD., the Chief Medical Education Officer for the association, the results of the survey should be available within six months. "The fact that AAMC is launching a survey will give you an idea of how interest has grown," Aschenbrener said. "The bottom line is there is not a whole lot yet implemented into the medical curriculum in terms of serious gaming, but the interest is definitely expanding and there are beginnings of some serious research on their impact." Some of that preliminary research indicates that the use of some games can improve the dexterity and coordination of surgeons for laparoscopic surgery. But whether gaming technology can help transfer surgical skills gained from use of the game-driven learning tool to the actual procedure on a patient is still an unresolved issue. "The use of simulation and gaming is one of the most promising tools that we have in medical education," Aschenbrener said. "If I knew the answer to this evidence-based question, it would
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Interest Growing Pulse!! research fueled development of the vHealthCare training platform for nurses at the University of Maryland School of Nursing. Image credit: BreakAway, Ltd.
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with HumanSim, with Duke University Medical Center physicians and other medical specialists serving as subjectmatter experts for HumanSim game and instructional designers, along with computer modeling personnel. The HumanSim staff is in turn to develop learning module content and the most accurate physiological virtual patient models possible based on Duke SME input. Virtual Heroes and Duke are also collaborating on several other medical education and training projects. "The idea of ILE@D is also to have a professional virtual environment where physicians and nurses learn together in a shared common space," Taekman explained. "This is a push in healthcare education towards training folks in the type of teams that they are going to be taking care of their patients in. Traditionally, nurses have been trained completely separately from physicians. The goal is to have the ILE@D system be integrated into the Duke undergraduate nursing and medical school curriculum. We also want to build courseware content in such a way that it can be re-used for graduate, continuing education and advanced nursing curricula." Taekman, who is also a founding member of the Society for Simulation in Healthcare (SSIH), also feels that the IIE@D will help solve student throughput problems caused by starting student exposure to simulated patients with mannequins. Limited student access to the few and expensive mannequins in the simulation center can lead to potential problems with student performance, he indicated. "Historically we have used mannequins, which is an effective way for people to learn," Taekman pointed out. "However, we have a throughput issue when we are trying to train a large number of people, such as all of the medical students. We want to use the virtual environment as a way of scaling interactive training." What Taekman means is that undergraduate students would first work with the ILE@D HumanSim virtual patient model alone or in teams before capstone training exercises with the mannequin itself. That approach would provide the student with more confidence when performing the mannequin-based training scenarios. This approach could also reduce costs.
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totally change how we do medical education. And that question is, what is the relationship between the performance in simulation and the performance in practice? We have good research on pieces of that question, but there is a huge need for more research to be done."
HumanSim on iPad. Image credit: Applied Research Associates, Inc.
Health Games Research One of the organizations involved in such research is the aptly named National Health Games Research program based at the University of California at Santa Barbara. This organization's goal is to advance the research, design, and effectiveness of digital games and game technologies that promote health. Games for Health also provides an extensive searchable database of games that is accessible via its Web site at http:// www.healthgamesresearch.org. For example, one of the games referenced on the extensive Games for Health database is CliniSpace. This learning tool is an online Web-driven immersive virtual environment powered by a gaming engine where a team of heath care professionals can assess virtual patients' conditions in a virtual hospital setting and provide proper diagnoses and treatment. "Well-designed health games are very powerful," said Health Games Research Director Debra Leiberman. "They provide experiential learning, where the player must make choices, take action and see the consequences of these choices and actions. This is a very effective way to learn by doing, or learning through experience. So games can not only improve knowledge, but they can also change behaviors." While most of the Health Games Research findings have been gathered from those games designed for patient self-help, the same principles can be applied to those games specifically geared for educating and training professionals, Leiberman pointed out "Doctors can be learners too with gaming technology," she said. "Games by their very nature deal with assessment. As a player, you are constantly getting feedback as to how you are doing, so you are being constantly assessed. This helps you do better next time and spurs you to try harder. Games can also provide decision support as to what to do next in terms of diagnosis and treatment."
Games for Health
Soft Skills Opportunity
Ben Sawyer is the President of Digital Mill and the founder of the Serious Games and Games for Health projects. The latter organization has held an annual conference for the past seven years, bringing companies like Microsoft together with university researchers, game designers and medical educators to highlight the latest developments in gaming for healthcare. Sawyer said that there has been considerable growth and interest in the area of games for medical professional education and training, so much so that the Games for Health annual event has begun holding a special session, "Ludica Medica," devoted to that specialty. According to the Games for Health organization, topics covered at the 2012 Ludica Medica session this June included: - the advancement of game engines to improve their ability to depict health related systems, biology, and virtual patients - the conversion of off-the-shelf game technologies including software, hardware, and controllers for use in medical modeling & simulation - the development of next-generation AI (artificial intelligence) systems to improve key component technologies such as realistic patient interviews; and - specialized medical and biological models and visualizations that can be plugged into new games for training & education.
"We have seen a lot of activity in the area, but I think that the most important thing to understand is that a lot of the work in healthcare games that I have seen, so far, has been focused on the first-person perspective, that of a surgeon performing a procedure or an emergency room physician assessing a number of trauma cases. But there hasn't been a lot in games for healthcare training that has delved into the softer skills side." Sawyer was referring to those games that are less concerned with portraying scenarios with the highest degree of physical accuracy than concentrating on the underlying human behavioral models by which people are making decisions in healthcare, such as in differential diagnoses, interpreting lab results and assessing patient manifestations. This emphasis is particularly valuable where health care professionals' soft skills are less well developed, he pointed out. "Soft skills training is an area that offers a lot of opportunity, especially when you think about games being able to teach things that don't necessarily have to involve physical models," Sawyer explained. "This also encompasses more focus on preventative health, not just response-driven health care provisioning. The need for better soft skills offers opportunities for new types of training, and this is where games could possibly play a larger, more outsized role." medsim
O
ver the next several months, The American College of Surgeons (ACS) and The Association for Surgical Education (ASE) will be releasing a joint curriculum for teaching medical students patient skills. The curriculum will contain 26 different modules (Table 1) spread across the first three years of medical school education. The modules cover a wide range of skills including communication, taking a history and physical, signing out a patient, and placing a central venous catheter with ultrasound guidance. Simulation has always played an important part in medical education; we typically have called it “practice”. However, in the current era of medical student education, with the increased demands of knowledge acquisition, patient safety and quality, surgical educators are looking for a more efficient and effective means of teaching current students the skills that they will need to care for their patients. This is where the ASE Committee on Simulation began to ask the question: is there a potentially better and more efficient way to teach basic skills to all medical students through a unified curriculum utilizing simulation? It has been a several year process to identify the skills within modules, the components of each module, then author and review
each skill module. The project obtained a large boost and support when the Division of Surgical Education at the American College of Surgeons joined. In the end this will be but one piece of an even larger curriculum for surgeons beginning with medical students and ending with practicing surgeons. The modules are designed to be taught within a proctored small or large group setting, or as an individual self Table 1. ACS/ASE Medical Student Surgical Skills Curriculum Modules Year 1 Universal Precautions; Venipuncture and Peripheral IV; Basic Vascular Exam; Female Pelvic Exam; Male Groin and Genital Exam; Digital Rectal Exam Abdominal Exam Year 2 Nasogastric Tubes; Foley Bladder Catheterization; Intermediate Vascular Exam; Sterile Technique – Gloving and Gowning; Sutures, Staples and Drains – care & removal; Basic Airway Management; Communication; History and Physical; Case Communication Year 3 Basic Knot tying; Basic Suturing; Intermediate Airway; Local Anesthetics; Basic Ultrasound; Arterial Puncture and Blood Gas; Central Venous Catheter; Thoracentesis; Paracentesis; Management of Surgical Wounds; Interosseous IV; Communication; During Codes; Safe and Effective Hand Offs
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Robert Acton, M.D., FACS, provides insights on efforts by The American College of Surgeons and The Association for Surgical Education to establish a joint curriculum for teaching medical students patient skills.
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Image credit: Dr. Roberta Sonnino
Medical Curricula
Medical Student Skills Simulation in 2012
paced session. They are self contained and each module can be done independently or in a stepwise fashion from one to the next in a logical progression. Each contains an assessment tool for scoring and assessing a student, and providing feedback. However, they are not designed to determine competency of the student with each module. Over time, data may accumulate that will permit this option, but at the present time that data does not exist to determine competency. Please look for this upcoming exciting curriculum and other curriculums being developed by the American College of Surgeons and the Association for Surgical Education. Project leaders have included Daniel B. Jones, M.D, FACS who was the initial chair of the ASE Simulation Committee when the project began, through the current chair, Dimitrios Stefanidis M.D., FACS. This author has provided much of the day-to-day work of coordinating with the module authors and evaluators. Connie Schmitz, Ph.D., from the ASE Committee on Assessment, has provided great support with her team in improving the assessment tools accompanying each module. Kathleen R. Liscum, M.D., FACS has co-chaired the joint ACS/ ASE Steering Committee with Dr. Jones, and are the two surgeons who provided vision and leadership on the project. Ajit K. Sachdeva, M.D., FRCSC, FACS, the Director of the Division of Education at the ACS has been instrumental in supporting this project as part of a larger vision of longitudinal surgical education. This very important project would not be approaching launch with out the support and collaboration of the American College of Surgeons and the Association for Surgical Education. This exciting curriculum is on track to be launched in Spring 2013 in conjunction with Surgical Education Week and the Association for Surgical Education annual meeting. Many of the modules have been utilized by other module authors within each other’s institutions. The modules have performed well, but at this time we cannot claim that they are validated, this information will come with use and return of evaluation data. Please look for further communications by the American College of Surgeons and the Association for Surgical Education as spring approaches and you start to use the modules to teach your students. medsim
PATIENT SAFETY
Do Bar Code Administration Systems Improve Patient Safety? A Nurse’s Perspective
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B.F Ingelson, RN, MHA and T. Natalini-Whitmore, RN, MS note that while arguments in favor of the Bar Code Medication Administration adoption to reduce medication error rates are compelling, the barriers to the system and receptivity of nursing staff must be considered.
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I
n 2000, the report To Err Is Human: Building a Safer Health System,1 drew national attention to the problems surrounding patient safety. According to the Institute of Medicine, as many as 98,000 Americans die each year due to mistakes made by physicians, pharmacists and nurses. Kohn estimates that over 7000 United States citizens die as a result of medication errors each year.2 Over the years, medication errors have been closely studied, but solutions addressing prevention have been ineffective.
Background The use of an effective medication administration error prevention system could dramatically reduce the reported 38% of errors that occur at point of care (administration) with the potential elimination of sentinel events (causing patient harm).3 Information technology can significantly reduce errors and costs while improving the quality of care received by patients in the health care system. Recent solutions have focused on the use of bar-code technology in the patient care areas. Bar-code tech-
nology has been utilized in the retail industry and has recently made a place in the health care industry in combination with “smart” software for use in clinical areas.4 The bar code scanning system would be used to scan the caregiver assigned bar code, scan the patient’s assigned bar code, and scan the unique medication bar code. The bar code would ensure the right patient receives the right dose, right medication at the right time, via the correct route. This technology assists the caregiver by providing a “double check”. The
went live (Post-test Phase I), and four years following implementation (Posttest Phase II). The predictor variables for technology adoption included nurse characteristics (age, years of experience) and knowledge, beliefs, and motivation to use computer technology. Computer attitudes were assessed using the 57-item Burkes’ "Nurses Computer-Use Attitude Questionnaire"©.5 This instrument is detailed in Table I.
Figure 1: Work flow for Bar Code Administration System At bedside, nurse scans employee ID badge or enters ID
Nurse scans patient ID band
Nurse scans each medication
Methods Nurse administers medications
Nurses are the last line of defense in the protection of the patient in the medication administration process. The use of technology to improve patient safety will only work if any medication delivery system is utilized as designed. Nurses may develop ways to “work a round” the system, if they do not accept the new system. Previous studies have identified the following beliefs about the use of bar code technology: it slows down the nurses work flow; there is difficulty scanning bar codes; computer down times and other system issues are potential barriers. While some of these challenges are inevitable, they can be overcome. Although bar code technology does not eliminate all errors, when systems are circumvented, the opportu-
Design The purpose of this longitudinal study was to assess the influence of hospital nursing staff knowledge, beliefs, attitudes and motivation on adoption of new technology, bar code medication administration (BCMA) and ultimately medication errors. The study had a single experimental group quasi-experimental design. The setting for the study was a not-for-profit California community hospital. The study had three phases, prior to BCMA implementation (Pre-test), two months after the system
Description of the Sample Pre-implementation questionnaires were completed by 109 RNs prior to any training on BCMA to decrease the influence of the training on their pretest responses. Post- implementation surveys were completed two months after the BCMA was implemented in their area. The pre-test and Phase I post-test data were linked using the individual identifier codes. The Phase II post-test was completed
Table I: Nurse Computer Use Attitude Questionnaire Variable and Scores Scale Knowledge:
Number of Items 12
Response Categories and Scoring Multiple Choice; each correct answer = 2 points Possible Score = 0-24 total points 1- 5 Rating Scale
Beliefs
18
1 = least favorable beliefs about computers 5 = most favorable beliefs about computers 1- 5 Rating Scale
Motivation
18
1 = lowest level of motivation to use computers 5 = highest level of motivation to use computers 1- 5 Rating Scale
Acceptance: Pretest 21 Satisfaction: Posttest
1 = lowest level of acceptance/satisfaction of computers 5 = highest level of acceptance/satisfaction with computers
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Relationship Between Computer Use and Acceptance/Satisfaction, Knowledge and Confidence Levels and Beliefs
nity for errors increases. Organizations need to consider methods to increase nurse buy in, so they will embrace the system and use it as designed. In order to ensure that patient safety is maintained, the nurse-patient relationship must be at the forefront of any potential change.
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human-related errors and misjudgments at the point of medication administration would be reduced, with a resulting increase in patient safety. Although the arguments in favor of the Bar Code Medication Administration (BCMA) adoption in the reduction of the medication error rates are compelling, the barriers to the system and the receptivity of nursing staff must be considered. In particular, nursing perceptions of the BCMA impact on the patient care delivery model has not been widely studied. Implementation of new computerized medication administration systems will challenge existing organizational patterns.
All methods were approved by the Hospital Institutional Review Board (IRB). All nurses working in the areas were invited to participate in the study prior to the installation of the BCMA. All study participation was voluntary with study consents obtained prior to completion of the pretest. Each participant understood that his or her responses would remain confidential and no one’s identity would be revealed. Subjects provided their own individual code name to enter on the pretests and the Phase I post-tests.
PATIENT SAFETY
Table II: Study Participant Demographics
Study Phase
1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0
2 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0
Mean Years at this Hospital
6.2
4.7
72
23
Posttest - 2 Months
40.9
6.2
4.7
72
23
Posttest – 4 Years
42.5
8.7
8.3
72
28
by a random sample of 100 RNs four years after the BCMA was implemented. No personal identifiers were included. Since the data from the Pre-test Phase I sample and the Phase II post-test sample could not be linked, the characteristics of the two groups were compared for similarities. Analysis of the demographic and professional characteristics of the two groups found no significant differences in the two groups. One hundred and nine (109) of the potential nursing staff respondents completed the pretest before the staff was trained on the BCMA system. The majority (N=62; 54%) were employed full-time, N=43(40%) were nursing students in Phase I. About three-fourths of this sample (N=80; 73%) had no prior BCMA experience. All of those who reported previous experience were student nurses whoKnowledge worked in other roles within the organization, and interfaced with BCMA printed reports, but not with medication administration functionality. Of the Phase II post-test surveys randomly distributed, 100 submitted their questionnaires. All participants were full-time staff members. No student nurses participated in Phase II.
Figure II: Pretest, Phase I Posttest, and Phase II Posttest Technology Scores
Knowledge
2
5
1.8
4.8 4.6
1.6 1.4
4.4 4.2
1.2 1
4
0.8
3.8 3.6
0.6 0.4 0.2
3.4 3.2
0
3
PreImplementation
2
Post 2 Mos Knowledge
Pr
Post 4 Yrs
5
1.8 1.6
1.4 4.8
4.8 4.6
Motivation
5
Acceptance
5
5 4.4 4.8 4.2
1.2 4.6 4.8 1 4.4 4.6
4.6 4 4.4 3.8
0.8 4.2 4.4 0.6 4 4.2 0.4 3.8
4.2 3.6 4 3.4 3.8
4
0.2 3.6 3.8
3.2
3.6 3.4
0 3.4 3.6
Data Analysis
3.2 3.4 3 PreImplementation 3.2
The overall goal of statistical analysis was to determine the predictors of BCMA computer adaption and of nurse confidence PreImplementation Post 2 Mos Post 4 Yrs levels in the use of BCMA and identify the changes in knowlKnowledge edge, beliefs, motivation over time. Descriptive statistics were calculated for all variables, and bivariate analysis was conAcceptance 5 ducted to ascertain the relationship of predictors (professional 4.8 4.6 characteristics and pretest technology mean scores). For each 4.4 technology subscale, the scores on each item were summed 4.2 and a mean item score was calculated. For the graphs of the 4 mean subscale item response for the Pre-test and Phase I and 3.8 Phase II post-test knowledge, beliefs, motivation mean scores, 3.6 3.4 see Figure II. 3PreImplementation
3
Post 2 Mos
Post 2 Mos
PreImplementation
PreImplementation 4.8 4.8 4.6 5 4.6 4.8 4.4 4.4 4.6 4.2 4.4 4.2 4 4.2 3.84 3.84 3.6 3.8 3.4 3.6 3.6 3.2 3.4 3.4 3 3.2 3.2 33
Post 4 Yrs
Post 4 Yrs
Post 2 Mos
Pre
Post 4 Yrs
Motivation Acceptance Belief
55
3
3.2 3
Post 4 Yrs
Post 2 Mos
5
Perception: Does Bar Code Medication4.8 Ad 4.6 Prevent Errors? 4.4 4.2 4 3.8
120 97
100 80
3.6 3.4
58.5 60 40
3.2 3
34
PreImplementation
Post 2 Mos 20
Post 4 Yrs
PreImplementation PreImplementation
Post Post 22 Mos Mos0
Post Post44Yrs Yrs
2
2 Mos PostBurkes’ 4 Yrs The PreImplementation mean scores on all Post items in the pretest 6 technology questionnaire ranged from 72% (3.58 of 5) on the Belief Acceptance 5 5 scale to a high of 88% (4.38 of 5) on the Motivation scale. The 4.8 4.8 Administration Perception: Does Bar Code Medication pre-test Knowledge mean score for the 12 items was 10.8 out Errors?4.6 4.6 Prevent 4.4 4.4 of a possible score of 24. The pre-test Acceptance item mean 4.2 120 4.2 score for the 18 items was 3.62 out of 5. There was a signifi4 4 97 100 cant correlation between the participants’ Beliefs and Motiva3.8 3.8 80 tion, as well as Acceptance scores at the time of the first Phase 3.6 3.6 58.5 3.4 3.4 I Post-test. 60 3.2 3.2 For the entire sample in Phase I, age and experience were 34 40 3 3 negatively correlated with Technology scores. This was prob20 7.6 PreImplementation Post 2ofMos 4 Yrs in the sample. 2 1 ablyPreImplementation related to the inclusion the studentPost nurses
Percentage
ISSUE 4.2012
Critical Care
40.9
Study Results: Pretest Technology Scores
MEDSIM MAGAZINE
Med-Surg
Pre Implementation
3.2
32
Area Worked
Percentage
1.8
Mean Years of Nursing Experience
Yes
No
Belief
Phase I
Phase II
Perception: Does Bar Code Medication Prevent Errors? 120 97
100
Percentage
2
Mean Age
80 58.5 60 40
20 Post 2 Mos
34
Post 4 Yrs 2
0
0
Yes
No
Undecided
Perception: Does Bar Code Medication Administration Phase I Phase II Prevent Errors?
Yes
No Phase I
Phase II
Post 2 Mos
Perception: Does Bar Code Medication Administration Prevent Errors? 120 97
100 80
58.5 60 40
34
20
7.6 2
1
0
Yes
No Phase I
Two months after the system was implemented, staff nurses from the critical care areas with low belief scores also had low satisfaction with the system. These scores may be related to an underlying resistance to change imposed by the use of BCMA. Among the Phase II sample, fouryear post-implementation, the negative correlation between experience and age with the technology scores seemed to fade. All of the technology knowledge, motivation, and confidence/acceptance improved over time, except beliefs in the use of technology. The belief scores declined slightly from that 72% (3.62 of 5) on the Pre-test, to 70% (3.52 of 5) on the Phase I Post-test two months after the BCMA system was implemented, to 68% (3.4 of 5) on the Phase II Post-test four years later. None of the changes were significant. When the 43 nursing student scores were analyzed separately, the student’s mean scores significantly improved from the Pre-test to the Phase I Post-test. This positive change may be due to their age and higher adaptability to new technol-
Undecided
Phase II ogy. This age group had been educated in more technologically savvy environments than the older nurses. Based on study results, higher satisfaction post technology implementation correlates to higher motivation. This indicates a relationship between staff members that have high motivation and knowledge are more satisfied using technology which leads to increased confidence. It would also appear that nurses with less experience have a higher level of satisfaction with technology related to the safety mechanism offered through the use of technology. It was interesting to note the decrease in belief scores four years post implementation. The BCMA system changed between Phases II and I. Further inquiry into nurses’ responses indicates a lower belief in the system rather than the functionality. Overall, 97% of nurses felt that the use of BCMA helped improve patient safety in Phase II.
Discussion Many of the nurses anecdotally noted that the system was often “down”, there were scanning issues, and all related
Post 4 Yrs
feelings of frustration that impact satisfaction. Of note, there has also been a change in the type of BCMA system in the past four years. The nurse may have compared the functionality differences between the two systems, with a higher overall level of satisfaction noted with the previous system that may have lead to the decrease in the belief of the system. System differences were significant. Staff training for the new system were two hours longer in order to provide a more complete knowledge of functionality. Screens offered different visual cues and the two systems varied significantly. Warning errors were also different. This is significant when assessing nurse workflow and potential work a rounds.
Conclusion Overall results of this study indicate that technology implementation may be more widely accepted when staff are motivated and believe in the technology. A four-year period of time has elapsed, providing nurses with a true settling in period, during which BCMA has been part of their workflow. Nurses new to the organization, enter into employment without options as to the adoption or use of the technology. It would also appear that nurses with less experience have a higher level of satisfaction with technology, which increase level of confidence possibly related to the safety mechanism offered through the use of technology. Recommendations for future implementations of any computer technology would be greater preparation of staff to believe in the value of technology. This would lead to an increased level of acceptance, motivation and satisfaction. Inclusion of staff in pre- implementation planning with a high level of involvement may address motivation. medsim
References: 1. Kohn, L, Corrigan, J, & Donaldson, J (eds) (1999). To err is human; building a safer health system. National Institute of Medicine, Washington, DC, National Academy Press. 2. Kohn, L, Corrigan, J, & Donaldson, J (eds) (1999). To err is human; building a safer health system. National Institute of Medicine, Washington, DC, National Academy Press. 3. Barker, K., Flynn, E., Pepper, G., Bates, D., & Mikeal, R. (2002). Medication errors observed in 36 healthcare facilities. Archives of Internal Medicine, 162, 1897-1903. 4. Puckett, F. (1995). Medication-management component of a point-of-care information system. American Society of HealthSystem Pharmacists, 52(6), 1305-1308. 5. Burkes, M. (1991). Identifying and relating nurses’ attitudes toward computer use. Computers in Nursing, 9(5), 190-201
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PreImplementation
Post 4 Yrs
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Post 2 Mos
Percentage
ation
3
News & Analysis
Medical News 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.
ISSUE 4.2012
Surgical Patient Safety Program Reduces SSIs – A surgical patient safety program that combines three components - accurate outcome measurement, support of hospital leadership, and engaged frontline providers - reduces surgical site infections (SSIs) by 33 percent in patients who undergo colorectal procedures, according to a new study published in this August’s Journal of the American College of Surgeons. SSIs are the most common complication for this high-risk population, occurring in 15 to 30 percent of patients after colorectal operations, according to the study authors. “Colorectal surgical site infections have been tough to prevent. This is a first step to understanding a strategy for prevention. Wound infections are an important risk factor for hospital readmission, increased length-of-stay, and reoperations,” said lead study author Elizabeth Wick, M.D., FACS, a colorectal surgeon at The Johns Hopkins Hospital, and assistant professor of surgery at Johns Hopkins School of Medicine in Baltimore, Maryland.
MEDSIM MAGAZINE
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Robotic Surgery Simulation USC, Mimic to Share Robotic Curriculum for Surgeons – A team of researchers at the University of Southern California and Mimic Technologies developed a first-of-its-kind program for surgeons that will help identify which training programs are working for robotic surgery. The new technol-
tems, LLC has announced the release of its newest Hands-on Surgical Training (HoST) module, Radical Hysterectomy, for the Ross robotic Surgery Simulator (RoSS). Users now have the ability to practice two real radical hysterectomy procedures, as performed by expert robotic surgeons. RoSS is the only portable, stand-alone surgical simulator in its class that allows surgeons to practice real surgeries outside the operating room on patented, procedure-specific HoST technology.
Simulation in Medical Research
Above Ross robotic Surgery Simulator (RoSS). Image Credit: Simulated Surgical Systems, LLC.
ogy, called MShare, provides a forum for surgeons and hospital administrators, worldwide, to communicate and share curricula that have been validated by new research. The new system was unveiled at the recent American College of Surgeons conference. Radical Hysterectomy HoST Released for Ross Robotic Surgery Simulator – Simulated Surgical Sys-
Simulations Could Lead To Better Pediatric Cardiac Pump – Structural and mechanical engineers at the University of California, San Diego, are working together to create blood flow simulations that could lead to improvements in the design of a cardiac pump for children born with heart defects. The Berlin Heart is currently the only FDA-approved cardiac pump for young children who can’t be outfitted with an adult-sized pump. The device is used to extend a patient’s life until a transplant becomes available. Simulation Explains Anti-HIV Drug Effects – Pooling data from thousands of tests of the antiviral activity of more than 20 commonly used anti-HIV drugs, AIDS experts at Johns Hopkins and Harvard universities developed what they say is the first accurate computer simulation to explain drug effects. The model already clarifies how and why
Surgical Simulators US Simulator Center News Mount Sinai First in US to Implement Virtual Brain Simulator – The Department of Neurosurgery at Mount Sinai School of Medicine in New York is the first in the United States to use the NeuroTouch virtual-reality simulator designed to improve outcomes and reduce complications in patients undergoing brain surgery. Designed by the National Research Council of Canada, the device uses 3-D software coupled with handheld surgical controls providing tactile feedback to closely mimic an actual brain surgery. This allows neurosurgeons in training to practice and hone their skills, and neurosurgery faculty to continually assess their skills and potentially to rehearse their procedures in advance.
Hospital Systems Hartford Hospital Gets $10 Million to Expand Simulation Center – The state of Connecticut is contributing $10 million toward the expansion of a medical training facility at Hartford Hospital. Boston Medical Center Opens $1.75M Simulation Center – Boston Medical Center opened its new Alan D. Solomont and Susan Lewis Solomont Clinical Simulation and Nursing Education Center. The 5,000-squarefoot, $1.7 million facility is mostly used by the Nursing Education, Emergency Medicine, Anesthesia, Surgery, OB/ Gyn, Respiratory Therapy and Medicine departments. Claxton-Hepburn Medical Center Builds Simulation Room – ClaxtonHepburn Medical Center in Ogdensburg, New York, constructed a simulation center in collaboration with Chart Institute, its liability risk carrier. Mayo Clinic Florida gets $7M for New Sim Center – Wayne and Delores Weaver, owners of the Jacksonville Jaguars football team, donated $7 million to the Mayo Clinic in Jacksonville, Florida, for a new simulation center.
Virtual Reality NeuroCog NIH Grant for VR Capacity Assessment tool – NeuroCog Trials, Inc., a cognitive services provider for the clinical trials industry, received a $1.2 million Phase II grant from the Small Business Innovation Research program from the National Institute of Mental Health (NIMH), part of the
Providence VA Simulation Center Opens with EMS Technology – The Providence VA Medical Center in Rhode Island opened a new simulation center that uses Education Management Solutions’ Simulation Management Technology for healthcare providers to practice and train for invasive procedures, emergency care and more – and for instructors to track their progress. Greenville Hospital System Opens New Simulation Center – Greenville Hospital System opened its new Health Sciences Education Building that will house the new University of South Carolina (USC) School of Medicine Greenville and the Greenville HealthCare Simulation Center. The $60 million, 91,000-square-foot facility adjacent to Greenville Memorial Hospital will also be home to the Greenville campus of the South Carolina College of Pharmacy and a USC certified registered nurse anesthetist program. New Simulation Lab at Kish Hospital in Illinois – Kishwaukee Community Hospital in DeKalb, Illinois opened its new Simulation Lab that allows providers to practice problem solving in a real-time and safe environment so they can hone skills and improve reaction times working as a team with other healthcare providers. Medical Schools KGS, USF Health’s CAMLS to Improve Trauma Training – Kforce Government Solutions (KGS), Inc., part of Kforce Inc., entered into a joint research agreement with the University
Find job vacancies in medical simulation and training
35
New medical simulation centers are opening at a rapid rate, bringing big changes to the sector’s employment market. Find new jobs in the sector at:
www.halldale.com/medsimjobs To advertise a job vacancy contact your regional office: Eastern USA & Canada - Justin Grooms justin@halldale.com
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Western USA - Pat Walker pat@halldale.com
ISSUE 4.2012
National Institutes of Health (NIH), for the validation and commercialization of its Virtual Reality Functional Capacity Assessment Tool (VRFCAT©). The VRFCAT is a virtual reality measure that assesses a patient’s ability to navigate a variety of daily challenges using realistic, simulated environments.
•
Europe/RoW - Jeremy Humphreys jeremy@halldale.com
MEdSim Magazine
some treatment regimens fail in some patients who lack evidence of drug resistance. Researchers say their model is based on specific drugs, precise doses prescribed and on “real-world variation” in how well patients follow prescribing instructions.
News & Analysis ISSUE 4.2012 MEDSIM MAGAZINE
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of South Florida (USF) to investigate and innovate, new and improved trauma training technologies and methodologies. The collaborative research activities will be conducted primarily at USF Health’s Center for Advanced Medical Learning and Simulation (CAMLS) in Tampa, Florida. Fox Valley Tech Starts New Med Sim Center – Fox Valley Technical College (FVTC) in Appleton, Wisconsin, broke ground on a 60,000-plus squarefoot Health Simulation & Technology Center, the first new construction project as part of passing of a $66.5 million public referendum. The new facility costs approximately $11.7 million and is expected to open in fall of 2013. College of DuPage Opens Hospital Simulation Lab – The College of DuPage in Glen Ellyn, Illinois, opened a $350,000 Hospital Simulation Lab for its nursing students. The facility in the school’s Health and Science Center consists of a nurse’s station, four hospital rooms, two viewing rooms and one debriefing room. CMU College of Medicine Celebrates Building Grand Opening – Central Michigan University’s College of Medicine officially opened its $24 million, 60,000-square-foot building. The new facility on CMU’s campus features simulation labs, clinics equipped with the latest technologies and classroom environments enhanced for teamcentered learning and will welcome the College of Medicine’s inaugural class in the summer of 2013. Austen Bio Opens New Sim Center in Akron – The Austen BioInnovation Institute in Akron , Ohio held the grand opening of its 30,000-square-foot Center for Simulation and Integrated Healthcare Education in October. Venango College Receives $30K for New Simulation Lab – Northwest Savings Bank will donate $30,000 over three years to Clarion University Foundation, Inc., for the School of Nursing and Allied Health Simulation Lab currently under construction at Venango College of Clarion University in Oil City, Pennsylvania. Louisiana Breaks Ground on Medical Education Training Center – Our Lady of the Lake Medical Center in Baton Rouge, Louisiana held a groundbreaking ceremony for the new Louisiana State University Medical Education
Above Marquette University College of Nursing’s new simulation lab. Image Credit: Marquette University.
and Innovation Center, a component of a public-private collaboration among the state of Louisiana. Lipscomb University to Open New Simulation Center – Lipscomb University in Nashville, Tennessee, will open its Health Sciences Simulation Center and home of its School of Nursing this fall. The $7 million, 24,800-square-foot building will feature an assessment skills lab with a 12-station unit. Clovis Community College Opens Sim Center – Clovis Community College in Clovis, New Mexico, opened the doors to its Joe and Charlyne Sisler Allied Health Center that houses the Kathryn Burns Skarda, R.N. Simulation Clinic. The simulation center is filled with mannequin patients that are able to respond to students actions. Students will be using the lab in October.
Nursing Education Marquette University College of Nursing Gets New Simulation Lab – Marquette University in Milwaukee, Wisconsin, partnered with Wheaton Franciscan Healthcare Center to bring a new clinical simulation lab to the school’s College of Nursing that is now open for students. The $4 million, 9,400-square-foot facility includes a six-bed simulated hospital with two intensive care rooms, two medical
surgical rooms, one pediatric/neonatal intensive care unit and one labor and delivery suite. Louisiana Tech Nursing Gets New Simulation Lab – Louisiana Tech University’s Nursing School in Ruston, Louisiana, moved to a new hospital simulation laboratory room that has one-way mirror partitions so instructors can observe students as they carry out medical emergency scenarios. Milwaukee to Begin $3 Million Nursing School Expansion – The Milwaukee School of Engineering in Milwaukee, Wisconsin, will begin construction soon on a $3 million learning center for its School of Nursing. The 25,000 square-foot facility will include new nursing labs and classrooms which will nearly quadruple the size of the existing nursing labs. Construction is expected to be completed this fall. Cedarville University Opens New Health Services Center – Cedarville University in Ohio opened its new $18 million Health Services Center that is home to the University’s School of Nursing and School of Pharmacy programs. The 80,000-square foot building includes classrooms, small group work space, research facilities and state-of-the-art simulation labs. The labs are equipped with hospital beds and mannequins that mimic patient needs, pharmacy equipment for pharmacists-in-training and a birth simulation suite. University of St. Thomas School of Nursing Reopens – The University of St. Thomas’ new School of Nursing opened this summer, 26 years after the old one closed. The school’s Nursing Simulation Center lab features eight patient beds and cutting-edge technology like virtual IVs that use computergenerated animations to teach students how to insert intravenous needles. The lab is equipped with five fully-functional simulation manikins that mimic human reactions such as blinking, breathing, chest movement with heart and breath sounds, and pulses. Johnson Foundation Provides Nursing Education Grants – The Robert Wood Johnson Foundation gave nine states a $300,000 grant to advance strategies aimed at creating a more highly educated, diverse nursing workforce. California is one of nine states chosen by the Robert Wood Johnson Foundation (RWJF) for a two-year, $300,000 grant
U of South Carolina Sim Center Receives SSIH Accreditation – The Society for Simulation in Healthcare (SSIH) accredited the Palmetto HealthUniversity of South Carolina School of Medicine Simulation Center, making it one of only 20 such training facilities in the world. The three-year accreditation establishes the program as one that uses best practices in simulation, including continuous quality review, instructor development and effective teaching methodologies. SSIH is a multidisciplinary, international group dedicated to the advancement of simulation in health care. Preliminary Accreditation for UC Riverside School of Medicine – The University of California, Riverside’s planned medical school received “preliminary accreditation” from the Liaison Committee on Medical Education , the national accrediting body for educational programs leading to the M.D. degree in U.S. and Canadian medical schools.
International Sim Centers Happy 10th Anniversary – The Center for Advanced Medical Simulation and Training at the Karolinska Institutet in Stockholm, Sweden will be celebrating its 10th anniversary of operation on November 9, 2012 with a series of lectures. Scotland’s NHS Lothian Opens New Simulation Suite – NHS Lothian in Edinburgh, Scotland opened a new Simulation Suite in St. John’s Hospital. The facility includes a life-like mannequin known as the “Sim Man” that will be use to boost training across NHS Lothian. The mannequin breathes, has a pulse, and can mimic all forms of medical deterioration, including heart attack and hemorrhage and will allow trainees or existing staff the chance to learn safely and build in confidence. The suite and the Sim Man will give doctors, nurses, anaesthetists and theatre staff the chance to participate in real-life
surgeries. LHSC’s expansion plans for its Canadian Surgical Technologies and Advanced Robotics (CSTAR) program focuses on research and development into computer-assisted surgical equipment and simulation technologies for health-care providers. An example of the new surgical equipment LHSC is hoping to acquire includes the da Vinci Si HD surgical system.
Military Medical Simulation Luke AFB Teams with Mayo Clinic Arizona – The Mayo Clinic Arizona and the 944th Aeromedical Staging Squadron (ASTS) at Luke Air Force Base, Arizona formed an educational affiliation that will allow doctors, nurses and medical technicians from the squadron to train with a premier medical institution. The 944th ASTS currently trains with the 944th MDS, the 944th Civil Engineer Squadron fire department, and the 56th Medical. Singapore Armed Forces Opens Medical Simulation Training Centre – The Singapore Armed Forces (SAF) Medical Training Institute (SMTI) officially opened its Medical Simulation Training Centre (MSTC). The 450-square-meter facility can be configured to create a variety of realistic environments and can simulate up to six different scenarios at any one time. The facility is equipped with multiple video recorders for real-time and post-activity review to assist in experiential learning and 20 high-fidelity human patient simulators. Keesler AFB Sim Lab Wins Air Force-Level Awards – The US Air Force’s 81st Medical Group’s Medical Simulation Laboratory at Keesler Air Force Base in Mississippi was recently awarded three Air Force-level achievement awards at the 2012 Air Force Medical Modeling and Simulation workshop. The Keesler medical simulation staff earned these first-place honors for the 2011 training year: Medical Scenario Development Team Award; Tier -I Mentorship Team Award; and the Outstanding Coordinator Award. Surgical Chloe Joins Vibrant Response Training Exercise – Surgical Chloe, a full-body surgical simulator, debuted at this year’s Vibrant Response, as a training force-multiplier for the Army’s Forward Surgical Teams. Each
ISSUE 4.2012
Accreditations
scenarios and perfect their skills without posing a risk to patient safety. National University of Singapore Opens Medical Ed Center – The National University of Singapore opened The Centre for Translational Medicine, a 15-story facility that will focus on medical education and research. The centre includes a medical library, lecture and seminar rooms, laboratories for disease investigation and the Centre for Healthcare Simulation. The simulation centre is equipped with an emergency room, a pediatrics acute ward, a labor ward, eight clinical wards, two procedural rooms, an intensive care unit, an operating theatre and 60 consultation rooms. New Simulation Center Planned for UAE – The Thumbay Group U.A.E, promoters of the Gulf Medical University and Gulf Medical University Campus (GMC) Hospitals in United Arab Emirates (U.A.E.) signed a Joint Collaboration MOU with Tellyes Scientific, China to develop a state of the art Simulation Center in the GMC Hospital in Ajman. The joint collaboration also involves the exploration of the possibility to establish a state of the art multispecialty hospital in Tianjin, China in the next three years. The Thumbay Group UAE is an international business conglomerate with its head quarters in Ajman, United Arab Emirates. New $1.3 Million Australian Mobile Health Training Centre – The Australian Minister for Health, Jillian Skinner, launched a $1.3 million mobile simulation centre that is expected to revolutionize the way clinical training is delivered in regional and remote areas of New South Wales. The 19-meter-long semi-trailer is equipped with world-class training equipment worth more than $300,000 including a simulated man, woman and baby and various simulated body parts. The internal areas are interchangeable and can be used as a ward, emergency department, debriefing or lecture area and separate control room.” London Health Sciences Centre Aims to Upgrade Simulation – London Health Sciences Centre (LHSC) is asking the city of London for $35 million to acquire more state-of-the-art equipment to perform minimally invasive surgery, develop new simulators to train health-care providers and become the training centre of choice for robotic
37 MEdSim Magazine
to advance state and regional strategies aimed at creating a more highly educated, diverse nursing workforce. The funding is through a new RWJF program, Academic Progression in Nursing.
News & Analysis
year, thousands of members of the Joint Task Force – Civil Support travel to Camp Atterbury, Indiana, to participate in the U.S. Army’s Vibrant Response training exercise hosted by Army North, United States Northern Command and other inter-governmental agencies. Chloe allows surgeons and medics to test their competencies in areas such as medical knowledge, patient care, communication and professionalism.
Forks, Fargo, Minot and Bismarck. The $444,000, 44-foot-long vehicles will each include a simulated emergency room, a simulated ambulance and a simulation control center. A nurse and two paramedics from each of the state’s six major hospital systems will staff each vehicle and bring training to rural emergency units and hospitals.
New Curricula
Simbionix Launching Four New Products – Simbionix USA Corporation, a provider of medical simulation training and education products, introduced four new products at the recent American College of Surgeons Exhibition in Chicago. The new products are the MentorLearn™ Online solution for the LAP Mentor™ and the GIBRONCH Mentor™, the LAP Mentor™ Appendectomy Module, the Suturing Module for the da Vinci®Si™ Skills Simulator and a Suggested Implementation of the ACS/APDS Surgical Skills Curriculum. Lippincott Williams & Wilkins Launches E-Record Learning Tool – Lippincott Williams & Wilkins, part of Wolters Kluwer Health, launched Lippincott’s DocuCare EHR, an educational electronic health record (EHR) program. This new tool helps nursing students learn how to electronically chart patient care and prepares future nurses to meet expanding industry requirements for proficiency in health information technology and patient documentation. medsim
ISSUE 4.2012
U of Texas, Seton Technology Develop First Gynecology Surgical Simulation – Obstetrics/gynecological residents from The University of Texas Southwestern Medical School Residency Program in Austin participated in the school’s first gynecology surgical simulation developed by Seton Healthcare as part of their curriculum. The new simulation training for OB/ GYN residents in the Clinical Education Center at University Medical Center Brackenridge aims to improve teamwork, communication and technical skills by placing residents in a complex and lifelike patient scenario. The program is one of just a handful in the country offering this type of hands-on gynecology surgical simulation, according to Seton. EMS Launches Next Gen Clinical Simulation Management Platform – Education Management Solutions (EMS), a provider of simulation-based educational training solutions for healthcare providers and educators, has launched Orion, its next generation clinical simulation management platform. Orion is an intuitive, featurerich, and powerful clinical simulation management platform for training programs focused on optimizing clinical outcomes.
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EMS Simulation UND Receives $5 M for Mobile Training Vehicles – The University of North Dakota School of Medicine and Health Sciences received a $5 million grant to the UND will allow emergency responders in rural areas to receive state-of-the-art training without traveling to major health care centers. The donation will be used to station four mobile training vehicles in Grand
New Products
Index of Ads ACEP Scientific Assembly www.acep.org/sa Anatomy In Clay www.anatomyinclay.com B-Line Medical www.blinemedical.com CAE Healthcare www.caehealthcare.com MEdSim Magazine www.halldale.com/medsim MEdSim Job Pages www.halldale.com/medsimjobs Mimic Technologies www.mimicsimulation.com MT3 Conference www.mt3conference.com Simbionix www.simbionix.com
IBC 25 13 OBC 21 35 17 4 IFC
Events Calendar 2-7 November AAMC San Francisco, CA www.aamc.org 6-8 November ASPiH Oxford, United Kingdom www.aspih.org 9-10 November HPSN Europe Mainz, Germany www.hpsn.com 17-18 November SimSummit Ottawa, Canada www.royalcollege.ca 3-6 December IITSEC Orlando, FL www.iitsec.org 5-7 December Sim-one Toronto, Canada www.sim-one.ca 9-12 December IHI Orlando, FL www.ihi.org 15-18 December SOMA Tampa, FL www.soma.org
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Join Us for the ACEP Scientific Assembly in
Oct. 14 -17, 2013 The largest emergency medicine educational conference in the world
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10/19/12 8:06 AM
Meet Caesar: If he were any more lifelike he would need dog tags.
The best place to train your medical personnel is where they’ll experience what it’ll be like to be out with the troops. And with Caesar, you can. Environmental conditions in combat or “point of injury” situations can be hostile and make emergency care demanding. Rugged, durable and water-resistant, Caesar is a trauma patient simulator that can be used in all types of terrain and climates. More importantly, Caesar behaves like a real soldier that’s been wounded, with dramatic bleeding, responsive speech and eye movements, and accurate responses to tourniquet applications and other treatments. Find out more about Caesar. Visit caehealthcare.com or call toll free 866-233-6384.
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