MEdSim Magazine - Issue 4/2014 by Halldale Group

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Issue 4.2014

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Education & Training

The Future of Global Health SIMULATION CENTER

The 4-1-1 on Creating an ROI COMMUNITY PROJECTS

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ISSUE 4.2014

Editorial comment

Editor's Comment On July 17th the United States Senate Subcommittee on Primary Health and Aging met to discuss the leading causes of death in the US. The first two, heart disease, 597,000 and cancer, 574,000 came as no surprise. However, the third leading cause, preventable medical errors in hospitals, 440,000 a year or more than 1000 per day is unacceptable. Tens of thousands more died outside of hospitals from misdiagnosis and medication errors. These errors cause human suffering and cost US healthcare more than $17 billion. When you include the indirect cost it is more than $1 trillion. This is not just a US problem, it is taking place all over the world. The panelists invited to discuss the issues: John James, Tejal Gandhi, Peter Pronovost, Ashish Jha, Joanne Disch, and Lisa McGiffert, recognized leaders in patient safety; offered suggestions to improve the problem. Foremost is that medical harm has not received the attention it should have. The American health care system cost about 50% more than the most inefficient systems in the world and the price is paid in hundreds of thousands of American lives. However, in terms of healthcare we rank somewhere in the middle of the pack in patient care. Solutions offered by the panelists included: 1. Senate should establish a standalone committee for patient safety. 2. Expand CDC efforts in identifying, tracking and reporting preventable infections and develop validated metrics to identify and report issues. 3. ID better measures for patient safety in ambulatory setting and redesign health care from a human factors perspective. 4. Set up a follow-up method for patients being dismissed to ensure they understand how to take their medications and what they are supposed to do. 5. Develop a reporting system to follow-up on non-filled prescriptions. 6. Develop a better system to minimize primary care. 7. Incentivize payers to have a more active role in reporting and identifying problems. 8. Improve data collection and develop validated metrics. 9. Misdiagnosis of outpatients is a primary area of concern but no way to identify. Investigate. 10. System to identify failure to order and follow up on test results. 11. System to share all information with patients. 12. Create standards for the reporting of health care quality and cost measures by creating the equivalent of the Securities and Exchange Commission and Federal Accounting Standards Board for health care. Pronovost stated that “Today there are no standards for publically reporting performance measures or using

them in pay for performance programs. We need a system that identifies all preventable harm, not just those that fit into a narrow definition.” One panelist stated the most frequently identified causes of sentinel events reviewed in 2013 were Human factors (635), Communication (563), Leadership (547), Assessment (505), Information management (155), Physical environment (138), Care planning (103), Continuum of care (97), Medication use (77) and Operative care (76). The first three factors relate to people: • Human factors - staffing levels, staffing skill mix, staff orientation, in‐service education, competency assessment, staff supervision, resident supervision, medical staff credentialing and privileging, rushing, fatigue, distraction, complacency, bias. • Communication - oral/written/electronic, among staff, with/among physicians, with administration, with patient or family. • Leadership - organizational planning and culture, community relations, service availability, priority setting, resource allocation, complaint resolution, collaboration, standardization and best practices, inadequate policies and procedures, non‐compliance with policies and procedures. As for changing policy, there needs to be a clear chain of accountability; clear communication; an educated board, not just in finance but patient safety; have CEO pay tied to compensation and develop a program where senior teams share success stories in their hospital and across their systems. These were a few of the outcome measures panelists felt needed to be addressed to achieve patient safety. They also felt that there should be a public reporting system for those hospitals with unacceptable error rates in infections, deaths and negative outcomes. There are some success stories. For example, automated workforce solutions allowed Anderson Regional in Mississippi to make agile staffing decisions based on organizational needs and census resulting in safe and effective staffing, improved productivity and $2.5 million in reduced labor cost in eight months. Policy issues of high reliability and reporting within the organization and transparency without penalty need to be established. Right now we are failing our healthcare professionals and their patients. Developing standards of education, practice and accounting need to be addressed. (See Publisher's Comment p.30)

Judith Riess Editor in Chief, MEdSim Magazine

e judith@halldale.com MEDSIM MAGAZINE 4.2014

Contents

ISSUE 4.2014

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 Advertising Director of Sales Jeremy Humphreys & Marketing t. +44 (0)1252 532009 e. jeremy@halldale.com Sales Representative Justin Grooms USA & Canada t. 407 322 5605 e. justin@halldale.com Sales Representative Chris Richman Europe, Middle East t. +44 (0)1252 532007 & Africa e. chrisrichman@halldale.com Sales & Marketing Karen Kettle Co-ordinator t. +44 (0)1252 532002 e. karen@halldale.com Marketing Manager Ian Macholl t. +44 (0)1252 532008 e. ian@halldale.com

Operations Design & David Malley Production t. +44 (0)1252 532005 e. david@halldale.com

Distribution & Stephen Hatcher

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03 Editor's Comment. Editor Judith Riess examines using new ideas and existing data to improve patient safety. 06 The Future of Global Health. Lisa V. Adams, MD looks at global health and global inequities and discusses how future students will be trained. 10 Simulation Opportunities for the Health Technologies Sector. Robert DiRaddo and Christine Bryce discuss the application of simulation technologies across a broad spectrum to achieve NRC goals. 14 Hands up for Health: Extending Simulation to Community Education. Beth Thomas, MD and Gabriel Reedy, PhD discuss Hands Up for Health, a community based simulation program designed to involve youth in healthcare careers. 18 The Changing Face of Ultrasound Training in the Era of Cloud-Based Services. Dan Katz, MD and Eric Savitsky, MD describe the steps taken to develop an affordable ultrasound training program. 24 The Importance of Standardization in Simulation Technologies and the Training of Technicians. Marty Kauchak spoke with James Cypert, MCSE, MCT, MCP, A+, N+, MOUS regarding consistency in the training of technicians. 26 The 4-1-1 on Creating an ROI. Amar Patel, DHSc(c), MS, NREMT-P, CFC, Director of the Center for Innovative Learning at WakeMed Health & Hospitals describes how to develop a business plan for your simulation center. 30 Publisher's Comment. Publisher Andy Smith compares the heathcare and aviation sectors and looks at the need to improve patient safety. 31 Seen & Heard. Updates from the medical community. Compiled and edited by the Halldale editorial staff.

MEDSIM MAGAZINE 4.2014

On the cover: Emergency Room providers assess a critically ill child during a simulation scenario that was testing the ED process at a new free-standing ED in Garner, NC. Image credit: WakeMed.

Artworker Daryl Horwell

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Education & Training

The Future of Global Health Lisa V. Adams, MD sheds light on how global health has become its own discipline and how future medical students will define competencies and equities in global health.

ver the last decade, the field of global health has grown by every conceivable measure. Students at all levels – sometimes as early as high school – are participating in global health projects and programs. As a result, more students are entering medical school with a range of overseas experiences under their belts, and are eager for advanced training. Many applicants inquire about formal global health opportunities during their medical school interviews, suggesting that global health may be a factor in their choice of a medical school. The medical student’s interest and desire for clinical opportunities in global health often continue into his or her residency and fellowship training. Several residency programs now offer global health tracks within, or across, specialties. Many non-profit organizations also offer volunteer service-learning opportunities for students, while organizations such as Child Family Health International1 are devoted exclusively to providing structured volunteer community-based programs to educate students and institutions on global health. However, in spite of this growth in the number of programs, opportunities and funding, demand among our learners appears to outstrip our offerings. In response to the high demand among students and the emergence of global health as its own discipline, many medical schools are establishing global health programs, centers and institutes. These new entities are often charged with defining curricular and co-curricular opportunities and determining what defines competence in global health. The field of global health has also piqued the interest of mid-career and retiring faculty, some because of earlier overseas experiences, and others who seek to apply their skills where the need is greatest, now that they have more time. Lastly, research opportunities in both communicable and non-communicable diseases seem 06

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to be on the rise, with several new requests for applications announced in recent years. These opportunities have targeted clinical researchers as well as those engaged in global health training and provision of technical assistance.2 Witnessing this remarkable growth has many global health educators wondering whether the training and guidance that we provide to students today will be applicable in the next decade, or beyond. Global health did not exist as an academic discipline when I was in medical school 25 years ago. It is unlikely that those early clinicians who blazed the path in the era of tropical medicine, and later international health (the precursors to global health) could have anticipated the evolution of their field to the currentday practice of global health. What indications do we have to help us predict what global health study and practice will look like 25 or 30 years from now?

Recalibrating the Compass: A Focus on Health Equity Many of us who work in global health are driven by the same motive: to heed the call so aptly described by Rwanda’s Minister of Health, Dr. Agnes Binagwaho, namely, “to work together towards

Above Geisel School of Medicine student volunteering at the Mascoma Clinic in Enflied, NH. The Mascoma Clinic is one of a network of clinics that provide medical services to the underserved and uninsured in the Upper Valley region. Image credit: Rob Bossi.

a future in which where a patient lives doesn't determine if they live.”3 While we may use different terms to describe our motivations - a sense of social justice, a moral or religious imperative, a sense of fairness, a recognition of health as a human right - I would posit that many of us are driven by a desire to reduce or eliminate health inequities in the world. Indeed, one of the most cited definitions of global health, published in the Lancet by Koplan et al., firmly puts health equity at the core of global health. Specifically, they define global health as “an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.4 If health equity is a common thread, we should be certain that our students have a strong foundation in understanding what health equity is, and how it can be achieved. As with global health, definitions of health equity, or more often health inequities, abound, but most encompass the concepts of systematic differences that result in worse health or greater health risks experienced by disadvan-

taged groups, often identified by social, racial, ethnic, economic or demographic distinctions.5,6 Reducing or addressing health inequities, sometimes referred to as health disparities, has been well studied in a variety of settings, especially across different populations in high- or middle-income countries. Applying this knowledge to global health settings will intersect with health systems strengthening to ensure, among other things, health care access and quality. If global health training or capacity-building will strengthen the health care workforce and improve quality, then global health research will create knowledge to improve the diagnosis and management of various diseases and organization of services, while global health practice will increase access. All of these (training, research and practice) together can improve overall health care delivery. By understanding the systematic nature of health care inequalities, clinicians can design innovative systematic solutions. Furthermore, since today’s challenges in global health are multifactorial and complex, the solutions must

be multidisciplinary. Tomorrow’s (and arguably today’s) global health practitioners must work well within multidisciplinary teams - with nurses and other allied health professionals, but also with educators, engineers, politicians and manufacturers. They must understand the various roles and contributions that colleagues across many disciplines can make. They must learn how to become what Rishi Manchanda calls, in his new book by the same name, “upstream doctors” - providers who can heal the acute problem, while looking upstream to the root problem and engaging aligned colleagues and services to address the causes. Eliminating or reducing health care inequities from the health care system may not guarantee the same health care outcomes for all, but it will certainly go a long way towards that goal.

The Importance of Partnerships Experts in global health recognize the importance of strong in-country collaborations in order to be effective, efficient and responsive to host country priorities.

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Education & Training How to build effective partnerships has been the challenge. While there may not be (there likely isn’t) a single approach that applies to all, or even most, international collaborations, there are some common characteristics that form the foundation for effective and equitable partnerships. In the past, international health partnerships were often unbalanced. At worst, the United States or European institution provided assistance to those in the global south as a charitable act, with at times the condescending attitude of helping “the poor natives” improve themselves. Equally unacceptable were the situations in which the US or European partners used the local teaching hospital as a site at which to train their students, or for their faculty to conduct research with little or no recognition of the host country partner’s participation or contributions. While these types of partnerships are more rare today, and such attitudes regarded as offensive, the truth is that there is often still a subtle undercurrent of a superior/inferior dichotomy to many international collaborations. It is ironic that the work aimed at reducing inequities in health should replicate inequities in professional relationships.

Dr. Lisa Adams discussing a patient after rounds with a medical Felix while internal medicine resident Theoneste looks on at the University Teaching Hospital in Kigali, Rwanda. Image credit: Lars Blackmore.

Partnering in Rwanda Fortunately, today there are many examples of university partnerships where the effective transfer of knowledge and skills is occurring, and the leadership is squarely in the hands of the hostcountry partner. One such example that I have been involved with is the Rwanda Human Resources for Health Program. Launched in 2012, this program is a comprehensive sevenyear commitment to rebuild the Rwandan medical education system, with the overall goal of creating a sustainable, highquality health care system. Eight medical schools, five nursing schools, two dental schools, and one health-management program comprise the consortium of US partners that send their faculty members to work for one year at a time in the teaching hospitals in Rwanda. This program has many unique features: the inclusion of multiple specialties and several health professions, the lengthy duration of stay for the faculty, and the number of collaborating schools, all of which have been described in detail elsewhere.7 An important feature of this partnership, as we consider equitable engagement, is that the Rwandan Ministry of Health is providing the leadership for this program. A comprehensive memorandum of understanding outlines the relationships and responsibilities of each partner, but the US partners serve at the invitation and under the direction of the Rwandan leadership team. In this relationship, we strive for Rwandanmanufactured and Rwandan-owned solutions to the health education problems. Not every Ministry of Health in every county would be willing or able to assume such a massive undertaking, and to be prepared for a revolutionary change in their health care system, but those countries that are ready for such responsibility ought to be given the reins. Partnerships like this one are well positioned to evolve into a meeting of equals: not necessarily equal in terms of financial investments or Gross National Products, but equal relationships in which each partner brings complementary skills and expertise to the table. We in the global north already know we have much to learn from our counterparts in the global south - both 08

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because great ideas are born everywhere, and because resource constraints often have historically led to impressive efficiency and innovation in health care delivery. The concept of “reverse innovation” has been described in the business world8,9 and is now being applied to health care.10 An open mind and humility required. Next, we must commit to create research and educational collaboratives in which each participating institution contributes in a unique and significant way. Additionally, if we expect these types of partnerships to become the norm in global health, we need to ensure that our students are well equipped as good partners who know how to build equitable and successful collaborations across cultures, disciplines and distance. Required courses may begin to resemble those more common to a business school curriculum - i.e. courses on negotiation and management - or may belong to the social science disciplines such as anthropology or sociology. A global health curriculum of the future will require flexibility and will draw upon the expertise of many colleagues outside of the traditional medical sciences.

Redefining Roles Beyond building effective and equitable partnerships, clinicians also need to consider the role for a US-trained global health practitioner of the future. As discussed, the traditional pattern of global-north-to-global-south assistance no longer applies. Access to information is not the major bottleneck it once was for many students in low-income countries. Internet bandwidth continues to improve, and open-access journals are gaining in popularity and prestige. In addition, the World Health Organization’s HINARI (Health InterNetwork Access to Research Initiative) Programme, established with the support of major publishers, now provides people in low-income countries with access to a wide range of electronic medical journals and other resources.11 Videotaped lectures and downloadable slide decks are available from many reputable

Internet sites. As our colleagues in Africa, Asia and South America gain access to the content, strengthen their own universities, and take advantage of the many scholarship programs to train their own leaders at internationally-renowned institutions, what role will the US graduate, with similar classroom learning and only a few months of overseas experience, have to offer to these international partners? The reality is that there are still - and may be for some years to come - sites in the developing world where there is either no doctor or too few doctors with sufficient training. While these positions will always be best filled by those who understand the culture and speak the language of the patients, there are some foreign doctors who make long-term commitments, and, despite always being somewhat outsiders, assimilate as much as any outsider can, while offering a real service to the population. In addition, until skill transfer is complete, there are patients in low-resource areas who benefit from short-term visits by foreign surgical teams to repair cleft palates, close obstetric fistulas and replace damaged heart valves. However, in the next decade or two, as health care workforces overseas are strengthened; as skill transfer to the rising generation of young, mobile and tech-savvy health care professionals occurs; and as our US colleagues enter existing equitable partnerships or establish new ones, what role will the US global health practitioner play? The good news is that every specialty has a place on the global health stage. Most collaborations now cut across many, if not all specialties, from dermatology to pathology; thereby students are free to pursue the specialty they are passionate about, without fearing any loss of options for future work in global health. As our international counterparts emerge as the top experts in traditional global health fields, like maternal and child health and infectious disease, US global health physicians will need to build partnerships in which they can add value. In the big picture of global health, the majority of students share a desire to achieve health equity for all. While the term “health equity” does not generate the same buzz as the concept of “global health” does at the present time, someday it will. If we want our students to be versatile to practice wherever there are health inequities, we should refocus their training accordingly. We have a lot to learn from colleagues who focus on domestic

health equity, and joining forces with them will surely make us a stronger force for good. There are more similarities than differences in working with underserved populations who have been subjected to systematic health inequities, regardless of whether they live in rural New Hampshire or urban Dar es Salaam. We need to teach our students to recognize these similarities, and equip them to take on the challenges, regardless of the setting. Looking to the future, such training will generate the most effective global health practitioners - some of whom may opt to practice in a very familiar part of the globe, in local communities where the needs are surprisingly stark.

Conclusion As we move beyond the north-assists-south pattern in global health, we must adapt the roles of our global health specialists and adjust their training accordingly. Realizing that a desire for health equity is at the heart of most global health work provides one direction. Challenging our students to focus on health equity as the underlying issue should well prepare them for a life of global health work - and a career that may take them around the globe, or have them land in their own backyard. medsim About the Author Lisa V. Adams, MD is the Associate Dean for Global Health at Dartmouth's Geisel School of Medicine. She is the Director of Geisel's Center for Health Equity and Advisor for the Global Health Initiative at Dartmouth College’s John Sloan Dickey Center for International Understanding. In these roles, she develops and oversees crosscutting global health programs involving faculty and students. Her area of expertise is domestic and international tuberculosis care and control. She has provided technical assistance to the national tuberculosis programs in Ghana, Swaziland and Tanzania on the development of pediatric tuberculosis clinical guidelines, pediatric TB care delivery and TB program monitoring. At Dartmouth, she teaches courses on global health to medical and college students. She is a collaborator of the DarDar Programs, a partnership between Dartmouth/Geisel and Muhimbili University of Health and Allied Sciences focused on tuberculosis and tuberculosis/HIV care and research. Most recently she spent six months in Rwanda as Dartmouth’s lead in Rwanda’s Human Resources for Health Program.

REFERENCES 1 Child Family Health International. www.cfhi.org. Accessed August 14, 2013. 2 Collins F, Beaudet A, Draghia-Akli R, et al. A database on global health research in Africa. Lancet Global Health. 2013; 1(2): e64-5. 3 Binagwaho A. Rwandan health minister hits back at critics of drug company deal. The Guardian. May 21, 2013. http://www.theguardian.com/ world/2013/may/21/rwanda-health-minister. Accessed August 14, 2013. 4 Koplan JP, Bond TC, Merson MH, et al. Towards a common definition of global health. Lancet. 2009; 373(9679): 1993-5. 5 Braveman P. Health disparities and health equity: concepts and measurement. Annu Rev Public Health. 2006; 27: 167-94. 6 Starfield B, Gérvas J, Mangin D. Clinical care and health disparities. Annu Rev Public Health. 2012; 33: 89-106. 7 Binagwaho A, Kyamanywa P, Farmer PE, et al. The human resources for health program in Rwanda--new partnership. N Engl J Med. 2013 Nov 21;369(21):2054-9. doi: 10.1056/NEJMsr1302176. 8 Immelt JR, Govindarajan V, Trimble C. How GE is disrupting itself. Harvard Business Review. October, 2009. http://hbr.org/2009/10/how-ge-is- disrupting-itself/ar/1. Accessed August 14, 2013. 9 Govindarajan V. The case for “reverse innovation” now. Bloomberg Businessweek. October 26, 2009. http://www.businessweek.com/stories/2009 10-26/the-case-for-reverse-innovation-nowbusinessweek-business-news-stock-market-and-financial-advice. Accessed August 14, 2013. 10 Reverse Innovation Health Care Conference. International Centre for Health Innovation. http://ichilglobalhealth.ca/about/. Accessed September 15, 2013. 11 HINARI Access to Research in Health Programme. World Health Organization. http://www.who.int/hinari/en/. Accessed August 15, 2013. M E D S I M M AGA Z IN E 4 . 2 0 1 4

Simulation Technology

Simulation Opportunities for the Health Technologies Sector Robert DiRaddo and Christine Bryce talk about the National Research Council of Canada’s simulation technology development.

obert DiRaddo and Christine Bryce talk about the National Research Council of Canada’s simulation technology development. Realism. Convenience. Affordability. These are objectives the National Research Council of Canada (NRC) has embraced over a successful history of developing simulation technologies for applications varying from vehicle part manufacturing to food packaging to medical device design. Today, NRC is advancing these goals and building on past success to usher in a new era of user-centric, real-time simulation throughout the health technologies industry sector. NRC developed NeuroTouch, the surgical virtual-reality (VR) simulator, in collaboration with teaching hospitals from across Canada and is now deploying it to an international group of early adopters. This development lays the foundation for future development to bridge technology gaps and ultimately contribute to better patient care.

Simulation for surgical training Surgical expertise is well-developed in industrialized regions, but challenges remain worldwide, due to gaps in training and in the requirement to perform a wide variety of operations. Constrained health care systems allot less and less operating room (OR) time to teaching (Roberts et al, 2012). Considering that 11% of the global burden of disease can be treated with surgery (Ozgediz et 10

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al., 2008), effective and affordable training takes on even more significance. Mimicking pilot training, the adoption of simulation in surgical training curricula will elevate the expertise of surgical residents and favourably impact patient care. “In the next 5-10 years, I expect every major neurosurgery centre to have simulators,” predicts Dr. Rolando Del Maestro, Director of the Neurosurgical Simulation Research Centre at the Montreal Neurological Institute and Hospital (MNI), a pioneer of simulation in surgical training and an early supporter of this R&D program at NRC. “Simulators allow us to see how the best neurosurgeons do procedures, and haptics provide insight to what sensible cues they are responding to. We can train people to that level of expertise and develop benchmarks for excellent performance.” Simulation allows students of all surgical specialties to understand the technical attributes necessary for a specialty, teachers to implement technical instruction based

Figure 3 Physical simulation of tissue dissection for accumulating human factor engineering user data . Image credit: NRC.

on competence rather than time spent in a program, and patients to benefit from the increased safety gained from repeated rehearsal of operative and other procedures. In addition, there is potential for regular assessment of individual competence so that technical abilities remain constant and may even improve. The development of NeuroTouch through the formation of a group of early adopters established the user-centric approach which has proven pivotal to producing realistic exercises that surgical residents can relate to. “I see high potential for consortiumwide studies in simulation performance,” says Dr. Joshua Bederson of The Mount Sinai Hospital in New York City. “We can involve thousands of participants, from students and residents to expert surgeons, in a multi-institutional study on specific surgical tasks and set international standards for performance in surgical simulation.” Dr. Bederson has performed such studies on smaller participant groups including expert neurosurgeons and students. While students’ skills did not reach the maximum score of experts over four repetitions, additional coaching sessions between repetitions proved effective in accelerating improvement, indicating how to improve teaching of the technique. Moving forward beyond NeuroTouch, NRC is well-positioned to address a variety of anatomic and surgical specialties by providing unique, integrated expertise in robust, real-time finite element simulation; affordable human-machine interactivity; and biological tissue models. Improving realism, convenience and affordability will expand offerings to include hybrid VR-mannequin training and extension to mass diffusion mobile platforms.

Simulation for distance learning Dr. Allan Okrainec of the University Health Network (UHN) in Toronto welcomes the concept of mass diffusion. His research team pioneered “telesimulation”, distance learning of surgical skills utilizing simulation, back in 2007 with the first-ever training course in laparoscopic surgery delivered via Skype, to

surgeons in Botswana. Numerous successful training courses have followed around the world. “Telesimulation is absolutely the way of the future,” he declares, conceding that while travel to training sites by expert trainers will never be eliminated, “simulation provides pre-training and supplements to on-site visits thus improving adoption and retention of new procedures.” January 2014 marked the launch of a new UHN research study which partners with Korle-Bu Teaching Hospital in Accra, Ghana, and uses VR in

telesimulation for the first time (Figure 1). This project, funded by Grand Challenges Canada and in partnership with NRC, has provided a pediatric surgical simulator to Ghana surgeons for training of Endoscopic Third Ventriculostomy (ETV), employed to treat hydrocephalus. Buildup of cerebrospinal fluid in the skull affects about 1/500 births and is readily treated surgically, but currently less than 10% of children in east, central and southern Africa receive treatment, according to Dr. Okrainec. The four-week training period went well and testing results are eagerly anticipated to demonstrate the

The Michigan Lung changed the way that lung simulation was perceived when it was introduced, and it is again ready to “breathe” new life into the respiratory industry. The updated user interface is more intuitive, and allows for easier setup and operation. The improved Training & Test Lung and PneuView3 software provides comprehensive data to users by displaying dozens of parameters including pressures, flows, volumes and more. A low cost of ownership ensures that everyone can affordably upgrade to the newest version today. For a “breath” of fresh air, visit www.michiganinstruments.com/pv3.

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Simulation Technology success of this training technique and confirm continuation to the next phase of the project. Further technological improvements can only benefit the affordability, convenience and robustness of telesimulation: better telecommunication, video quality, and interconnectivity “so that all simulators can ‘talk’ to each other,” envisions Dr. Okrainec. “We could upload patientspecific images to connect all simulators on the same case before surgery, to share expertise and learnings, and work together to improve patient outcome.”

Simulation for Personalized Rehearsal The integration of patient-specific images with surgical simulation presents a significant opportunity: the ability to rehearse a high-risk procedure, using data for the actual patient, in a realistic yet safe environment. CT and MRI scan images can be transformed into three-dimensional renderings and incorporated into an exercise offering haptic feedback so that best approaches may be formulated before stepping into the OR. Simulators, and the surgeons using them, will only be as good as the data they rely on. High-quality images clearly are needed to plan and execute excellent patient care, including surgery. Leveraging its expertise in processing and augmenting large information sets from images and sensors, as well as in differential tissue behaviours, NRC is actively working with Canadian industry to move simulation into the rehearsal domain and optimize creation of the ready-for-simulation patient case. A key technology gap, says Dr. Bederson, is the development pipeline. “Better haptics mean that it is harder and longer to generate rehearsal scenarios. The high sophistication and detail within NeuroTouch makes it a challenge.” Adds Dr. Del Maestro: “If surgical rehearsal were generally viewed as a prerequisite to high-risk surgery, it could hasten regulatory approval and wide acceptance of surgical simulation.”

Simulation for Surgical Robotics “It began in the mid-1990s with the desire to move imaging and other technologies 12

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into the OR,” says Dr. Garnette Sutherland of the University of Calgary, and ultimately translated into the ability to perform robotic surgery within the bore of the MR magnet from a remote sensory immersive work station. Robotics in surgery “are a disruptive technology, completely different from before” and rely on state-of-theart engineering to recreate the sight, sound and touch of microsurgery. “Technology push may come from engineers, but there needs to be a technology pull; neurosurgeons need to be convinced that the technology will either make the performance of surgery easier and/or improve patient outcome.” Wider adoption of surgical robotics would be facilitated by realistic training modules, and interactive simulation is a natural mechanism to provide it. Like simulators, robotics rely on highquality imaging, force feedback (haptics) and efficient computation for success, albeit at a far higher level of sensitivity to actually duplicate the movements of instruments in a surgeon’s hand. Dr. Sutherland points to the current computational gap as a barrier to wider distribution: “Currently, no computer can deal with the complexity needed for patient-specific cases, and none can replicate the past memory and experience that help surgeons ‘guess’; for instance, predicting the site where bleeding will start. Can a computer learn to guess?”

Simulation for Rehabilitation and Wellness In the movie Star Trek II: The Wrath of Khan, the Kobayashi Maru exercise tests potential starship captains on their management of a doomed mission, ending in the destruction of either the merchant ship they were trying to rescue or their own ship. Dr. Del Maestro’s research team at MNI, working with Dr. Penny Werthner and Sommer Christie from the University of Calgary, designed their own Kobayashi Maru simulation of surgery where bleeding could not be controlled and the patient was doomed to die. Unexpectedly, two expert surgeons beat the scenario and stopped the bleeding by focusing all energies into locating the bleeding source. EEG measurements on the participants (Figure 2) showed that for those considered most expert, no difference was observed between real and simulated situations, whereas residents showed a measurable difference. “Can we teach this highest level of focus to junior residents?” muses Dr. Del Maestro. The research team at MNI aims to understand how surgical errors and other stresses in the OR affect surgeons. “Errors always occur – there are always situations not

Figure 1 Telesimulation session between the University Health Network in Canada and the Korle-Bu Hospital in Ghana. Image Credit: University Health Network.

encountered before, but with experience, it is easier to analyze and manage the error. Simulation can help us understand, and teach, the analysis-management processes an expert demonstrates.” Research on stress control using simulated environments can be translated to everyday life situations outside of surgical training, especially considering the increasing trend of outpatient and home care. For example, rehabilitation programs could be accessed from home, customized to the needs of individuals using VR-based tools to demonstrate and evaluate exercises and tasks. A range of programs addressing mental and physical wellness needs can be developed, based on proven fundamental expertise in biomechanics and interactive feedback.

Simulation for Human Factor Engineering (HFE) Human factor engineering and evaluation have become an important aspect of device development, especially in a field where safety is critical and use errors have a direct impact on the health and welfare of millions daily. The Food and Drug Administration of the USA has established guidelines and a reporting procedure for HFE as part of medical device pre-market review. “Human factors go beyond ergonomics and design to safety and security, so not just ease of use but safe use,” notes Patricia Debergue, researcher at NRC. “A new device undergoes many stages of development, from idea to mock-up to refined design, and testing is associated with every stage.” Testing in the hands of not just the developers, but most importantly the intended users, whoever they may be: health care professionals, homebased caregivers, or individuals administering to themselves; ages from elderly to children; various physical abilities and/or constraints. Companies developing new devices, especially smaller companies, may look to external sources of specialized expertise and infrastructure to generate objective data, mitigate risk, minimize reliance on animal testing, and ultimately reduce the number of iterations within a development cycle. Simulation can aid in the testing by imitating the intended uses and use environments, early in the life cycle of the new product when the design can still be changed. For instance, a developer testing a novel surgical instrument needs to not only replicate physical attributes of the device and the biological tissue, but also capture the real situation as much as possible, such as light level, noise and distractions of the OR, in order to recreate the level of focus required. Both physical modelling using polymer or biological tissue mock-ups and VR representation can help to collect meaningful usability test data under realistic conditions and carefully observe users’ approaches and reactions to the new product or design. NRC has a comprehensive biomechanics, tissue and polymeric testing capacity ideally suited to support such work. (Figure 3)

Summary This overview offers a window into the future role of simulation across the health technologies industry sector; medical training, distance learning, personalized rehearsal, robotics, rehabilitation/ wellness and human factor engineering. Current technological gaps are already being narrowed as innovative medical devices are being developed by companies from large multinationals to small businesses. NRC partners with such innovators to help

mitigate the risk and accelerate the development cycle, offering simulation and software solutions which realistically mimic actual applications, customized to users’ needs. According to Rolando Del Maestro, “Our goal should always be excellent patient care and excellent patient outcome... Simulation is a step change in medicine, and as globalization of this technology occurs it may rival the importance of the introduction of anesthesia or sterile technique to surgical outcomes. Transitioning this dream to an approachable reality will result in a worldwide improvement in the care of surgical patients.” medsim

Figure 2 Surgeon being monitored for personal stress levels while interacting with a surgical simulator. Image Credit: Neurosurgical Simulation Research Centre, McGill.

About the Authors Robert DiRaddo, Ph.D., joined NRC in the early 1990s, working on simulation for the automotive, packaging and petrochemical industries. In the mid-2000s, Robert initiated the development of simulation for the health care sector with NeuroTouch, which is currently installed at 17 locations worldwide. E-mail: robert.diraddo@cnrc-nrc.gc.ca Christine Bryce, Ph.D., has 15 years’ experience in the petrochemical industry. Currently an independent consultant, she supports R&D documentation and project development in fields varying from oil and gas to health care, carbon capture, and linguistics. E-mail: christine.bryce@bell.net

REFERENCES Roberts NK, Brenner MJ, Williams RG, Kim MJ, Dunnington GL. Capturing the teachable moment: A grounded theory study of verbal teaching interactions in the operating room. Surgery 151(5):643–650, 2012. Ozgediz D, Jamison D, Cherian M, McQueen K. The burden of surgical conditions and access to surgical care in low- and middleincome countries. Bulletin of the World Health Organization, 86(8):646-647, 2008. ME D S IM MAGA Z INE 4 . 2 0 1 4

COMMUNITY Projects

Hands up for Health: Extending Simulation to Community Education Beth Thomas, MD and Gabriel Reedy, PhD describe one of their simulation programs that involves potential learners and helps establish positive partnerships in the community.

edical simulation is not just for the clinical learner; rather, it can have far reaching impact and can contribute meaningfully to the community. The value of simulation in healthcare training is well recognized. Literature shows a growing trend that simulations empower participants to take on responsible roles, find ways to succeed and solve problems, which drives deeper learning (Issenberg et al., 2005) and that experiential learning is a highly effective alternative to traditional learning (Kolb, 1984). However, as part of a larger effort within our simulation centre to consider the ways that simulation can be used more broadly, we have found that a thoughtfully designed simulation program can equally be used to provide meaningful learning experiences to potential learners in our wider community. This article describes the innovative work of Hands Up For Health at King’s Health Partners Simulation and Interactive Learning (SaIL) Centre in London, UK, which uses the power of simulation to reach young people. The program shows that extending simulation to community education can foster strong positive partnerships, and break down traditional barriers between the hospital and the community. In doing so, it helps to promote transparency, openness, improved health, and aspirations for careers in healthcare among urban youth in inner London. The program also supports ongoing collaboration between the hospital and wider community.

King’s Health Partners, London, UK King’s Health Partners Simulation and Interactive Learning (SaIL) Centre is a state-of-the-art simulation centre based within an 14

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Healthcare professionals teach basic life support and first aid skills in school. All images: St. Thomas Hospital Simulation Program.

Academic Health Sciences Centre (AHSC) in central London. The AHSC partnership consists of the university and four large hospital systems with 21,000 students and over 25,000 employees; it serves a highly diverse local population of over two million people while providing specialist services for a further five million. The population of this urban area has a high level of income inequality and deprivation, as measured by a number of indicators, and consists of a high proportion of ethnic minorities, first generation immigrants, and people for whom English is not their first language. The Centre plays a key role in the education and training of the current and future health professionals who are part of the AHSC, but we also recognized a need to make connections with our wider community and considered this to be a valuable part of our work. In this spirit, we wanted to turn our centre into an open institution in which our wider community, including patients, local residents, schools, youth organizations, local governments, and other organizations, could explore health and healthcare in an exciting, friendly, fun and safe environment.

What is Hands Up For Health? Hands Up For Health (HUfH) is a charity-funded innovative interactive learning experience designed for inner-city young people at risk of social and economic disadvantage. It uses experiential simulation activities set in a healthcare context and facilitated

by inter-professional healthcare faculty, to engage young people in health issues with which they can identify. The programs’ key aims are to: • Increase enthusiasm and knowledge of science and health • Strengthen ‘life skills’ for employability and positive health behaviours • Widen participation to healthcare careers

Background Across the UK, but especially in the innerLondon area where our centre is located, there are high levels of child poverty and low levels of social mobility (Social Mobility and Child Poverty Commission, 2013). The links between child poverty and social mobility are clear; poorer children fall behind in development before the age of three and do not catch up, creating educational attainment gaps resulting in low social mobility. Whilst more people in the UK are in work than ever before, the number of young people that have been unemployed for more than two years is at a 20-year high. Presently, one-fifth of 18-24 year olds are not in full-time education or employment. Not only does this negatively impact these individuals; employers are also missing out on talent and potential that could make a major contribution to the economy. Specific attention has been given to social mobility within “the professions”, these being roles with recognizable entry points (e.g. standard qualification requirements), codes of ethics, systems for selfregulation and a strong sense of vocation and professional development, which have typically been seen as the more elitist career paths. Healthcare is the third largest profession, therefore is deemed a priority for increasing social mobility. There is a particular focus on medicine, which is lagging behind many other professions. Furthermore, the British Medical Association has made the case for having a workforce that is representative of the society it serves to provide the best possible care to the UK population (Milburn, 2012). Increasing social mobility in healthcare, therefore, should be a priority of those in the profession. Schools across the UK are now responsible for providing careers advice. A survey of UK schools in 2013 by the

Office for Standards in Education (Ofsted) highlighted a need to create stronger and better links between employers, employees and young people, and to improve the provision of both careers insights and careers guidance provided by qualified professionals. Health and poverty are inextricably linked, so tackling social mobility and improving youth employment will have long-term positive effects on health across the population, reducing demand on health services in the future. HUfH addresses all these issues and offers an innovative way of engaging with this often hard-to-reach population, to increase access to health and healthcare education for young people with a goal of intervening in a life course that could lead to becoming socially disadvantaged as an adult.

Program Design HUfH has been developed by a multidisciplinary team of healthcare professionals in collaboration with simulation experts, students and teachers. A multipilot, iterative design shaped the content and final design of the program, which responds to the educational and health needs of the local population. The learning outcomes of the program also align with national strategies and curriculum aims for health education in the UK. The program has features that will be recognisable to anyone engaging in designing or leading simulation learning experiences for healthcare professionals. Indeed, that was one of our goals for the programme. Learners engage in two days of activities spread between their school or youth club and the hospital simulation centre. Day 1 is delivered at the school or the youth club, and the program consists of half-day of first aid skills training and a half-day of ‘life skills’ activities. The latter is centred around experiential learning activities followed by small-group discussions to explore non-technical skills relevant to adolescents, like communication, teamwork and leadership. The second day of the program consists of a visit to the clinical simulation centre of an inner-city tertiary hospital, where learners engage in a full day of immersive and life-like simulations using various modalities. The simulations are

Learners value the opportunity for hands-on learning and the realism of the simulation experience.

set in a hospital-like environment, using real-life clinical equipment, state-of-theart manikin technology, and actors serving as simulated patients. All the scenarios are designed to facilitate exploration of topical health issues that adolescents can relate to, such as drug and alcohol abuse, teenage pregnancy, and knife trauma. Participants put the life support, communication and team-working skills from Day 1 into practice at the centre. The design of Hands Up for Health gives young people the chance to learn valuable life skills and to empower young people to make informed, responsible and voluntary decisions about their own wellbeing. They do this while gaining insight into what it is really like working in healthcare, which helps to raise their aspirations for a career in health professions. As the whole process is facilitated by diverse inter-professional teams, and all learning is framed using personal experiences and integrating opportunities for reflection, the learning is relevant and transferable. This challenges their social views and enhances their ‘life skills’, something which can often be neglected in the classroom setting. The innovative program is the only known use of simulation to combine the teaching of health skills with ‘life skills’ MEDSIM MAGAZINE 4.2014

COMMUNITY Projects

– those “abilities for adaptive and positive behavior that enable individuals to deal effectively with the demands and challenges of everyday life” (WHO, 1997) – while also widening access to healthcare. It is also the only simulation program that is specifically aimed at positively impacting the lives of underprivileged inner-city youths.

Evaluation and Impact All participants complete anonymous feedback forms, which consist of a mixture of open- and closed-ended questions, to explore their experience in the programme. To date, more than 500 children and young people (aged 9–24 years) have participated in the program, and we have seen a 43% reported increase in the number considering careers in healthcare after participation in the program. Learners report taking away valuable learning that is regarded as relevant, meaningful and congruent with the intentions of the programme design. They specifically value the opportunity for hands-on learning with real-life applications, and the realism of the simulation experience. Literature shows this to be a highly effective alternative to traditional approaches, and even more so with students who are disadvantaged economically or academically (Bredderman, 1982). As one respondent explained, ‘practicing in a real life situation is the best way to learn’. Learners responded well to the design of the simulation activities being oriented to their age, commenting on how the scenarios being ‘connected to young people’ made them more relevant and useful to them. This is important because literature tells us that learning is more persistent and meaningful when it is relevant to the learner (Dewey, 1938). They also value the opportunity to learn from real healthcare professionals, who positively influenced their learning and attitudes toward healthcare careers. Students show an increased awareness of, and in some cases, aspirations to, healthcare careers, as a result of participating in the program. This supports literature that shows role modeling to have a measurable effect on career choice and aspiration (McHarg et al., 2007). As we continue to explore the impact of the programme, we are conducting a further in-depth analysis of the nature of participants’ learning and their experiences in the programme.

Our evaluation strategy includes both focus groups and observational studies, as well as interviews with students who have attended the programme in previous years, to see what longerterm impact their participation may have had.

Simulation in Community Education Simulation is a valuable part of healthcare professionals’ training, but in this program, we have shown that the approach can also be used to engage in open dialogue with wider communities and directly improve the health and aspirations of the populations we serve. HUfH is an example of a carefully designed community education program, offering youth-focused, experiential learning in a meaningful, fun, and innovative way, whilst also being responsive to the educational and health needs of the local population. medsim About the Authors Dr. Beth Thomas, MBBS, BSc, is a Clinical Simulation Specialist Educator at the Simulation and Interactive Learning (SaIL) Centre at Guy’s and St. Thomas’ Trust and part of King’s Health Partners, London, UK. Following her personal experiences as a patient, she left clinical practice in 2009 to dedicate her time to clinical education. She has extensive experience in health professions simulation and teaching. In her role at King’s Health Partners, she designs, delivers and evaluates mixed-modality clinical simulation courses. She is passionate about using simulation to engage with the broader community, and leads an innovative simulation-based health education program for inner city youths, known locally as Hands Up for Health. Gabriel B. Reedy, M.Ed., Ph.D., C.Psychol., is a learning scientist and cognitive psychologist at King’s College London. He is the Director of Clinical Education Programs at King’s Learning Institute, King’s College London, where he leads an innovative interprofessional graduate program for clinician educators. He is also the Educational Research Lead for the Simulation and Interactive Learning (SaIL) Centres of King’s Health Partners, London, UK, where he helps to design, deliver, evaluate, and research simulation-based educational interventions. Acknowledgements Guys’ and St. Thomas’ Charity Dr. Peter Jaye, King’s Health Partners Simulation Lead

REFERENCES Bredderman, T: What research says: Activity science - the evidence shows it matters. Science and Children 1982; 20:1, 39-41. Dewey, J: Experience and Education. Collier Books, New York, 1938. Issenberg S, McGaghie W, Petrusa E, Gordon D, and Scalese R: Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher 2005; 27:1 10-28. Kolb D: Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs, New Jersey, Prentice-Hall, 1984. McHarg, J., Mattick, K., Knight, L: Why people apply to medical school: implications for widening participation activities. Medical Education 2007; 41:8, 815-821. Milburn, A: Fair Access to Professional Careers, A Progress Report by the Independent Reviewer on Social Mobility and Child Poverty. 2012. Available from: <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/61090/IR_FairAccess_acc2.pdf> [Accessed December 2013]. Office for Standards in Education (Ofsted): Careers Guidance Commissioned Survey. 2013. Available from: <http://www.ofsted.gov.uk/sites/ default/files/documents/surveys-and-good-practice/c/Careers%20guidance-commissioned%20survey.pdf> [Accessed December 2013]. Social Mobility & Child Poverty Commission: State of the Nation 2013: Social Mobility and Child Poverty in Great Britain. Available from: <https:// www.gov.uk/government/uploads/system/uploads/attachment_data/file/292231/State_of_the_Nation_2013.pdf> [Accessed December 2013]. World Health Organization (WHO): Life Skills Education in Schools. Geneva: WHO, 1997. Available from: <http://www.asksource.info/pdf/31181_ lifeskillsed_1994.pdf> [Accessed July 2013]. 16

MEDSIM MAGAZINE 4.2014

Ultrasound Meets Patient Simulator With HeartWorks TTE Mobile, Ultrasound Simulation can now be incorporated into patient simulations within your centre, allowing image acquisition and accurate decision-making all within a mobile, versatile and easy to use product. To find out more please contact:

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Education & Training

The Changing Face of Ultrasound Training in the Era of Cloud-Based Services Dr. Dan Katz and Dr. Eric Savitsky describe how they created a cloud based training solution for ultrasound training.

his is a three-part series that uses a case study to describe the introduction of disruptive innovation into medical education and training. The first installment describes identifying an unmet need in medical education and creating a cloud-based training solution. The second installment reports the process of successfully guiding a nascent educational technology from an idea into a successful commercial product. In the final installment, the authors detail the rapidly changing dynamics of medical education and how next-generation simulation products will need to address future challenges. A stab-wound victim is rolled onto a gurney by paramedics within a trauma bay, while physicians, nurses, techs, and other emergency healthcare providers stand by waiting to go to work. “We have a twenty-four year-old-male here with multiple stab wounds to the chest and abdomen. He was stable en route but is now decompensating!” shouts the paramedic over a sea of voices and noises. “Most recent vitals are a heart rate of 115, respiratory rate of 34, blood pressure of 60 over palp, and 85 percent oxygen saturation on a non-rebreather mask.” The trauma team springs into action placing intravenous 18

MEDSIM MAGAZINE 4.2014

catheters and assessing the patient. Various medical equipment and devices flood the trauma bay: ventilators, infusion machines, vacuum devices, equipment carts, and tubes of all shapes and sizes. Upon completing the primary survey, a team member immediately reaches for an ultrasound machine and begins to perform an eFAST (extended Focused Assessment with Sonography in Trauma) examination. She applies ultrasound gel to select points along the patient’s body, places the probe on the gel, and, in a matter of seconds, assesses the patient’s internal anatomy and discerns pathologic findings. The initial eFAST scan shows evidence of a left-sided pneumothorax and hemoperitoneum. “We need to insert a left-sided chest tube and initiate a mas-

Anytime-anywhere ultrasound training. All images: Authors.

sive transfusion protocol immediately,” announces the physician. While the rapid transfusion of blood products is initiated, a hiss of air is heard as the chest tube is inserted into the patient’s left pleural cavity. Within moments, the patient’s oxygen saturation and other vital signs begin to improve and the patient is promptly transferred to the operating room for an exploratory laparotomy. This physician was able to rapidly integrate information obtained from an eFAST exam and make a correct and expedient therapeutic decision that resulted in a favorable patient outcome. Similar life-threatening situations play out on an hourly basis in emergency departments throughout the world, with point-ofcare ultrasonography as a focal point in the evolution of patient care. The eFAST exam is a very important application of point-ofcare ultrasound. Point-of-care ultrasound refers to the use of portable ultrasonography at a patient’s bedside for diagnostic (e.g., symptom or sign-based examination) or therapeutic (e.g., image guidance) purposes. Kendall et al. defined the characteristics of point-of-care ultrasound (see table 1) (Kendall, 2007). Point-ofcare ultrasound is rapidly becoming the preferred imaging modality for discrete indications across multiple clinical specialties. Advances in ultrasound technology have fueled the emergence of point-of-care ultrasonography, including improved ease-of-use, superior image quality, and lower cost ultrasound units. Table 1: Characteristics of Point-of-Care Ultrasound • Exam is for a well-defined purpose linked to improving patient outcomes • Exam is focused and goal-directed • Exam findings are easily recoagnizable • The exam is easily learned • Exam is quickly performed • Exam is performed at the patient’s bedside Some medical experts have suggested that personal ultrasound machines will one day replace the iconic physician stethoscope (Wittenburg, 2014). Like the stethoscope, ultrasonography is safe, noninvasive, and highly operator dependent. While traditional methods of performing a physical examination will remain critically important, practitioners that become skilled in the use of point-of-care ultrasonography also become uniquely empowered. Conditions such as cardiac valvular disorders that are inferred by auscultation can be visualized and quantified by ultrasound. Time-sensitive definitive diagnoses such as a ruptured abdominal aortic aneurysm or cardiac tamponade are made in minutes rather than hours. Kobal et al. demonstrated the value of attaining competence in ultrasonography during medical school. He found that first-year medical students with only 18 hours of ultrasound training outperformed seasoned cardiologists in detecting various cardiac abnormalities (Kobal, 2005). Ultrasound procedural guidance has been shown to limit infection rates and decrease discomfort for patients during vascular access procedures and prevent iatrogenic complications during invasive procedures (AHRQ, 2001). Ultrasonography is among the safest imaging modalities in modern medicine. In fact, ultrasound is used to image delicate structures such as unborn children, in part because ultrasound waves contain no

ionizing radiation. Comparatively, X-rays and CT scans are typically contraindicated in pregnant patients. Point-of-care ultrasonography has the potential to save hundreds of millions of dollars on an annual basis across health systems. It has the capacity to revolutionize patient care and improve procedural efficacy, decrease complications, and limit patient discomfort (Kendall 2007, Moore 2011, AHRQ 2001, Kobal 2005, Wittenburg 2014).

Portable ultrasound being used in a resourceconstrained setting.

Bedside Ultrasound’s Unfulfilled Promise In recognition of ultrasound’s potential to improve health care, the American Medical Association passed resolution #802 in 1999, asserting that all medical specialties have the right to use ultrasound in accordance with specialty-specific practice standards. Despite decreases in the cost and physical size of ultrasound units, as well as improvements in image quality and functionality, widespread adoption of ultrasound by practitioners has continued to lag. For example, in recent surveys, point-of-care ultrasound was only used in 34 percent of emergency departments in California and in only 19 percent of nonacademic emergency departments in the United States. (Moore, 2006, Stein 2009) If ultrasound has so many benefits, why have so few healthcare providers integrated it into daily practice? There are several significant barriers that have historically hindered widespread ultrasound adoption. Pointof-care ultrasound is a highly operatordependent modality. A practitioner must MEDSIM MAGAZINE 4.2014

Education & Training cal presentations are rarely encountered. The inability to train on sufficient numbers of pathologic cases is a recognized impediment to ultrasound competency. Similarly, the assessment of ultrasound competency is another obstacle to ultrasound adoption, which requires a similar set of resources.

The Groundwork for Future Success

The SonoSim Ultrasound Training Solution.

be able to acquire a desired ultrasound image, optimize the image, interpret the image, and integrate the information into clinical decision-making. Developing ultrasound competency and applying ultrasound findings towards clinical care is a complex process. It requires integrated psychomotor (optimal image window acquisition) and cognitive (image interpretation) skills. The extremely high opportunity cost of training healthcare providers is another critical barrier to ultrasound adoption. Optimal training requires: (1) a qualified instructor; (2) trainees; (3) an ultrasound machine; and (4) a patient with a pathologic (abnormal) condition. All of these elements must come together in one physical space and time, and the process must repeat itself, with new patients representing alternative pathologic conditions presenting over time. It may take months or even years before a care provider is able to scan a sufficient number of patients with certain pathologic conditions (e.g., leaking abdominal aortic aneurysm) to develop competence, especially if these clini-

A seemingly unrelated grouping of disparate activities provided a solution to these longstanding barriers to ultrasound adoption. Dr. Eric Savitsky, a UCLA Professor of Emergency Medicine, was heavily involved in international humanitarian efforts upon becoming a UCLA faculty member in the late 1990’s. He founded and served as Executive Director of the UCLA Center for International Medicine (CIM), a non-profit organization dedicated to improving global health through education, training, and technology. The UCLA CIM initially specialized in sending volunteer healthcare providers overseas to provide medical education and training. After organizing multiple medical missions, he recognized the limitations of relying upon short two- to four-week “train-the-trainer” trips. Specifically, it was difficult to maintain longterm impact when training staff returned to the United States. In response, the UCLA CIM began

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developing computer-based, medical training programs that sought to provide a portable, cost-effective, and sustainable training experience. The UCLA CIM evolved into a leading developer of computer-based, “train-the-trainer” medical education programs that were used by a variety of international and non-governmental organizations, including the United Nations, International Rescue Committee, and Project HOPE. One challenge that presented itself was how to successfully train international staff to perform invasive procedures. Computer-based training was ideal for didactic instruction, but was not conducive to developing psychomotor procedural skills. At the time, the need for hands-on training still dictated the need for in-country training resources. Through his international work, Dr. Savitsky also witnessed first-hand the tremendous global potential for ultrasound to save lives in resource-constrained settings. This strong foundation in computer-based medical education and experience with digital multimedia programming would prove highly instrumental in the years that followed. Concurrently, in his role as the UCLA Emergency Medicine Director of Trauma Services and Education, Dr. Savitsky was an early adopter of ultrasound at the UCLA Medical Level I Trauma Center. Apart from expediting the care of trauma patients, Dr. Savitsky appreciated the tremendous value of ultrasound in a skilled operator’s hands, including superior clinical acumen and diagnostic accuracy. In 2001, his belief in the potential of point-of-care ultrasound motivated him to spearhead an effort to train his fellow colleagues on performing FAST exams in trauma settings. However, Dr. Savitsky was rapidly confronted with the high opportunity costs associated with ultrasound training, and recognized that limited access to certain pathologic conditions would hinder the development of ultrasound competence amongst healthcare providers. He also identified additional unmet challenges to the successful integration of ultrasound into clinical practice including maintaining ultrasound skills, assessing for ultrasound competency, and ensuring quality assurance.

An Unusual Source of Inspiration While attending an E3 Consumer Electronics Show in Los Angeles, in an attempt to stay abreast of the latest digital multimedia technologies, Dr. Savitsky had an epiphany. He was able to identify a group of seemingly unrelated technologies that could all operate at the intersection of digital media, health, and education. He used this inspiration to team with a group of UCLA researchers and scientists to begin work on a computer-based tool for procedural training. He was hopeful that providing computer-based, hands-on skill training would solve the procedure training difficulties encountered by the UCLA CIM in a scalable and sustainable way. By 2004, Dr. Savitsky had invented a novel approach to providing integrated didactic instruction, hands-on training, and knowledge assessment using a laptop computer. It involved interweaving traditional storytelling with digital multimedia elements, real-patient ultrasound imagery, and motion sensing technology. This advance in medical education would help address the problem of how to efficiently train, assess, and provide refresher training for large numbers of individuals seeking to learn how to perform ultrasonography. The newly developed intellectual property was successfully transitioned by Dr. Savitsky to the UCLA Office of Intellectual Property and Technology Transfer, and subsequently into the private sector. Over the ensuing years, through a combination of federal research dollars and multiple Small Business Innovation Research (SBIR) awards and grants, the invention transitioned into a full-fledged consumer product. The end result was the development of the SonoSim® Ultrasound Training Solution, which was taken to market by a company called SonoSim. The SonoSim Ultrasound Training Solution is marketed as a breakthrough product that overcomes the longstanding barriers to ultrasound education by providing integrated didactic instruction, hands-on training (simulation), and knowledge assessment. It has a cloud-based architecture that enables delivery of

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Education & Training anytime-anywhere ultrasound education via Mac or PCs.

The Evolution of an Ultrasound Training Solution In 2011, the National Center for Research on Evaluation, Standards, and Student Testing (CRESST) performed an independent study comparing the effectiveness of SonoSim’s SonoSimulator® versus live instructor-based FAST ultrasound learning (Chung, 2011). The study found that “participants who received simulation-based practice scored significantly higher on interpreting ultrasound images,” and that “there were no statistical differences between the two conditions on scan time, window acquisition, and window interpretation.” The study concluded that the SonoSimulator was a promising new ultrasound training tool. The SonoSim Ultrasound Training Solution was able to overcome the historical barriers to ultrasound training. SonoSim’s didactic courses are streamed to end-users from a cloud-based server in an interactive multimedia format using still and dynamic ultrasound imagery, audio narration, computer graphic imagery, and animation. Ultrasound cases obtained from real patients allow for an on-demand, authentic ultrasound scanning experience. End-users learn the exact probe movements expert sonographers used to scan the original patients. The training replicates the tactile experience of using an actual ultrasound probe to scan a real patient. User interactions can be tracked, analyzed, and reported for purposes of competency assessment and refresher training. Medical institutions and physicians are under constant pressure to deliver

more specialized and efficient patient care. In response, undergraduate medical education programs will need to seek alternatives to traditional time-based approaches to curricular design to prepare students for these challenges. Recent technological advances have provided an opportunity to simultaneously usher in an era of performance-based medical school curricula. In response, SonoSim’s cloud-based architecture enables rapid scaling and worldwide delivery of digital content. Cloud-based simulation has important performance tracking and assessment implications that will help educational institutions address future challenges. These issues will be further explored in future articles of this series. medsim

The Benefits of Point-of-Care Ultrasonography.

About the Authors Dr. Dan Katz is an Emergency Medicine Physician at Cedars Sinai Medical Center in Los Angeles, CA and is VP of Business Development for SonoSim. Eric Savitsky, MD is a Professor of Emergency Medicine at the University of California at Los Angeles (UCLA) and is the inventor of the SonoSimulator. Brian Bernstein is a Marketing Associate at SonoSim, Inc., and holds a B.A. degree in economics from the University of California, Los Angeles. Brady Grover is the Sales and Marketing Coordinator at SonoSim, Inc., and holds a B.S. degree in business management from Pepperdine University.

REFERENCES Agency for Healthcare Research and Quality (AHRQ). Making health care safer: a critical analysis of patient safety practices. Evidence report/technology assessment, no. 43, 2001. Chung GKWK, Gyllenhammer RG, Baker EL. The effects of practicing with a virtual ultrasound trainer on FAST window identification, acquisition, and diagnosis. Los Angeles (CA): National Center for Research on Evaluation, Standards, and Student Testing (CRESST); 2011. Report No. 787. Kendall JL, Hoffenberg SR, Smith RS. History of emergency and critical care ultrasound: the evolution of a new imaging paradigm. Crit Care Med. 2007 May;35(5 Suppl):S126-S130. Kobal SL, Trento L, Baharami S, et al. Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol. 2005 Oct1; 96(7) 1002-1006. Moore CL, Molina AA, Lin H. Ultrasonography in community emergency departments in the United States: access to ultrasonography performed by consultants and status of emergency physician-performed ultrasonography. Ann Emerg Med 2006; 47:147-153. Moore CL, Copel JA. Point-of-Care ultrasonography. N Engl J Med. 2011 Feb 24; 364(8): 749-757. Stein JC, River G, Kalika I, et al. A Survey of Bedside Ultrasound Use by Emergency Physicians in California. J Ultrasound Med 2009; 28:757-763. Wittenburg M. Will ultrasound scanners replace the stethoscope? BMJ. 2014 May 29; 348:g3463. 22

MEDSIM MAGAZINE 4.2014

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Interview

The Importance of Standardization in Simulation Technologies and the Training of Technicians Marty Kauchak spoke with James Cypert, MCSE, MCT, MCP, A+, N+, MOUS regarding consistency in the training of technicians.

r. Cypert is the technical director for the School of Nursing at California Baptist University. Until February 2014 he was the president of SimGHOSTS, a non-profit organization. SimGHOSTS is dedicated to supporting the growing international population of professionals operating medical simulation technology and spaces through: hands-on training events, online resource sharing development, and greater community awareness engagements. He completed this interview with Group Editor Marty Kauchak on July 3, 2014. MEdSim: Weâ&#x20AC;&#x2122;re pleased to see you have remained active with SimGHOSTS and the community after recently resigning as organization president. James Cypert: Thanks. I remain very passionate about the medical simulation profession and community. MEdSim: Your presentation at this August's HEATT 2014 conference is titled, "There is No Technology without the Technician". Briefly discuss your justification for that statement. JC: The title comes from the point of view technology requires individuals that are willing to put the time and effort in to become knowledgeable in its use and application. It is our view that with technology, no matter how simple a system or technology becomes, there will always be those who do not wish to take the time to understand its underlying complexities. When faced with the implementation of any technological solution, there comes with it, some very difficult challenges that need to be successfully mitigated in order to have the technology fully utilized and filling all of its intended purposes. Technicians and 24

M E D S I M M A G A Z I NE 4 . 2 0 1 4

technologists can make technology work for the people it was intended to serve. Vendors will always highlight how simple every solution is. The reality is that the more simple it becomes to operate a technology, the more complicated it is to service, configure, install, update and complete other life cycle support needs. Without the technician, the end user will be fully exposed to those complications. SimGHOSTS further believes innovations in technology will continue as they have since most of us can remember. Platforms will get smaller, operate faster, and store more content. They will become more convenient and easier to operate. No matter how much we achieve there will always be a need for someone willing to understand how it operates, how to fix, maintain and upgrade it, and willing to teach others about it. The technician or technologist is a key component to full technology implementation. MEdSim: As a follow on to your statement about vendors, provide your "help wanted list": offer suggestions to the medical simulation equipment manufac-

Technicians and technologists can make technology work for the people it was intended to serve. Image credit: James Cypert.

turers to help them increase the effectiveness and efficiency of their devices. JC: Every year SimGHOSTS’ leadership moderates a “Meet Your Vendor” session for the top sponsoring exhibitors. The general consensus is to continue to innovate, but also consider standardizing among each other. Early in the days of the internet, and before it really started to take off, industry (manufacturers and suppliers) came together and began to standardize and even agreed to standards that would promote consistency as well as promote themselves. We believe industry would do well to continue finding new ways to make things operate easier, provide better support, and deliver products easier to maintain and upgrade. MEdSim: What are some shortfalls in the medical simulator technician community's credentialing and certification processes? JC: There is too much emphasis on background experience and who is, or who is not, the best qualified to be a “Sim Tech.” It is not all that complicated. Look at the systems the industry uses and then proceed from there. A technician should be trained and certified in the technologies they support. The problem is the temptation to continue in “silos”. The community would do well to avoid those mistakes and stop concentrating on previous job experiences and fully define the skill sets that are necessary for the job. If it requires a knowledge of human anatomy then train it and certify to that requirement. If the position requires understanding network protocols, then do the same! MEdSim: Another follow up: how is SimGHOSTS acting as a proponent and making a difference in the way your professionals are credentialed and certified? JC: We as an organization are advocating for the definition of the skill sets required to complete our tasks, and identifying other skill sets that may not be fully required but are invaluable. Once identified, we provide access to this knowledge in our online community and at our annual events. We connect technicians with other technicians around the world. We gather the collective knowledge and distribute it amongst our members. MEdSim: Discuss your forecast for the

The technician or technologist is a key component to full technology implementation. Image credit: James Cypert.

supply and demand of medical simulator technicians in the US through the next five years. JC: From our perspective we can see that Healthcare Simulation is still in the early-adopter phase. Most of the events we have participated in report that 40% of attendees surveyed “have never been to a simulation meeting previously” or are “new to the job”. At every simulation event people speak to the delegates as the innovators, pioneers, and cuttingedge, early adopters of healthcare education - and so it’s not hard to see why as an industry, we are only at the “tip of the iceberg” with regards to integration. Healthcare simulation will continue to rapidly expand into healthcare educational and training programs around the world. Eventually, the medium-to-large sized learning programs that take simulation seriously will realize that they need a technician or multiple technicians who help to remove the burden of technology from the clinical educators. It is just not cost effective to pay two-to-three times the salary to a clinical educator with 1/10th the technical experience. Programs that succeed treat their spaces like small businesses with serious commitments to maximize logistical efficiency. There is just no way to continually operate the amount of technology involved in these simulation spaces without

technical expertise to diagnose, repair, or replace multiple, high-level systems. You mentioned the US but the demand for Sim Techs will continue to increase well into the future around the world. The role of simulation in healthcare education is expanding with no current decline expected. The benefits of simulation are well known. It is currently common practice for nursing programs, medical schools, and graduate medical education and even among practicing professionals within hospital systems. Many states are even increasing the utilization of simulation to serve as clinical experience in nursing programs. With the shift away from “watch one, do one, teach one”, training continues for the benefit of patient safety and the demand will only increase. MEdSim: On a closely related topic, what are some positive trends and shortfalls you see in US medical simulator technicians' formal education programs. JC: There really are too few formal education program for simulation technicians. The best you can do is hire an individual with technical experience who can communicate well and will never tire of learning on the job. Beyond that, connecting your Sim Tech to annual SimGHOSTS training and networking events is the best way to get up to speed and stay ahead of the game. However, now that the organization has become an official 501c3 tax-exempt educational organization and has solidified itself as the “go-to” annual event, the SimGHOSTS board of directors is expanding the conversation to include official training programs that will enable individuals to train to a specific standard of skill sets. The demand is huge for this training. The new SimGHOSTS’ leadership sees the opportunity for the organization to provide it. Another SimGHOSTS effort is providing the entire database of recorded sessions from previous organization meetings at very little cost. Numerous hours of technical training and presentation video content is available to subscribers at a nominal fee. The plan is to expand this database with even more recorded content from our two 2014 events, one which occurred in Australia this June, the other to convene in the US (August 5-8). medsim M E D S I M M A G A Z I NE 4 . 2 0 1 4

SIMULATION CENTER

The 4-1-1 on Creating an ROI Amar Patel, WakeMed Director of the Center for Innovative Learning describes how to develop a business plan and show ROI for your center.

ost all of us have taken medical simulation classes to improve our caregiving skills using real-life scenarios much like students who wish to learn a foreign language frequently take ‘immersion’ courses where only the foreign language is spoken in the classroom. In doing so, participants do two important things: they step out of their comfort zone, and they come face-to-face with the unknown. It can be a scary yet exhilarating and fulfilling experience, especially when we succeed. The benefits of simulation have been proven over and over again. As educators and program directors, we are not only tasked with helping others understand the value of simulation, but providing a business case on the ongoing value of simulation itself. We have all been asked “what were you doing before simulators?” Research studies continue to show how students have more fun learning through simulation, rather than through passive teaching methods like lecturing,

MEDSIM MAGAZINE 4.2014

and the student retention rate of information is often much higher (Crofts et al., 2007; Wayne et al., 2006). Furthermore, there is clear evidence that simulation allows trainees to actively experiment and use their clinical skills and decision making without actual risk to real patients. Finally, it helps meet the overwhelming demand to engage students, and improve both teamwork and communication behaviors. For any health care discipline, the demand for simulation use is there and while we hope that people will understand the value of the technology as a valuable learning tool, it is up to each of us to show the data that supports the education modality. So let’s get down to brass tacks: how much money does simulation actually cost, and how do the return on investment and the return on expectation compare?

Dollars and Sense You may be thinking, “I know that simulation training works, but how much money are we going to have to invest?” In these tough economic times, budgets are being cut, and organizations have to use their training dollars wisely. And what type of return on investment can we expect? How will we know our spending is worth it? The answer is a multi-layered one that involves logistics, the size and scale of training, and statistical results, as well as the intangible factors that can be a bit more difficult to measure. First and foremost, you need to be willing to collect data to prove the business case. After all, education is a business and health care is a very complex business and both need to continually prove their net worth.

Above Air medical providers are caring for a critical ill infant in WakeMed's air ambulance during a simulation scenario designed to test the transition of care from EMS to air medicine. Image Credit: WakeMed.

Finally, there are simple equations that can help you understand how much upfront investment is required to start a simulation program. You have to know what to ask! By using some rough figures, you can easily formulate a business plan that will help you and a simulation board of directors layout the 1, 3, 5, and 10 year plan for the use and integration of simulation technology.

Business Plan We donâ&#x20AC;&#x2122;t often consider the need for a business plan in developing and maintaining a simulation program; however, the business plan clearly outlines the short and long-term goals of any business. Understanding, researching, and having to clearly articulate your program objectives, short and long-term goals, the target audience, potential competitors, and a funding model will help everyone see where there is value and costs (SBA.gov, 2011). Furthermore, a well-developed business plan will continue to guide any simulation program through the toughest of decisions. If you have no familiarity with developing a business plan, it is important that you take the time to understand all of the different components needed to make a solid business plan. Although writing a business plan can be time consuming, with a little bit of research, any of us can do it. There are truly only four major driving forces that have pushed simulation significantly forward. First, is the desire to lower the cost of both education and health care. In this tough economic environment, health care administrators are always looking for ways to provide education at a reduced rate and con-

tinue to improve the care delivery model. What if we could provide education that is not only effective but also efficient and improve patient outcomes? Those of us in simulation realize this is possible. You have to invest in education to show an impact through education or you have to spend money to make money. Second, simulation technology allows individuals better access to information where they have an opportunity to repeatedly practice varied symptomologies and complex cases. Is there a better way to learn? Likely not. Third, there are lots of studies that show how simulation does improve the retention rate of those participating in a simulation experience. It is imperative to verbalize that value to our stakeholders and share with them these studies. Finally, we need to reduce the number of medical errors. The rate of medical errors is staggering and while we continue to improve on how care is provided, the reported number of errors continues to rise (Allen, 2013; SoRelle, 2000; Starmer et al., 2013). Both simulation technology and the process of simulation can help

MEDSIM MAGAZINE 4.2014

SIMULATION CENTER identify where there are vulnerabilities in the health care system and use those identified vulnerabilities as a starting point for program development. Instead of being reactive, we can be proactive. To integrate simulation, these four powerful motivators will play a valuable role in outlining the educational need and impact a process analysis has in anyone’s business plan. They highlight the true value of the technology and show the impact the entire simulation process can have on an institution.

Logistics: What Do We Want, and How Do We Get It? First, before you can determine your organization’s ROI, you must answer several key questions about the type of training you want to provide your participants. If you’re considering mobile training, the up-front costs of using simulation technology actually depend on a number of logistical factors, including: • The training location: Is it possible for attendees to participate in training remotely, via computer, or must they go to another physical location? Can the training come to them? If so, what is the associated travel cost? • The length of the training: how many hours/days/weeks will participants invest? • The depth of the training: will participants simply take part in computer simulation, or will the training involve interactive, real-life scenarios involving mannequins or human patient simulators? Will there be actual environmental components to the training, such as fire or water? Will emergency service vehicles play a role in the training? Will you involve disaster medicine teams? How much will you simulate simulation? It’s only common sense that the more intense the training, the more expensive it will be. Fortunately, there is simulation training available to fit every budget, and a quick search on the Internet can provide a wealth of information about what other programs are doing. All of us understand the limitations of health care teams, whether it’s staffing, budget or simple location issues. It is extremely important to do your research and understand what you can do, and where you need help. 28

MEDSIM MAGAZINE 4.2014

Emergency Room providers manage a radiation patient during a simulated scenario. Image Credit: WakeMed.

Level of Commitment: Are You Ready? With ROI, decision makers compare the timing and magnitude of the gain they expect to make versus their investment cost. To calculate any type ROI, a basic math equation is used to show the overall financial outcome of the investment. ROI = gains – investment costs / investment costs Let’s suppose your organization has invested in simulation training in the past with positive results, and your administration is ready and able to commit to a stationary, in-house training program. They’ve considered the creation of a simulation lab, but questions remain, specifically about funding. The following are factors to consider: • How will the organization secure funding? Are there people/organizations/corporations that are willing to partner with you and invest in the simulation lab? If so, for what period of time, and how will you report on the use of those funds? • Can your simulation program be selfsustaining? • Do you want to build a new facility, or will you use an existing structure? • How much staff will you need? • What type of equipment will you invest in? What are the monthly maintenance costs? Utilities costs? • What will you need to charge participants? Will you earn revenue by selling simulator time to other training organizations? • And the number one question: Can simulation ever be financially profitable? The following is an example of an ROI equation to help answer that question: $700,000 (saved) - $500,000 (the simula-

tion center budget)/ $500,000 (the simulation center budget) = 40% ROI If, in fact, the organization chooses to move forward with utilizing simulation technology, it is imperative that stakeholders in the project be at the decisionmaking table from the beginning. That would include a board of directors or a steering committee, as well as others who may have a vested interest in the training. Frequent communication about progress is imperative, not only to fuel the fires of continued support, but because it’s the right thing to do. Continue to discuss program objectives with them, as well as short and long-term planning, and keep them abreast of progress. It is also important to remember that creating an ROI is not an overnight adventure. It takes years of planning, development, and implementation to see the results. In the end, an open line of communication can only help show the positive return of investment the simulation program is making.

Cost vs. Benefit to Patients While the financial costs of simulation training are relatively easy to measure in dollars and cents, there is also long-term statistical data that will need to be evaluated for ROI reporting. As educators, we should always measure clinical ROI in terms of the impact on patient care. At its core, ROI is “the amount of improvement in care brought about by a certain investment. ROI can also refer to the theory that if you invest in health care quality now, then the quality of care for patients will improve in the future” (Robert Wood Johnson Foundation, 2013). As we calculate the ROI from using simulation technology, we will need to examine its impact on system processes. Have unnecessary policies and/or procedures been eliminated? Have we become more efficient with one of our most valuable resources - time - during patient care? Did we reduce the number of complications and readmissions following medical procedures? Did we reduce the number of caregiver errors? Ultimately, did our quality and patient outcomes improve? The answers to these questions provide valuable data to administrators as well as outside investors as to the worthiness of the investment in simulation.

Return on Expectation We continue to hear about showing the return on investment. Yet, a true ROI is developed using revenue and expense as the metric. Even the health care definition of ROI refers the cost of care (Robert Wood Johnson Foundation, 2013). So, what if there was another option in helping us prove our worth? Would you be interested? Return on expectation - or ROE - is a measurement factor that has more intangible qualities than hard, statistical data (Kirkpatrick & Kirkpatrick, 2010). However, it is equally important. ROE is a collaborative agreement that unites an organization in working towards a common goal (Kirkpatrick & Kirkpatrick, 2010). On the other hand, ROI is a summative measurement that evaluates individual pieces of a project and determines the success of the efforts of each. Even though ROE may include measurements that are not as scientific and formula-driven as ROI, do not be misled to think that ROE is “soft”. In fact, it’s just the opposite. ROE is usually determined at the beginning of a project, as in, ‘What are our goals for this project? What do we hope to gain, not only financially, but corporately with regards to how our work contributes to the community?’ ROE establishes common ground when determining the long-term value of simulation training. The real results of simulation training will be evident when “the rubber meets the road” - when employees are actually using their new, advanced skills on the job. That’s when you’ll see both the ROI as well as ROE. Through their successes on the job, they will build a chain of evidence - including improved patient outcomes - that demonstrates the bottom line value of simulation training. In a nutshell: 1. Identify key stakeholders. 2. Create a steering committee or a board of directors. 3. Develop a business plan. 4. Develop a marketing plan. 5. Sell yourself! Don’t be afraid to do tours and demonstrations. It only helps show the value of the program. 6. Collect data on what you do. 7. Integrate the program with patient safety and/or risk management. 8. Share the data with your key stakeholders, the steering committee, and your participants. 9. Create an end of year summary report. 10. Tell your story! Don’t be afraid to present your program locally, regionally, and nationally. And the final equation is a simple one: A Return = Outcomes + Simulation. medsim About the Author Amar Patel is the Director of the Center for Innovative Learning at WakeMed Health & Hospitals. Mr. Patel is responsible for integrating technology based educational programs to include human patient simulation, healthcare gaming, and hybrid learning environments. He is an adjunct instructor at the school of medicine, department of emergency medicine, at the University of North Carolina Chapel Hill, and a doctoral candidate in Health Sciences at Nova Southeastern University.

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MEDSIM MAGAZINE 4.2014

Publisher's comment

ISSUE 4.2014

7 Days in July

"... three aircraft go down in one week killing 462, during the same week, US healthcare was responsible for roughly 7,000 deaths..."

ME D SIM M A G A Z INE 4 . 2 0 1 4

On the 17th July Malaysian Airlines MH17 crashed in Ukraine, all 298 people aboard were killed, on the 23rd July, Transasia Airways, GE222 crashed on landing in Taiwan in bad weather with 48 fatalities and on the 24th July, Air Algerie, AH5017 crashed in Mali, N Africa killing all 116 on board. A total of 462 deaths globally. This was truly a disastrous week for aviation and all of us who work with the airlines (see sister magazine CAT) felt almost offended that three accidents in a week could possibly happen, even though MH17 was shot down and AH5017 possibly the result of a terrorist attack, i.e. two crashes were to an extent possible to class as unavoidable or at least beyond the control of the airlines. It was last November in Tatarstan that we recorded the last fatal accident in commercial aviation (globally) when 48 perished. Four years since the last fatal airline accident in the USA. At all three sites, governments, airplane manufacturers and air accident investigators are attempting to find out what happened, to learn from any mistakes and the resulting recommendations, whatever they are, will be broadcast to the global airline community and acted upon. You as ‘joe public’ could have known about each accident within minutes due to the heavy press coverage, even though it is thought that only one US national was lost. Also on the 17th July, a Senate Hearing on Patient Safety convened with the subtitle ‘More than one thousand preventable deaths per day is too many: The need to improve patient safety.’ http://www.help.senate.gov/hearings/ hearing/?id=478e8a35-5056-a032-52f8a65f8bd0e5ef To make the obvious comparison; three aircraft go down in one week killing 462, during the same week, US healthcare was responsible for roughly 7,000 deaths or pro rata the equivalent of just over 15 similar aircraft. We have no count of those not fatally injured by healthcare. Though a ‘disastrous week’ for aviation this was not a ‘disastrous week’ for healthcare, just another week much like the last, despite a 15 year effort to improve patient safety. Yet no paper reported, no TV station commented and hardly any healthcare outlets responded. This is not surprising as the last thing patients need is

to be anymore frightened of hospitals than they already are. None of us wants the reputation of the healthcare industry to suffer and the status of the profession to fall any further. If this was reported on, as are airline accidents of any type, the effect would be truly disastrous. Can 2014 be, to quote Churchill, ‘the end of the beginning’ in the patient safety effort? It would be true to say, as Dr. Peter Pronovost did in the Senate Q&A, that we count many more patients deaths as avoidable today than we did some years ago, because we now appreciate that they are avoidable but adds we have not appreciably moved the needle of patient care over that fifteen year period. That is progress of a sort. Two other quotes, among many powerful statements, stand out and are paraphrased here. First: If I make an improvement in treatment in my hospital it will stay within these four walls because there is no mechanism to tell other hospitals. Second: There are 300 hospitals in the US with a CLABSI rate ten times the average, and we know how to fix this. The first point is difficult to address with regulation and legal issues acting against the best interests of future patients, hospitals and the country but it must be addressed if we are to take advantage of the excellent work that is going on. As an example see the ACS Tennessee study elsewhere in this publication. On the second point can we simply expect those 300 hospitals, not to mention those thousands with simply a worse than average infection rate, to adopt the best practices outlined by Dr. Pronovost and his team and train their people to put things right very quickly? If they do not, after being given the opportunity and reasonable time, perhaps it is time to make their details available in the press so that patients can avoid ‘avoidable harm.’ (See Editor’s Comment p.3)

Andy Smith Publisher, MEdSim Magazine

e andy@halldale.com

World News & Analysis

MedicalNews 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.

NEW PRODUCTS & DEVELOPMENTS

FIRST RESPONDER

New Simulation Stethoscope and App

STARS Simulation Program Comes to Saskatchewan

MT Tool has launched the MT S-Scope, its new simulation stethoscope and app, a Bluetooth-connected stethoscope that can be driven by any IOS device. The app contains a library of heart, lung, bowel and bruit sounds and displays a variety of conditions for demonstration and teaching purposes. It includes patient cases for student evaluation in Objective Structured Clinical Examinations (OSCE) with standardized patients – with a complete bio and case history leading up to the appropriate section of the sound library. Standardized patients and/or instructors choose the desired sound on the IOS device

according to listening post maps, and the sounds play in the stethoscope. The company says it will continue collaborating with the user community to expand its library of sounds and cases and offering custom apps for universities that want to use their own content.

ACADEMIC

Nursing Simulation Grants and Scholarships Thomas Edison State College has received $700,000 in grants from three independent foundations to provide nursing scholarships and support the development of a nursing simulation program. The first is a three-year, $650,000 grant from the Helene Fuld Health Trust to provide scholarships for students working to become registered nurses. Scholarships from this fund will go to students enrolled in the college’s Accelerated 2nd Degree Bachelor of Science in Nursing (BSN) Program designed for adults with non-nursing bachelor’s degrees who are interested in becoming registered nurses. The intense, one-year program combines online and classroombased courses with clinical experiences

to prepare graduates for the National Council Licensure Exam for RNs. The second grant, $50,000 from the Robert Wood Johnson Foundation (RWJF) New Careers in Nursing Scholarship Program, will support underrepresented students who already hold a Bachelor’s degree and plan to earn a BSN through the college’s Accelerated 2nd Degree BSN Program. Five students at Thomas Edison State College, one of 52 schools in the US to receive a RWJF grant, will be awarded NCIN scholarships, a program of RWJF and the American Association of Colleges of Nursing (AACN). The third grant from the Investors Foundation provides the school with $37,500 that will be used to acquire simulation software and a patient manikin.

Human patient simulators are making their way across Saskatchewan, Canada, as part of Shock Trauma Air Rescue Society (STARS) air ambulance’s new Saskatchewan Mobile Education Program (MEU) that was established to improve critical care for patients in rural communities. The MEU, a specially-equipped motor home, is set up like an emergency room and operates a human patient simulator. In it, STARS and rural health care providers train to approach critical care as a team, making the chain of survival response more efficient. The mannequin can run a number of life-like scenarios that mimic situations of a critically ill and injured patient and when controlled by a STARS staff member, it can breathe, bleed, speak and accurately mirror human responses to medical care. When not being used in the MEU, the mannequin can be used in other environments including hospital emergency rooms, classrooms and mock accident scenes. Using the MEU, STARS can bring training to health care workers who can’t leave their posts or travel long distances at regular intervals to train. Inside there is a control room equipped with a computer and four viewing monitors that can follow the participants’ actions, display diagnostic tests and vital signs for the scenario being played out, and help the operator control the mannequin’s reactions. There is also a viewing screen for observers of the simulation exercise. ME D SIM M A G A Z INE 4 . 2 0 1 4

World News & Analysis PATIENT SAFETY

Surgical Safety Program Reduces Infections in Heart Surgery Patients A Canadian hospital has reduced a common postoperative complication of openheart surgeries – infection at the surgical site – by 77 percent through its participation in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®). According to a study presented at the 2014 ACS NSQIP National Conference, Vancouver General Hospital in Vancouver, British Columbia, reduced its rate of cardiac surgical site infections (SSIs) using a “best practices bundle”, a combination of scientifically proven, up-to-date methods for reducing these potentially serious infections. The hospital’s new surgical patient safety program, aligned with NSQIP best practices, quickly resulted in a dramatic reduction of SSIs, said Rael Klein, MD, FRCP, a study coauthor and an anesthesiologist at the University of British Columbia in Vancouver. Sternal (chest) infections can be devastating because they are close to vital structures such as the heart, Klein said. Reducing the SSI rate means fewer postoperative complications and reduced hospital stays for patients and great cost savings for the hospital. At an approximate cost of $30,000 to treat a sternal infection, the hospital saved about $300,000 in the past year, according to lead author Barbara A. Drake, RN, clinical quality and safety coordinator for Vancouver General Hospital. Klein and other members of Vancouver General’s multidisciplinary cardiac surgery quality improvement team led the SSI reduction effort after finding their average cardiac NSQIP SSI rate

was seven percent, about twice that of other comparable hospitals that participate in ACS NSQIP. The NSQIP database is the leading nationally validated, riskadjusted, outcomes-based program to measure and improve the quality of surgical care in hospitals. The goal was to reduce the cardiac NSQIP SSI rate to two percent – and the quality improvement team lowered the infection rate to a NSQIP average of 1.6 percent in the nine months after fully instituting the surgical best practices bundle in July 2013, Drake said. The team included surgeons, anesthesiologists; a nurse practitioner; an infection control specialist; quality coordinators; pharmacists; educators; nurse leaders and staff nurses who queried frontline providers, searched published best practices and then identified several areas needing improvement. Specifically, the group improved guidelines for prophylactic antibiotic use – so providers routinely administered the proper, weight-based intravenous dose of antibiotic at the best time and gave the patient a second dose if needed during long procedures. Patients received new types of wound dressings designed to reduce the chance of infection and the nurse practitioner led the team in standardizing the postoperative wound care of surgical sites. Another change involved active warming of patients to normal body temperature once they were taken off the cardiac surgery bypass machine. Patients are deliberately cooled when on the cardiac bypass machine, but Drake says warming the patients as soon as

possible can help reduce the chance of infection because cold constricts blood vessels, hindering oxygen needed for healing. Many of the new improvements came from information obtained from Safer Health Care Now, a program of the Canadian Patient Safety Institute. The team called the SSI reduction program CLEAN, which stands for: C: Clean hands before touching the dressing, apply chlorhexidine wipes to the body before surgery, use clippers for hair removal instead of shaving, and perform nasal decolonization (disinfecting the nostrils with ultraviolet light). L: Leave the dressing on for 72 hours postoperatively and leave the pink chlorhexidine disinfectant on the skin for six hours after the operation. E: Engage patients and staff on best practices for SSI prevention. A: Appropriately use antibiotics. N: Normothermia (normal body temperature), normal blood glucose (sugar), nutritious meals and no smoking for patients. The infection control practitioner monitors all cardiac in patients who received cardiac bypass and/or valve surgery for 90 days and there was an average of one sternal infection per month – but since July 2013, only two sternal infections were recorded – and there were none for eight consecutive months. The other study authors were Peter L. Skarsgard, MD; Wendy Bowles, NP; Rita Dekleer, ICP; Jennifer Kelly, RN; Howard Paje, RN; Jessie Rodrigue, RN; Emily Trew, RN; Tina Oye, RN; and Markus Zurberg, RN.

INTERNATIONAL

Virtual Physiological Human Project will Transform Healthcare The one-year-old Insigneo Institute at the UK's University of Sheffield has showcased the first phase of technology that will lead to the creation of a virtual human body and revolutionise global healthcare. The Institute’s goal is to create the Virtual Physiological Human, an in silico (computer simulated) replica of the human body that will enable virtual testing of treatments – and ultimately transform the economics and practicalities of modern medical treatment and medical research. The Virtual Physiological Human (VPH) programme is backed by European Commission funding. Since 2007, the EC 32

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has funded almost €220 million to collaborative in silico projects across Europe. The VPH will allow collaborative investigation of the human body as a single complex system using integrated computer models of the mechanical, physical and biochemical functions of a living human body, and will eventually lead to a better healthcare system, with personalised care solutions, a more holistic approach to medicine and a preventive approach to treatment. In time, it will lead to treatment that sees the body as a single multi-organ system rather than a collection of individual organs.

INTERNATIONAL

Training for Safe Anesthesia in Rugged Environments A group from Johns Hopkins is providing anesthesia training in Sierra Leone, as part of a project to help underdeveloped countries be able to provide anesthesia, even during frequent episodes of electricity outages. Johns Hopkins Department of Anesthesiology and Critical Care Medicine’s (ACCM) Doctors, Eric Jackson, John Sampson and Ben Lee are leading the project study that will introduce Gradian’s Universal Anesthesia Machine (UAM) in Sierra Leone. The UAM is a self-powered unit developed for austere conditions and contributed to more than 2,000 successful surgeries in other African countries such as Liberia, Ghana and Malawi. Its manual bellows ensure safe assisted respiration even without a high-pressure gas source and the device can work with or without electricity. It doesn’t require bottled oxygen, is designed to be simple to operate, maintain and repair, and is significantly less expensive than anes-

thesia machines used in the developed world. New technology means training, so IngMar Medical is partnering with Johns Hopkins to provide training where critical resources such as personnel, supplies, equipment, and reliable electricity are scarce. The group is using IngMar Medical’s QuickLung® Breather, a test lung capable of active

breathing and its RespiTrainer®, a multiskill ventilation and airway trainer. “The RespiTrainer lets the team train personnel, including nurses and anesthesiologist technicians, with different levels of experience – both those who need training in general procedures, like intubation, and those who need training in procedures that rarely occur,” said Dr. Adaora Chima, Senior Research Study Coordinator for Johns Hopkins’ Austere Anesthesia Health Outcomes Research Group. The team has seen good results, but its evaluation studies indicate a need for further training, so now Johns Hopkins is considering bringing IngMar Medical’s high fidelity ASL 5000 Breathing Simulator to Sierra Leone. That will provide more sophisticated simulation for training, said Chima, adding “we’ll start trainees with the RespiTrainer and QuickLung Breather, and then work up to the ASL 5000.”

INTERNATIONAL

UC Irvine School of Medicine Integrating Google Glass The University of California Irvine School of Medicine is taking steps to become the first in the US to integrate Google Glass into its four-year curriculum, from first- and second-year anatomy courses and clinical skills training, to third- and fourth-year hospital rotations. The school’s leaders believe faculty and students will benefit from Glass’s ability to display information in a smartphone-like, hands-free format that will let them use the Internet via voice commands and securely broadcast and record patient care and student training activities. UC Irvine’s comprehensive employment of the device will elevate the student experience unlike anything ever before, said Dr. Warren Wiechmann, assistant clinical professor of emergency medicine and associate dean of instructional technologies, who will oversee implementation of the Google Glass four-year program.

Improving how humans and systems work together in healthcare

ROBOTICS

Mimic Releases MSim 3.0 Mimic Technologies has released MSim 3.0, the latest version of the robotic surgery software platform that powers the company’s dV-Trainer®’s training scenarios, creates the pathway for new Mimic training methods and provides the architecture for customizing curriculum. Updated for dV-Trainer customers on a quarterly basis, this release includes the availability of Maestro AR™, Mimic’s recently released Partial Nephrectomy training module that provides 3D virtual instruments for interaction with anatomy in a 3D video environment.

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World News & Analysis NEW PRODUCTS & DEVELOPMENTS

NEW PRODUCTS & DEVELOPMENTS

Red Llama Releases SimPraxis Trainers for iPad

3D Simulated Heart

Red Llama’s SimPraxis® surgical simulation platform applications are now available on iOS – including the SimPraxis Laparoscopic Cholecystectomy and SimPraxis Laparoscopic Nissen Fundoplication procedures. These Apps are authored by University of Washington Surgeons Mika Sinanan, MD (Laparoscopic Cholecystectomy); Carlos Pellegrini, MD and Roger Tatum, MD (Laparoscopic Nissen Fundoplication). SimPraxis training modules offer detailed surgical training using highfidelity video in interactive simulations, didactics and anatomy quizzes and let users review potential errors, injuries and complications associated with each step. The trainers teach the relevant anatomy, the specific steps of the procedure, and

Dassault Systèmes has unveiled the first 3D realistic simulation model of a whole human heart. Developed with a multidisciplinary team of heart experts to help combat cardiovascular disease, Dassault says the ‘Living Heart Project’ will launch the next frontier in diagnosing, treating and preventing heart conditions through personalized, 3D virtual models. At the center of the project is a 3D heart model powered by Dassault Systèmes 3DEXPERIENCE platform’s realistic simulation applications. The company used the latest advancements in simulation provided by the SIMULIA applications to develop a comprehensive 3D heart model, capturing the electrical and mechanical behavior of the heart. Recent research from the World Health Organization says 17.3 million people died from cardiovascular diseases globally in 2008, and an American Heart Association report says the real total direct medical costs of cardiovascular disease will reach $818.1 billion over the next three decades. According to Dassault, the current lack of realistic 3D human models limits researchers’ ability to predict device behavior in humans – and the Living Heart Project attracted a multidisciplinary community of medical researchers, practitioners, device manufacturers and industry regulators who will have access to 3D computational models to accelerate the translation of research innovation into market-driven products and services. Using echocardiogram, MRI and CT scan images, along with cardiac research data, personalized 3D heart simulations will soon allow medical professionals to better understand the behavior of a patient’s heart without the need for additional invasive diagnostic procedures. The company says “this realistic human heart simulation will not only become a valuable educational and translational tool to incite research innovation, but may also lead to accelerated regulatory approval cycles, reduced development costs for new and more personalized devices and will ultimately enable early diagnoses and improve treatment outcomes.”

the required port placements and help orient users to the surgical team’s roles, become familiar with the necessary instruments and master the key risks of the laparoscopic hysterectomy. All actions and decisions made are captured for complete formative tracking and summative scoring for a meaningful and accurate assessment.

NEW PRODUCTS & DEVELOPMENTS

Immersive Medical Simulation Training Plextek Consulting, a Cambridge, UK technology company, has created an immersive medical simulation training system for the military using the Oculus Rift virtual-reality headset, which can be used for medical or disaster relief training. The smart solution simulates prehospital care on the battlefield and allows trainees to negotiate and prioritize clinical needs, teaching teamwork and decision-making skills within high-stress

‘under-fire’ scenarios. Using the Oculus Rift, soldiers can look all around their surrounding environment and head across the virtual battleground and attend to the casualties by navigating with a hand-held controller. The project was completed for the UK Government’s Defence Science and Technology Laboratory (Dstl), which supplied funding through the Centre for Defence Enterprise 2013 themed-competition: The Medic of the Future.

ACADEMIC

Saskatoon Institute for Medical Simulation Opens The Saskatoon Institute for Medical Simulation (SIMS) has opened as the ﬁrst privately owned medical simulation centre in Saskatchewan, Canada, to offer continuing education to healthcare professionals through in-situ and in-house simulation. Until now there hasn’t been training space in Saskatchewan for practicing healthcare professionals (including first responders) to access simulation to improve their clinical, teamwork and communications skills. Rural and remote healthcare professionals were at a greater disadvantage due to their distance from training centres, so SIMS also offers insitu training across the province. 34

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“SIMS was recently hired by managers in a rural region who identified a need for updated training in cardiac arrest situations,” said SIMS co-founder Shelly Luhning. When SIMS conducted the scenario in the region’s own emergency room, the doctors and nurses realized they were slow in assembling and connecting the deﬁbrillation machine – they had only practiced with a pre-assembled machine at their continuing education courses. By practicing the whole situation using a mannequin in their own environment, wasting time figuring out how to assemble equipment in a cardiac emergency is no longer an issue.

INTERNATIONAL

ACADEMIC

Torbay Hospital First in UK to Trial Google Glass

Boost for Northwest College Nursing

Surgeons at Torbay Hospital, part of South Devon Healthcare NHS Foundation Trust, are investigating the use of Google Glass in medical and surgical education, part of a trial that began in November 2013 when Core Surgical Trainee and app inventor, Dr George Brighton, acquired a set on loan (from IT company Entrenext Mobile in partnership with Delve Productions in the US) before the official launch in the UK. Google Glass has great potential for

medical education, the surgeons believe, as surgeons could use it to mentor junior surgeons through a procedure or stream procedures into lecture theatres full of students so they could see and hear what is happening during a surgical procedure from the surgeon’s view point. Its lightweight frame and tiny display rest above the wearer’s eyes and assists surgeons with varied functions like maps, voice search and video calls.

Northwest College (NWC) in Wyoming is using donations from West Park Hospital and Powell Valley Healthcare to improve nursing simulation. The school will open a new campus building in August with a simulation center with high-fidelity pediatric, obstetrical and adult manikins to replicate hospital situations. West Park Hospital committed $100,000 for the Adult Simulation Room, and Powell Valley Healthcare (PVHC) will contribute $75,000 for the Obstetrics Simulation Room. PVHC relies on NWC’s nursing graduates to care for its patients and residents, according to PVHC CEO Bill Patten. The center will be available to current nurses for recertification in specialty fields and to provide exposure to infrequent emergent care patient scenarios, and eventually the building will have space for emergency training and allied health coursework in areas such as phlebotomy and radiology.

HOSPITAL

Danbury Hospital Opens Center for Simulation & Clinical Learning Danbury Hospital, part of the Western Connecticut Health Network, has opened the Harold A. Spratt Center for Simulation and Clinical Learning, thanks to a generous gift from its namesake. The center will create virtual clinical scenarios for individuals and care teams using high-fidelity mannequins and actors trained for clinical simulation. Most of the 8,000-square-feet

facility opened in May and it will continue to grow with new equipment and clinical rooms, including a surgical skills lab and an ambulance lab for EMS scenarios. Ultrasonography/transthoracic echocardiology simulation equipment will also be installed thanks to a grant from the Connecticut Health and Education Facilities.

PATIENT SAFETY

Simulation in Medical Education Improves Patient Care Using simulation techniques in medical education results in improved patient care, better outcomes and other benefits, according to a study led by Loyola University Chicago Stritch School of Medicine researcher, William C. McGaghie, PhD. The study team analyzed 23 medical education studies published between 2006 and 2013 that measured the effects of simulation-based mastery learning (SBML) and found SBML improved outcomes in four areas: the educational laboratory, patient care practices, patient outcomes and collateral effects. The studies examined the impact of SBML on clinical skills such as management of ICU patients on ventilators, laparoscopic surgery and communicating with chronically ill patients about goals of care. Outcomes included improved procedural and communication skills, fewer complications and ICU admissions, and reduced healthcare costs. SBML “is a powerful educational model that improves clinical skills and has important downstream effects on health and society,” reported McGaghie, director of the Ralph P. Leischner Jr., MD

Institute for Medical Education at Loyola University Chicago and his colleagues in the journal Medical Education. “Simulation-based mastery learning is beginning to produce strong and lasting educational effects when it is implemented, managed and evaluated with thought and rigor,” the team wrote. “We believe the mastery model, with or without simulation technology, holds great promise to help medical learners to acquire and maintain a broad array of technical, professional and interpersonal skills and competencies. In a coda, the authors wrote that implementing SBML as a new paradigm will not be easy because of barriers like educational inertia, conventional thinking, costs and time-based education schedules; but these barriers can be overcome. “We cannot continue to educate 21st century doctors using 19th century technologies,” wrote the team that consisted of first author McGaghie and co-authors S. Barry Issenberg of the University of Miami Miller School of Medicine, and Jeffrey H. Barsuk and Diane B. Wayne of Northwestern University Feinberg School of Medicine. ME D SIM M A G A Z INE 4 . 2 0 1 4

World News & Analysis NEW PRODUCTS & DEVELOPMENTS

NEW PRODUCTS & DEVELOPMENTS

New Training Module

Endovascular Training

VirtaMed UroSim™ features a new training module for the safe transurethral resection of bladder tumors (TURB), with numerous challenges including multiple papillary and solid tumors in various sizes and places. The new TURB module is available on the VirtaMed UroSim platform and can be combined with Trans-Urethral Resection of the Prostate (TURP), laser Benign Prostatic Hyperplasia (BPH), and morcellation training. Surgeons can perform simulated TURB surgical procedures using an original resectoscope with the goal of safely removing bladder tumors without per-

Simbionix is offering a new platform and two modules to enhance hands-on training for clinicians. Simbionix’ solutions for endovascular training in the ANGIO Mentor™ family of products provide simulation platforms for practicing endovascular skills and complete procedures. The new ANGIO Mentor Flex is a portable training solution that provides realistic simulation and tactile feeling of an actual procedure. It comes in a case that can be checked as luggage on flights within airline weight restrictions and it is fully compatible with the ANGIO Mentor Suite stationary platform. The entire library of 19 procedure modules can be operated on either system. Simbionix is also introducing two new applications – the Transradial Coronary Intervention Module and Transseptal Puncture Module with echocardiography because of the increasing popularity and safety of the transradial approach and the large number of practicing physicians not yet trained in transradial catheterization. Simulation helps users perfect these procedures that require a skill set distinct from trans-femoral procedures, with a steep learning curve. The Transradial Coronary Intervention Module presents challenging anatomies and scenarios for coronary angiography and intervention using the transradial approach, such as tortuous subclavian, brachial loop and CABG. The module trains clinicians in appropriate equipment selection and techniques as well as negotiating complications, such as spasm and perforation. Transseptal puncture is required for advanced cardiac procedures and uses echocardiography guidance for transseptal puncture, allowing better visualization of heart structures and helping reduce complication rates. The Transseptal Puncture Module lets learners practice left atrial access by puncturing the intra-atrial septum – where life threatening complications can occur during simulations. This module is the only one that includes real time ICE (intracardiac echocardiography) simulation, which teaches cardiologists how to maneuver an ICE catheter and interpret the echocardiographic image

forating the thin bladder wall, controlling bleeds and avoiding complications. Afterwards, users get an objective feedback report with exportable video, pictures and other relevant data.

NEW PRODUCTS & DEVELOPMENTS

Managing Bipolar Disorder Sleep Disturbances CME Outfitters, LLC (CMEO) has released its certified neuroscience CME Medical Simulation: “Clinical Decision Making in Action: A Medical Student With Bipolar Disorder.” It’s designed to help physicians anticipate the challenges a young woman diagnosed with bipolar disorder will face while embarking on her medical residency – including the impact sleep disruption, long hours and rotating shifts will have on her bipolar disorder and the best way to manage and stabilize her mood during challenging periods. The online, competency-based, branch-logic patient simulation features video clips and links to resources and provides a safe environment for clinicians matching real-life experiences to improve clinical decision-making. Learners view a video of a patient, make assessments based on the patient’s story and history, and receive guidance from Daniel Buysee, MD, of University of Pittsburgh School of Medicine, in one virtual session. The simulation is free and can be completed anytime. All physicians, physician assistants, nurse practitioners, nurses and pharmacists with an interest in sleep and mood disorders are encouraged to participate. CMEO is accredited by the Accreditation Council for Continuing Medical Education. HOSPITAL

ACADEMIC

Innovation Center

Liberty University Osteopathic School of Medicine to Open

Willis-Knighton Health System has opened its new Innovation Center in Louisiana that includes a virtual hospital for training Willis-Knighton staff, local healthcare students and students from nine nursing schools throughout Louisiana and East Texas, including the Louisiana State University School of Medicine. Willis-Knighton renovated an old hospital to create the center and the virtual hospital is in what was once an intensive care unit, providing training opportunities that mimic real-world situations with 22 patient rooms, two operating suites, high-fidelity simulators, a recovery area and a labor and delivery suite. 36

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Liberty University Osteopathic School of Medicine in Lynchburg, Virginia will begin classes in August with an inaugural class of 162 students, all of whom are set to earn their Doctor of Osteopathic Medicine (DO) degrees in Spring 2018. The program will be housed in the new Center for Medical and Health Sciences, a $40-million building with a Center for Standardized Patient and Simulation that includes a 5,300-square-foot Anatomy Lab and a 5,000-square-foot Osteopathic Manipulative Medicine Lab.

ROBOTICS

Advancing Robotic Surgery Education Florida Hospital Nicholson Center’s research into remote surgery or telesurgery began with two questions: “Can it be done?” and “Is it safe?” According to research funded with a $4.2 million grant from the US Department of Defense (DoD), the answer to both questions is yes. For the past three years, Roger Smith, Chief Technology Officer at the Florida Hospital Nicholson Center, has asked physicians to try their hand at telesurgery using a robotic surgery simulator developed by Mimic Technologies, Inc. In a telesurgery environment, there would be a communications delay between a surgeon performing an operation in one location and the patient in another location. The goals were to determine how this delay would impact surgeons during an operation, and how long a delay is safe? The research determined a 200-mil-

liseconds delay (almost the speed of a blink) was imperceptible to surgeons and that most could compensate for delays up to 500 milliseconds (half a second). The next task was to determine if communications between two metropolitan hospitals could be conducted within that 200 millisecond window, and again the team said yes after conducting experiments using the existing connectivity between Florida Hospital locations in Central Florida. They found there was a 5 millisecond delay between hospitals, well within the 200 millisecond threshold needed to operate safely. More tests from Celebration Health to Daytona Beach, Tampa, and even Fort Worth, Texas came back with safe levels of delay. Next, the team will look to repeat their connectivity tests to Denver, Colorado and Loma Linda, California.

In addition to the telesurgery experiments, the DoD grant funded the creation of the world’s first standardized robotic surgery curriculum, called the Fundamentals of Robotic Surgery – a standard for learning materials and tests that measures if a surgeon is prepared to operate on a patient using a daVinci robot. The Nicholson Center team gathered 30 robotic surgery experts from around the world, representing 17 medical societies, to create a curriculum covering the essential skills necessary to be a proficient robotic surgeon. After three years of collaboration, this curriculum was published and hospitals worldwide are using it to train physicians new to robotic surgery. The DoD extended the Nicholson Center’s funding for continued work on advancing robotic surgery.

INTERNATIONAL

NEW PRODUCTS & DEVELOPMENTS

Construction of New UK Medical Clinical Skills Centre

Simbionix Introduces New Vaginal Cuff Suturing Module

Construction of a Medical Clinical Skills Centre has begun at Noble’s Hospital on the Isle of Man, UK, which is primarily funded by the Medical Clinical Skills Charitable Trust. The Centre will give all doctors on the island access to continuing education through the use of simulators and mannequins, and will give senior medical staff access to regular revision and update training. The Isle of Man Medical Research Charitable Trust, The Eric and Marion Scott Trust, The Microgaming Health and Care Trust, The Manx Stroke Foundation and other private donations also provided financial support for the development of the Medical Clinical Skills Centre, which will be a two story extension to the Keyll Darree Education and Training Centre, on the Noble’s Hospital estate.

Simbionix’ new Vaginal Cuff Suturing Module for the LAP Mentor lets students and surgeons practice advanced vaginal-cuff suturing cases using unidirectional and bidirectional knotless barbed sutures. It includes potential complications such as suspected injury to the bladder, ureters and colon as well as objective performance metrics. Real suturing handles allow for lifelike practice of the suturing skills. The Unidirectional Barbed Suture has 360-degree unidirectional anchors with a surgical needle on one end and an adjustable fixation loop on the other. The anchors are oriented in one direction and allow tissue approximation without the need to tie surgical knots. The Bidirectional Barbed Suture consists of 360-degree bidirectional anchors with surgical needles on both ends that also allow for tissue approximation without tying surgical knots.

ACADEMIC

Interprofessional Simulation Based Course The University of Wisconsin is running what it says is the first inter-professional simulation-based course in the United States in August at the UW Health Clinical Simulation Program. The new 4th year elective 'The Interprofessional Simulation Team Immersion Course' is a highly interactive, hands-on inter-disciplinary course. Students from up to five professional

disciplines will learn together and practice healthcare scenarios on high-fidelity manikins. Topics include effective team performance, crisis resource management, healthcare ethics and leveraging the unique roles of inter-professional partners. The course will utilize clinical dilemmas and critical thinking to model improvement in the quality of patientcentered care, minimize healthcare

errors, and positively impact health outcomes. The course uses clinical simulation where communication skills and clinical skills can be learned and practiced in a realistic setting that encourages feedback, reflection, and skill mastery. It is open to medical, nursing, physician assistant, pharmacy and physical therapy students. ME D SIM M A G A Z INE 4 . 2 0 1 4

World News & Analysis ACADEMIC

ACADEMIC

NEW PRODUCTS & DEVELOPMENTS

New Learning Centre

$1 Million Grant

LapSim Update

The Trent University Fleming School of Nursing in Ontario, Canada has opened its new Nursing Clinical Simulation Learning Centre in the university’s Life and Health Sciences Building. The centre incorporates Trent’s new technological resources, expanding capabilities in nursing education and increased interprofessional development opportunities with other universities and health centres.

The University of Central Florida (UCF) College of Nursing has received a $1 million grant from Florida Hospital to establish its second endowed chair in HealthCare Simulation to work closely with the university’s nursing faculty, Institute for Simulation and Training, and College of Engineering and Computer Science. Computer scientist and engineer Gregory F. Welch, Ph.D., is the inaugural appointee to the Florida Hospital Endowed Chair in Healthcare Simulation. A UCF faculty member, he has coinvented various patents and is currently working with a team of UCF nursing professors to research and prototype a healthcare simulation training technology by giving manikins emotions to improve simulated patient interactions with personal touch. Welch is also an adjunct professor at the University of North Carolina at Chapel Hill where he earned his Ph.D. and led research efforts to develop a three-dimensional remote health-care consulting technology to let physicians’ coach emergency medical personnel through procedures while they are responding to emergencies.

Surgical Science has released its annual major update of the LapSim virtual reality laparoscopic trainer that includes more than 50 new enhancements and upgrades. The update brings scenario control to LapSim, includes an improved results dashboard and metrics interactivity, introduces survey functionality, and delivers new training exercises for bariatrics and nephrectomy.

Calendar Organised by Halldale Group: 22-24 August 2014 HEATT 2014 – Healthcare Education Assessment Training & Technology Rosen Shingle Creek Resort, Orlando, Florida, USA www.halldale.com/heatt Other simulation & training events: 30 August – 3 September 2014 2014 AMEE Excellence in Education Milan, Italy www.amee.org/conferences/amee-2014 10-12 September 2014 IWISH – International Workshop on Innovative Simulation for Healthcare Bordeaux, France www.msc-les.org/conf/iwish2014 10-13 September 2014 Minimally Invasive Surgery Week Las Vegas, Nevada, USA www.sls.org 11-12 September 2014 Simulation Summit 2014 Toronto, Canada www.royalcollege.ca/events/ simulationsummit 12-13 September 2014 7th Annual ACS-AEI Postgraduate Course/CAMLS Tampa, Florida, USA www.facs.org/education/ accreditationprogram/pg-course.html 17–20 September 2014 NLN Education Summit Phoenix, Arizona www.nln.org/summit 11-13 November 2014 ASPIH Annual National Conference 2014 Nottingham, UK www.aspih.org.uk 38

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ACADEMIC

Simulation Teaching Hospital The University of Texas (UT) System has opened its new 15,000-square-foot simulation teaching hospital, called the UT Rio Grande Valley (UTRGV) Smart Hospital near the South Texas/Mexico border. Currently the UTRGV Smart Hospital is being used by the Regional Academic Health Center (RAHC), a satellite of the UT Health Science Center at San Antonio. By 2015, it will be used by a new university called the UT Rio Grande Valley that is being created by combining UT Brownsville, UT Pan American and the RAHC, and in 2016 it will also be used by the new UTRGV medical school. The UTRGV Smart Hospital was built using $10 million in funding from the UT System Board of Regents. It is equipped with the latest medical simulation technology to provide hands-on training to current and future doctors, nurses, and other health professionals.

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84.5% of trauma practitioners recommended EMS personnel attempt intubation at least once on a patient with a severe traumatic brain injury, when transport time is greater than 20 minutes.*

Time Is Ticking Immediate management of the compromised airway in a trauma patient is crucial. There is no time for second-guessing or failed attempts. Exposure to simulation can help facilitate critical decision-making training exercises to develop skills competency and confidence to perform high-risk interventions.

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Visit us at laerdal.com/GetTheFacts to learn more about how simulation-based education can support emergency medical training. *Journal of Trauma-Injury Infection & Critical Care. 58(3):509-517, March 2005. Salomone, Jeffrey P.MD,FACS; Ustin, Jeffrey S. MD; McSwain, Norman E. Jr. MD, FACS; Feliciano, David V. MD, FACS ÂŠ2014 Laerdal Medical. All rights reserved. Printed in USA. #14-14329

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