Simulation technology Simulation technology in critical care: in critical care: 1000 deaths for 1000 deaths for

medical educationmedical educationTechnology for teaching Technology for teaching

and evaluating critical care and evaluating critical care knowledge, skills and knowledge, skills and

attitudesattitudes

Randy S. Wax, MD, FRCP(C)Technology Application Unit and Critical Care

Unit, Department of Medicine, Mount Sinai Hospital

Lecturer, Department of Medicine, University of Toronto

Learning objectivesLearning objectivesWhy simulation?Features of a simulatorApply simulation technologyLimitations and resource

requirements

A traditional approach to learningA traditional approach to learning

Problem #1Problem #1Just because students learn a task

in the classroom doesn’t mean they can demonstrate successful performance during a crisis.

Problem #2Problem #2Some clinical experiences are so

life threatening that students are not going to be involved in the management.

Problem #3Problem #3Some are so rare that the student

may not ever experience the situation until they are in the midst of caring for the patient.

Different simulation Different simulation formatsformats

Patient management problems (paper/pen)

Computerized simulation– Internet-based

Role playing/standardized patientsMannequin-based (e.g., CPR BCLS

trainer)Virtual reality

Why simulation?Why simulation?Used in many “high reliability”

fields– Aviation– Nuclear power– Military flight operations

Why simulation?Why simulation? No risk to patients Many scenarios can be presented,

including uncommon but critical situations in which a rapid response is needed – E.g. malignant hyperthermia 1:40,000 cases

Participants can see the results of their decisions and actions; errors can be allowed to occur and reach their conclusions

Why simulation?Why simulation? Identical scenarios can be presented to

different clinicians or teams The underlying causes of the situation

are known With mannequin based simulators

clinicians can use actual medical equipment– examine limitations in the human-machine

interface

Why simulation?Why simulation? Re-create clinical environments

– Assess interpersonal interactions with other clinical staff

– Evaluate and improve teamwork, leadership, and communication skills

Why simulation?Why simulation? Intensive and intrusive recording of the

simulation session is feasible– Audiotape– Videotape– Physiological monitoring of participants

(EEG, ECG, etc.)

Why simulation?Why simulation? There are no issues of patient

confidentiality Recordings can be preserved for

research, performance assessment, or accreditation

How can we use How can we use simulation?simulation?

Skills trainingEvaluation

Epidemiology and modification of errors (and their consequences)

Crisis resource management

What can you What can you teach/evaluate?teach/evaluate?

Specific skills– Intubation– Bronchoscopy– Defibrillation

Integration of knowledge, skills and decision making– Resuscitation– Refractory hypoxemia

Level 1 Level 2 Level 3

Skill Integrate High-fidelity

Medical Student

Bag ventilation

Hypoxemic patient

Ward team

Resident Intubate Hypoxemic patient

ER/ICU RN, RT

Fellow/Staff

LMA, surgical airway

Difficult airway management

Full ER/ICU team

CME

Evaluation of the evaluation toolEvaluation of the evaluation tool Type of simulator

– Low to high fidelity Type of simulation

– Full theatre environment or real location– Training device for specific tasks

Efficacy of assessment– Valid– Reliable

SIM MANSIM MAN

Life-size Life-size mannequinmannequin

Computer Computer ControlledControlled

Teach airway Teach airway managementmanagement

Use airway devicesUse airway devices

Fibreoptic intubationFibreoptic intubation

Difficult airway– Decreased cervical range of motion– Tongue edema– Pharyngeal edema– Laryngospasm– Trismus– Fiberoptic intubation/bronchoscopy– Surgical airway – Detectable carbon dioxide

Breath soundsBreath sounds

Check pulse & blood pressureCheck pulse & blood pressure

Obtain peripheral IV Obtain peripheral IV accessaccess

Mask ventilationMask ventilation

Decompress tension Decompress tension pneumothoraxpneumothorax

Monitor cardiac rhythmMonitor cardiac rhythm

Shock unstable rhythmsShock unstable rhythms

Additional featuresAdditional featuresChest tube insertionInvasive hemodynamicsVentilator management (including

HFOV)

Control crisis situationsControl crisis situations

Give feedbackGive feedback

Assessment instrumentsAssessment instruments Specific

– Debriefing (oral or written…good for factual)– Observation and scoring system (checklist

or score sheet or palm pilot)– Time to performance of specific task

Global– Simulated mortality as end-point– Time to solve problem

How can we use How can we use simulation?simulation?

Skills trainingEvaluation

Epidemiology and modification of errors (and their consequences)

Crisis resource management

Epidemiology of Medical Epidemiology of Medical ErrorError

Types of errors made during anaesthesia simulation

37%

17%13%

10%

33%

Monitor usageAirwaymanagementVentilatormanagementDrugadministrationOther

Schwid and O’Donnell Anesthesiology 1992

Crisis Resource Crisis Resource ManagementManagement

Using all available resources during a crisis to achieve safety and efficiency– Information– Equipment– People

Crisis Resource Crisis Resource ManagementManagement

Error countermeasures– Reduce the frequency of errors– Correct errors– Limit the impact of errors

ResourcesResources Simulator PLUS operational budget Competency standards

– Who/what are you testing? Content experts

– Set objectives and clinical setting Simulation experts

– Translate objectives and clinical setting into functional simulation scenarios

AV equipment (debriefing)

Limitations of simulationLimitations of simulationDifficult to demonstrate improved

outcome from use of simulation– Adverse events are unusual– Extreme number of potential

confoundersForced to use simulation

performance as surrogate outcome

Initiatives at MSHInitiatives at MSH

Initiatives at MSHInitiatives at MSHMock cardiac arrests

– ACLS protocols– Use of equipment– Systems issues (elevators, cancel

arrest)– Crisis resource management– Feedback/debriefing

Initiatives at MSHInitiatives at MSHLife-saving delegated medical acts

– ICU/CCU nurses– Use of epinephrine/atropine– Defibrillation

Pre-ACLS interventions– Bag-valve-mask ventilation– Understanding respiratory failure and

shock

Initiatives at MSHInitiatives at MSH Medical and Critical Care Residents Continuing education courses

– Difficult airway management– Advanced ARDS strategies

Technology evaluation– OCCIN Project

Multidisciplinary approachPortable

Parting commentsParting comments Simulation is fun for students and

teachers You can use simulation technology as

an evaluation tool Choose the most appropriate tool for

achieving educational goals Remember basics of education,

otherwise simulator is an expensive toy