Simulation at the point of care: Reduced-cost, in situ training viaa mobile cart

Peter H. Weinstock, MD, PhD; Liana J. Kappus, MEd; Alexander Garden, MBChB, PhD;Jeffrey P. Burns, MD, MPH

I n the early 1990s a group lead byDavid Gaba at Stanford Universityadvocated simulation-based train-ing in the management of anes-

thesia crises, using crew resource man-agement principles from aviation (1–3).This approach is now the dominant par-adigm for crisis resource management(CRM) training in all medical domainsand internationally has become acceptedas an effective tool for team training. Ir-respective of the clinical domain, the po-tential benefits of simulation-based CRM

training are a lack of patient risk andefficient and scheduled use of trainingtime to learn and practice the work placeskills and behaviors required to managerare or hazardous clinical events by plac-ing the adult learner in an authentic en-vironment (4).

Contemporary medical simulation pro-grams have typically evolved as dedicatedfacilities meant to replicate the patient careenvironment, either within the hospital orat an off-site location (5). The location ofthe facility has implications on fidelity,cost, and access to simulation. The use ofdedicated simulation rooms within the hos-pital reduces the extent to which trainingexercises will disrupt, or be disrupted by,the actual delivery of patient care. In addi-tion, on-site simulation facilitates the train-ing of native teams without causing theoperational disruption caused by the re-lease of the entire team from the hospital.In contrast, off-site simulation results inrelease from clinical responsibility, thusproviding the benefit of uninterruptedtraining. Yet, in turn, this often requiresthe creation of ad-hoc teams from differenthospitals or different parts of the same hos-pital, and the use of actors to fill the roles of

clinical disciplines who are absent. Because ofthese disadvantages, we have pursued in-hospital simulation as our preferred approachto enable training of intact teams which webelieve significantly enhances the realism andvalue of the training exercise (6).

Optimally, a dedicated simulation roomis fully equipped with all technologies andequipment that are required to create anauthentic patient care environment. Thisencourages the suspension of disbelief toenhance positive educational transfer.However, dedicated rooms are expensive toequip, occupy nonreimbursable space, andcannot completely replicate the many dis-tinctive patient care environmentsthroughout the hospital. The dogma inother industries is that fidelity or realismshould be maximized, because of the criti-cal importance of the distinctive environ-ment of the workplace. For example, com-mercial airline pilots undertake crisistraining in simulators that replicate theactual aircraft cockpit model that they flyday to day rather than in generic cockpitsimulators that are used for lower-levelskill training (1). In addition, airline educa-tors quickly acknowledged the importanceof including all members of the flight team,

From the Division of Critical Care Medicine (PHW,LJK, JPB), Department of Anesthesia, Program in Med-ical Simulation, Children’s Hospital and Harvard Med-ical School, Boston, MA; Harvard Medical School (PHW,JPB), Boston, MA; and Department of Anesthesia (AG),Wellington Hospital, New Zealand.

The simulator center is supported by funds pro-vided by the Division of Critical Care Medicine, Depart-ment of Anesthesia and Children’s Hospital Boston.

The authors have not disclosed any potential con-flicts of interest.

For information regarding this article, E-mail:peter.weinstock@childrens.harvard.edu

Copyright © 2009 by the Society of Critical CareMedicine and the World Federation of Pediatric Inten-sive and Critical Care Societies

DOI: 10.1097/PCC.0b013e3181956c6f

Objective: The rapid growth of simulation in health care haschallenged traditional paradigms of hospital-based education andtraining. Simulation addresses patient safety through deliberativepractice of high-risk low-frequency events within a safe, structuredenvironment. Despite its inherent appeal, widespread adoption ofsimulation is prohibited by high cost, limited space, interruptions toclinical duties, and the inability to replicate important nuances ofclinical environments. We therefore sought to develop a reduced-costlow-space mobile cart to provide realistic simulation experiences toa range of providers within the clinical environment and to serve asa model for transportable, cost-effective, widespread simulation-based training of bona-fide workplace teams.

Design: Descriptive study.Setting: A tertiary care pediatric teaching hospital.Measurements and Main Results: A self-contained mobile sim-

ulation cart was constructed at a cost of $8054 (mannequin notincluded). The cart is compatible with any mannequin and con-

tains all equipment needed to produce a high quality simulationexperience equivalent to that of our on-site center—includingdidactics and debriefing with videotaped recordings completewith vital sign overlay. Over a 3-year period the cart delivered 57courses to 425 participants from five pediatric departments. Allindividuals were trained among their native teams and withintheir own clinical environment.

Conclusions: By bringing all pedagogical elements to the ac-tual clinical environment, a mobile cart can provide simulation tohospital teams that might not otherwise benefit from the educa-tional tool. By reducing the setup cost and the need for dedicatedspace, the mobile approach provides a mechanism to increase thenumber of institutions capable of harnessing the power of simu-lation-based education internationally. (Pediatr Crit Care Med2009; 10:176–181)

KEY WORDS: pediatrics; critical care; simulation; education; pa-tient safety; in situ

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thus broadening the scope of training be-yond pilots and enhancing the emotional/experiential components of reality that relyon relationships between actual teammembers (7).

We agree with the view that the effec-tiveness of simulation-based training canbe optimized by maximizing the realism ofcritical aspects of the simulation (8, 9) andthat this can be achieved by undertakingthe simulation within the actual workplaceenvironment, with full participation bythose individuals who normally constitutea clinical team. We, therefore, sought todevelop a mobile simulation cart thatwould enable effective point-of-care, simu-lation exercises in actual work environ-ments throughout the hospital. We aimedto use the mobile approach to facilitate sim-ulation of bona-fide workplace teams by cre-ating favorable logistics for members other-wise engaged in a typical workday (followingsimulations, members could easily andpromptly return to their nearby clinicalposts). The cart would also serve as a modelfor widespread implementation of simulationthat is more feasible due to transportability,space, and cost containment.

In this report, we describe the develop-ment and implementation of a mobile simu-lation cart capable of delivering all compo-nents of high-quality medical simulation,using a standardized approach to crisis man-agement, to the actual point of care in fiveclinical areas within a tertiary pediatric teach-ing hospital. Simulation scenarios were basedupon real situations from each department.

METHODS

Mobile Simulation Cart Components. Themobile simulation cart (Figs. 1 and 2) wasdesigned to allow educators to use simulationtechnology on par with the permanent center.Based upon the literature and our own ex-perience, we defined three key elements ofsuccessful simulation-based CRM trainingcourses— didactic presentations, realisticfull body simulation (10), and video-baseddebriefing (11–13)—that would form the ba-sis of the cart’s design.

To support didactics with slide-show capabil-ity, the cart houses a laptop computer (“LT1,”MacBookPro, Apple, Cupertino, CA) and LCDprojector (HC100U Colorview Home Theater,Mitsubishi, Tokyo, Japan). Presentations are dis-played on available screen or wall space at thepoint of care. External speakers ensure adequatesound quality in rooms with poor acoustics.

To support the range of available humanpatient simulators, the cart has cargo space forthe mannequin (SimBaby, Laerdal, Stavenger,Norway) and associated equipment includinglaptop (“LT2,” Dell, Round Rock, TX), control

box (LinkBox, Laerdal), simulated patientmonitor, and air regulator/compressor.

To allow for video-based debriefing, thecart included integrated audiovisual equip-ment to record and play back recordings ofteam performance, with superimposed vitalsigns from the physiologic monitor (Fig. 1B).Although other video layouts are currentlyavailable in various formats, the visual vitalsign overlay approach carries the benefit ofeconomy of space (i.e., all information sharedin the largest single view) and prevents theneed for participants to divert their attentionamong multiple screens. To achieve superim-position of video, the signal carrying the vitalsigns is sent via a splitter (Expandview 4-port,Belkin, Compton, CA) to both the physiologicmonitor and media converter (Ultimate Plus,Sony, Tokyo, Japan). The video from a cart-mounted digital video camera (CAM, HDRHC1Handycam, Sony, Tokyo, Japan) is also fedinto the media converter that blends the twoimages. A bidirectional media converter(TwinPact 100, Canopus, San Jose, CA) con-verts the blended audio and video from analogto a digital signal, which is captured by videosoftware (iMovie06, Apple, Cupertino, CA).The captured video is thus available for imme-diate playback through the LCD projector andexternal speaker without any additional edit-ing steps or time.

The cart (Fig. 2A) needed to be large enoughto hold all necessary equipment yet smallenough to be unobtrusive in the clinical envi-ronment (Fig. 2B)—final dimensions were fivefeet tall by three feet wide by two-feet deep.

Mobile Simulation Cart Cost. Total costwas $8054 (Table 1). The majority of costencompassed reusables including a laptopcomputer, video camera, and LCD projectorthat served dual purposes (didactic presenta-tion and then debriefing). With the added ex-pense of the human patient simulator($33,000; SimBaby, Laerdal), total cost rose to$41,054.

Mobile Simulation Cart Personnel Re-quirements. The mobile cart requires minimalsetup and breakdown time between coursesand can be transported and setup for immedi-ate simulation and debriefing within 40 min-utes. To perform mobile simulation, typicalsupport staff required one technician fortransport and delivery of the scenario accom-panied by a facilitator to conduct the debrief-ing. The level of cost and expertise required interms of support cost is the same for bothmobile and nonmobile simulation facilities.

Standardization of Crisis Resource Man-agement Training. We explicitly sought to usethe mobile simulation program to implementa standard multidisciplinary format in CRMthroughout the hospital. This was developedthrough collaboration between the clinicalleadership from individual departments in-cluding nursing, and support staff each with abroad understanding of the physical and logis-tic (e.g., scheduling) nuances of their clinicalenvironment. Typical courses were 4.5 hours

and included a didactic lecture on CRM,game play to introduce the concept of teamcohesiveness, and two simulation experi-ences each followed by a 30-minute, video-based debriefing.

RESULTS

Usage and Demographics

Implementation of point-of-care simu-lation using the mobile simulation cart be-gan in January 2004. Over the following 36months, we performed 57 mobile simula-tion exercises, involving five clinical depart-ments and 425 clinicians (Table 2). Thus,far the multidisciplinary teams that havebeen trained include: 135 physicians from 7subspecialties, 242 nurses, 20 respiratorytherapists, 11 clinical assistants, 10 radiol-ogists, and 7 technicians.

Mobile Simulation Programs

Standardized mobile simulationcourses were introduced within five clin-ical areas. Individual department demo-graphics are shown in Table 2.

Emergency Department/Trauma Pro-gram. Our institution is certified as alevel I trauma program with a team com-posed of surgeons, emergency depart-ment physicians, anesthesiologists, surgi-cal subspecialists, registered nurses,pharmacists, and respiratory therapists.To accommodate this wide range of prac-titioners with varying schedules, thecourse was initially abbreviated to 1 hour.The sessions occurred bimonthly and in-volved a STAT page convening the fullcomplement of the trauma team to theemergency department. Mobile simula-tion facilitated recruitment of partici-pants by allowing them to convene in afamiliar and easily accessible location.This course was soon extended to a pre-planned, 2-hour course in response toparticipant feedback expressing the needfor more time for both framing of theexercise as well as video-based debriefing(data not shown), thus underscoring theimportance of delivering all three compo-nents of the educational experience.

Cardiac Catheterization Laboratories.Mobile simulation allowed practicewithin the uniquely complex environ-ment of the catheterization laboratory,which includes large obtrusive fluoro-scopic equipment, dim-lighting, and poorpatient access. To enhance realism andengage the proceduralist, we made threeadditions to our usual mobile system.

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First, fluoroscopic cine studies from ac-tual cases were captured, edited, and thenreplayed through actual monitors in realtime at appropriate moments during thecatheterization. Second, the physiologicdata from the simulation was transmittedto the catheterization laboratory moni-toring system to allow these data to bedisplayed in an authentic manner. Last,the manikins were adapted to contain in-tegrated task trainers to allow the inter-ventional cardiologist to gain access andplace appropriate devices in real time.

Postanesthesia Care Unit. The busymilieu of the postanesthesia care unit is dif-ficult to emulate in the isolated simulationroom of the permanent center. In addition,the high patient turnover within the postan-esthesia care unit emphasized the impor-tance of allowing clinicians to train close to orwithin their posts to insure representation ofthe complete team and to avoid disruption ofpatient flow within the operating rooms. Toavoid cancellations, the postanesthesia careunit course was scheduled several hours be-fore the first operating room cases.

Cardiac Intensive Care Unit. Point-of-care simulation allowed participants toeasily interact with monitoring and life-support devices such as extracorporealmembrane oxygenation that are uniqueto their environment. Over a 3-year pe-riod, 32 4.5-hour courses were imple-mented for 220 participants including 10extracorporeal membrane oxygenationspecialists who would otherwise not beable to participate due to staffing levels.

Operating Room. By bringing simula-tion to the hospital operating rooms, estab-

Figure 1. Mobile simulation cart blueprint—Connection flowchart. (A) The flow diagram indicates the required equipment and connections to provide on-site didactics, simulation, and debriefing via the mobile simulation cart. (B) Screen capture of resulting video material with vital sign overlay. (See“Methods” section and Figure 2 for complete description of components).

178 Pediatr Crit Care Med 2009 Vol. 10, No. 2

lished surgical care teams could train to-gether around relevant cases within theirwork environment. First to participate wasthe otolaryngology service. An additional ben-efit of authentic point-of-care training sur-faced within these programs, namely the abil-ity to dynamically identify real areas ofsystems improvements (Table 3).

DISCUSSION

The ideal environment to practice work-place tasks is where the work actually takesplace. To harness this concept, we haveimplemented point-of-care, simulation-based education throughout our teachinghospital via a mobile simulation cart thatdelivers all components of the pedagogy—didactic teaching, high-fidelity simulation,and video-based debriefing, complete withvital sign overlay. Point-of-care trainingmay represent the next generation in theevolution of simulation-based education byadvancing both feasibility (e.g., reducedcost and space) as well as numerous aspectsof fidelity. In our experience, the mobileapproach brings the unique effectiveness ofsimulation directly to a wide range of in-terdisciplinary teams and enables theseteams to train together in their own envi-ronment while reducing the setup expense,and space and logistic obstacles inherent ina dedicated simulation suite.

With the mobile simulation cart, wehave been able to deliver simulation-

based CRM training to a wide range ofgroups within our hospital with a hard-ware cost of $41,000. Of note, when ac-companied by lower fidelity manikins(such as those used in Pediatric AdvancedLife Saving and Advanced Cardiac LifeSupport) total cost can be contained evenfurther (e.g., $11,054 Nursing Baby, Lae-rdal). This compares favorably with thecosts associated with the developmentand maintenance of a dedicated hospital-based simulator suite. Our own centerpublished start-up costs as high as$472,000, including the simulator mani-kin (6). The personnel required to per-form simulation-based education pro-grams at our institution were the samefor both mobile and fixed-location simu-lation (e.g., operator and facilitator) sinceprogram development, administration,equipment upkeep, and maintenance areunaffected by venue. Despite its reducedcost, the specific design of the cart al-lowed the delivery of the entire simula-tion education package—didactic teach-

Figure 2. The mobile simulation cart: Build and components. The mobile simulation cart (A) contains all audio-visual components necessary to providecomprehensive in situ simulation—didactics presentations, realistic full body simulation, and video-based debriefing—at the point of care. (see Key). (B)The mobile simulation cart is easily hidden within the clinical environment.

Table 1. Setup cost

Equipment Cost ($)

Bi-directional media converter $632.00Media converter $385.00Laptop $2,882.00Video editing software $285.00High definition digital

camcorder$1852.00

Camera case $29.00High-grade tripod with fluid

head and remote control$349.00

Video light $102.00Stereo microphone $90.00LCD projector $1,296.00Portable audio monitor (for

audio playback in large room)$152.00

Total $8,054.00

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ing, high-fidelity patient simulation, andvideo-based debriefing.

The markedly reduced cost of the mo-bile cart compared with a fixed locationsimulation suite, with preservation of edu-cational content, provides an opportunityto overcome some of the financial limita-tions that prevent adoption of these tech-niques by many centers internationally(14). In this way, the mobile cart may rep-resent a “tipping point” in the move towardlarge-scale adoption of simulation by pro-viding a less expensive alternative. Low costand easy integration are common elementsof what is referred to in the business liter-ature as a “disruptive technology” or animportant innovation that overturns exist-

ing dominant technology or status quo(e.g., the microcomputer vs. mainframes)(15). A comprehensive mobile cart such asthat described here brings us closer to suchan incarnation of simulation and thereforemay have major effects on how medicaleducation is delivered on a larger interna-tional scale.

Even more profound than the eco-nomic considerations is the conceptualevolution that point-of-care simulationtraining represents. By implementingsimulation-based training in the actualclinical environment, trainees learnwithin the context of their everyday workmilieu and among their own team mem-bers. This achieves high fidelity for the

environment and team. As our simula-tion program evolved, we increasingly ap-preciated that a genuine intact team (par-ticipants playing their professional rolesas they would in actual practice) is criti-cal to participants’ perception of the sim-ulation as authentic. These observationsare very much in line with emerging obser-vations within the simulation literature.Dieckmann et al recently reviewed models ofreality as they relate to simulation, notingthe complex interplay between human be-ings, the simulator, and technical devices.All three elements are regarded as criticalcomponents of the “environment” and thereality for the participant (16). Having theparticipants practice on “their own turf”

Table 2. Usage and demographics

DepartmentCourse Frequency(Duration of each)

TotalCourses

Total CourseHours

No. of ParticipantsTotal Environmental Nuances

Cardiac Intensive CareUnit

Monthly (4.5 hrs) 32 126 220 Unique equipment (e.g. extracorporeal membraneoxygenation)

MD 59 Private bed spacesRN 151 Supply roomRT 10

Cardiac CatheterizationLaboratory

Bimonthly (4 hrs) 4 16 25 Large obtrusive equipment (e.g., fluoroscopy,monitors)

MD 11 Dim lightingRN 8 Radiation exposures

Tech 6 Limited patient accessPost-anesthesia Care

UnitMonthly (3 hrs) 10 30 61 Busy environment

MD 10 High patient flowRN 51

Trauma Monthly (1 hr) 10 100 110 Size of teamMD 50 Crowded roomRN 30 Organization of equipmentCA 10RT 10Rad 10

Operating room Pilot (4 hrs) 1 4 9 Equipment (e.g., surgical, procedural)MD 5 Video monitoringRN 2 Sterile environmentCA 1

Tech 1Totals 10.5 hrs monthly 57 courses 294 hrs 425 participants

MD, physician; RN, nurse; RI, respiratory therapist; Tech, technician; CA, clinical assistant; Rad, radiologist.

Table 3. Benefits and limitations of in-situ point-of-care simulation

Benefits Possible Limitations/Risks Proposed/Applied Solutions

Full team training Cancellations Pre-planned courses/simulationsInterdisciplinary course development and planningEarly hours

Accessibility Mixing of equipment/medications Use and maintain only real materialsa

Realism Infection control issues Aseptic technique throughout all exercisesCost containment Wear and tear on equipment See discussiona

Identification of latent safety threatswithin actual clinical environment/system

Injury to equipment and personnel within theclinical environment

Performance-space based safety measuresb

Exposure of nearby family and staff Pre-course discussion/preparation/consent

aReusables are maintained within the Center inventory. Cost of disposables as well as modest increases in routine maintenance are absorbed byindividual departments as educational expenses thus avoiding charges to real patients; binstallation of the mobile simulation center at the point of care istreated as that of a theatrical space with a focus on safety (e.g. all loose wires are secured and all movable structures are reinforced).

180 Pediatr Crit Care Med 2009 Vol. 10, No. 2

insures optimum fidelity of two of thesecomponents (people and technical devices)thereby potentially making simulation-based education more effective. In addition,because “real” equipment (e.g., defibrilla-tor) is used, not only is the perceived fidel-ity of simulation enhanced, but the need tospecifically purchase such equipment fortraining purposes is circumvented.

By delivering courses within the clinicalenvironment, we enable participation byclinical staff who are bound to their postsdue to clinical obligations. Although someteam members within our programs werepaid to participate on nonclinical days,point-of-care simulation facilitated simula-tion by the complete healthcare team bycreating favorable logistics for membersotherwise engaged in a typical workday.This provides both an increase in fidelityand an increased opportunity for participa-tion in the training. Because of existingsilos among different specialties, operatingroom courses run at off-site centers aretypically designed and scheduled by indi-vidual specialties, with single disciplineparticipants using actors to play other clin-ical roles. Through mobile simulation, de-livered to the actual operating rooms, weare able to complete the team with practi-tioners who would normally deliver careand thereby “round out” and enhance boththe reality of the experience as well as thesubsequent debriefings.

There are significant limitations to thepoint-of-care simulation based-educationconcept (Table 3). These include the needto cancel the training because of compet-ing clinical demands. Overall, in our ex-perience, cancellations were relativelyrare—two due to real traumas and threecatheterization laboratory courses due tourgent patient care needs. We attributethis mostly to the fact that the majority ofcourses were preplanned by a wide rangeof contributors well versed in the sched-ules and logistics of their departments.Unannounced simulations would un-doubtedly carry a higher cancellationrate. Cancellations were further mini-mized by using clinical space during“low-traffic” hours (before 0700, after1700 or before operating room starttimes). Early morning courses had theadded benefit of accommodating postshift“off-hour” (e.g., night-shift) teams thatwould otherwise be unable to undergosimulation training. Courses were alsoheld at scheduled maintenance times forprocedural units or on Mondays followinga typical flow of intensive care unit week-end discharges.

Another potential limitation of pointof care involves exposure. Deliveringhighly emotional experiences into theclinical setting via simulation-based edu-cation raises the bar regarding risks tothose inadvertently exposed to the inter-vention. Although most of our sites wereessentially isolated (e.g., proceduralunits), within certain clinical contexts(e.g., at the bedside), casual observationby nearby family and staff must be con-sidered and will require careful prepara-tion and possibly obtaining formal con-sent from those at risk of exposure.

Medical simulation in situ via a mobilecart does not ensure effective training forhospital-based clinicians, just as a class-room does not ensure the effectiveness ofthe teacher. Whether the simulation ex-ercise occurs in a dedicated suite or at thepoint of care, it is ultimately a tool that isonly as effective as the teacher. In light ofthis, one of the basic tenets of our pro-gram is that all faculty who lead simula-tion exercises must complete formaltraining in debriefing before becoming aninstructor. A second tenet of the programis that all training scenarios are jointlydeveloped by program clinical leaders,who have specific content expertise, andsimulation program faculty, who haveformal training in adult education, to en-sure that the exercises are viewed as au-thentic, challenging, and productive.

CONCLUSION

Simulation as an effective and uniquetraining tool in medicine is now well es-tablished. Mobile simulation carts repre-sent a likely next step in the evolution ofmedical simulation by enhancing thetraining of clinicians in their actual workenvironment. The mobile simulation cartis a reduced-cost, space-efficient solutionthat allows technology transfer to the siteof use, and this will foster innovativetraining and quality improvement exer-cises at the point of care. On an interna-tional level, institutions lacking thespace, resources, and dedicated staff todevelop their own simulation centers willespecially benefit from the adoption ofmobile simulation carts. Going forward,multi-institutional studies are now re-quired to better understand the cost-effectiveness of point-of-care vs. dedi-cated site simulation training with regardto advances in knowledge, behaviors, andattitudes of trainees within health care.

ACKNOWLEDGMENT

We thank Mr. Gavin Hayes, BS(BioMed), for his technical assistance incart construction as well as in prepara-tion of blueprints and figures.

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