Application of simulation in anesthesia

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Slide 1 : David M. Gaba, M.D. Director, Patient Safety Center of Inquiry at VA Palo Alto HCS Professor of Anesthesia, Stanford University School of Medicine Applications of Simulation in Anesthesiology
Slide 2 : Why Use Patient Simulation? Regardless of the application, there is never a risk to a patient Simulators allow the presentation at will of a wide variety of scenarios, including uncommon but critical events The underlying (medical) causes of each situation are known
Slide 3 : Why Use Patient Simulation? The same events can be presented to different clinicians or teams Errors can be allowed to occur and play-out that in a real patient would require immediate intervention by the investigator/instructor
Slide 4 : Why Use Patient Simulation? Clinicians can be required to interact with actual medical equipment and a variety of clinical personnel (and personalities) Intensive and archival recording of clinician performance is facilitated, e.g. Multiple video views and audio ECG, EEG
Slide 5 : Diverse Applications of Patient Simulation in Anesthesiology Education Training Research Risk management and public relations Performance Assessment (covered later)
Slide 6 : Distinction Between “Education” and “Training” Education The goal is to improve knowledge and conceptual understanding Training The goal is to improve the performance of tasks or functions
Slide 7 : Applications of Simulators in Anesthesiology EDUCATION Example Target Groups: University students Pre-clinical medical students Example Target Curriculum: Applied physiology or pharmacology
Slide 8 : Applications of Simulators in Anesthesiology EDUCATION Example Target Group: 2nd year medical students in “Preparation for Clinical Medicine” Course Example Target Curriculum: “Introduction to the Integrated Management of the Ill Patient” Interleaving of Dx, Monitoring, Rx
Slide 9 : Applications of Simulators in Anesthesiology EDUCATION Example Target Group: 2nd year medical students in basic anesthesiology classroom course Example Target Curriculum: Early exposure to clinical anesthesia
Slide 10 : Applications of Simulators in Anesthesiology EDUCATION Example Target Group: Anesthesiology clerkship students Example Target Curriculum: Introduction to anesthesiology Complements OR experience
Slide 11 : Applications of Simulators in Anesthesiology EDUCATION Example Target Group: Pharmaceutical or device manufacturer representatives or executives Example Target Curricula: Introduction to clinical environments “Anesthesia for Amateurs” (Boston CMS)
Slide 12 : Applications of Simulators TRAINING Training is targeted at specific professional groups Training curricula focus on skills & behaviors required for tasks on the job
Slide 13 : Applications of Simulators TRAINING Example target group Novice anesthesia residents Example training curricula Basic airway management skills Techniques for induction of anesthesia Managing routine abnormalities during anesthesia; calling for help
Slide 14 : Applications of Simulators TRAINING Example target group Experienced anesthesia residents Example training curricula Preparation for anesthesia specialty rotations Advanced airway management skills Anesthesia Crisis Resource Management (ACRM)
Slide 15 : Applications of Simulators TRAINING Target Population: Experienced Anesthesia Personnel Example training curriculum: Hands-on experience with the use of a new pharmaceutical agent (e.g. remifentanil): Familiarity: Mixing, dosing, infusion set-up Safety: Recognition of and response to side-effects and complications
Slide 16 : Applications of Simulators TRAINING Example target group Non-anesthesia physicians and nurses Example training curriculum: Principles and practice of safe conscious sedation Credentialing requirement in some institutions
Slide 17 : Applications of Simulators TRAINING Example target group Experienced anesthesiologists (CME) Example training curricula Advanced airway management skills Use of new techniques or technologies (e.g. drugs, monitors) Anesthesia Crisis Resource Management (ACRM)
Slide 18 : Many Centers Run “Anesthesia Crisis Resource Management - ACRM” -- Why? Crises or challenging situations occur frequently Major gaps exist in training and performance concerning decision making and teamwork Patient safety may be improved by targeting these issues more than medical/technical issues
Slide 19 : Crisis management behaviors have been studied extensively in aviation Resulting in special training: Crew Resource Management (CRM)
Slide 20 : Crisis Management Successful crisis management requires BOTH: Sound technical skills of individuals Sound crisis management behaviors and teamwork
Slide 21 : Principles of Dynamic Decision Making and Teamwork Cognitive Components: Know the Environment Anticipate and Plan Use All Available Information & Cross Check Prevent/Manage Fixation Errors Use Cognitive Aids
Slide 22 : Team Management Components: Leadership & followership Communication Distributing the workload Calling for help early Principles of Dynamic Decision Making and Teamwork
Slide 23 : Approach of Anesthesia Crisis Resource Management (ACRM) & Its Derivatives Training “Philosophy”: Single-Discipline, Discipline-Specific: “Training Crews to Work in Teams” Example: Training anesthesiologists to work with with each other & in teams Ideally to be complemented with multidisciplinary combined team training
Slide 24 : Approach of Anesthesia Crisis Resource Management (ACRM) & Derivatives Training “Philosophy”: Primary emphasis on decision making and teamwork behaviors but embedded within technically challenging situations Typically aim for > 60% emphasis on these behaviors, <40% on medical/technical details
Slide 25 : Approach of Anesthesia Crisis Resource Management (ACRM) & Derivatives Training “Philosophy”: Full-day simulation-based course Highly interactive, with high instructor-participant ratio Detailed debriefings after each simulation
Slide 26 : ACRM Simulation Scenarios High-fidelity (x surgery), typically 4 per session @ 30-45 min, participants rotate roles Spectrum of challenging clinical situations Equipment & environment failures Clinical crises “Stat” or “Crash” cases Spectrum of challenging interpersonal situations (surgeon, nurse, patient, family)
Slide 27 : Simulation Room -- VA Palo Alto
Slide 28 : Scenarios are challenging medically, technically, and in terms of teamwork
Slide 29 : A Picture of “Face Validity”
Slide 30 : Debriefings with video allows discussion of alternatives and pros & cons of CRM behaviors & technical choices
Slide 31 : Beyond ACRM: Expansion “Within” & “Without” ACRM derivatives for other specialties Instructor training Progressive curriculum Clinical catastrophe Combined team training Multiple patient simulations Simulation for executive level
Slide 32 : Crew Resource Management (CRM) Training Applies to Many Medical Domains OR - ICU Emergency Dept. - Cardiac arrest teams Delivery room - Cath lab / radiology Field responders - Military medicine Non-code patient emergencies (IMPES) Interns - Medical students (intro) Etc.
Slide 33 : Applications of Simulators RESEARCH A wide variety of research on human performance in health care requires simulation * “Educational research” & performance assessment * Clinical techniques (e.g. pediatric sedation) * Human machine interaction * Decision making * AI in ICU * Telementoring * Stress * Fatigue
Slide 34 : Applications of Simulators RESEARCH Simulation is a key research tool in human performance because it provides: Reproducibility Controllability Criticality All in a confidential environment with no risk to patients
Slide 35 : Applications of Simulators RESEARCH Research extends well beyond anesthesiology and health care and well beyond medical investigators, e.g. Cognitive or social psychology Biomedical engineering At several centers PhDs have been awarded based on experiments using a simulator
Slide 36 : Applications of Simulators RISK MANAGEMENT Appropriate simulation training may REDUCE: The frequency of adverse clinical events The impact of clinical events that do occur The likelihood of litigation after an event A jury’s perception that the institution did not take patient safety seriously
Slide 37 : Applications of Simulators PUBLIC RELATIONS Ongoing training & research activities attract considerable media attention Highly visual & dynamic Outreach programs are feasible, including Schools - Youth groups Museums - Politicians
Slide 38 : Video-link with HM, Queen Elizabeth II The video-conferencing set-up Dr. Gaba addresses Her Majesty Dr. Donovan introduces Dr. Gaba to Her Majesty
Slide 39 : Key Challenges Ahead for Simulation in Anesthesiology and Health Care Pedagogical Challenges Integrating different types of simulation-based education & training On-screen & mannequin; Principles, technical skills, & behavioral skills Integrating simulation-based training with clinical training
Slide 40 : Key Challenges Ahead for Simulation in Anesthesiology and Health Care Challenges of the Clinical Environment Principles of patient safety taught in the simulator must be a part of the real clinical environment They must be constantly reinforced or the training will be vitiated
Slide 41 : Unanswered Questions About Simulation Training and/or CRM Each can be the topic of a multi-day seminar Does it work? How effective is it? Is it “cost-effective” Who should get it and how often? Can you assess performance using the simulator, i.e. for certification & recertification Covered in later talk
Slide 42 : Does It Work? High face validity for this belief We do not currently know for sure We may well never know for sure Suggestive data from many sources Definitive experiments may be impossible due to logistics and cost
Slide 43 : Obstacles to Investigating the Impact of Simulator Training on Performance No gold standard for measuring performance Need to use simulation to test simulation High inter- and intra- individual variability will require large cohorts of subjects
Slide 44 : Prototypical Experimental Design Chopra, et al; others 3x
Slide 45 : A Definitive “Impact on Performance Experiment” Will Be Very Expensive The number of simulations required is very high: Familiarization sessions Training sessions Testing sessions Expert evaluation of performance is expensive
Slide 46 : at MDD/SD = 0.1, N=1944 Estimate of Required N (per cohort) for 80% power, a = 0.05 How Large Must the Cohorts Be?
Slide 47 : Unanswered Questions Regarding Investigations of Impact on Performance After how many simulation sessions can or should the impact be measured? After 1 session only? Naive to think that a single course can have a profound impact In commercial aviation simulation (and CRM) is a career-long endeavor
Slide 48 : Should We Attempt to Perform Definitive Studies of Simulation Impact? Goal: To convince the skeptics Answer: Maybe -- if the resources are there BUT… Beware of being sucked into: Under-powered studies with high risk of Type II error Studies of “one-off” simulation sessions rather than integrated long-term use of simulation
Slide 49 : Bottom Line ...no industry in which human lives depend on the skilled performance of responsible operators has waited for unequivocal proof of the benefits of simulation before embracing it… Neither should anesthesiology . (Gaba, Anesthesiology 76:491-494, 1992)
Slide 50 : The End

 


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