Best Practices in Simulation Plann

7/31/2019 Best Practices in Simulation Plann

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Best Practices in Simulation Plann

At the recent International Conference on Residency Education, several

speakers emphasized the importance of planning when using expensive

simulation labs. Residents who train exclusively on high fidelity

simulators frequently complain about the complexity and confusion of learningin this manner. I decided to write an article about the best way to plan the use of4-step progressive simulations.

Preplanning

a. Begin by analyzing what competencies should be taught in this manner.

Dangerous, painful, rare and embarrassing procedures make the best candidates.

Determine what level of competency is required depending on the level of the

resident. Setobjectivesfor each stage.

b. Create learning activities including written instructions for each level of the

progressive process described in the following document. Train preceptors to

provide the necessary role modeling.

c. Create assessment tools appropriate for each level.

d. Train raters to use the assessment tools.
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1. Intentional Role Modeling

An experienced preceptor demonstrates (without comment to the trainee) the

complete procedure including interactions with patients/families and team

members. This provides the student with an understanding of the goal of

training including completion time, explanations given to the patient, safetymeasures etc.

This step may involve watching a video if an experienced preceptor is notavailable for observation.

2. Low Fidelity Simulation

Low fidelity simulations use learning resources such

as videos, animations and virtual reality with written procedural guides. Ideally

this will involve a self-directed process whereby the learner learns the basic step

by step mechanics and can repeatedly use the required resources until they

believe they have reached an understanding of the objective.

Assessment at this stage uses multiple choice and listing questions; either paper

based or online with a pass mark of >80%. Learners must have the option toretest at this stage.

3. Mid Fidelity Simulations


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Mid fidelity simulators are the body parts task trainers that expose students to

the tools used to complete procedures in a portable, minimally complex manner.

Again students practice with minimal supervision or peer support until they feelconfident to undergo formal testing. Direct observation by raters or a lab

supervisor followed by a feedback session is the usual test at this stage. Students

should be allowed to retest after returning to the simulation if they dont

demonstrate proficiency.

The student now has the basic knowledge and tool proficiency to move to theinteractive level.

4A. Interactive Hybrid Patient Simulation

Hybrid simulations are used for simple procedures which might be painful or

embarrassing for patients to have beginners practice. Simulated body parts areattached to standardized patients who act out pre-arranged scenarios and


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Interactive models

More recently, interactive models have been developed that respond to

actions taken by a student or physician.]Until recently, these simulations

were two dimensional computer programs that acted more like a textbook

than a patient. Computer simulations have the advantage of allowing a

student to make judgements, and also to make errors. The process of

iterative learning through assessment, evaluation, decision making, and

error correction creates a much stronger learning environment than

passive instruction.

Computer simulators

3DiTeams learner is percussing the patient's chest in virtual field

hospital

Simulators have been proposed as an ideal tool for assessment of students

for clinical skills. For patients, "cybertherapy" can be used for sessions

simulating traumatic expericences, from fear of heights to social anxiety.

Programmed patients and simulated clinical situations, including mock

disaster drills, have been used extensively for education and evaluation.

These lifelike simulations are expensive, and lack reproducibility. A

fully functional "3Di" simulator would be the most specific tool available

for teaching and measurement of clinical skills. Gaming platforms have

been applied to create these virtual medical environments to create an

interactive method for learning and application of information in a

clinical context.

Immersive disease state simulations allow a doctor or HCP to experience

what a disease actually feels like. Using sensors and transducers

symptomatic effects can be delivered to a participant allowing them to

experience the patients disease state.
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Such a simulator meets the goals of an objective and standardized

examination for clinical competence This system is superior to

examinations that use "standard patients" because it permits the

quantitative measurement of competence, as well as reproducing the same

objective findings.

Modern medical simulation

The American Board of Emergency Medicine employs the use of medical

simulation technology in order to accurately judge students by using "patient

scenarios" during oral board examinations.[1]

However, these forms of

simulation are a far cry from high fidelity models that have surfaced since the

1990s

Due to the fact that computer simulation technology is still relatively newrelative to flight and military simulators, there is still much research to be done

about the best way to approach medical training through simulation. That said,

successful strides are being made in terms of medical education and training. A

thorough amount of studies has have shown that students engaged in medical

simulation training have overall higher scores and retention rates than thosetrained through traditional means.

The Council of Residency Directors (CORD) has established the followingrecommendations for simulation

1.Simulation is a useful tool for training residents and in ascertainingcompetency. The core competencies most conducive to simulation-basedtraining are patient care, interpersonal skills, and systems based practice.

2.It is appropriate for performance assessment but there is a scarcity ofevidence that supports the validity of simulation in the use for promotion

or certification.

3.There is a need for standardization and definition in using simulation toevaluate performance.

4.Scenarios and tools should also be formatted and standardized such thatEM educators can use the data and count on it for reproducibility,

reliability and validity.

Training

The main purpose of medical simulation is to properly educate students invarious fields through the use of high technology simulators. According to the

Institute of Medicine, 44,000 to 98,000 deaths annually are recorded due

primarily to medical mistakes during treatment.[3]

Other statistics include:
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225,000 deaths annually from medical error including 106,000 deaths due to"nonerror adverse events of medications"

7,391 deaths resulted from medication errors

If 44,000 to 98,000 deaths are the direct result of medical mistakes, and the

CDC reported in 1999 that roughly 2.4 million people died in the United States,

the medical mistakes estimate represents 1.8% to 4.0% of all deaths,

respectively.

A near 5% representation of deaths primarily related to medical mistakes is

simply unacceptable in the world of medicine. Anything that can assist in

bringing this number down is highly recommended and medical simulation has

proven to be the key assistant.

Examples

The following is a list of examples of common medical simulators used for

training.

Advanced Cardiac Life Support simulators Partial Human Patient Simulator (Low tech) Human Patient Simulator (High tech) Hands-on Suture Simulator (Low tech) IV Trainer to Augment Human Patient Simulator (Low tech) Pure Software Simulation (High tech) Anaesthesiology Simulator (High tech) Minimally Invasive Surgery Trainer (High tech) Bronchoscopy Simulator Battlefield Trauma to Augment Human Patient Simulator Team Training Suite Harvey mannequin (Low tech)Advantages

Studies have shown that students perform better and have higher retention rates

than colleagues under strict traditional methods of medical training. The table

below shows the results of tests given to 20 students using highly advanced

medical simulation training materials and others given traditional paper based

tests. It was found that high technology learning students outperformedtraditional students significantly.

E-Learning vs. Textbook Learning


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Mode of LearningMean Test Score on Multiple

Choice Test

Time to Complete

Module

E-Learning (N=20) 4.03 / 5 (80.6%) "B" 2830 minutes

Traditional Paper

Based3.05 / 5 (61%) "D" 2830 minutes

Significant

DifferenceYes (p < .001) N/A

In addition to overall better scores for medical students, several other distinct

advantages exist not specifically related to training.

Less costly Time efficient Less personnel required Many automated processes Ability to store performance history Track global statistics for many linked medical simulators Less medical related accidents

Medical Simulation

There is a lot of discussion at the University of Saskatchewan about the use of

medical simulation in health science education. To understand the decisions

being made in this area, you need to understand that there are four distinct

categories of simulation:1. Physical Simulators

2. Human Manipulated Physical Simulators

3. Virtual Simulators4. Virtual Environment Simulators

Physical Simulators

Physical simulators are reusable mannequins that students practise skills on

such as physical examinations, injections and other invasive treatments. Using

this type of simulator provides initial practice when willing patients are in short

supply or when practise could be invasive, unpleasant or painful to patients.Once the student has developed an acceptable level of skill, they complete their


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learning with human patients. Below you can see some examples of physical

simulators manufactured by Kyoto Kagaku Co. Ltd., which were recentlydisplayed at the university.

Human Manipulated Physical Simulators

A more sophisticated level of simulator is a full body mannequin that can be

manipulated by a human operator located behind a two-way mirror. This type ofsimulator can answer questions, raise limbs as well as be

examined/draped/treated. This provides students with a more holistic simulation


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in which they role-play interactions with the patient. The draw back here is ahigh initial cost as well as an ongoing expense of an operator.

Virtual Simulators

Virtual Simulators use 3D animation to teach parts of the body (Guide to aHealthy Heart) or to teach steps in a procedure (Sim Praxis video)

Costs to create these simulations can be very high, therefore, they are oftenpurchased as CDs with a textbook or accessed through sponsored online sites.

See also The Visible Human

Virtual Environment Simulators

The Virtual Environment Simulators are computer-based medical scenarios that

usually include a 3D model of a location, equipment, personnel and patients that

students enter with an Avatar. They work well for What if? case studies suchas disaster training, pandemic planning, problem solving and modeling of

unusual diagnosis that students might not encounter in their clinical experience.

Costs of initial production can be lowered by using already existing virtualworlds such as Second Life, a virtual world with a higher population than theprairies. Cost per student is frequently minimal.

USES OF SIMULATION IN MEDICAL EDUCATION

Studies in cognitive psychology inform us that the recall of information and itsapplication are best when it is taught and rehearsed in environments similar to

workplace. The healthcare professions are heavily task- and performance-based

where non-technical skills, decision making and clinical reasoning are important

alongside integrity, empathy and compassion. Most of these attributes are

difficult to teach and assess in the traditional classrooms. Enhanced patient

safety on one hand has to be the ultimate outcome of any medical curriculumwhile on the other hand, it itself can be potentially compromised in an

apprenticeship-based model of medical education. A range of simulation

techniques are very well placed to be used alongside clinical placements. Thesecan be employed to enhance learning of healthcare professionals in safe

environments, without compromising the patient safety, while maintaining ahigh degree of realism..

It enhances the students understanding

Simulation-based learning is used to promote medical students' mastery of

communication skills, medical interviewing, physical examination and basic

clinical procedures. Students and tutors both recognize the effectiveness of

simulation-based learning in medical education.


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Virtual patient education will help to prevent the medical errors

There are very few medical schools that would not routinely use such

simulation as a standard part of their curriculum. This is not because they are

cost effective (although they are) but rather because they have been shown to

reduce human error in performing these clinical skills and provide a safe

environment for doctors to learn such procedures without endangering real

patients. Simulation has taken many forms in Medicine including: (1)

Computer-based simulations; (2) Standardised patients widely used in OSCE

training and examination; (3) Virtual environments; (4) mannequins such as

Resuscitation Annie, and (5) so-called "high fidelity" simulations resembling as

much as possible the actual clinical situations. These forms of simulation have

been used to teach the important skill of clinical decision-making as well as

technical procedures.

Best Practices in Simulation Plann

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