Simulation and Medical Performance Peter G. Schulam, M.D., Ph.D. Associate Professor Department of...
-
Upload
warren-bishop -
Category
Documents
-
view
230 -
download
2
Transcript of Simulation and Medical Performance Peter G. Schulam, M.D., Ph.D. Associate Professor Department of...
Simulation and Medical Performance
Peter G. Schulam, M.D., Ph.D.Peter G. Schulam, M.D., Ph.D.
Associate ProfessorAssociate Professor
Department of UrologyDepartment of Urology
Eric Savitsky, M.D.Eric Savitsky, M.D.
Associate ProfessorAssociate Professor
Department of Emergency MedicineDepartment of Emergency Medicine
CASIT andCASIT and
David Geffen School of Medicine at UCLADavid Geffen School of Medicine at UCLA
To Err is HumanInstitute of Medicine November 1999
44,000 – 98,000 44,000 – 98,000 deaths per year as a deaths per year as a result of medical result of medical errors.errors.
Cost of $17-29 billion Cost of $17-29 billion per year.per year.
Medical Errors
Performance Level of 99.9%Performance Level of 99.9%
Airline-2 dangerous landings/dayAirline-2 dangerous landings/day
Banking-32,000 checks incorrectly Banking-32,000 checks incorrectly deducted/hourdeducted/hour
Types of Errors
DiagnosticDiagnosticError or delay in diagnosisError or delay in diagnosisFailure to act on results Failure to act on results
TreatmentTreatmentError in drug dosingError in drug dosingDelay in responding to an abnormal test Delay in responding to an abnormal test Error in performanceError in performance
Medical ErrorsLocations
Intensive Care UnitsIntensive Care Units
Emergency DepartmentsEmergency Departments
Operating RoomsOperating Rooms
Why?
Lack of standard credentialingLack of standard credentialing
Fragmented health care systemFragmented health care system Lack of access to all informationLack of access to all information
Human variabilityHuman variability
Physician Variability
# of
com
plic
atio
ns
# of procedures
Learning Curve
Traditional Training
Problems with the apprenticeship modelProblems with the apprenticeship model Variability of experienceVariability of experience Practice on real patientsPractice on real patients InefficiencyInefficiency
CostCost The OR is an expensive classroomThe OR is an expensive classroom
Lack of standardized proficiency criteriaLack of standardized proficiency criteria
Surgical TrainingLaparoscopic Cholecystectomy
Southern Surgeons Club - 2.2% incidence of bile Southern Surgeons Club - 2.2% incidence of bile duct injuries in first 13 pts/group (control 0.2%) duct injuries in first 13 pts/group (control 0.2%) NEJM 1991NEJM 1991
8,839 lap cholecystectomies by 55 surgeons - 90% 8,839 lap cholecystectomies by 55 surgeons - 90% of bile duct injuries occurred during first 30 cases of bile duct injuries occurred during first 30 cases Am Surg 1995Am Surg 1995
54% of surgical errors are potentially preventable 54% of surgical errors are potentially preventable Nat Acad Press, 1999Nat Acad Press, 1999
Training Simulators Inanimate modelsInanimate models
Animal modelsAnimal models
Cadaveric modelsCadaveric models
Virtual realityVirtual reality
Inanimate Models
BenefitsBenefits CheapCheap Reuse materialsReuse materials Accessible at Accessible at
any timeany time Minimal Minimal
psychological psychological stress inhibiting stress inhibiting learninglearning
Inanimate Models
LimitationsLimitations Lack of realismLack of realism Can only Can only
simulate the simulate the most basic most basic taskstasks
Difficult to Difficult to monitor monitor progressprogress
Animal Models BenefitsBenefits
Realistic Realistic physiologyphysiology
Closer to Closer to realistic realistic anatomyanatomy
Complex Complex proceduresprocedures
More realistic More realistic working working environmentenvironment
Animal Models
LimitationsLimitations ExpensiveExpensive Ethical issuesEthical issues Difficult to Difficult to
monitor monitor progressprogress
Cadaveric Models
BenefitsBenefits
Realistic Realistic
anatomyanatomy
Rohen & Yokochi. Color Atlas of Anatomy. 1993
Cadaveric Models
LimitationsLimitations ExpensiveExpensive Physiologically Physiologically
unrealisticunrealistic Unnatural Unnatural
tissue tissue propertiesproperties
Difficult to Difficult to monitor monitor progressprogress
Rohen & Yokochi. Color Atlas of Anatomy. 1993
Virtual Reality Simulators
Benefits of Virtual Reality
Unlimited availabilityUnlimited availability Potential for a variety of tasks/proceduresPotential for a variety of tasks/procedures
From non-anatomic to surgical “pre-flight”From non-anatomic to surgical “pre-flight” Allows for repetitive skill assessmentAllows for repetitive skill assessment
Minimal psychological stress inhibiting learningMinimal psychological stress inhibiting learning Monitors trainee activity/improvementMonitors trainee activity/improvement
Benefits of Virtual RealityVirtual Mentor
Computer can guide a trainee through a procedure Computer can guide a trainee through a procedure
and provide immediate feedbackand provide immediate feedback Fulfills the continual, high-quality feedback Fulfills the continual, high-quality feedback
requirement for efficient learningrequirement for efficient learning Establish metricsEstablish metrics
Limitations of Virtual Reality
Complexity of organ modelingComplexity of organ modeling
Lack of force feedbackLack of force feedback
Procedure based systemsProcedure based systems
Potential >> Today’s RealityPotential >> Today’s Reality
Holy Grail
Simulation of a patient’s data set Simulation of a patient’s data set allowing for allowing for
pre-procedural planningpre-procedural planning
Procedural Outcome
DiagnosisDiagnosis HistoryHistory Physical ExamPhysical Exam Ordering of data (labs and xrays)Ordering of data (labs and xrays) Interpretation of dataInterpretation of data
InterventionIntervention Familiarity/Dexterity with the tool setFamiliarity/Dexterity with the tool set Understanding the order of the operationUnderstanding the order of the operation Familiarity of the anatomyFamiliarity of the anatomy Adapting to anatomical variabilityAdapting to anatomical variability Controlling surgical mishapsControlling surgical mishaps
Decrease Physician VariabilityTask Specific Simulation
Definition of Simulation
“ “A device or exercise that enables the A device or exercise that enables the participant to reproduce, under test participant to reproduce, under test conditions, phenomena that are likely to conditions, phenomena that are likely to occur in actual performance” occur in actual performance”
KrummelKrummel