Simulators in Anaesthesia, the future and past

Simulators in anaesthesia

1. SIMULATORS IN ANAESTHESIA Dr. Manasvi Sharma Moderator: Dr Rajesh Kar

2. How can anaesthetist experience the difficulties of patient care without putting patients at undue risk? How can we assess the abilities of anaesthetist as individuals and teams when each patient is unique?

3. The answer is SIMULATIONS

4. Simulation refers to the artificial replication of sufficient elements of a real-world domain to achieve a stated goal. This technique well known in the military, aviation, space flight, and nuclear power industries.

5. Uses of simulations Team training, as human factor or CRM training Training in dynamic plant control Training in diagnostic skills Dynamic mockup for design evaluation Test bed for checking operating instructions Source of data on human errors relevant to risk and reliability assessment Vehicle for (compulsory) testing/assessment and recertification of operators

6. Objectives Describe the current state of education and research in simulation. List the various simulators, mannequins and models available for emergency medicine training. Discuss the strengths and weaknesses of each simulation modality. List some of the best practice examples for using simulation in EM residencies.

7. Outline Introduction Spectrum of Simulation Equipment Best Practice Examples

8. Introduction Characteristics Cues and consequences are like reality Situations can be complex Fidelity (exactness of duplication) is not perfect Feedback to users questions, decisions, and actions.

9. History 1928 Edwin Link develops first flight simulator – “Link Trainer” 1960 Laerdal introduces first “ Resusci -Annie” 1968 “Harvey” cardiology simulator 1970 First power plant simulators 1973 First computer aided modeling of physiology 1975 Standardized patients and OSCE’s introduced 1988 First full body, computerized mannequin at Stanford 1989 ACRM – Anesthesia focused on patient safety and education movement at this time 1990 Term Virtual Reality was introduced, Screen Based Simulators Introduced

10. Harvey

11. Introduction Why is this a valuable tool? Or is it? Learners can learn without risk to patient. Learning can be focused without regard to patient care needs/safety/etc. Opportunity to repeat lesson/skill to mastery. Specific learning opportunities  guaranteed. Learning can be done at convenient times. Performance can be observed/recorded.

12. Introduction Why is simulation important in medical education? Problems with clinical teaching New technologies for diagnosis/treatment Assessing professional competence Medical errors and patient safety Deliberate practice

13. Setting of the Simulation Exercise Setting introduction (SI): The introduction delivers general information on how the exercise will be conducted, logistical information, and some of the known pitfalls of the course. Simulator briefing (SB) or familiarization: They learn how to use the simulator, what it can and cannot do, what is “normal” (e.g., normal breath sounds), and how they can interact with the environment (e.g., how to call for help, how to request information about the patient that is not directly available in the simulation environment).

14. Theory input (T): Most exercises have didactic and theory components on relevant content information. Sometimes this material is made available in advance via readings or online exercises. Breaks (B): For complex courses (e.g., anesthesia crisis resource management [ACRM]), breaks are important for socialization between participants and with instructors. It also is a venue for informal sharing and storytelling.

15. Case briefing (C): In many simulation scenarios, participants receive a briefing about the upcoming case. Simulation scenario (S): Most simulation exercises involve a scenario that posits a given clinical situation and challenges to be posed for participants to deal with. Debriefing (D): Most scenarios are followed by some form of debriefing or feedback. Ending (E): Especially for multiple-scenario courses, there may be a separate final session to end the course. This is an opportunity to summarize issues that were covered, to address questions, and to consider how best to apply the principles covered to real patient care.

16. Site of Simulation Dedicated centre - One or more simulators are used in a dedicated simulation facility, typically in rooms that can partially or fully replicate, in a relatively generic fashion, various clinical environments (e.g., operating room, ICU, labor and delivery, emergency department).

17. In-Situ Simulation In-situ simulation is conducted in an actual clinical workplace; the simulator “replaces” a patient. It is especially useful for unusual workplaces that are difficult to recreate realistically in a simulation center , such as a catheterization laboratory, computed tomography scanner, ambulances, or air rescue aircraft. Most in-situ simulation is performed “mobile” as a temporary setup, but increasingly in-situ simulation is established as “residential simulation,” in which a simulator is permanently installed in a clinical workplace (e.g., creating a simulation-specific room in the actual ICU.

18. Moving Patient Simulation - The advent of completely portable and wireless simulators supports exercises in which the simulated patient can be moved from one clinical site to another.

19. Mobile Simulation: “Have Simulator—Will Travel” Mobile simulation means the simulator and the audiovisual gear are moved (made mobile) outside the originating institution for purposes of the simulation event. Mobile simulation can be conducted as in-situ simulation in an actual site of a remote client institution, by setting up for simulation in conference rooms or hotel meeting rooms, or by having a simulation facility built into a truck or bus.

20. Outline Introduction Spectrum of Simulation Equipment Best Practice Examples

21. Available Simulation Equipment Standardized Patients Improvised Technology Screen Based Simulation Task Trainers Low/Mid/High Fidelity Mannequins Virtual Reality

22. Evaluating Simulators Usability Validity Face, Content, Construct, Concurrent, Predictive Transfer Efficiency Cost Evidence

23. Examples – Vascular model A = Sock skin B = Film canister for support C = Foam curler connective tissue D = Straw vessel

24. Examples – Lumbar puncture model A = Box spinous process B = Film canister lateral masses b = Lid of film canister C = Foam curler connective tissue D = Dural “pop” from packing bubbles Not seen – pillow muscular layer

25. Screen Based Simulation Desktop Computer Strengths – low cost, distance learning, variety of cases, improving realism, self guided Weaknesses – procedural skills, teamwork skills

26. Screen Based Simulation Laerdal Microsim www.Anesoft.com ACLS Critical Care Anesthesia Sedation Neonatal

27. Task Trainers Devices designed to simulate a specific task or procedure. Examples: Lap simulator Bronch simulator “Traumaman” Artificial knee

28. Task Trainers

29. Task Trainers Strengths High fidelity, good research on efficacy, may have self guided teaching, metrics available Weaknesses Poor haptics on most machines, expensive, focus on single task, not integrated into complete patient care

30. Low Fidelity Mannequins Features: Static airways +/- rhythm generation No/minimal programmed responses. Strengths: Low cost, reliable, easy to use, portable Weaknesses: Limited features, less interactive, instructor required

31. Low Fidelity Mannequins Examples

32. Mid Fidelity Mannequins Relatively new class of mannequins, often used for ACLS training. Features: Active airways – ETT, LMA, Combitube Breathing/pulses, rhythms Basic procedures – pacing, defibrillation Some automated response and programmed scenarios

33. Mid Fidelity Mannequins Strengths: Active airways, somewhat interactive, moderate cost, moderate portability Weaknesses: Semiskilled instructor, limited advanced procedures (lines, chest tubes)

34. High Fidelity Mannequins Mannequin with electrical, pneumatic functions driven by a computer. Adult, child and newborn models Features: Dynamic airways, reactive pupils Heart sounds, lung sounds, chest movement Pulses, rhythms, vital signs Abdominal sounds, voice CO2 exhalation, cardiac output, invasive pressures Bleeding, salivation, lacrimation

35. High Fidelity Mannequins Procedures O2, BVM, Oral/nasal airway, ETT, LMA, Cric Pericardiocentesis, PIV Defibrillation, Pacing, CPR Needle or open thoracentesis TOF, Internal gas analysis Foley placement Reacts to medications

36. Features

37. Laerdal vs. METI Laerdal Instructor programmed physiology changes Windows Terrific Airway Reliability Ease of Use Cost: 35-45K METI Physiology modeled to respond to interventions Macintosh Drug Recognition Gas Analyzer Two Cost Levels ECS: 45K HPS: >150K

38. High Fidelity Mannequins Strengths Many dynamic responses, preprogrammed scenarios, widest variety of procedures, most immersive. Weaknesses Cost, procedures are not very realistic, reliability, lack of portability, significant instructor training required.

39. Virtual Reality Advanced form of human-computer interaction Allow humans to work in the computer’s world Environment understandable to us Four necessary components Software Hardware Input devices Output devises

40. Input and Output devices

41. Virtual Reality Types of VR applicable to medicine Immersive VR Desktop VR Pseudo-VR Augmented reality

42. Immersive VR

43. Desktop VR

44. Pseudo-VR

45. Augmented Reality

46. Outline Introduction Spectrum of Simulation Equipment Best Practice Examples

47. Research Rapidly expanding body of literature since 2000. First issue of ‘Simulation in Healthcare’ Jan 2006. Many articles on ‘look at what we did’ level and data that says ‘everyone thought it was nifty.’ Focus on best practices in teaching/learning and assessment using simulation.

48. Best Teaching Practices Screen based teaching with feedback is better than self study. Comparing simulation to other teaching modalities demonstrates some slight advantages. Simulation can be an effective replacement for live practice for some skills. Learner centered teaching with simulation. Team behavior can be effected by focused simulation experiences.

49. Best Teaching Practices Orientation Introduction to session Expectations What is real/what is not Self assessment Debriefing Evaluation

50. How To Best Use Simulation Provide feedback Give opportunities for repetitive practice Integrate simulation into overall curriculum Provide increasing levels of difficulty Provide clinical variation in scenarios Control environment Provide individual and team learning Define outcomes and benchmarks

51. Best Assessment Practices Simulation has some data to support its use as an assessment modality. Task trainers appear to be a valid method for assessing procedural competence. Multiple simulated encounters are needed to accurately assess resident abilities. Checklists scoring of videotaped performance can have a high degree of inter-rater reliability.

52. Validation that simulator performance correlates with real practice. There are many aspects of human knowledge/skills/attitudes to assess and the correct tool must be used for each one. ”Softer” competencies like professionalism can be assessed with the aid of simulation technology. The scoring/evaluation system chosen to assess simulated performance is critical.

53. Best Assessment Practices Determine what you want to assess. Design a simulation that provokes this performance. Observe/record the performance. Analyze the performance using some type of rubric: checklist, GAS, etc. Debriefing, feedback and teaching.

54. Summary Simulation is one tool (new, expensive and exciting) in our educational repertoire. (Similar to lecture, case discussion, skill lab, MCQ, SP, etc.)

55. Summary Provide feedback Give opportunities for repetitive practice Integrate simulation into overall curriculum Provide increasing levels of difficulty Provide clinical variation in scenarios Control environment Provide individual and team learning Define outcomes and benchmarks Determine what you want to assess. Design a simulation that provokes this performance. Observe/record the performance. Analyze the performance using some type of rubric: checklist, GAS, etc. Debriefing, feedback and teaching.

56. THANK-YOU