Simulation in Otolaryngology – Head and Neck Surgery in the context of ACGME Core Competencies, Milestones, Patient Safety and Accreditation Ellen S Deutsch, MD, FACS, FAAP Director, Peri-Operative Simulation Center for Simulation, Advanced Education and Innovation The Children’s Hospital of Philadelphia Chair, AAO-HNS Otolaryngology Surgical Simulation Task Force March, 2013

COI I have no disclosures Inclusion of specific simulators in this presentation does not necessarily imply endorsement

The Future Simulation will be essential to: – Learn the Core Competencies – Achieve Milestones – Fulfill CLER objectives – Achieve certification and accreditation – Enhance physician satisfaction – Improve the safety and quality of patient care Our opportunity – How – When

Simulation is not new We “stand on the shoulders of giants” – American Bronchoesophagological Association website: /jacksonspeaks/index.html /jacksonspeaks/index.html /jacksontracheotomy /index.html /jacksontracheotomy /index.html Search: about ABEA Evolving – Technology – Understanding adult learning – Societal expectations – Resource limitations Photos courtesy of Dr. John Tucker

Otology Basic otologic procedures – Constructed Temporal bone surgery – Cadaveric – Physical – Virtual w haptic and acoustic feedback – Web-based Model courtesy of Steve Handler, MD Deutsch Laryngoscope DOI: /lary Wiet et al; Laryngoscope 2012

Otology Areas of investigation: – Tissue biomechanics – Metric development, integration – Standardized curriculum development – Validation, dissemination Example: – Virtual Temporal Bone Dissection System: Development and Testing; Wiet et al; Laryngoscope 2012 – A virtual temporal bone dissection system was developed and compared to cadaveric temporal bones. There was no statistical difference between practice on the simulator compared to practice on human cadaveric temporal bones. Model courtesy of Steve Handler, MD Deutsch Laryngoscope DOI: /lary Wiet et al; Laryngoscope 2012

Sinus / Rhinology Simulators Rhinologic – Constructed or adapted Sinus – Constructed – Virtual with haptic feedback Instrument interface Extensive validation, demonstration of improved performance during actual procedures Malekzadeh et al; Laryngoscope 2011 Steehler et al; Oto-Head Neck Surg 2012 Weiss et al; Ophth Plastic Recon Surg 2008

Sinus / Rhinology Example: – From Virtual Reality to the Operating Room: The Endoscopic Sinus Surgery Simulator Experiment; Fried et al; Oto Head Neck Surg 2010 – Subjects trained to criterion proficiency levels were equivalent or outperformed subjects trained by conventional methodology – Simulator training can improve resident skills to a proficiency level for all members of the group – This proficiency level is at least equal to that achieved by conventional training with finite repetition of live surgical procedures Malekzadeh et al; Laryngoscope 2011 Steehler et al; Oto-Head Neck Surg 2012 Weiss et al; Ophth Plastic Recon Surg 2008

Head and Neck Simulators – “Traditional” – Biologic – Robotic

Broncho-Esophagology Simulators – Biologic – Virtual with haptic interface – High technology

Non-technical skills Examples: – Delivering bad news – “Complex scenarios” Combining technical skills with teamwork, communication, leadership and other safety skills

Non-technical skills Simulators: – “Confederates” – High technology manikins – Hybrid combinations

Educational modalities are complementary Resident perception, Likert scale, ANOVA significant difference in mean performance scores LectureAnimal Lab High-tech Manikin Virtual Bronch “Bad News” Confederate Cognitive +++ Psychomotor + Affective +++ Normal/Abnormal ++ Complications + Endoscopy ++ Team ++ Overall realism + Manual realism + Deutsch et al; Annals ORL 2009

Simulators are tools Develop comprehensive curriculum: – Based on needs or gap assessment – including Core Competencies – Credentialing, regulatory requirements Address logistics of delivery: – Substitute for 1 hour lecture – Allow unstructured practice +/- review – “Boot camps” Integrate into daily activities – “Just in time” “Just in place” – Insert into rounds or into the OR schedule Provide a unique or a progressive experience – Implement debriefing of real events

Milestones Use simulation to develop and validate assessment tools Assess skills performed on simulators or in simulated environments

Boot camps Full day of simulation – Skills and tasks – Procedures – “Complex scenarios” FRIDAY Faculty only: Orientation, review of simulators and scenarios SATURDAY Breakfast, Orientation, Introductions Foreign Body Tonsil x3 (PTA test model) Fiberoptic Skills x3Mask ventilation, LMA, Intubation x3 Break Epistaxis x3Cricothyrotomy / Tracheotomy x3 Rigid Endoscopy x3 Lunch; Introduction to high-technology manikins It’s 3 am; Do I Really Need to Call my Attending? Complex Scenarios: Anaphylaxis, Hematoma after thyroidectomy x4 Break Complex Scenarios: Anaphylaxis, Hematoma after thyroidectomy x4 It’s 3 am; Do I Really Need to Call my Attending? Debrief residents; snacks Debrief faculty; then faculty dinner

Boot camps Large numbers of residents / fellows Large number of faculty Large spaces and lots of equipment Benefits for faculty as well as residents / fellows

Oto-HNS Surgical Simulation Task Force Established in February, 2011 Charge: 1.Identify existing relevant committees 2.Describe existing state of the art within ORL 3.Describe state of content in other areas 4.Develop a clear proposal

Our Proposal a.Investigate ORL simulation capabilities b.Analyze needs from perspective of educators, and learners at all career stages c.Educate and provide resources for AAO-HNS members d.Leverage relationships with other groups engaged in simulation e.Identify, develop and leverage resources to improve simulation equipment, curriculum, competency assessment, research and advocacy f.Conceptualize “future state”

Simulation at the AAO-HNS Seminars Instructional courses Open simulation forum Simulation “potpourri” Survey of simulation implementation in residencies Invitational simulation summit

Safe Keeping Journey Focus: – Methods to identify and manage cognitive bias – Methods to resolve conflicts Small group, unit-based, inter-professional sessions Didactic and interactive, culminating in simulation events to practice skills REQUIRED for all caregivers including physicians, nurses, respiratory therapists, pharmacists, social workers, therapists, most technicians, technologists, etc.

Optimize value of simulations

Optimize value detail

Systems Improvements Example: Simulation to Implement a Novel System of Care for Pediatric Critical Airway Obstruction; Johnson et at; Arch Oto HNS 2012 High-fidelity simulation was an effective method to design and implement a novel system of care for pediatric critical airway obstruction. The novel system was associated with more rapid response times and elimination of simulated patient deaths.

Challenges General: – Demonstrating value – lack of skill translation – potential for discrepant modeling ORL: – relatively small market share – specialized nature of our simulation needs, particularly for specific technical skills

Contributions to ACGME programs Core competencies – Patient Care – Medical Knowledge – Practice-based Learning – Interpersonal and Communication Skill – Professionalism – Systems-based Practice Milestones CLER

The Future of Simulation? Medical student Resident / Fellow Attending Expert Board certification Re-entry Maintenance of certification Ongoing professional development Development of expertise ACGME Competencies, Milestones, CLER

Thank you