Manage Relationships, Information, and Processes Dennis Breen MD Eau Claire Family Medicine University of Wisconsin School of Medicine and Public Health

Wide variety of skills Some performed infrequently Lack of Opportunity Critical care, procedural, behavioral, and teamwork Difficult to teach consistently Even more difficult to evaluate

Simulated clinical experiences Develop and maintain skill competence Skills performed and evaluated Improve interdisciplinary team-based care Hospital (in-situ) Mock Codes Health education centers While still learning Virtual Hospitals

Discuss Integration of human patient simulation into the education of residents and other members of the health care team. Use of clear objectives, situational awareness, teamwork skills, and evidence based guidelines in developing a simulation experience. Importance of debriefing for crisis resource management and skill competence.

HPS and Virtual Hospital (15 minutes): History of our experience with human patient simulation. Review of resource development and implementation. Clinical Simulated Experiences (15 minutes): Review of strategies for development of the simulated team experience. Design of simulated team experiences for multidisciplinary participants. Discussion of debriefing strategies Open Discussion and reaction (15 minutes): Participant reaction to / experience with simulation Some evaluation strategies

Partner with CVTC - develop use of HPS in medical and allied health education Developed scenarios - require residents to assess and manage patients presenting with common acute critical conditions (MI, PE, GI bleed ) 2005 – CVTC - develops Virtual Hospital Research interest – Experiential learning, interdisciplinary team training

Visit health care simulation centers Bring back ideas to improve our own center Medical Education Technologies, Inc. Stanford - Dr. David M. Gaba M.D. and Dr. Steven Howard M.D. CRM – crew resource management Harvard - Dan Raemer, PhD. and Jenny Rudolph, PhD. Comprehensive Course Faculty Development at Center for Medical Simulation

LEVEL I: PRESENTATION STATEEVENTS MINIMAL BEHAVIORS EXPECTED State #1: Chest Pain Begins INSTRUCTOR NOTE: HPS: Simulator will respond appropriately to oxygen administration ECS: When oxygen applied, open Oxygen Treatment Scenario and choose corresponding liter flow implemented by learners HR 56 BP 114/42 RR 24 Sinus bradycardia SpO2 96% with O2 in place at 4 LPM or 94% on room air Breath sounds clear Bowel sounds normoactive LOC alert and oriented x3 Pupils equal Complains of 4/10 nonradiating substernal crushing chest pain Tell learners when they inquire: Weight 100kg Skin pale, cool, clammy Abdomen soft and obese ABC BSI/Standard Precautions Obtain history Assessment Monitoring Obtain and monitor vital signs Establish or maintain IV(s) Initiate or maintain oxygen Obtain and interpret 12 lead ECG Administers medications (morphine, nitroglycerin, aspirin per local protocol) Communication with patient and significant others Document care EMS Assess the scene and take appropriate steps for scene management Initiate immediate management for life-threatening conditions Differentiate between primary causes of chest pain of cardiac origin and all other potential causes. Develop management alternatives for probable differential diagnosis to include as needed: airway management, respiratory and /or ventilatory support, fluid therapy, pharmacological support, and transportation to an appropriate facility. Determine appropriate transport Physician Brief examination/Differential diagnosis Stabilization Plan: Labs obtained: CK, CK-MB and Troponin I STAT and every 8 hours x 3, CBC, electrolytes, BUN, creatinine, glucose, PT/PTT STAT Chest x-ray STAT NPO Aspirin Morphine Critical Error: Failure to obtain medication history; NTG administration Nursing Institute chest pain protocol Interventions Obtain blood for labs Anticipates further orders Communicates with physician concerning status and response to intervention Delegates care as appropriate Coordinates care of team Respiratory Care Monitor oxygenation Titrate oxygen per local protocol LEVEL II: ACUTE INTERVENTION

CRM (crisis or crew resource management) teamwork Training crews to work as teams Crisis – sequence of events that offer a clear and present danger to the patient, brief and intense “Technique” not a “technology” Debriefing skills CRM – How did you feel that went? Evaluate – Team Skills

Staged experiences Gradual introduction of personnel into the simulation Utilization of team members as needed “Hot seat” Video use Task Trainers and/or Mannequin-based Ob-Gyn trainer with other mannequins METi / Laerdahl Mock Codes in hospitals – In-situ simulation

Incorporate training into residency curriculum. Thinking Teamwork Decision making Develop interdisciplinary health care curriculum. Schedule Residents during clinical to do a course. Other members of the health care team Teams ER OB ICU Surgery/Cath. Lab

Mission Statement Center’s Purpose – goals Mock codes CRM Skills development Research What we want to do Stakeholders’ What will clients’ do differently after attending

Personnel/Facilities needed Equipment Video Budget External Resources Society for Simulation in Healthcare

Theory of Experiential Learning Imprinting requires upper level of activation. See model of emotion – Barrett Requires some parts of simulation be real-like Eyes blink Pulse Breathing Heart Sounds

Experience Reflection Conceptualization Experimentation Experience

Imprinting requires upper level of emotional activation Experience Lecture James A. Russell, Lisa Feldman Barrett Circumplex model of emotion

Strategies for development Critical incidents, timely topics, case reports, rare events, closed malpractice claims, M&M Bring cases to life – PBL Develop Objective – Skills development and evaluation Crisis (crew) resource management (CRM). Interview parties to be involved

Realism Feasibility Impact Time efficiency – 10 to 20 minutes Flexibility of execution Balance of technical issues and CRM

Elements of Simulation Experience Narrative Characteristics of patient(s) Clinical situation Abnormal events Patient records Props Guidelines for operator or instructor Instructions for actors or confederates Information for participants to read or be given before scenario (Pre-brief) Teaching Points for Debriefing References - EBM

For single or multidisciplinary participants Gradual introduction of participants – small group – skills vs CRM Large group experience –CRM

“A simulation is an excuse to have a debriefing.” Immediately after scenario Emotions - still “running high.” Objectives of debriefing: “Defuse” emotions from the experience Sort out thinking process Answer participants questions Link simulated experiences to real life Students do the talking Facilitator asks questions and guides discussion

Understanding the results, the actions that caused them and the frames that affected the actions. Frames = knowledge, assumptions, feelings

Advocate and Inquire with good judgment. ◦ Neither judgmental nor non-judgmental ◦ Share observation and opinions ◦ Use curiosity, respect Advocacy = my views etc. - I observed, believed, felt concern for - Inquiry= learners perspective – What was your observation, belief, concern (knowledge, assumptions, feelings)

Communication Leadership Followership / shared leadership Workload distribution Anticipation and Planning Utilization of all available resources Knowledge of work environment Calling for help early enough

Must collaborate with other health care team members to improve the quality and safety of health care in their future practices.

Safe and controlled virtual environment Infrequent critical interventions Thoughtful simulation experience Utilize – Situation awareness Information processing Team based resources Evidence based guidelines Develop appropriate differential diagnoses and care plans Respectful debriefing

Requires physician: Demonstrate understanding of individual disciplinary roles and responsibilities Display skills and behaviors appropriate to his/her role in team protocols Demonstrate effective communication skills to enhance team functioning Demonstrate respect for the patient and other health care team members Initiate practice based learning and improvement Maximize available resources within the healthcare system