Simulation and Medical Performance Peter G. Schulam, M.D., Ph.D. Associate Professor Department of Urology Eric Savitsky, M.D. Associate Professor Department of Emergency Medicine CASIT and David Geffen School of Medicine at UCLA

To Err is Human Institute of Medicine November ,000 – 98,000 deaths per year as a result of medical errors. Cost of $17-29 billion per year.

Medical Errors Performance Level of 99.9% Performance Level of 99.9% Airline-2 dangerous landings/day Airline-2 dangerous landings/day Banking-32,000 checks incorrectly deducted/hour Banking-32,000 checks incorrectly deducted/hour

Types of Errors Diagnostic Diagnostic  Error or delay in diagnosis  Failure to act on results Treatment Treatment  Error in drug dosing  Delay in responding to an abnormal test  Error in performance

Medical Errors Locations Intensive Care Units Intensive Care Units Emergency Departments Emergency Departments Operating Rooms Operating Rooms

Why? Lack of standard credentialing Lack of standard credentialing Fragmented health care system Fragmented health care system  Lack of access to all information Human variability Human variability

Physician Variability

# of complications # of procedures Learning Curve

Traditional Training Problems with the apprenticeship model Problems with the apprenticeship model  Variability of experience  Practice on real patients  Inefficiency Cost Cost  The OR is an expensive classroom Lack of standardized proficiency criteria Lack of standardized proficiency criteria

Surgical Training Laparoscopic Cholecystectomy Southern Surgeons Club - 2.2% incidence of bile duct injuries in first 13 pts/group (control 0.2%) NEJM 1991 Southern Surgeons Club - 2.2% incidence of bile duct injuries in first 13 pts/group (control 0.2%) NEJM ,839 lap cholecystectomies by 55 surgeons - 90% of bile duct injuries occurred during first 30 cases Am Surg ,839 lap cholecystectomies by 55 surgeons - 90% of bile duct injuries occurred during first 30 cases Am Surg % of surgical errors are potentially preventable Nat Acad Press, % of surgical errors are potentially preventable Nat Acad Press, 1999

Training Simulators Inanimate models Inanimate models Animal models Animal models Cadaveric models Cadaveric models Virtual reality Virtual reality

Inanimate Models Benefits Benefits  Cheap  Reuse materials  Accessible at any time  Minimal psychological stress inhibiting learning

Inanimate Models Limitations Limitations  Lack of realism  Can only simulate the most basic tasks  Difficult to monitor progress

Animal Models Benefits Benefits  Realistic physiology  Closer to realistic anatomy  Complex procedures  More realistic working environment

Animal Models Limitations Limitations  Expensive  Ethical issues  Difficult to monitor progress

Cadaveric Models Benefits Benefits  Realistic anatomy Rohen & Yokochi. Color Atlas of Anatomy. 1993

Cadaveric Models Limitations Limitations  Expensive  Physiologically unrealistic  Unnatural tissue properties  Difficult to monitor progress Rohen & Yokochi. Color Atlas of Anatomy. 1993

Virtual Reality Simulators

Benefits of Virtual Reality Unlimited availability Unlimited availability Potential for a variety of tasks/procedures Potential for a variety of tasks/procedures  From non-anatomic to surgical “pre-flight”  Allows for repetitive skill assessment Minimal psychological stress inhibiting learning Minimal psychological stress inhibiting learning Monitors trainee activity/improvement Monitors trainee activity/improvement

Benefits of Virtual Reality Virtual Mentor Computer can guide a trainee through a procedure and provide immediate feedback Computer can guide a trainee through a procedure and provide immediate feedback Fulfills the continual, high-quality feedback requirement for efficient learning Fulfills the continual, high-quality feedback requirement for efficient learning Establish metrics Establish metrics

Limitations of Virtual Reality Complexity of organ modeling Complexity of organ modeling Lack of force feedback Lack of force feedback Procedure based systems Procedure based systems Potential >> Today’s Reality Potential >> Today’s Reality

Holy Grail Simulation of a patient’s data set allowing for pre-procedural planning

Procedural Outcome Diagnosis Diagnosis  History  Physical Exam  Ordering of data (labs and xrays)  Interpretation of data Intervention Intervention  Familiarity/Dexterity with the tool set  Understanding the order of the operation  Familiarity of the anatomy  Adapting to anatomical variability  Controlling surgical mishaps

Decrease Physician Variability Task Specific Simulation

Definition of Simulation “A device or exercise that enables the participant to reproduce, under test conditions, phenomena that are likely to occur in actual performance” “A device or exercise that enables the participant to reproduce, under test conditions, phenomena that are likely to occur in actual performance”Krummel