1. Medical Simulation and RCP Training Bernie Roth MD Clinical Professor of Medicine - UW Pulm Div Professor of Medicine – USUHS PCCM/Sleep - MAMC

2. Disclaimer I have no affiliation with makers of simulators The content of this presentation represents the private views of the author and in no way reflects the official views of the Department of the Army or the Department of Defense Thanks to Paul Kettle RRT who should be giving the lecture

3. Overview Medical Simulation –What is it? –Why use it? Three Ventilator Simulators –The cheap –The expensive –The ridiculously expensive Designing a curriculum

4. What is Medical Simulation? “A situation or environment created to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions.” –Center for Medical Simulation, Cambridge, MA

5. What is Medical Simulation? Simulation vs. Simulator Task / Skills Simulator –Intubation, Ventilator with test lung, Bronchoscopy Standardized Patient Human Patient Simulator –High fidelity simulator with a scenario –Evaluate knowledge, skills and attitude –Excellent for team training Virtual Reality –Virtual task –Virtual patient –Virtual scenario

6. Why Use Simulation? Patient Safety (Useful mistakes) Experiential / Emotional Learning (next) Teach integrative approach to problems Standardize curriculum Teach decision making Practice working in teams Planned experience of rare events Because the ACGME and Joint Commission wants us to… J Qual Pat Saf 2007; 31:185-202

7. Circumplex Model of Emotion: Russell and Feldman Barrett, 1999 Emotionality of the Experience Is the Difference

8. Ventilator Simulators - Cheap Evita Trainer by Drager http://www.draeger.com/US/en_US/produ cts/medical_ventilation/adult_icu_ventilatio n/rsp_Evita_XL.jsp http://www.draeger.com/US/en_US/produ cts/medical_ventilation/adult_icu_ventilatio n/rsp_Evita_XL.jsp Hamilton http://www.hamilton-medical.com/Online- simulation.683.0.htmlhttp://www.hamilton-medical.com/Online- simulation.683.0.html You can download these for free!

9. Moderately Expensive Patient/Ventilator Simulator SimMan by Laerdal ASL 5000 Breathing Simulator –by IngMar Medical –Simulate breathing with altered Res or Comp Your ventilator

10. The ASL 5000 Breathing Simulator Just intubate the patient And add your ventilator IngMar Medical

11. Ridiculously Expensive Patient/Ventilator Simulator METI-HPS and your ventilator

12. Pulmonary Spontaneous respiration Mechanical ventilation Assisted ventilation Chest excursion Oxygen consumption Uptake and elimination of anesthetic gases Variable lung and thorax compliance Variable airway resistance Breath sounds Intrapleural volume Functional residual capacity METI – HPS (Human Patient Simulator)

13. Designing a Simulation Curriculum Make sure you know how to do “it” correctly Do your Homework –Evidence Based –Expert Review Ask for Help –Physicians –Nurses –Respiratory therapists

14. Planning & Evaluating a Scenario What is the learning objective? –Value of the scenario is not in complexity –Use the Simulation Recipe Checklist evaluation –Break down into smallest identifiable task –Go / No Go for each task –Scaled evaluation sometimes more useful Who will evaluate? –One of the players vs. outside the room –Depends on resources available and goals of the simulation

15. Simulation Recipe Who is your target audience? – goal is to push them to the edge of their practice Needs Assessment – what does your audience need to work on? Learning Objectives - choose 2 or 3 objectives based on your needs assessment. Objectives may be clinical and/or behavioral. Note – it is not cost effective to use simulation to teach purely factual knowledge. Use it to teach application of knowledge to a new clinical situation or to work on behaviors.

16. Simulation Recipe - example Who is your target audience? – Respiratory Therapists just out of school Needs Assessment – Many of the therapists are very green and get very nervous around sick patients Learning Objectives – –Demonstrate ability to perform patient/ventilator assessment –Demonstrate ability to identify common problems causing tachypnea and hypoxia on the ventilator (mucous plugging, bronchospasm, pulmonary edema) – Demonstrate the ability to respond to these problems with appropriate therapy

17. Simulation Recipe Plot - Use real cases from experience or QI data that illustrates learning objectives. Give to students verbally before the scenario and/or have it in the form of a medical record. Set-up - Room, mannequin, monitor, crash cart, IV poles, other props, actors as other RCP, physician, nurse, family member, etc Script of the scenario - What the mannequin and actors will do – start simple and focus on target audience.

18. Simulation Recipe-example Plot – –RT called stat to patient’s bedside –62-year-old man with pneumonia on ventilator –Peak pressure is alarming on ventilator and patient is hypoxic due to mucous plugging Set-up – –SimMan - RR- 34, BP-190/100, P-114, O2 sat-85%, decreased breath sounds –Ventilator set with AC, rate-16, TV-420cc, peak pressure limit of 40, FiO2-50%, vent is alarming with Peak pressure limit – ASL 5000 simulator – 85% of max tracheal resistance –Assigned bedside nurse actor (can direct simulator issues) Script of the scenario – –Patient will continue to deteriorate until patient is removed from ventilator, bag mask ventilated and suctioned –If above done, resistance will fall to normal and ventilation will be normal when ventilator restarted with improved patient VS

19. Simulation Recipe Medical record (Optional) – patient notes, history and physical, medication list, ECG’s, labs, x-rays Teaching Points –Critical actions -- series of steps necessary to successfully complete task and demonstrate understanding of the teaching points. –Common Pitfalls -- common mistakes that your learners may make that you specifically want to remind them to avoid. Debriefing – most important part –based on the teaching points outlined above –based on what you observed during the simulation

20. Evaluation (formative vs. summative) CLINICAL TASKS Go No Go Patient disconnected from the ventilator Bag Valve Tube ventilation done correctly Auscultates patient’s chest Suctions appropriately Continues Bag ventilation till O2 Sats improve Reconnects ventilator BEHAVIORAL ACTIONS Exceeds Meets Fails to Meet Fails to Meet Communicates impression and plan to nurse Recognize Peak Pressure alarm suggests obstruction

21. Summary – Simulation Recipe Simulation allows students to experience a “true- to-life” scenario where they can make mistakes and learn without hurting patients Know your audience and their needs Develop learning objectives (2-3) Develop the plot, set-up and script Observe critical actions/common pitfalls Give Feedback/Debrief Have serious fun and your students will, too!

22. Contact Me bernard.roth@us.army.mil We can talk about Simulation Or Ask Me Now?