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Part Three: Medical SimulationWhat Medical Simulation Programs are Available.P,G, Brindley MD FRCPC,''^'^ G. I. Suen MD FRCPC/ J, DrurTimond Mom'

Introduction

1. Regional Simulation Program, Capital Health,Edmonton

2. Division of Critical Care Medicine, University ofAlberta, Edmonton,

3. Canadian Resuscitation Institute

Correspondence to:Peter G, Bnndley MD FRCPCAssistant Professor, University of AlbertaProgram Director Critical Care MedicineAttending Physician, Critical Care MedicineMedical Lead for Patient Simulation, Capital HealthVice-President Canadian Resuscitation Institute4H1,22 University of Alberta Hospital,8840-112th St. Edmonton AlbertaEmail peterbhndley@cha.ab,caTel 780-407-8822Fax 780-407-6018

Acknowledgements: To the Respiratory Therapists ofthe Capital Health Region, Alberta for your dedicationand caring.

Key words: Medical education • medical simulation •communication skills • crisis resource management

Conflicts of interest: None, Dr Brindley is the MedicalLead for Patient Simulation for Capital Health, Albertaand Vice-president for the non-profit CanadianResuscitation Institute.

Background: This manuscript is part-three of a three-part series on Medical Simulation, Part-one addressedthe "why" of Simulation, namely, why MedicalSimulation offers novel opportunities to improve edu-cation, continuing-competency, and patient safety.Part-two focused on the "how" of simulation, namely,how to design, implement, and maintain a viable pro-gram. Part-three will now cover the "what", namelywhat the future directions are likely to be, what sort ofprograms ^TQ currently available, and what evidencesupports their implementation.

Definitions: Our definition of "Medical Simulation"means any technique, "low-tech" or "high tech", thatattempts to realistically recreate clinical situations andallow training with minimum patient risk. In this way itresembles the "war-games" of the military or "flightsimulators" of aviation. Medical training has alwaysinvolved graduated acceptance of decision-makingand supervised practice. Equally, examinations havelong included aaors. As such, medical training hasalways incorporated a degree of simulation of realpractice. What has changed is the explosion of avail-able technology; the principles of adult education, thefocus on patient safety, and the expectation of proofvia research. Simulation is therefore a huge topic. Wehope to offer a concise introduction.

The Future of SimulationThis is an exciting cinic lor MedicalSimulation! As we outlined, in part-one of this series, there are manyarguments in favour of Simuiation.and numerous educators, cliniciansand administrators have becomestrong advocates. A number of cen-tres have subsequently developedsustainable simulation jirograms- byapplying many of the principles thatwe outlined in part-two. The cutting-edge of simuiation now appears tobe evidence-hasecl simulation, col-laborative simulation and develop-ing the science of simulation. Thiswill be the focus of this third andfinal manu.script.

Growing InfrastructureLocal simulatioTi initiatives remainvery important, but widespread col-laborations can now promote thedevelopment of national standards,national advocacy, and multi-centretrials- in addition to the straightfcjr-ward exchange of ideas. To facilitatecollaboration, national organizationsnow exist such as the Society forSimulation in Healthcare (SSIH)'. theCritical Care Education Network(formerly the Canadian ResuscitationInstitute (CRI)-, and the Society inEurope for Simulation Applied toMedicine (SESAM)\

The SSIH hosts the annual"International Meeting on Simulationin Healthcare" and now administersa peer-reviewed journal, called"Simulation in Healthcare", This hassignificantly raised the expectationsfor authors to undertake evidence-based simulation research. This is instark contrast to erstwhile manu-scripts that were typically merelydescriptive: descriliing what hadbeen tried and how it had been con-ceived.

Iastead of each simulatitjn centrecreating its own scenarios locally,efforts have been made by groups,such as the CRI, to develop

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marketable courses. This centralizedeffort should raise the quality ofSimiilatitjn as it usually involves anin-depth needs-assessments (e.g.studying what areas ought to beaddressed: what are the deficienciesin the current curriculum; what arethe needs of learners), taking painsto incoqiomte principles of adulteducation and psychology (e.g.encouraging self-directed learning,bilateral exchange of ideas betweenfacilitator and trainee; courses thatare easily modifiable based uponfeedback), and developing metricsto analyze participant satisfaction.Evidence-based programs now exist.A few of these are outlined in orderto provide practical examples ofwhat is possible. What follows is farfrom exhaustive, but may help tho.seeager to see how they too can pro-vide unique opportunities for educa-tion, patient safety, health care-work-er safety, and meaningful research.

Acute Critical EventsSimulationThe Acute Critical Events Simulation(ACES) program was designed bythe CRI. ACES originated with thegoal of improving patient safety fol-lowing the identification of recurrenterrors during resuscitation. This twoday course was designed by facultyfrom across Canada to aid with theacquisition of knowledge and proce-dural skills, but especially behaviorsand communication. It has beendelivered to hundreds of candidatesin both urban and regional settings,and successfully modified for MDs,RNs, and RTs.

Evaluations have consistently beenvery favorable. Analysis of a Likert-scale questionnaire (0 to 5. with 5repre.senting .strongly agree) issuedto the first 50 participants found anoverall rating of 4.38 (95% Cl, 4.12-4.65) in 2002 and 4.44 (95% Cl, 4.3-4.59) in 2003. Participants also feltthat ACES was very useful, withscores of 4.33 (95% C.I 4.01-4.67) for2002 and 4.37 (95% C.I 4.19-4.55)for 2003. Comparing evaluationsfrom one year to the next alsodemonstrated how the course couldhe easily modified using a needs-

Figure 1: Simulation of Severe Acute Respiratory Distress Syndrome {SARS)Photo: Dr. Peter Brindley/Dr Randy Wax

Figure 2; The Acute Critical Events Simulation CoursePhoto: CRi Critical Care Education Network

assessment beforehand and feed-back afterwards.4 ACES is one of thefirst courses to focus on CrisisResource Management (CRM) skillsand as such offers a unique andimportant supplement to otherexcellent life support courses.

Simulating Telephone CallsIn Canada, large distances and lowpopulation density means frequenttransport of acutely-ill patients to asingle urban centre. A great deal ofcare is coordinated by telephone.but communication skills are rarelyaddressed. As such, acuce-care tele-conference calls have been simulat-

ed to help panicipants develop the"verbal-dexterity" and probiem-solv-ing abilities required lo care for iheacutely-ill. Of note, very littleresearch has been done regardinghow best to transition care from onegroup to another (for example frompre-hospital to the emergency room)or how to safely transport unstablepatient.s across enormous distances.In addition, this strategy providesmany of the putative benefits ofHigh-Fidelity Simulation but withminimal cost or logistics. Whilelargely descriptive in nature, qualita-tive evaluation suggested the exer-ci,se was extremely well received,the exercise was deemed realistic,

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Figure 3: The Acute Critical Events Simulation CoursePhoto: CRI Critical Care Education Network

and tliat mistakes mirrored those inreal-practise. All participants felt thisstrategy was superior to didactic ses-sions, and complementary to clinicalexperience. Simulated calls withinthe same hospital could be per-formed just as easily, and plans areunder way to train both referringand receiving staff using this

Simulating Transportationof the Acutely IIIWrighl et al." performed a uniquestudy a.ssessing the feasibility of pro-viding high fidelity simulation in anair ambulance helicopter. Due tocost limitations, the simulation wasperformed while the helicopter wasrunning at flight idle, rather than infull fliglit. Despite this limitation.they were able to simulate the noiseand vibration present during flightwhich has profound implicationswhen trying to resuscitate patients.As they described in detail, alarmscan be missed and monitors canbe blurred, making the helicopterenvironment particLilarly difficult towork in.'"

Twelve residents completed the sim-ulations and all rept)rted animproved awareness of the chal-lenges faced in .such environments.All residents agreed thai the simula-tion was educational and should be

used for future training." One caneasily imagine other difficult scenar-ios that healthcare workers mightfind themselves working in, such asin the back of an ambulance, or con-fined spaces such as elevators.Optimizing transportation remains apoorly studied area, but one withenormous potential.

Simulating DisasterResponseHigh-fidelity simulation has beenused as a method of developing(and refining) complex hospital pro-tocols and disaster plans. These rec-ommendations are often extensivelydiscussed beforehand, but then filedaway in policy binders, and rarelypracticed. Without testing and re-finement, experience suggests theywill not be properly applied duringthe chaos of an evolving crisis.Equally, it is not appropriate to learnthrough "trial-and-error" when theconsequence of "error" could be toworsen an already desperate situa-tion. Furthermore, while patient-safety is finally receiving longoverdue attention, similar attentionis needed for "healthcare workersafety'". Overall, a good example ofthese challenges, and opportunities,was the outbreak of severe acuterespiratory syndrome (SARS) in2002-3.

Abrahamson. Canzian and Brunetused Simulation to develop andteach the resuscitation of cardiacarrest patients with SARS7 This ,syn-drome presented new paradigmsin care delivery and, as such, previ-ously entrenched treatment methodswere not applicable. For example,hospital workers needed to re-trainnot to vigorously bag ventilatepatients or risk dispersing the SARSvirus. Furthermore, workers neededto leam how to put on a personalprotective suit (PPS) before theycould Stan.

Intubation of the SARS patientrequired a PPS in order to mitigateexpo.sure and transmission. How-ever, this .seriously hampered com-munication and procedural dexteri-ty. As Abrahamson et al. note.Simulation "provided insights thathad not been considered in earlierphases of development"." Expressedanother way, if you plan in a board-room, you will typically come upwith boardroom solutions! They hadinitially timed individuals at V/2 to2Vi minutes to don the suits anddesigned their protocols around thisassumption. However, during simu-lation, when an entire team had togown up, the time to don the suitsincreased dramatically to 3 '/2 to 5 V>minutes. Using results from the actu-al simulation, they revised their pro-tocol and corrected unanticipatederrors in infection control. Impres-sively, these authors were able totrain 275 health care workers withintwo weeks in this new protocol: afeat that would have been difficultwithout using Simulation. SARStherefore represents an excellentexample of how Simulation offersopportunities for patient safety.These same opportunities existwhether for training in mass casual-ty, avian flu. or just another "disas-trous day" in an overcrowded emer-gency room.

Use of Simulation inClinical TrialsSimulation tiflers unique opportimi-ties to improve the development ofclinical trial protoccsls. Furthermore,

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once developed, researchers need tobe confident that bedside staff willduplicate these complex protocolsprecisely. If a protocol is violated itmay mean that a patient's data can-not be used. Tliis decreases the sta-tistical power of the study, delays itscompletion, and wastes resourcesand money. Experiencf has alsosuggested that study outcomes canbe sij nificantly different based uponwhether the first few patients areincluded or excluded (likely becauseof early mistakes adhering to thestudy protocol). Significantly, thisalso rai.ses ethical concerns regard-ing how appropriate it is to performtrials if the fust few candidates areexposed to risks. In fact, minimizingharm and striving for equipoise (thebelief that benefit and harm areequal for all study paiticipants) is afundamental requirement for studyapproval. Overall, Simulation offersa way to protect the rights of studyparticipants, at the same time asoptimizing the study's statisticalpower, and protecting the investiga-tors' scarce resources.

Wright et al!^ describe using a highfidelity simulator when designing acomplex clinical trial in which multi-ple medications were given at pre-cise times for patients undergoingcoronary bypass surgery. As with theSARS resuscitation study, Wrightfound unanticipated problems wiihtheir protocol during simulation, thatlikely would not have been foundotherwise. They were able to train48 research coordinators and furtherrefine their protocol before anypatients were actually subjected toexperimentation.*^

Rapid Response TeamTrainingBu.sy medical staff often failure torecognize when inpatients showearly clinical deterioration.^'"Equally concerning, even whendeterioration is recognized, health-care workers often fail to initiatetreatment or access help ' "" There islittle doubt that, for many acuteillnesses, outcome is far better withearly intervention compared to

Figure 4: Routine Multi-Disciplinary Operating-Room Simulation

Figure 5: Use of Simulation to Tram Muitidisciplinaty Rapid Teams

waiting for full cardiovascular col-lapse.''"'- However, there is equallystill considerable debate as to thebest way to institutionalize rapidresponse.'""" Different jurisdictionshave implemented different rapidresponse teams. These teams differbased upon their composition (e.g.whether an MD or RT is the firstresponder) and its activation trig-gers. In Canada, by far the mostcommon model is the MedicalEmergency Team (MET)."

In theory, MET is activated whenhospital inpatients display predeter-mined aberrant vital signs. METoften consists of a physician, respi-

ratory therapist, and nurse. Theseprofessionals must be able to worktogether in an efficient and collegialway despite varied and stressful sit-uations and disparate training.Equally, despite numerous patientscompeting for their attention, wardnurses are expected to remember toactivate MET in a timely manner.Medical Simulation has thereforebeen recommended as a way to trainall of the personnel involved inthese calls.

DeVita et ta/.'^'' designed a curricu-lum utilizing High FidelitySimulation which focused on devel-oping multidisciplinary team skills

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Figure 6: IM • ' . ' •.•_•!. L J ' C LiiuLdlfon Network (criedunet.ca): A National CollaborationCommitted to Increasing Medicai Education and Simulation)Photo: CRI Critical Care Education Network

during medical crises. A total of 138individuals were trained including21 respiratory therapists, 48 physi-cians, and 69 critical care nurses.Following this training, simulatedsurvival (following predeterminedcriteria for death) increased from 0%to 89^t. A similar Medical OutreachProgram has been developed by theCRI, and has trained healthcareworkers throughout the Province ofOntario (following generous govem-ment support).- These initiativessuggest that Simulation has enor-mous potential to help in both triageand resuscitation.

While few would argue with theidea of responding rapidly, thecurrent research has not shownan unequivocal benefit followingMET implementation." Simulationresearch may offer insights a.s towhy not. It may also be invaluableregarding how best to intrc^duce ini-tiatives such as MET, and in under-standing the complexities of hospitalculture within which the MET mustfunction. Overtime, Simulation mayhelp to finesse rapid response, indi-vidualize programs for different hos-pitals, or even suggest alternativestrategies. Simulation has a vital, andcurrently underutilized, role in thistopical debate.

Barriers to Simulation (andhow to overcome them)Dr. David Gaba. a renown championfor Medical Simulation has empha-

sized that, despite many putativebenefits, widespread Simulation Lscurrently the exception in health-care.'^ Furthermore, due to cost andtime constraints, most training pro-grams that do use Simulation exposetrainees only a few times per year.For Simulation to be truly acceptedand effective, sessions must happenroutinely and Ix" "fully integrated intothe routine fabric of health care deliv-ery".''^ In fact, the more that Simu-lation becomes integratetl into every-day practice, the greater the supponit is likely lo garner. In this way par-ticipants will increasingly regardSimulation as a normal (non-puni*tive) pait of working in healthcare.

Tlujse already in clinical practice (asopposed to trainees) are currentlyeven less likely to be required toparticipate in Simulation. This is instark contrast to other profe.ssionssuch as the airline industry' whichmandates regular Simulation fromthe newest employee throughto seasoned veterans. As such,senior clinicians need tcJ lead byexample. In the current voluntarysystem, this means requesting simu-lation experience. Otherwise quality-improvement, and patient-safety, isunlikely to be .seen as a system-wideimperative. Equally, for those re-entering clinical practice or changingroles for example from trainee toindependent practitioner Simulatitmoffers a way to smooth the transitionand offer reassurance.

Numerous comparisons exist be-tween healthcare and other profes-sions that long-ago mandatedSimulation. Therefore, it is quite rea-sonable to mandate Simulation train-ing in healthcare. In fact, increasing-ly, this appears to be a necessarystep towards promoting its accept-ance. For example, courses such asAdvanced Cardiac Life Support(ACLS®) and Advanced Trauma LifeSuppon (ATLS®) have been mandat-ed for years. Few healthcare workersappear to object to these courses.Similarly, hospitals have been per-forming mock fire-drills for decades.As such, it seems no different to per-form "mock-codes" and "mock trau-mas", and to do so using the hospi-tal's overhead announcement .sys-tem. Overall, healthcare's inertia isincreasingly difficult to defend.Understanding its causes is anotherimportant step forward.

SavolcleUi et al.'^' surveyed 154 anes-thesiologists to determine barriers toSimulation. Ninety percent of .staffphysicians reported at least onepotential reason. These included"lack of time", "lost income', and"lack of training opportunities".Notably, however, a significant addi-tion harrier for staff physicians was'performance anxiety". Approx-imately one quarter of respondentsreported fearing the judgments ofpeers and worried about a stre.ssfiilor intimidating environment in thesimulator.'" Therefore, medical edu-cators musi take great care that par-ticipants feel .safe to learn...and .safeto learn from mistakes-

Simulation ResearchLord Kelvin stuted ihal if knowledgecould not be expressed "in numluTs"then it was •'meagre and unsatisfactory". liiis "KeKin's Curse" 17 compli-cates quantitative-research of qualita-tive-skills such as communication andteamwork. Of note, whether didacticlecturing is lieneficial has never teenheld lo similar scrutiny, nor haveother professions demanded proofl">efore mandating widespread simula-tion. TTie skills addressed throughSimulation are not "meagre" orunimportant, as we know that

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communication and teamwork to beone of the greatest causes of preventa-ble medical error (see Part One).However, advocates need to acceptthat traditional research methods andexpectations may not apply.Simulation proponents should acceptthat applications for research grantsmay compete poorly against tradition-al research. Stiutegies tlierefore includeeasuring niiiltidisciplinar>- input andapproaching novel funding agencies,as well as dogged persistence.

Simulation outcomes tend to bequalitative in nature (e,g, is a studentable to run a resuscitation more effi-ciently; can a coworker function bet-ter within a multidisciplinary team).These outcomes, while vital, are dif-ficult to express in numerically.Eurthermore, following the "scientif-ic method" means accepting thatresearch may or may not ultimatelydemonstrate a benefit. In short, itmay never be conclusively proventhat simulators significantly improveclinical outcome.

An intriguing question is that, givenall of the potential benefits ofMedical Simulation (and the lack ofany obvious downside), just whatlevel of proof is needed. Regardlessmost siniLilation research does notreach the level expected of tradition-al research. For example, in a reviewof over 670 articles covering34 years, McGaghie el al. identifiedthat only 5% of simulation researchpublications met or exceeded mini-mum quality standards.'" Instead,many proponents have focusedupon arguments such as the aviationindustry mandates regular simulationtraining for pilots entrusted with pas-senger's lives, and therefore medicalstaff, entrusted with a patient's lives,should be no different. Equally ifSimulation was instead a pharma-ceutical agent, with this much poten-tial to improve outcome and no clearside effects, practitioners woulddemand widespread access. Thesecommon sense arguments are worthmaking, but cannot be confusedwith definitive ciata or proof.

We may indeed be approaching astate where Medical Simulation will

become accepted based upon itswidespread acceptance and its "facevalidity". However, it must be appre-ciated that data is a very powerfulally whenever we are looking tomandate change or redirect funding.Competition for resources is fierce,and without research it will be hard-er for administrators to secure fundsfor Simulation, or for educators todemand its widespread application.In short, Simuiation is almost cer-tainly here to stay, but how rapidlyaccepted or widely integrated itbecomes will he influenced uponhow well it grows into a scientificdiscipline. The challenge ahead isclear; whether we will rise to it willrepresent the next chapter in theevolving ,story of Medical Simulation,

SummaryTlie niimlx^r of simulation programs isincTeasing rapidly. Furthermore, thereis an increased emphasis upon collab-oration, incorporating principles ofadult education, and demandingsimulation research. High qualityMedical Simulation now covers thegamut from programs designed toimprove acute resuscitation and triage,to improving communication, toimproving pandemic planning, andimproving clinic"a! trials. Tliere is aneed for higher quality evidence-based research if Medical Simulation Lsto reach its potential. However, signif-icant research challenges have yet tobe systematically addressed. Obstaclesremain but the opportunities are sim-ply too great not to persevere.

References1, Society for Simulation in Health Care-

Available at: www,ssih,org/public/.Accessed Jan 04. 2008,

2,Critical Care Education Network/Canadian Resuscitation Institute.Available at:www, cri ed u net. ca/e n/porta I. AccessedJan 04, 2008.

3. Society in Europe for SimulationApplied to Medicine, Available at:wvvw,sesam,ws/. Accessed Jan 04,2008,

4. Brindley P, NeJiipovitz D, Kim J, CardinalP, The Acute Cntical Events Simulation(ACES) Program, A Novel CanadianEducational Initiative to Improve Careof the Criticaiiy III, Critical Care Rounds2005;6(2):l-6,

5, Brindley P. Novel technique for criticalcare training, C/MA/2007; 176(1 ):68,

6, Wright SW. Lindsell CJ, Hinckley WR,Wiiiiams A, Holland C, Lewis CH, et al.High fidelity medical simulation in thedifficult environment of a helicopter:feasibility, self-efficacy and cost, BMCMed Educ 2006, Oct 5;6:49,

7, Abrahamson SD, Canzian S, Brunet F,Using simulation for training and tochange protocol during the outbreakof severe acute respiratory syndrome.Cr/f Care 2OO6:1O(1):R3,

8, Wright MC, Taekman JM, Barber L,Hobbs G. Newman MF, Stafford-SmithM. The use of high-fidelity humanpatient simulation as an evaluative toolin the development of clinical researchprotocols and procedures. ContempClin Trials 2005; 26(6):646-59.

9, Hillman K, Chen J, Cretikos M, BeilomoR, Brown D, Doig G, for the MERITStudy Investigators, Introduction of themedical emergency team (MET) system:a cluster-randomised controiied trial.Lancet 2005; Jun 18-24;365(9477):2091-7,

10, Devita MA, Beilomo R, Hillman K,Kellum J, Rotondi A, et al. Findings ofthe first consensus conference onmedical emergency teams, Crit CareMed 2006;34(9):2463-78

11, DeVita MA, Smith GB, Rapid responsesystems: Is it the team or the systemthat is working? Crit Care Med 2007Sep;35(9):2218-9,

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13, DeVita MA, Schaefer J, Lutz J,Dongalli X Wang H, Improving med-ical crisis team performance, Crit CareMed 2004 32: S61-65,

14, DeVita MA, Schaefer J, Lutz J,Dongalli T Wang H. Improving med-ical emergency team (MFT) perform-ance using a novel curriculum and acomputerized human patient simula-tor, Qual Saf Health Care. 2005;14(5):326-31

15, Gaba DM, The future vision of simula-tion in health care, Qual Saf HealthCare 2004; 13 SuppI 1:i2-10.

16, Savoldelli GL, Naik VN, Hamstra SJ,Morgan PJ, Barriers to use of simula-tion-based education. Can J Anaesth20G5,52(9>:944-50,

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