Simulation in Healthcare A Multifaceted Tool David M. Gaba, M.D. Associate Dean for Immersive and Simulation-based Learning, & Professor of

Transcription

1 Simulation in Healthcare A Multifaceted Tool David M. Gaba, M.D. Associate Dean for Immersive and Simulation-based Learning, & Professor of Anesthesia; Stanford University Director, Patient Simulation Center of Innovation, VA Palo Alto HCS EIC, Simulation in Healthcare

2 Disclosures Nothing ACCME disclosable pertaining to the topic of this talk, but - Consultant to Karl Storz, Inc. re airway management (no $ exchanged hands yet) - Sci Adv Board & shareholder, SEA Medical Systems (startup)

3 It s Not (always) About Technology A technique NOT a technology - For interactive and often immersive activities that re-create experiences of a real-world environment»to amplify or replace actual experiences» Even better than the real thing

4 It s Not About Technology Simulation is Probably Pre-Historic Likely a preparation or surrogate for hunting or war Full Immersion Simulation The Real Thing Photos via Adobe Photoshop Time Machine

5 Simulation is Very Diverse in Application (11 Dimensions) Purpose/goal of simulation - Education Training Assessment Research Unit of participation - Individual Team Work Unit Hospital Knowledge, skill, or behavior addressed - Knowing Doing Deciding Teamwork

6 11 Dimensions of Simulation Application in Health Care Clinical domain(s) - Clinic Ward Cath-Lab OR/ICU/ED - Psych Int Med / Peds Surg/Anesth/EM Discipline(s) of health care personnel - Clerk Allied-Health Nurse MD Execs Experience level(s) of participants - K-12 Univ Prof School Trainee Staff

7 11 Dimensions of Simulation Application in Health Care Patient age - Neonate/Infant Child Adult Elderly Technologies and techniques Roleplay Computer Screen Virtual Reality Computerized Mannequin

8 11 Dimensions of Simulation Application in Health Care 2012 David M. Gaba, M.D. Site Home Library Sim Center Extent of Direct Participation Remote viewing Remote w verbal interaction Remote w hand-on interaction Feedback method(s) None Critique by Simulator Instructor in the Room Work Unit (in-situ) Direct on-site interaction Post-hoc Debriefing (+/- video)

9 Types of Simulation Verbal, role-playing, storytelling Computer-screen simulation including virtual patients Part-task & procedural trainers

10 Types of Simulation Standardized patient or family actors Multiplayer Online Virtual-worlds (MOG) Computerized mannequins

11 Re-invention of Mannequin-based Interactive Patient Simulation 2012 David M. Gaba, M.D. Pre-prototype Simulator 5/1986 Almost 26 years! Gaba & DeAnda, VA/Stanford

12 CASE 1.2 circa David M. Gaba, M.D.

13 CASE David M. Gaba, M.D. Gaba & DeAnda, VA/Stanford Which eventually led to: 1991 CASE 2.0 Gaba & Williams, VA/Stanford

14 Complex Dynamic Domains Need More Than Medical Knowledge Expert knowledge & technical skills, AND Sound decision-making behaviors, AND Optimal communication & teamwork behaviors

15 Aviation Developed Special Training on These Behaviors IN CONTEXT Crew Resource Management (CRM)

16 Team Management in Healthcare A Prototypical Picture

17 CRM Can Be Adapted to Healthcare Howard SK, Gaba DM, Fish KJ, Yang GS, Sarnquist FH: Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviation, Space, and Environmental Medicine 63: , 1992 Gaba DM, Howard SK, Fish KJ: Crisis Management in Anesthesiology, Churchill Livingstone, 1994 Disclosure I do get royalties!

18 CRM Can Be Adapted to Healthcare Now >two decades of experience! 2001

19 Simulation Adds Something Special to Teamwork & Communication Training 2006 March, 2006 AHRQ Web M&M

20 Simulation Engages Participants With Clinical & Behavioral Challenges These people are highly ENGAGED in the clinical scenario; they are NOT merely passive participants

21 Participants can Deploy and Practice Teamwork Skills Experiential exercises force participants to Walk the walk not just talk the talk This takes practice

22 Simulation Integrates Teamwork & Medical Work Team skills executed in context during medical decision & action, with Time pressure Uncertainty Competing goals Perceived risk

23 Simulation Allows Cross-Training and Cross-Role Experiences 2012 David M. Gaba, M.D. - E.g. Nurses can be doctors; doctors can be nurses - E.g. Inexperienced trainees can learn what it s like to be in charge (to be it ) -- no supervising staff guaranteed to bail them out These experiences cannot be provided ethically during real patient care

24 Many Flavors of Teamwork Training Crisis Resource Management TeamSTEPPS VA Medical Team Training (MTT) Commercial vendors (often with aviation background)

25 Doing Simulation is All About Pedagogical Choices On their own vs. teacher in the room? Debriefing vs. no debriefing? Own roles or cross-roles or both? Use actors/confederates or not? If so, how to script confederates?

26 Perfect Reality Isn t Always Desirable Can utilize unreality to maximize learning for specific target populations Cognitive Scaffolding Instructor in Room; Cues & Clues Stop/Pause/Restart/FF/Restore Time compression/expansion Death protection

27 Choices: Complementary Approaches for Mannequin-based Simulation Multidisciplinary Target Population? Site of Action? Advance Warning? {esp for In-situ} Dedicated Sim. Center Yes -- scheduled training Singlediscipline Combinedteam In-situ sims in actual clinical space No unannounced events

28 Single-Discipline Course Address issues for crews from a single discipline (sims do have entire team -- confederates play other team members) - Logistically simpler - Can focus on unique technical, cognitive, and teamwork issues of each discipline - Can expose participants to a wide variety of clinical situations & interpersonal challenges

29 Combined-team (Mutlidisciplinary) Course Train complete teams of staff who do or might actually work together (in OR, ICU, ED, Delivery Room, Cath Lab, etc.) - Trains actual teams to work as a team - Encourages crossdiscipline understanding and cross-training

30 In-Situ Simulation - Pros Probes/trains actual team in actual setting Can unmask systems issues in actual clinical care areas Good for short courses & unannounced drills Available to all, even without a dedicated sim center

31 In-Situ Simulation Cons Limitations to organize, schedule, control & for AV Real clinical areas might be occupied or might be needed on short notice Sims distracting to real care; staff vulnerable to being pulled to duty Real clinical supplies are costly

32 In-situ Simulation (Systems Probing) Is a Prospective Process Improvement Tool Provides known challenging problems for the system to deal with Get to define the rules and parameters of evaluation Scenarios elicit behaviors likely to occur in real cases (at least sometimes) Goal: create opportunities for change individual --> health care system

33 Many Challenges Remain: Pedagogical Challenges Doing simulations well {of any kind} Applying training (+sims) comprehensively Integrating different types of simulationbased training Optimally integrating simulation with other forms of training

34 Many Challenges Remain Cultural Challenges The (real) clinical world must reinforce what is taught in (simulation) training -- currently it often does not - Design and culture trump training (always!) - Much more time spent in real world than in training sessions - Incentives and disincentives of various kinds play out in the real world

35 Financial Challenge! 2012 David M. Gaba, M.D. e.g. GSC

36 The Integrated Simulation Vision for Healthcare

37 The Simulation Vision Is a (many) DecadeS-long Proposition The Vision is of training that is: - Comprehensive & Integrated - Continuous for individuals, teams, work units - Coupled with performance assessment - Over an entire career; embedded in work processes

38 (Simulation) Training Must Be For a Lifetime (cumulative effect) Career-long combination of modalities as individuals & teams, repeatedly cycling through: - Didactics & seminars - On-screen simulators & virtual worlds - Courses in dedicated sim center - In-situ simulations & drills

39 For Healthcare Professionals Retirement or Death is the Only Escape from Simulation!

40 Simulation is a Key Enabling Technique for Quality, Safety, Efficiency Not a Fad Society for Simulation in Healthcare Membership

41 2750 International Meeting on Simulation in Healthcare Attendance 2012 David M. Gaba, M.D

42 SSH 501c3 professional society 3,500+ members

43 501c6 trade organization

44 International Nursing Association for Clinical Simulation and Learning

45 What is the Evidence? Zeltser MV, Nash DB Am J Med Qual, 2010; 25: 13-23

46 {Incidentally} What is the Evidence for Simulation in Commercial Aviation? There is mandatory yearly training & checking of flying performance - Studies can be grafted onto these activities Yet, nothing like Level 1A evidence that it saves planes or lives No randomized trials; they would be unethical to conduct -- pilots are 1 st ones at the scene of an accident

47 Utstein-style Research Agenda Conference; June, David M. Gaba, M.D. (Issenberg, Ringsted, Østergaard, Dieckmann, Simul Healtc, 2011; 6: ) Experts conference - Funded by Laerdal Foundation - Convened by SESAM/SSH -20 participants - From Europe & North America 4 working groups identified key topics - research questions articulated for each June 11

48 SSH Held a public Research Summit just prior to IMSH David M. Gaba, M.D. Methodology of NIH State of Sci Conf Open to public (reg fee to cover food) 10 Working Groups each developed review/position paper Each plenary then held separate breakout groups Breakout info used to modify paper 11 Monographs appeared in August SiH supplement Aug 11

49 Research Summit: Highlights of Presentations & Discussion Evidence base is small in nearly all areas Effect of simulation on skills & tasks has best evidence base (but still imperfect) Design of simulators should leverage integrated system design processes Research USING simulation to study human performance is powerful but still underrepresented

50 Research Summit: Highlights of Presentations & Discussion Simulation is powerful technique for performance assessment - Metrics & psychometrics still require more study - But: Unique window on performance - Can already be used for even high- stakes exams Debriefing is key technique but little evidence on what works best, when, how

51 Research Summit: Highlights of Presentations & Discussion 2012 David M. Gaba, M.D. Need for more theory-based research & study of fundamentals Need to study systematic variations around standard approaches Translational research paradigm applies to simulation (more in this talk later) Simulation research should aim to - Create systematic programs of work - Study care processes & pt. outcomes

52 Translational Research (thanks to Bill McGahie) 2012 David M. Gaba, M.D. Translational research: from {laboratory} bench to {clinical} bedside Everyone agrees that some adaptation is needed for education research Many different versions of the translational research paradigm have been articulated

53 Translational Research Levels Simulation Education Research McGahie et al; Gaba {this talk} 1 Performance during simulation 2 Performance during clinical care 3 Outcomes in patients (efficacy) 3 Cost-effectiveness in patients (cost-efficacy) 4 Dissemination (can it be done by others?) 5 Adoption (will others actually use it?) 6 Population health impact (if they do, what impact will it actually make?)

54 Measuring Intermediate (T0, T1) Variables Fair to good measures of learning at least knows, knows how Modest proof of shows how in simulation (T1 but plagued by difficulty in providing equally sim-savvy control group) A few studies show improved clinical performance or outcome (T2 or T3) but VERY hard to do this research

55 T3 Outcome Measurement is Tractable When: Simulation intervention is circumscribed; AND Outcome is easily measured; AND Outcome is moderately common Example: Infections & complications after CVC insertion

56 T3 Outcome Measurement is Difficult When Event is rare Outcome is subtle & hard to measure Behavior/skill is complex Intervention is complex (e.g. CRM sims) Many confounds between intervention & outcome

57 The Pharmaceutical Analogy for Simulation: A Policy Perspective Who would study a drug by: - Using a low dose of the study drug - Dosing haphazardly to only a few subjects - Not repeating treatment as necessary - Ignoring any exacerbating factors - Using only a single modality - Following subjects for only a short time (Gaba D: Sim Healthc; 2010, 5:5-7) And then expect a major change in outcome??

58 Simulation Interventions Have Been Limited Infrequent Often low-intensity curricula Little reinforcement in real work No coupling to performance assessment In only a few disciplines/domains Small studies & short time horizons

59 Real Test of Simulation Needs a Long Time Horizon Current studies chip away at small questions (this is good work, but.) The REAL question is: Does simulation improve quality when there is: Long-term adoption Comprehensive, integrated model Career-long Training & assessment Evaluated over long time horizon

60 DRIVERS Professions Liability insurers HC Payers Regulators, accreditors, government THE PUBLIC The Ultimate Driver!

61 Public is Ultimate Driver How Best To Engage the Public? Does the public really care? - Historically, public more interested in access to & cost of care than in quality - Everyone wants to save money on everybody else s healthcare but not on their own (corollary to Wildavsky s Law) - How do we activate public support without scaring them?

62 Why Wait?...no industry in which human lives depend on the skilled performance of responsible operators has waited for unequivocal proof of the benefits of simulation before embracing it... Neither should anesthesiology {healthcare} (Gaba, Anesthesiology 76: , 1992) kills

63 Bottom Line Lesson Save a Life Just Do It! And whoever saves a life, it is as though he had saved all mankind (appearing in various forms in the Talmud, Sanhedrin 4:5 and the Quran 5:32)

64

65 On-Screen Simulators 2012 David M. Gaba, M.D.

66 Online Virtual Worlds Innovation in Learning s CliniSpace

67 Food is an Important Part-task Trainer

68 Part-task Simulation Training for Laparoscopic Surgery 2012 David M. Gaba, M.D.

69 Part-Task Simulation in Cardiac Surgery 2012 David M. Gaba, M.D.

70 Endovascular Simulation 2012 David M. Gaba, M.D.

71 Virtual Reality & Mixed Reality Mixed Reality Simulation Mini-CAVE

72 Mannequin-based Simulation

73 Development of Mannequin-based Simulation at Stanford CASE 0.5 Pre-Pre-Prototype, May, 1986

74 CASE 1.2 circa David M. Gaba, M.D.

75 CASE 1.3, 1991 CASE 2.0, 1991

76 Early Simulation Center 2012 David M. Gaba, M.D.

77 One kind of current portable simulator 2012 David M. Gaba, M.D.

78

79

80

81 Hundreds of Simulation Centers & Thousands of Jobs Have Been Created

82 (Simulation) Training Must Be For a Lifetime (cumulative effect) Career-long combination of modalities as individuals & teams, repeatedly cycling through: - Didactics & seminars - On-screen simulators & virtual worlds - Courses in dedicated sim center - In-situ simulations & drills

83 Real Test of Simulation in Healthcare Needs a Long Time Horizon Current studies chip away at small questions (this is good work, but.) The REAL question is: Does simulation improve quality when there is: Long-term adoption Comprehensive, integrated model Career-long Training & assessment Evaluated over long time horizon

84 David M. Gaba, M.D.

85 Decadal Survey 2012 David M. Gaba, M.D.

86

87 Technology & Curricula 2012 David M. Gaba, M.D.

88 IMPLEMENTORS Certifying Boards Hospitals & Networks Sim Ctrs & Societies

89

90 Lesson #9a: Perfect Reality Isn t Always Necessary Lower fidelity simulations often equally effective, matching type of reality to training needs Even stories/books/movies are very engaging Experienced people fill in the gaps; the inexperienced may be blissfully ignorant