1510 Bridging the Gap Presentation Dr Mark Mathieson and Dr Chris Bollen

							Bridging the Gap between Student to
       Doctor using Simulation

         Dr Mark Mathieson
          Dr Chris Bollen
    Overview of this presentation
• Set the scene- who are we?
• Why the need for sim sessions?
• What has been done?
• What has been the feedback? (videos and
  survey)
• Conclusions/comments/questions!
 The Queen Elizabeth Hospital
                  •   350 bed metropolitan hospital
                  •   Western area of Adelaide with
                      low socioeconomic
                      demographics and very
                      diverse cultural groups in the
                      local population
                  •   42 Interns (44 in 2012)
                  •   over 80% from international
                      backgrounds (either
                      International Graduates or
                      International students
                      graduating from universities all
                      over Australia)
                  •   Specialties include Aged Care,
                      Acute Medical Unit, Palliative
                      care
                  •   10 interns per year rotate to
                      general practice (increase to
                      20 in 2012)

Who are we?
 TQEH Clinical Education Team
 The simulation education team is
• a ward nurse (playing a junior role),
• a sim man operator ( clinical skills
coordinator)
• and doctor ( Director of GP Training)
•Dedicated rooms for Sim Man, operators
and briefing/feedback sessions
        Why the Need?
   Expectations Versus Reality
• Junior Doctor- PGY 1
   – Colleagues, nurses and community expect action and
     knowledge of doctors in emergency situations
   – The system expects you to perform BLS/ALS
     confidently plus assess unwell patients

• Medical school experiences of clinical scenarios are
  variable within the same State and Interstate
• There is a gap between theoretical knowledge and
  practical application
• Orientation of interns in 5 days is overload
How many of you have felt like this?
 Why use Simulation Training ?
• All training is valuable?
• All doctors need to be trained-lifelong
  learners
• Refreshers required
• Individual experiences are variable
• Practice less common scenarios and
  common scenarios not well performed
• Performance enhanced by reflection in
  non-threatening environment
         Missing in daily action!
• Feedback on performance?
• Takeover by senior staff
• Performance under stress
• Mistakes = poor outcome/delays in
  treatment/patient deaths/loss of confidence
   – (1.8-4% of all deaths are 20 to medical error )
• Time pressures
• Unit culture
• Clerical vs clinical skills
      What has been done?
        The Scenarios

TOPIC                                      Number of interns
                                           completing
Anaphylaxis post antibiotics (ward)        16
Upper GI Bleed with melaena (ward)         18
Rapid Atrial Fibrillation complicating a   12
chest infection and fever in older
person (ED)
Hypoglycaemia (ED)                         13
           2011 sessions
Intern numbers
Completing 0 scenarios 1

Completing 1 scenario    37

Completing 2 scenarios   9

Completing 3 scenarios   2

Completing 4 scenarios   0
Evaluation by the Interns and Educators
The Feedback
The Interns Speak for Themselves
      The simulation sessions are of real value in my daily work.




“Close   to real life.”

“Increases my confidence when encountering similar situations on
the wards.”

“It provides, sharpens and improves the knowledge, skills and
confidence to deal with real situation in the wards from the
experience and knowledge through Sim man simulation.”
        Simulation training has improved my clinical performance.




“Depends on the number of clinical scenarios done and also the similarity of the
scenarios to actual clinical situations. Nevertheless, confidence has increased –
definitely.”

“It has improved my clinical performance related to simulated situations during
training. If exposed to more/variety of simulation of common clinical presentation, it
would provide even more improvement.”
          The feedback session was useful in understanding my
                        strengths/weaknesses.




“Good time to not only review my performance but receive other peoples views on my
interaction and also management skills - and how I can improve - definitely helpful.”

“It helps to highlight and remind me of important things that I have missed out during
the session; good reminder for real life situations.”
I was more confident participating in the second session compared to
                               the first
Participating in a simulation session with other interns would be useful.




“Feel more comfortable around fellow colleagues. Learning from our mistakes during
the simulation together, also able to learn from each other.”

“In my opinion, perhaps another session could be organised to involve several interns
at one time, to assess teamwork, communication skills and leadership skill.”

“Because on the wards there are usually other people around, so some sessions
individually and some where you need to work with others would help improve our
practice in different situations.”
What was one piece of information you have retained from the simulation
                             session(s)?

“Always examine the patient even if it is not real one :)”

1)Be Systematic

“It helps me to be prepared when dealing with the real situation.”
“Being systematic in assessment.’

2) Stay Calm

“To be calm and know when to call for assistance.”
“Staying calm and always going back to ABCs! Recognising that there is help and
learning to delegate work and go back to basics in thinking through managing a
patient.”

3) Clear Communication

“Ask for ISBAR from nurse regarding the patient.”
“The need to give clear instructions.”
“The need to convey the most relevant information in the shortest time to the other
treating staff members.”
I want to do more simulation sessions.
             Conclusion
• Simulation training helps to build JMO
  confidence
• Exposure to common emergency
  situations requiring urgent management
• Reiterates importance of good
  communication and a systematic approach
• Practice in a leadership role
• Learning from immediate feedback
             Future Directions
•   Remedial tool
•   More realistic effects in scenarios
•   Introduction in orientation
•   Team scenarios (multiple interns)
•   Videotaping for feedback session
 Special Acknowledgements
• Ann McPhedran – Clinical Skills Education
  Officer
• Natalie Hickman – Medical Education
  Officer
• Rosie Everett – Administrative Assistant
• Norm Madsen – intern
• Tharani – intern
• Jesslyn Ding – intern
• Jason – intern
                Questions?
• Plus Speaker contact details
• Dr Mark Matheson
• Dr Chris Bollen

Director GP Training TQEH
chris.bollen@health.sa.gov.au
Clinical Skills Education Officer - Ann McPhedran
Ann.McPhedran@health.sa.gov.au
                            References
Tallentire VR, Smith SE, Skinner J, Connor HS. Understanding the behaviour of newly
qualified doctors in acute care contexts. Med Educ. 2011. 45(10): 995-1005

Hutton IA, Kenealy H, Wong C. Using simulation models to teach junior doctors how to
insert chest tubes: a brief and effective teaching module. Intern Med J. 2008;38 (12):
887-91.

Crochet P, Aggarwal R, Dubb SS, Ziprin P, Rajaretnam N, Grantcharov T, Ericsson KA,
Darzi A. Deliberate practice on a virtual reality laparoscopic simulator enhances the
quality of surgical technical skills. Ann Surg. 2011 Jun;253(6):1216-22.

Ruesseler M, Weinlich M, Müller MP, Byhahn C, Marzi I, Walcher F., Simulation training
improves ability to manage medical emergencies. Emerg Med J. 2010 Oct;27(10):734-
8.

Frengley RW, Weller J, Weller JM, Torrie J, Dzendrowskyj P, Yee B, Paul AM, Shulruf B
Henderson KM. The effect of a simulation-based training intervention on the
performance of established critical care unit teams. Crit Care Med. 2011 Jul 14.
       How stressful did you find the simulation session?




In your opinion, what would be a beneficial number of sessions to
                 complete during the intern year?
The introductory simulation video was useful in helping me prepare for
                             the scenario.




“Very informative about expectation in the session.”
“Gave me a better idea of what to expect although it is a lot more different when being
in the scenario.”
“It gives a background understanding of what is to be expected from the training.”
       Does the simulation training require changes to be made in
                              presentation?




“Liaise with intern in regard to appointment date and time because workloads vary
daily. it would be heavy while the ward work has not been finished and still need to
devote 30 min. without flexibility.”
“May be more practical if you could talk to sim man a bit more, but I understand that
this may not be feasible. Overall very good.”
Does the simulation training require changes to be made in the
                      feedback method?




   Have you had a second session of simulation training?
 Any other additional comment or feedback regarding clinical skills or
                        simulation sessions?

“As many sessions as possible, including in the orientation week. In my opinion, the
simulation session was the best skills session we have had this year.”

“A final Team Simulation session might be interesting. With a team leader, airway,
circulation and Defib/Drug person.”

“It may be beneficial not only for interns, but to develop our skills as an RMO to have
these simulation sessions for RMOs not for the sake of management skills (although it
would be beneficial to revisit certain scenarios) -but more so for RMOs to learn how to
support interns, to teach and also both intern and RMO learn teamwork effort - which I
believe if cultivated, would help with better patient management.”

“Keep it up. Enjoyed it!”