Applications of Simulation in Anesthesiology

Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Applications of Simulation in Anesthesiology • David M. Gaba, M.D. - Director, Patient Safety Center of Inquiry at VA Palo Alto HCS - Professor of Anesthesia, Stanford University School of Medicine Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Why Use Patient Simulation? • Regardless of the application, there is never a risk to a patient • Simulators allow the presentation at will of a wide variety of scenarios, including uncommon but critical events • The underlying (medical) causes of each situation are known Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Why Use Patient Simulation? • The same events can be presented to different clinicians or teams • Errors can be allowed to occur and play-out that in a real patient would require immediate intervention by the investigator/instructor Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Why Use Patient Simulation? • Clinicians can be required to interact with actual medical equipment and a variety of clinical personnel (and personalities) • Intensive and archival recording of clinician performance is facilitated, e.g. - Multiple video views and audio - ECG, EEG Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Diverse Applications of Patient Simulation in Anesthesiology • Education • Training • Research • Risk management and public relations • Performance Assessment (covered later) Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Distinction Between “Education” and “Training” • Education - The goal is to improve knowledge and conceptual understanding • Training - The goal is to improve the performance of tasks or functions Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Applications of Simulators in Anesthesiology EDUCATION • Example Target Groups: - University students - Pre-clinical medical students • Example Target Curriculum: - Applied physiology or pharmacology Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Applications of Simulators in Anesthesiology EDUCATION • Example Target Group: - 2nd year medical students in “Preparation for Clinical Medicine” Course • Example Target Curriculum: - “Introduction to the Integrated Management of the Ill Patient” »Interleaving of Dx, Monitoring, Rx Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Applications of Simulators in Anesthesiology EDUCATION • Example Target Group: - 2nd year medical students in basic anesthesiology classroom course • Example Target Curriculum: - Early exposure to clinical anesthesia Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Applications of Simulators in Anesthesiology EDUCATION • Example Target Group: - Anesthesiology clerkship students • Example Target Curriculum: - Introduction to anesthesiology »Complements OR experience Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Applications of Simulators in Anesthesiology EDUCATION • Example Target Group: - Pharmaceutical or device manufacturer representatives or executives • Example Target Curricula: - Introduction to clinical environments - “Anesthesia for Amateurs” (Boston CMS) Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Applications of Simulators TRAINING • Training is targeted at specific professional groups • Training curricula focus on skills & behaviors required for tasks on the job Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Applications of Simulators TRAINING • Example target group - Novice anesthesia residents • Example training curricula - Basic airway management skills - Techniques for induction of anesthesia - Managing routine abnormalities during anesthesia; calling for help Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Applications of Simulators TRAINING • Example target group -Experienced anesthesia residents • Example training curricula -Preparation for anesthesia specialty rotations -Advanced airway management skills -Anesthesia Crisis Resource Management (ACRM) Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Applications of Simulators TRAINING • Target Population: - Experienced Anesthesia Personnel • Example training curriculum: - Hands-on experience with the use of a new pharmaceutical agent (e.g. remifentanil): » Familiarity: Mixing, dosing, infusion set-up » Safety: Recognition of and response to side-effects and complications Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Applications of Simulators TRAINING • Example target group - Non-anesthesia physicians and nurses • Example training curriculum: - Principles and practice of safe conscious sedation » Credentialing requirement in some institutions Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Applications of Simulators TRAINING • Example target group - Experienced anesthesiologists (CME) • Example training curricula - Advanced airway management skills - Use of new techniques or technologies (e.g. drugs, monitors) - Anesthesia Crisis Resource Management (ACRM) Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Many Centers Run “Anesthesia Crisis Resource Management - ACRM” -- Why? • Crises or challenging situations occur frequently • Major gaps exist in training and performance concerning decision making and teamwork • Patient safety may be improved by targeting these issues more than medical/technical issues Crisis management behaviors have been studied extensively in aviation Resulting in special training: Crew Resource Management (CRM) Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Crisis Management • Successful crisis management requires BOTH: - Sound technical skills of individuals - Sound crisis management behaviors and teamwork Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Principles of Dynamic Decision Making and Teamwork • Cognitive Components: - Know the Environment - Anticipate and Plan - Use All Available Information & Cross Check - Prevent/Manage Fixation Errors - Use Cognitive Aids Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Principles of Dynamic Decision Making and Teamwork • Team Management Components: - Leadership & followership - Communication - Distributing the workload - Calling for help early Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Approach of Anesthesia Crisis Resource Management (ACRM) & Its Derivatives • Training “Philosophy”: - Single-Discipline, Discipline-Specific: “Training Crews to Work in Teams” »Example: Training anesthesiologists to work with with each other & in teams »Ideally to be complemented with multidisciplinary combined team training Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Approach of Anesthesia Crisis Resource Management (ACRM) & Derivatives • Training “Philosophy”: - Primary emphasis on decision making and teamwork behaviors but embedded within technically challenging situations »Typically aim for > 60% emphasis on these behaviors, <40% on medical/technical details Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Approach of Anesthesia Crisis Resource Management (ACRM) & Derivatives • Training “Philosophy”: - Full-day simulation-based course - Highly interactive, with high instructorparticipant ratio - Detailed debriefings after each simulation Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. ACRM Simulation Scenarios • High-fidelity (x surgery), typically 4 per session @ 30-45 min, participants rotate roles - Spectrum of challenging clinical situations »Equipment & environment failures »Clinical crises »“Stat” or “Crash” cases - Spectrum of challenging interpersonal situations (surgeon, nurse, patient, family) Simulation Room -- VA Palo Alto Scenarios are challenging medically, technically, and in terms of teamwork A Picture of “Face Validity” Debriefings with video allows discussion of alternatives and pros & cons of CRM behaviors & technical choices Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Beyond ACRM: Expansion “Within” & “Without” • ACRM derivatives for other specialties • Instructor training • Progressive curriculum • Clinical catastrophe • Combined team training • Multiple patient simulations • Simulation for executive level Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Crew Resource Management (CRM) Training Applies to Many Medical Domains - ICU - Cardiac arrest teams - Cath lab / radiology - OR - Emergency Dept. - Delivery room - Field responders - Interns - Etc. - Military medicine - Medical students (intro) - Non-code patient emergencies (IMPES) Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Applications of Simulators RESEARCH • A wide variety of research on human performance in health care requires simulation * “Educational research” & performance assessment * Clinical techniques (e.g. pediatric sedation) * Human machine interaction * Decision making * AI in ICU * Telementoring * Stress * Fatigue Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Applications of Simulators RESEARCH • Simulation is a key research tool in human performance because it provides: »Reproducibility »Controllability »Criticality - All in a confidential environment with no risk to patients Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Applications of Simulators RESEARCH • Research extends well beyond anesthesiology and health care and well beyond medical investigators, e.g. - Cognitive or social psychology - Biomedical engineering • At several centers PhDs have been awarded based on experiments using a simulator Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Applications of Simulators RISK MANAGEMENT • Appropriate simulation training may REDUCE: - The frequency of adverse clinical events - The impact of clinical events that do occur - The likelihood of litigation after an event - A jury’s perception that the institution did not take patient safety seriously Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Applications of Simulators PUBLIC RELATIONS • Ongoing training & research activities attract considerable media attention - Highly visual & dynamic • Outreach programs are feasible, including - Schools - Museums - Youth groups - Politicians Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Video-link with HM, Queen Elizabeth II The video-conferencing setup Dr. Donovan introduces Dr. Gaba to Her Majesty Dr. Gaba addresses Her Majesty Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Key Challenges Ahead for Simulation in Anesthesiology and Health Care • Pedagogical Challenges - Integrating different types of simulationbased education & training »On-screen & mannequin; »Principles, technical skills, & behavioral skills - Integrating simulation-based training with clinical training Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Key Challenges Ahead for Simulation in Anesthesiology and Health Care • Challenges of the Clinical Environment - Principles of patient safety taught in the simulator must be a part of the real clinical environment - They must be constantly reinforced or the training will be vitiated Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Unanswered Questions About Simulation Training and/or CRM Each can be the topic of a multi-day seminar • Does it work? How effective is it? Is it “cost-effective” Who should get it and how often? • Can you assess performance using the simulator, i.e. for certification & recertification Covered in later talk Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Does It Work? • High face validity for this belief • We do not currently know for sure • We may well never know for sure - Suggestive data from many sources - Definitive experiments may be impossible due to logistics and cost Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Obstacles to Investigating the Impact of Simulator Training on Performance • No gold standard for measuring performance - Need to use simulation to test simulation • High inter- and intra- individual variability will require large cohorts of subjects Anesthesiologists Familiarization Individual Simulator Testing 3x N Prototypical Experimental Design Chopra, et al; others No additional training (Control) Simulation exercises (No ACRM) ACRM-type Simulation * Some scenarios the same as during initial testing and training, some different Individual Simulator Testing* SCORING by > 2 observers Compare SCORING by > 2 observers Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. A Definitive “Impact on Performance Experiment” Will Be Very Expensive • The number of simulations required is very high: »Familiarization sessions »Training sessions »Testing sessions • Expert evaluation of performance is expensive Required N per Cohort How Large Must the Cohorts Be? at MDD/SD = 0.1, N=1944 500 450 400 350 300 250 200 150 100 50 0 Estimate of Required N (per cohort) for 80% power, a = 0.05 0 0.25 0.5 0.75 1 1.25 1.5 Minimum Detectable Difference / Std. Dev Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Unanswered Questions Regarding Investigations of Impact on Performance • After how many simulation sessions can or should the impact be measured? - After 1 session only? »Naive to think that a single course can have a profound impact »In commercial aviation simulation (and CRM) is a career-long endeavor Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Should We Attempt to Perform Definitive Studies of Simulation Impact? • Goal: To convince the skeptics • Answer: Maybe -- if the resources are there • BUT… Beware of being sucked into: - Under-powered studies with high risk of Type II error - Studies of “one-off” simulation sessions rather than integrated long-term use of simulation Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D. Bottom Line • ...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 . (Gaba, Anesthesiology 76:491-494, 1992) Patient Safety Center of Inquiry at VA Palo Alto HCS © 2000 David M. Gaba, M.D.