Application of simulation in anesthesia Application of simulation in anesthesia

Patient Safety Center of Inquiry Patient Safety Center of Inquiry at VA Palo Alto HCSat VA Palo Alto HCS

© 2000 David M. Gaba, M.D.© 2000 David M. Gaba, M.D.

• David M. Gaba, M.D.David M. Gaba, M.D.

- Director, Patient Safety Center of Inquiry Director, Patient Safety Center of Inquiry at VA Palo Alto HCSat VA Palo Alto HCS

- Professor of Anesthesia, Stanford Professor of Anesthesia, Stanford University School of MedicineUniversity School of Medicine

Applications of Simulation in AnesthesiologyApplications of Simulation in Anesthesiology



Why Use Patient Simulation?Why Use Patient Simulation?

• Regardless of the application, there is Regardless of the application, there is nevernever a a riskrisk to a patient to a patient

• Simulators allow the presentation at will of a Simulators allow the presentation at will of a wide variety of scenarios, wide variety of scenarios, including uncommon including uncommon but critical eventsbut critical events

• The underlying (medical) causes of each The underlying (medical) causes of each situation are knownsituation are known




• The same eventsThe same events can be presented to different can be presented to different clinicians or teamsclinicians or teams

• Errors can be allowed to occurErrors can be allowed to occur and play-out that in a and play-out that in a real patient would require immediate intervention by real patient would require immediate intervention by the investigator/instructorthe investigator/instructor




• Clinicians can be required to interact with actual medical equipment and Clinicians can be required to interact with actual medical equipment and a variety of clinical personnel a variety of clinical personnel (and personalities)(and personalities)

• Intensive and archival recording of clinician performance is facilitated, Intensive and archival recording of clinician performance is facilitated, e.g.e.g.

- Multiple video views and audioMultiple video views and audio

- ECG, EEGECG, EEG



Diverse Applications of Diverse Applications of Patient Simulation in AnesthesiologyPatient Simulation in Anesthesiology

• EducationEducation

• TrainingTraining

• ResearchResearch

• Risk management and public relationsRisk management and public relations

• Performance Assessment (covered later)Performance Assessment (covered later)



Distinction Between Distinction Between “Education” and “Training”“Education” and “Training”

• EducationEducation

- The goal is to improve The goal is to improve knowledgeknowledge and conceptual and conceptual understandingunderstanding

• TrainingTraining

- The goal is to improve the The goal is to improve the performanceperformance of tasks or functions of tasks or functions



Applications of Simulators in AnesthesiologyApplications of Simulators in AnesthesiologyEDUCATIONEDUCATION

• Example Target Groups:Example Target Groups:- University studentsUniversity students- Pre-clinical medical studentsPre-clinical medical students

• Example Target Curriculum:Example Target Curriculum:- Applied physiology or pharmacologyApplied physiology or pharmacology




• Example Target Group:Example Target Group:- 2nd year medical students in “Preparation 2nd year medical students in “Preparation

for Clinical Medicine” Coursefor Clinical Medicine” Course

• Example Target Curriculum:Example Target Curriculum:- ““Introduction to the Integrated Introduction to the Integrated

Management of the Ill Patient”Management of the Ill Patient”

»Interleaving of Dx, Monitoring, RxInterleaving of Dx, Monitoring, Rx




• Example Target Group:Example Target Group:- 2nd year medical students in basic 2nd year medical students in basic

anesthesiology classroom courseanesthesiology classroom course

• Example Target Curriculum:Example Target Curriculum:- Early exposure to clinical anesthesiaEarly exposure to clinical anesthesia




• Example Target Group:Example Target Group:- Anesthesiology clerkship studentsAnesthesiology clerkship students

• Example Target Curriculum:Example Target Curriculum:- Introduction to anesthesiology Introduction to anesthesiology

»Complements OR experienceComplements OR experience




• Example Target Group:Example Target Group:- Pharmaceutical or device manufacturer Pharmaceutical or device manufacturer

representatives or executivesrepresentatives or executives

• Example Target Curricula:Example Target Curricula:- Introduction to clinical environmentsIntroduction to clinical environments

- ““Anesthesia for Amateurs” (Boston CMS)Anesthesia for Amateurs” (Boston CMS)



Applications of SimulatorsApplications of SimulatorsTRAININGTRAINING

• Training is targeted at Training is targeted at specific specific professional professional groupsgroups

• Training curricula focus on skills & behaviors Training curricula focus on skills & behaviors required for tasks on the jobrequired for tasks on the job




• Example target group Example target group - Novice anesthesia residentsNovice anesthesia residents

• Example training curriculaExample training curricula- Basic airway management skillsBasic airway management skills- Techniques for induction of anesthesiaTechniques for induction of anesthesia- Managing routine abnormalities during Managing routine abnormalities during

anesthesia; calling for helpanesthesia; calling for help




• Example target group Example target group -Experienced anesthesia residentsExperienced anesthesia residents

• Example training curriculaExample training curricula-Preparation for anesthesia specialty rotationsPreparation for anesthesia specialty rotations-Advanced airway management skillsAdvanced airway management skills-Anesthesia Crisis Resource Management (ACRM)Anesthesia Crisis Resource Management (ACRM)




• Target Population:Target Population:- Experienced Anesthesia PersonnelExperienced Anesthesia Personnel

• Example training curriculum: Example training curriculum: - Hands-on experienceHands-on experience with the use of a new with the use of a new

pharmaceutical agent (e.g. remifentanil):pharmaceutical agent (e.g. remifentanil):» Familiarity:Familiarity: Mixing, dosing, infusion set-upMixing, dosing, infusion set-up

» Safety:Safety: Recognition of and response to side-effects and Recognition of and response to side-effects and complicationscomplications




• Example target group Example target group - Non-anesthesia physicians and nursesNon-anesthesia physicians and nurses

• Example training curriculum:Example training curriculum:- Principles and practice of safe conscious sedationPrinciples and practice of safe conscious sedation

» Credentialing requirement in some institutionsCredentialing requirement in some institutions




• Example target group Example target group - Experienced Experienced anesthesiologistsanesthesiologists (CME) (CME)

• Example training curriculaExample training curricula- Advanced airway management skillsAdvanced airway management skills

- Use of new techniques or technologies Use of new techniques or technologies (e.g. (e.g. drugs, monitors)drugs, monitors)

- Anesthesia Crisis Resource Management (ACRM)Anesthesia Crisis Resource Management (ACRM)



Many Centers Run “Anesthesia Crisis Many Centers Run “Anesthesia Crisis Resource Management - ACRM” -- Why?Resource Management - ACRM” -- Why?

• Crises or challenging situations occur frequently Crises or challenging situations occur frequently

• Major gaps exist in training and performance concerning decision making and teamworkMajor gaps exist in training and performance concerning decision making and teamwork

• Patient safety may be improved by targeting these issues more than medical/technical Patient safety may be improved by targeting these issues more than medical/technical issuesissues

Crisis management behaviors have been studied extensively in aviation

Resulting in special training:

Crew Resource Management

(CRM)



Crisis ManagementCrisis Management

• Successful crisis management requires Successful crisis management requires BOTH: BOTH:

- Sound Sound technicaltechnical skills of individuals skills of individuals

- Sound crisis management Sound crisis management behaviorsbehaviors and and teamworkteamwork



Principles of Dynamic Decision Principles of Dynamic Decision Making and TeamworkMaking and Teamwork

• Cognitive Components: Cognitive Components: - Know the Environment Know the Environment

- Anticipate and PlanAnticipate and Plan

- Use All Available Information & Cross CheckUse All Available Information & Cross Check

- Prevent/Manage Fixation ErrorsPrevent/Manage Fixation Errors

- Use Cognitive AidsUse Cognitive Aids



• Team Management Components: Team Management Components:

- Leadership & followershipLeadership & followership

- CommunicationCommunication

- Distributing the workloadDistributing the workload

- Calling for help earlyCalling for help early

Principles of Dynamic Decision Principles of Dynamic Decision Making and TeamworkMaking and Teamwork



Approach of Anesthesia Crisis Resource Approach of Anesthesia Crisis Resource Management (ACRM) & Its DerivativesManagement (ACRM) & Its Derivatives

• Training “Philosophy”:Training “Philosophy”:

- Single-Discipline, Discipline-Specific: Single-Discipline, Discipline-Specific: “Training Crews to Work in Teams”“Training Crews to Work in Teams”

»Example: Training anesthesiologists to work Example: Training anesthesiologists to work with with each other & in teamswith with each other & in teams

»Ideally to be complemented with Ideally to be complemented with multidisciplinary combined team trainingmultidisciplinary combined team training



Approach of Anesthesia Crisis Resource Approach of Anesthesia Crisis Resource Management (ACRM) & DerivativesManagement (ACRM) & Derivatives

• Training “Philosophy”:Training “Philosophy”: - Primary emphasis on decision making and Primary emphasis on decision making and

teamwork behaviors but embedded within teamwork behaviors but embedded within technically challenging situationstechnically challenging situations

»Typically aim for > 60% emphasis on these Typically aim for > 60% emphasis on these behaviors, <40% on medical/technical detailsbehaviors, <40% on medical/technical details



Approach of Anesthesia Crisis Resource Approach of Anesthesia Crisis Resource Management (ACRM) & DerivativesManagement (ACRM) & Derivatives

• Training “Philosophy”:Training “Philosophy”:

- Full-day simulation-based courseFull-day simulation-based course

- Highly interactive, with high instructor-Highly interactive, with high instructor-participant ratioparticipant ratio

- Detailed debriefings after each simulationDetailed debriefings after each simulation



ACRM Simulation ScenariosACRM Simulation Scenarios

• High-fidelity (x surgery), typically 4 per session @ High-fidelity (x surgery), typically 4 per session @ 30-45 min, participants rotate roles30-45 min, participants rotate roles- Spectrum of challenging clinical situationsSpectrum of challenging clinical situations

»Equipment & environment failuresEquipment & environment failures»Clinical crisesClinical crises»““Stat” or “Crash” casesStat” or “Crash” cases

- Spectrum of challenging interpersonal situations Spectrum of challenging interpersonal situations (surgeon, nurse, patient, family)(surgeon, nurse, patient, family)

Simulation Room -- VA Palo AltoSimulation Room -- VA Palo Alto

Scenarios are challenging medically, Scenarios are challenging medically, technically, and in terms of teamworktechnically, and in terms of teamwork

A Picture of “Face Validity”A Picture of “Face Validity”

Debriefings with video allows discussion of alternatives and pros & cons of CRM behaviors & technical choices



Beyond ACRM: Beyond ACRM: Expansion “Within” & “Without”Expansion “Within” & “Without”

• ACRM derivatives for other specialtiesACRM derivatives for other specialties• Instructor trainingInstructor training• Progressive curriculumProgressive curriculum• Clinical catastropheClinical catastrophe• Combined team training Combined team training • Multiple patient simulationsMultiple patient simulations• Simulation for executive levelSimulation for executive level



Crew Resource Management (CRM) Crew Resource Management (CRM) Training Applies to Many Medical DomainsTraining Applies to Many Medical Domains

- OROR -- ICU ICU

- Emergency Dept.Emergency Dept. -- Cardiac arrest teams Cardiac arrest teams

- Delivery roomDelivery room -- Cath lab / radiology Cath lab / radiology

- Field respondersField responders -- Military medicine Military medicine

- Non-code patient emergencies (IMPES)Non-code patient emergencies (IMPES)

- InternsInterns - Medical students (intro)- Medical students (intro)

- Etc.Etc.



Applications of SimulatorsApplications of SimulatorsRESEARCHRESEARCH

• A wide variety of research on human performance in A wide variety of research on human performance in health care requires simulationhealth care requires simulation

** “Educational research” & performance assessment“Educational research” & performance assessment* Clinical techniques (e.g. pediatric sedation) * Clinical techniques (e.g. pediatric sedation) * Human machine interaction * Human machine interaction * Decision making* Decision making * AI in ICU * AI in ICU * Telementoring* Telementoring * Stress * Stress * Fatigue * Fatigue




• Simulation is a key research tool in human Simulation is a key research tool in human performance because it provides:performance because it provides:

»ReproducibilityReproducibility

»ControllabilityControllability

»CriticalityCriticality

- All in a confidential environment with no risk to All in a confidential environment with no risk to patientspatients




• Research extends well beyond anesthesiology Research extends well beyond anesthesiology and health care and well beyond medical and health care and well beyond medical investigators, e.g.investigators, e.g.- Cognitive or social psychologyCognitive or social psychology

- Biomedical engineeringBiomedical engineering

• At several centers PhDs have been awarded At several centers PhDs have been awarded based on experiments using a simulatorbased on experiments using a simulator



Applications of SimulatorsApplications of SimulatorsRISK MANAGEMENTRISK MANAGEMENT

• Appropriate simulation training Appropriate simulation training maymay REDUCE:REDUCE:

- The The frequencyfrequency of adverse clinical events of adverse clinical events

- The The impactimpact of clinical events that do occur of clinical events that do occur

- The The likelihoodlikelihood of litigation after an event of litigation after an event

- A jury’s A jury’s perceptionperception that the institution did that the institution did not take patient safety seriouslynot take patient safety seriously



Applications of SimulatorsApplications of SimulatorsPUBLIC RELATIONSPUBLIC RELATIONS

• Ongoing training & research activities Ongoing training & research activities attract considerable media attentionattract considerable media attention- Highly visual & dynamicHighly visual & dynamic

• Outreach programs are feasible, including Outreach programs are feasible, including - SchoolsSchools - Youth groups- Youth groups- MuseumsMuseums - Politicians- Politicians



Video-link with HM, Queen Elizabeth IIVideo-link with HM, Queen Elizabeth II

The video-conferencing set-upThe video-conferencing set-up

Dr. Gaba addresses Her MajestyDr. Gaba addresses Her Majesty

Dr. Donovan introduces Dr. Donovan introduces Dr. Gaba to Her MajestyDr. Gaba to Her Majesty



Key Challenges Ahead for Simulation in Key Challenges Ahead for Simulation in Anesthesiology and Health CareAnesthesiology and Health Care

• Pedagogical ChallengesPedagogical Challenges

- Integrating different types of simulation-based Integrating different types of simulation-based education & training education & training

»On-screen & mannequin; On-screen & mannequin; »Principles, technical skills, & behavioral skillsPrinciples, technical skills, & behavioral skills

- Integrating simulation-based training with Integrating simulation-based training with clinical training clinical training



Key Challenges Ahead for Simulation in Key Challenges Ahead for Simulation in Anesthesiology and Health CareAnesthesiology and Health Care

• Challenges of the ClinicalChallenges of the Clinical EnvironmentEnvironment - Principles of patient safety taught in the Principles of patient safety taught in the

simulator must be a part of the real clinical simulator must be a part of the real clinical environmentenvironment

- They must be They must be constantlyconstantly reinforcedreinforced or the or the training will be vitiatedtraining will be vitiated



Unanswered Questions About Unanswered Questions About Simulation Training and/or CRMSimulation Training and/or CRM

Each can be the topic of a multi-day seminar Each can be the topic of a multi-day seminar • Does it work?Does it work?

How effective is it? Is it “cost-effective”How effective is it? Is it “cost-effective”Who should get it and how often?Who should get it and how often?

• Can you assess performance using the simulator,Can you assess performance using the simulator, i.e. for i.e. for certification & recertificationcertification & recertification

Covered in later talkCovered in later talk



Does It Work?Does It Work?

• High face validity for this beliefHigh face validity for this belief

• We do not currently know for sureWe do not currently know for sure

• We may well We may well nevernever know for sure know for sure- Suggestive data from many sourcesSuggestive data from many sources

- Definitive experimentsDefinitive experiments may be impossible may be impossible due to logistics and costdue to logistics and cost



Obstacles to Investigating the Impact of Obstacles to Investigating the Impact of Simulator Training on PerformanceSimulator Training on Performance

• No gold standard for measuring performanceNo gold standard for measuring performance- Need to use simulation to test simulationNeed to use simulation to test simulation

• High inter- and intra- individual variability will require large cohorts High inter- and intra- individual variability will require large cohorts of subjectsof subjects

NAnesthesiologists

No additionaltraining

(Control)

Simulationexercises

(No ACRM)

ACRM-typeSimulation

Individual Simulator Testing

* Some scenarios the same as during initial testing and training,

some different

SCORINGby > 2

observersCompare

Familiarization

Individual Simulator Testing*

SCORINGby > 2

observers

Prototypical Experimental DesignChopra, et al; others

3x



A Definitive “Impact on Performance A Definitive “Impact on Performance Experiment” Will Be Very ExpensiveExperiment” Will Be Very Expensive

• The number of simulations required is very The number of simulations required is very high:high:

»Familiarization sessionsFamiliarization sessions

»Training sessionsTraining sessions

»Testing sessionsTesting sessions

• Expert evaluation of performance is expensiveExpert evaluation of performance is expensive

050

100150200250300350400450500

Req

uire

d N

per

Coh

ort

0 0.25 0.5 0.75 1 1.25 1.5

Minimum Detectable Difference / Std. Dev

at MDD/SD = 0.1, N=1944

Estimate of Required N (per cohort) for 80%

power, = 0.05

How Large Must the Cohorts Be?



Unanswered Questions Regarding Unanswered Questions Regarding Investigations of Impact on PerformanceInvestigations of Impact on Performance

• After how many simulation sessions can or should After how many simulation sessions can or should the impact be measured? the impact be measured?

- After 1 session only? After 1 session only?

»Naive to think that a single course can have a Naive to think that a single course can have a profound impactprofound impact

»In commercial aviation simulation (and In commercial aviation simulation (and CRM) is a CRM) is a career-longcareer-long endeavor endeavor



Should We Attempt to Perform Definitive Should We Attempt to Perform Definitive Studies of Simulation Impact?Studies of Simulation Impact?

• Goal: To convince the skepticsGoal: To convince the skeptics• Answer: Maybe -- if the resources are thereAnswer: Maybe -- if the resources are there• BUT… Beware of being sucked into: BUT… Beware of being sucked into:

- Under-poweredUnder-powered studies with high risk of Type II error studies with high risk of Type II error

- Studies of “one-off” simulation sessions rather than integrated long-Studies of “one-off” simulation sessions rather than integrated long-term use of simulationterm use of simulation



Bottom LineBottom Line

• ...no industry in which human lives depend ...no industry in which human lives depend on the skilled performance of responsible on the skilled performance of responsible operators has waited for unequivocal proof of operators has waited for unequivocal proof of the benefits of simulation before embracing the benefits of simulation before embracing it… Neither should anesthesiology .it… Neither should anesthesiology .

(Gaba, Anesthesiology 76:491-494, 1992)(Gaba, Anesthesiology 76:491-494, 1992)



Health & Medicine

Application of simulation in anesthesia Application of simulation in anesthesia