Simulation and the Family Medicine Physician: Current and future applications for technical skills training

Simulation and the Family Medicine Physician: Current and future applications for technical skills training Annual International Family Practice Congress

November 5, 2015

Deborah Rooney PhD

MEDICAL SCHOOL UNIVERSITY OF MICHIGAN

Copyright 2015. All Rights Reserved.

Disclosures and conflicts of interest

•  None (yok)

My Background

•  Medical education since 1991

•  Nine years in surgical education

•  PhD in Educational Psychology

•  Director of Education and Research, Clinical Simulation Center, University of Michigan (UMCSC)

UM Clinical Simulation Center (UMCSC)

2315 2314 2305

UMCSC Spaces

UMCSC Utilization

Today’s talk: Simulation-based education

o  Brief history of developments that influenced simulation

Simülasyonu etkileyen gelişmelerin kısa bir tarihçesi

o  Examples of simulation-based training for technical skills targeted toward Family Medicine

Teknik beceriler için gerekli olan güncel simülasyon bazlı eğitim

o  Projected trends in simulation-based training for the family medicine physician

Simülasyon temelli eğitimde öngörülen akımlar

Simulation-based education is not new

Sushruta, 2600 years ago Used specific simulation models for procedural simulation;

•  Gourds, fruit, clay pots, leather pouch full of “slime,” mud, or water, bamboo, wax on wood

•  Included full size patient simulator for splinting and ligature •  Suture training on the stem of a lotus lily, or cloth

Simulation-based education is not new

Simulasyon bazlı eğitim yeni değil

n = 2

n = 690

History of Simulation-based Education

1973 Dr. Gordon introduces “Harvey”


1970s Standardized Pts

History of Simulation-based Education 1973 “Harvey”

1980-90s Computers


1970s Std Pts

1990s Virtual Reality


1970s Std Pts

1980s Computers

1973 “Harvey”

1970s Std Pts


1980s Computers

1990s VR

1998 Standards

2000 Error

1973 “Harvey”

1970s Std Pts


1980s Computers

1990s VR

1998 Standards

Development & refinement of best practices •  Invention and proof of concept of specific

simulators, skills curricula

•  Development of practical tools to support learning and assessment in complex settings

•  Application of educational theories

History of SBE* for technical skills: 2000 to present

*SBE= Simulation-based Education

Educational Theory and Technical Skills: Bloom

Bloom, based on Dave, R. (1967). Psychomotor domain. Berlin: International Conference of Educational Testing.

Higher order psychomotor skills

Lower order psychomotor skills

Watch instructor and repeat (copy)

Complete task with verbal instruction

Combine learned skills to meet novel requirements

Apply automatic strategies

Perform with expertise without assistance

Naturalization

Articulation

Precision

Manipulation

Imitation

GOAL

Freq

uenc

y

Urgency (risk)

urgency frequency

urgency frequency

(CVC, critical care)

Current Trends: technical skills training

( PE, IV)

Address Gap

Impact Pt Care

Value ?

Current Trends: technical skills training

•  M2 (second year medical students), n=12

•  Technical skills training prior to clinical experience; ü Central line (CVC) placements ü Thoracentesis ü Lumbar puncture

Kelley S, et al. Impacts of Electives in Family Medicine on Preclinical Medical Students. Society of Teachers of Family Medicine 2015 Conference on Medical Student Education.

Addressing gaps: SBE preclinical training

Training •  3 x 2-hour sessions

•  Lecture followed by hands-on practice

•  2-3 preceptors acted as coaches Assessment

•  Before, after, and 6-month follow-up •  Knowledge

•  Attitudes related to Family Medicine

•  Skills test after course and 6-month follow-up Kelley S, et al. Impacts of Electives in Family Medicine on Preclinical Medical Students. Society of Teachers of Family Medicine 2015 Conference on Medical Student Education.

Addressing gaps: SBE preclinical training

Knowledge Test •  9 item •  MCQ

Topics •  Contra/inidicatations •  Anatomy

Preclinical training: assessment


SBE preclinical training: improves knowledge

Knowledge Knowledge Mean Difference

P (two-tailed)

Pre-course Post-course 1.18 0.007

Pre-course Follow-up 1.17 0.012 Post-

course Follow-up 0.18 0.34 Kelley S, et al. Impacts of Electives in Family Medicine on Preclinical Medical Students. Society of Teachers of Family Medicine 2015 Conference on Medical Student Education.

Change in knowledge test scores

Skills Test •  Time •  Needle redirects (pokes) •  Ordered steps

Preclinical training: assessment


Steps = Insert spinal needle with stylet in place -> Check opening pressure -> Obtain spinal fluid in tube -> Replace stylet -> Remove needle

Example Skills Test: Lumbar puncture

SBE preclinical training: skills assessment


1 2 3 4 5

SBE preclinical training: improves skills


Performing the skills-based and hands-on procedures as part of the course improved my; knowledge Mean 8.29 (SD 1.32)

confidence Mean 8.09 (SD 1.58)

skill Mean 8.23 (SD 1.50)

(1=strongly disagree, 10=strongly agree)

SBE Preclinical training: improves attitudes

The course improved my perception of family medicine ü  Post mean 7.23 (SD 1.48) ü  Follow-up mean 7.37 (SD 1.66) ü  p=0.62

The course has led me to reconsider (or has reinforced my interest in) family medicine as possible career option

ü  Post mean 5.54 (SD 1.66) ü  Follow-up mean 5.94 (SD 1.96) ü  p=0.22

(1=strongly disagree, 10=strongly agree)

SBE Preclinical training: improves attitudes

Simulation to attract students to family medicine

What about impact to patient care?

Ya hastaya etkisi?

∅

Improves patient outcomes: Central Venous Catheter (CVC) placement in MICU

Sim-based, mastery training central line placement skills in Medical ICU (MICU);

•  Presentation with contra/indications for CVC •  Video demonstration of CVC IJ placement •  One-on-one instructor & trainee practice with

feedback •  Pre-post training assessment

Barsuk JH, McGaghie WC, Cohen ER, O'Leary KJ, Wayne DB. Simulation based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. Crit Care Med. 2009 Oct;37(10):2697-701.

SBE improves patient outcomes: Central Venous Catheter (CVC) placement

Sim-based, mastery training central line placement skills in Medical ICU (MICU);

•  Fewer needle passes •  Fewer arterial punctures •  Fewer catheter adjustments

Barsuk JH, McGaghie WC, Cohen ER, O'Leary KJ, Wayne DB. Simulation based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. Crit Care Med. 2009 Oct;37(10):2697-701.

Cohen ER, Feinglass J, Barsuk JH, et al. Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical intensive care unit. Simul Healthc. 2010 Apr;5(2):98-102.

Follow-up research compared pre-post Catheter-Related Bloodstream Infections (CRBSI) and potential cost-savings for the hospital

-Cohen and colleagues

CVC placement in Medical Intensive Care Unit (MICU)


4.2/100 MICU CVC CRBSI/adm.

0.42/100 MICU CVC CRBSI/ adm.

SBE CVC training improved infection rates

•  Training cost ~US$110,000 ( 319,000)

•  Approximately 9.95 CRBSIs were prevented in MICU patients/ CVCs in the year after intervention

•  Each translated to US$82,000 ( 240,000) and 14 added hospital days


2M

SBE CVC training reduced costs

What about the future?

Gelecekte neler olabilir?

Simulation

System-based Trng & Assmnt

Streamlined Trng & Assmnt

Non-technical

Skills Trng & Assmnt

Projections

Simulation

System-based Trng & Assmnt


Shared

Projections

•  Increased incentives for system-level patient-safety initiatives

•  Hospital safety officials interested in incorporating simulation in quality control cycles

•  Interprofessional training is preferred

•  Prepare for new EHR

•  SBE sessions targeted provider/nurse pairs practicing delivery of maternity care

•  Triageà labor à complicationà postpartumà discharge

•  Supplement to classroom/online

Systems-based training: EHR & Maternity Care

193 individuals 64, 2-hr sessions x 4 weeks

Smith R, Hammoud M, Marzano D. (2014) University of Michigan

Results

•  100% participation

•  Reduced anxiety toward EHR

•  Operationalized knowledge

•  Fostered teamwork

•  Increased interest in SBE

36

25

23

12 5

92

OB Faculty

OB Residents

Midwives

Family Med Faculty Family Med Residents Nurses

Smith R., Hammoud M., Marzano D. (2014) University of Michigan

Systems-based training: EHR & Maternity Care

Simulation


Non-technical

skills

Authentic Trng & Assmnt

Projections

Costs associated with dedicated simulation resources

•  Space

•  Expertise

•  Time

•  Using available web-based curriculum on computer

•  Self-directed training and assessment

•  Addresses knowledge, skills, attitude

Future Training: Streamlining technical skills training with technology

Future training targeting technical skills: retinal exam

•  Originally developed for residents, soon to be adapted by medical students (n=170)

•  3 weeks to teach retinal exam skills

•  30 minutes/session = 85 teaching hours

•  Teaching commitment = 0

Future training targeting technical skills: endoscopy

Residents; •  Family medicine •  IM-Gastroenterology •  Surgery

ü Self-directed learning

ü 24 hour access

ü Built-in assessment

Simulation

Non-technical

skills


Systems-based Trng. & Assmnt

Projections

•  “Overlooked” domains

•  More complex skills (decision-making)

•  Communication and professionalism

End-of-Life (Palliative) Care

Targeted Trainees: •  2nd and 3rd year Family Medicine residents (n=30)

Learning Goals: •  Improve residents’ knowledge about symptoms

associated with dying process •  Improve residents’ ability to treat symptoms •  Improve residents’ communication skills with patient/

families

End-of-Life Care Program: logistics

Intervention •  Presentation •  Clinical simulation •  10 x 2 hour sessions

Pre-post assessment •  Knowledge •  Communication (social worker acting as family member)

•  Comfort

Chiang C, Kelley S, & Petersen, K. Teaching End-of-Life Care to Resident Physicians Using Clinical Simulation. Healthcare Professional education Day, University of Michigan, 2015

Communication Skills: third-year medical students in Turkey

Final thoughts

Deborah Rooney, PhD [email protected]

teşekkür ederim

Sorular ? Questions?

Health & Medicine

Simulation and the Family Medicine Physician: Current and future applications for technical skills training