John C' Messenger, MD, FACC

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Simulation Training to Improve Heart Attack Care
for Rural Hospitals

• John C. Messenger, MD, FACC
• Associate Professor of Medicine
• Division of Cardiology
• Director, Cardiac Catheterization Laboratories
• University of Colorado Denver

November 5th, 2008
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Background

• Multiple therapies have been demonstrated to
  improve survival in patients suffering a heart
  attack--acute myocardial infarction (AMI).
• Published guidelines, endorsed by multiple
  medical societies, are now update almost yearly.
• Despite this, the rates of guideline-recommended
  treatment adherence for AMI care are suboptimal
  in many healthcare settings
• Rates lower in rural hospitals versus urban
• Effective dissemination and education of rural
  providers may play a role in this.

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Background

• CRUSADE Registry Data
• Association between hospital processes of care
  and outcomes among patients with AMI
• Better adherence to guideline-based treatments
  for heart attack patients ? Better Clinical
  outcomes

Peterson ED et al. JAMA 2006 295(16)1912-20.
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Why a Rural Hospital Setting?

• Rural hospitals have not been specifically
  targeted in recent national quality campaigns
• No mandatory reporting requirements for AMI
  quality measures
• Care teams appear to differ from urban hospitals
• Low volume AMI centers

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Rural Health Care and AMI

• Acute Myocardial Infarction
• Small Numberslimited opportunities to care for
  these patients
• 3 of pts were discharged home from the ED
  despite a final diagnosis of MI in rural
  hospitals
• No mandatory QI programs for AMI care
• Unknown which quality improvement methods work
  best for AMI care in the rural setting
• Unknown which educational programs are effective

Westfall JM et al. Ann Fam Med 20064153-158
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How do healthcare providers learn about changes
in care?

• Read journals with updated scientific statements
• Throw-away magazines on medical topics
• Attend annual or semi-annual meetings of
  professional societies with didactic lectures
• E-mails sent with links to educational websites
• Local continuing education programs
• Lunch or dinner programs with speakers
• Word of mouth through practices/hospitals

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Human Learning Level of Interactivity
Retention Teach Others 90 Collaborative
Simulations Learn By Doing 75 Simulations Discuss
ion Groups 50 Web Seminars, IM,
chat Demonstration 30 Animation Audio
Visual 20 PowerPoint Slides Lecture 5 Streaming
media Source Andersen Consulting
Why Use Simulations?

• Interaction is associated with learning
  achievement and retention of knowledge
• Participants learned faster and had better
  attitudes when they used an interactive
  instructional environment

Najjar, L. J. (1998). Principles of educational
multimedia user interface design. Human Factors,
40(2), 311-323.
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Pilot of a novel educational program

• Use medical simulation as a platform for
  education in rural hospitals
• Embed an up-to-date didactic curriculum
• Create a realistic setting
• Exposure to rare events
• Team training
• Cover the spectrum of care
• Create a safe environment to practice and teach
• Take education to rural hospitals

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Medical Simulation

• Training tools developed to imitate
• Anatomic regions
• Clinical tasks
• Real patients
• Real-life circumstances in which medical care is
  rendered

Issenberg SB and Scalese RJ. Persp Biol Med,
(51)131-46, 2008
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Spectrum of Simulations
Computerized Case Scenarios
Case Scenarios with role playing
VR Surgical Simulations MIST-VR, ES3, GI Mentor,
etc
High-Fidelity Endovascular Simulators
Flight Simulators for Airline Industry
Programmed Patient Training
Mannequin based Simulation SimMan (Laerdal) or
METI HPS
Surgical Box Trainer
Anesthesia OR Simulations
Lower Cost Higher Cost
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Recommendations from IOM

• Use simulators to ensure that clinical training
  is safe for patients
• Develop simulators for use in skills assessment
• Use simulation technology to improve individual
  and team performance through interdisciplinary
  team training
• Use simulation for problem solving and recovery
  from problems crisis management

To Err is Human Building a Safer Health System,
Institute of Medicine, Committee on Quality,
National Academy Press, 1999
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Features and Uses of Medical Simulations That
Lead to Most Effective Learning

• Feedback
• Repetitive Practice
• Range of Difficulty
• Multiple learning strategies
• Clinical variation

• Controlled environment
• Individualized learning
• Defined outcomes and benchmarks
• Simulator validity and realism
• Curricular integration

Best Evidence Medical Education (BEME)
Collaboration Issenberg SB et al. Med Teach
27(1)10-28, 2005
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Goal of Rural Hospital Simulation Project

• Implement a novel training program aimed at
  improving adherence rates to guideline-recommended
  treatment of AMI in rural hospitals in order to
  improve clinical outcomes.
• Incorporate most recent guidelines
• Directed at appropriate levels for EMS, Nursing,
  Physicians
• Encourage team training as it really occurs in
  the management of AMI
• Provide for interaction and practice
• Incorporate immediate and summative feedback on
  performance
• Take education and training to rural providers to
  maximize benefit

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Project Objectives

• Evaluate acceptance and effectiveness of a
  simulation-based educational program
• Focus on recognition and management of AMI
  patients presenting to rural hospitals
• Assess the state of AMI care in rural hospitals
  in Colorado before and after simulation training

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Our Team

• Multidisciplinary group
• University of Colorado Denver
• Cardiologists
• Family Medicine
• Rural Health Nursing
• Colorado Foundation for Medical Care
• Medical Simulation Corporation
• Funded by AHRQ

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Target Audience

• Rural Healthcare Providers
• Physicians
• Nurse practitioners
• Physician assistants
• Nurses
• ER technicians
• First responders/EMS

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Rural and Critical Access Hospitals in Colorado
100 miles
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Project Outline

• Simulation-based training
• On-site training with physicians from UCD
• Formal didactic curricula using simulation
• Recognition of AMI
• Guideline-based treatment of AMI
• Recognition of life-threatening complications of
  AMI
• Focus on core quality measures and best
  practices
• Pre and Post training assessment of AMI
  management
• Survey of participants regarding utility of
  simulation training
• Retrospective and prospective chart review of AMI
  patients at participating hospitals

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Simulation Training

• Use of SimMan, with four AMI scenarios
• Touch screen interface with introduction to the
  simulator by the proctor
• Proctor records orders/instructions
• Team training with 3-5 participants per group
• MD, RN, EMS

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Components of the Scenarios

• Brief introduction to each case on computer
• Patient can be interviewed and examined by
  participants
• Continuous heart rhythm and vital sign monitoring
• Labs, X-ray, EKGs available for interpretation
  by participants
• All treatments recorded, with pharmacology
  algorithms built in to simulation
• Simulated adverse events occur in each case
  requiring appropriate treatment

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Example of Simulated Case
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Simulation Implementation
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Components of the Simulation Training Program

• Each scenario with 4-5 post-simulation questions
• guideline recommended care
• risk assessment and reperfusion therapy
• Expert feedback during simulations provided by
  faculty during and after each case
• Following the simulation training, review of
  didactic curriculum on updated AMI management
  guidelines for 2008 performed
• Post training assessment of the simulation
  training program by participants

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Participants in Simulation Training Program
95 healthcare professionals at 5 rural hospitals
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Healthcare Provider Evaluation of Simulation
Training

• Proportion
• Strongly Agree or Agree
• 98
• 99
• 98
• 98

• Proportion Strongly Agree
• 85
• 86
• 65
• 87

• Questions
• Simulated cases realistic and engaging
• Requires critical thinking skills
• Using this system confidence and skills can be
  improved
• Useful for on-site training of healthcare
  providers

n85 respondents
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Performance on case-based questions
Overall correct
Range

• Case 1
• Case 2
• Case 3
• Case 4

• 95
• 79
• 90
• 100

• 75-100
• 40-100
• 50-100
• 100

Scores from 18 groups at 5 hospitals
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Variability in Performance on case-based questions
Scores from 18 groups at 5 hospitals
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Ongoing Research Efforts

• Determination of quality of care for AMI patients
  at the participating rural hospitals
• Baseline In the period from 1/2007 to 12/2007
• Following Simulation Training From
  7/2008-6/2009.
• Chart abstraction by CFMC into the ACTION
  Registry (Duke Clinical Research Institute)
• Allow for benchmarking of AMI care compared to
  hospitals participating in ACTION.

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Challenges Encountered

• Despite using a commercially available simulator,
  development time was longer than anticipated.
• While many hospitals were eager to participate,
  the chart abstraction component of this project
  limited many due to limited staffing resources
• Tailoring the evidence based guidelines to all
  levels was more difficult than expected.
• Coordination of training at each hospital took
  more effort than expected.

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Lessons Learned

• The actual delivery of on-site rural healthcare
  training was easier than anticipated
• Having on-site faculty to discuss AMI care was
  well received
• Partnering with CFMC (that had pre-existing
  relationships with these hospitals) enabled this
  project
• Provision of CME and CEU credit hours resulted in
  significant participation at each site

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Conclusion

• Use of a novel simulation based training program
  focusing on AMI care in rural hospitals was felt
  to
• Be realistic and engaging
• Require critical thinking skills for AMI care
• Improve confidence and skills in AMI care
• Useful for on-site training
• Education was easily delivered on-site to a large
  number of participants
• Accepted by physicians, nurses and EMS
• Evaluation of the impact of simulation on
  guideline-based AMI care is ongoing

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Collaborators on this project

• University of Colorado Denver
• Jack Westfall MD, MPH
• Andrew Klein MD
• John Rumsfeld MD, PhD
• Fred Masoudi MD, MSPH
• John Carroll MD
• Michael Kim, MD
• Cathy Jaynes RN, PhD

• Medical Simulation Co.
• Amy Ketron
• Shannon Gettings
• Colorado Foundation for Medical Care
• Deb Chromik
• Niki Hyde
• Nancy Borgstadt

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Questions/Comments