Clinical Simulation and Patient Safety

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Clinical Simulation and Patient Safety

• Paul Bradley
• Director of Clinical Skills
• Peninsula College of Medicine and Dentistry

Scottish Clinical Skills Network University
Campus Hamilton September 27th, 2007
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• Patient safety how big is the problem?
• So what does clinical simulation have to offer?
• How can we go about this?

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Patient safety how big is the problem?
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Why Patient Safety

• To err is human in the USA
• An organisation with a memory in the UK

Kohn LT, Corrigan JM, Donaldson MS. To err is
human building a safer health system.
Washington, DC National Academy Press
2000 Department of Health. An organisation with
a memory. London Stationery Office 2000
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The size of the problem

• 400 die/seriously injured in adverse events
  involving medical devices
• 10,000 people experienced serious adverse
  reactions to drugs
• 1,150 suicides in people with recent contact
  with mental health care
• 28,000 written complaints about clinical
  treatment in hospitals
• NHS pays 400 million a year settlement of
  clinical negligence claims
• Potential liability of around 2.4 billion
• Hospital acquired infections cost nearly 1
  billion.

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The size of the problem

• 850,000 adverse events in the UK per year
• 10 of all hospital admissions
• In the USA estimated 44,000 90,000 deaths per
  year thats equivalent to 15-30 September 11ths
• 1 million extra hospital days in USA
• 12.9 of all hospital admissions in NZ

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5th NPSA Report - 2005

• Analysis of the 1,804 serious incidents resulting
  in death.
• Reducing to 576 deaths that could be interpreted
  as potentially avoidable and related to patient
  safety issues.
• 425 occurred in acute/general hospitals.
• 71 related to a range of diagnostic errors
• 64 related to patient unrecognised deterioration
• 43 involved a problem with resuscitation after
  cardiac arrest.

National Patient Safety Agency. The fifth report
from the Patient Safety Observatory - Safer care
for the acutely ill patient learning from
serious incidents. London 2007.
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Recommendations - deterioration

• Better recognition of patients at risk of, or who
  have deteriorated
• Appropriate monitoring of vital signs
• Accurate interpretation of clinical findings
• Calling for help early and ensuring it arrives
• Training and skills development
• Ensuring appropriate drugs and equipment are
  available

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Recommendation - resuscitation

• Improving communication
• Better situation analysis
• Regularly risk assessing resuscitation processes
  locally
• Training and skills development
• Ensuring appropriate equipment is available

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These are not new concerns and, in spite of much
high quality work over many years, still more
energy and commitment towards improvement is
needed.
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It isnt history
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So what does clinical simulation have to offer?
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Simulation
The technique of imitating the behaviour of some
situation or process (whether economic, military,
mechanical, etc.) by means of a suitably
analogous situation or apparatus, especially for
the purpose of study or personnel training.
The Oxford English Dictionary Online 2006
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Simulation in medical education is not new
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Too dangerous

• Chess 6th Century
• War games
• Weapons simulations

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Too costly

• Space exploration
• Mission training

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Too important

• Civil and military aviation
• Nuclear power industry

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Simulation in skills education
Part task trainers
Haptic/VR simulators
Simulated patients and role plays
Hi- and intermediate fidelity simulation
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The movements in modern medical simulation
1950 1960 1970 1980 1990 2000
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The movements promoting modern medical simulation
Åsmund Lærdal Resuscitation movement
1950 1960 1970 1980 1990 2000
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The movements promoting modern medical simulation
Stephen Abrahamson Sim One
1950 1960 1970 1980 1990 2000
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Sim-One
It breathes has a heart beat, temporal and
carotid pulse (all synchronized), and blood
pressure opens and closes its mouth blinks its
eyes and responds to four intravenously
administered drugs and two gases (oxygen and
nitrous oxide) administered through mask or tube.
The physiologic responses to what is done to him
are in real time and occur automatically as
part of a computer program.
Abrahamson S, Denson JS, Wolf RM. Effectiveness
of a simulator in training anesthesiology
residents. Qual Saf Health Care
200413(5)395-397.
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The movements promoting modern medical simulation
Patient simulator
1950 1960 1970 1980 1990 2000
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The movements promoting modern medical simulation
1950 1960 1970 1980 1990 2000
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Features of modern simulators

• Complete human body
• Capable of speech
• Complete integrated physiology/pharmacology model
  (high fidelity)
• Open/close mouth
• Trismus
• Realistic airway
• Pharyngeal oedema
• Respiratory chest (? abdominal wall) movements

• Appropriate anatomical landmarks
• Lungs capable of spontaneous, assisted or
  mechanical ventilation
• ? consumption of O2, exhalation of CO2 and uptake
  of anaesthetic gases
• Tongue swelling
• Difficult airways
• Synchronised breath sounds
• Bowel sounds

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Features of modern simulators

• Monitoring
• Pulses palpable
• Synchronised with heart sounds
• Blood pressure measurable
• Variety of physiological outputs to standard
  monitors e.g.
• CVP
• Temperature
• Pulse oximetry

• Procedures
• Defibrillation
• Pneumothorax decompression
• Cardioversion
• Cricothyroidotomy
• External pacing
• Pericardiocentesis
• Venepuncture
• Chest drain insertion
• Cannulation
• Intramuscular injection
• Urinary catheterisation

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The movements promoting modern medical simulation

• 40.2 Skills objectives
• basic clinical method
• obtain and record a comprehensive history
• perform a complete examination and assess mental
  state
• interpret the findings obtained from the history
  and examination
• reach a provisional assessment of patients
  problems and formulate with them plans for
  investigation and management
• basic clinical procedures including
• Basic and Advanced Life Support
• venepuncture
• insertion of an intravenous line

1950 1960 1970 1980 1990 2000
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The movements promoting modern medical simulation
Sim-One
1950 1960 1970 1980 1990 2000
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BEME systematic review

• Providing feedback
• Allowing repetitive practice
• Integrating within curriculum
• Providing a range of difficulties
• Being adaptable allowing multiple learning
  strategies
• Providing a range of clinical scenarios
• Provides safe, supportive learning environment
• Active learning based on individualized needs
• Defined outcomes
• Simulator validity as a realistic recreation of
  complex clinical situations

Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL,
Scalese RJ. Features and uses of high-fidelity
medical simulations that lead to effective
learning a BEME systematic review. Medical
Teacher 200527(1)10-28.
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The benefits of simulation

• Risks to patients and learners are avoided
• Undesired interference is reduced
• Tasks/scenarios can be created to demand
• Skills can be practised repeatedly
• Training can be tailored to individuals
• Retention and accuracy are increased
• Transfer of training from classroom to real
  situation is enhanced
• Standards against which to evaluate student
  performance and diagnose educational needs are
  enhanced

Maran NJ, Glavin RJ. Low- to high-fidelity
simulation - a continuum of medical education?
Medical Education 200337(s1)22-28
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Potential application of simulation

• Routine learning and rehearsal of clinical and
  communication skills at all levels
• Routine basic training of individuals and teams
• Practise of complex clinical situations
• Training of teams in crisis resource management
• Rehearsal of serious and/or rare events
• Rehearsal of planned, novel or infrequent
  interventions
• Induction into new clinical environments and use
  of equipment
• Design and testing of new clinical equipment
• Performance assessment of staff at all levels
• Refresher training of staff at all levels

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Responsibilities for patient safety
and the place for clinical simulation
Patient safety
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How can we go about this?
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Building on theories of learning

• Medical education and clinical skills learning is
  a theory rich educational environment
• Behaviourism
• Constructivism
• Social constructivism
• Reflective practice
• Situated learning
• Activity theory

Bradley, P., Postlethwaite, K. (2003).
Simulation in clinical learning. Medical
Education, 37(s1), 1-5.
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Learning theories

• Theories can inform our practise
• Models of teaching and learning can be developed
  that best support our students
• Theories can be tested
• Theories can be revised

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Activity theory
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Activity Theory
Mediating artifacts
Mediating artifacts
Object 2
Object 2
Object 1
Object 1
Subject
Subject
Object 3
Rules
Community
Division of labour
Community
Division of labour
Rules
Simulator
Work in operating theatre
From Engeström Y 2001 Expansive learning at work
toward an activity theoretical reconceptualization
. Journal of Education and Work 14,2,133-156
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Research

• Evidence to date has been weak and patchy
• Much published work is descriptive or at low
  level of evaluation
• Despite this simulation has certainly established
  itself as a major educational movement
• We cannot always wait for the results of
  empirical research to address major issues
• Sound, robust research is still needed to address
  key areas

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A possible way forward

• Use multiple methods approaches
• Encompass the interpretive paradigm
• Make more targeted use of the scientific paradigm
  to capitalise upon its particular range of
  convenience
• Strive for increased theoretical clarity with
  respect to learning theories
• Together, these ideas could lead to rather
  different kinds of enquiry

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Conclusions

• Clinical simulation can enable learning of
  institutions, individuals teams
• It can play an important part in addressing
  issues of patient safety
• Has a role at all levels of seniority within and
  between professional groups
• It exists as a spectrum of educational activities
  - it is not a dichotomy of low and high fidelity,
  but a continuum
• Not just technological/computerised include
  important human interactions - may be one-to-one
  or within or between teams
• Clinical simulation can test and challenge
  systems, policies and plans
• Evidence to date tends to be of a low level
  evaluative nature, to be weak in methodology and
  to be of limited generalisability
• Robust research focussed on higher level outcomes
  is required

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paul.bradley_at_pms.ac.uk
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Responsibilities for patient safety
Patient safety
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and the place for clinical simulation
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and the place for clinical simulation
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Simulators
Don't forget - Let the learning drive the
technology