Simulation in Pediatric Health Care
Tom Kallay, MD
An 8-year-old boy presents to your office for a follow-up appointment after an asthma exacerbation. He reports feeling better while at home this morning, but on the car ride to your office his chest started “hurting,” and he began to experience shortness of breath. During his intake he appears to be in a moderate amount of distress, with evidence of tachypnea and tachycardia. His pulse oximeter reports a value of 90%. Your staff administers nebulized bronchodilator therapy and oxygen, and a call is made for paramedic transport to the nearby hospital. Within the next few minutes the staff becomes concerned that he may need emergent airway support, but you are not sure if the equipment is functioning properly since the last time it was used. The paramedics arrive and safely transport the child to a facility that provides a higher level of care. Although emergency interventions were not required during this situation, you and your staff feel that you could have been better prepared. You decide to take measures to optimize the function of your staff and office environment for the rare emergency.
1. What is simulation?
2. How does simulation apply to health care?
3. What modalities of simulation are available for medical training?
4. How does one create and deliver simulation training?
5. Why should a primary care physician use simulation?
Simulation is a powerful tool for learning. In the most general sense, simulation is a learning technique in which people or technology are used to mimic real-life encounters. These encounters are practiced in simulated conditions, and typically the learner receives performance feedback as if the learner were in the real situation.
Simulation has a long legacy of use for education and evaluation in many high-risk industries. Examples include flight simulators for pilots and astronauts, war games for military personnel, and technical operations for nuclear power personnel. Simulation provides learners of all levels an opportunity to practice and develop knowledge and skills without the threat of causing harm to individuals. Currently, high-risk industries use robust simulation programs that are embedded into the culture of training and skill maintenance. Because health care is a high-risk industry, it seems intuitive that simulation would have a place in medical training, with the purpose of improving patient safety and outcomes.
Simulation in Medicine
Simulation in medicine began in 1960 with Resusci Anne, a mannequin designed for mouth-to-mouth resuscitation training. This was a new resuscitation technique conceived by Peter Safar, MD, and James Elam, MD, in 1957, which influenced Norwegian toy-maker Asmund Laerdal to create the mannequin for practicing the principles of resuscitation. The airway could be obstructed, necessitating neck hyperextension followed by thrusting the chin forward to insufflate the lungs. An internal spring placed in the chest of the mannequin permitted the practice of cardiac compressions, and subsequently, cardiopulmonary resuscitation (CPR) training was born.
Computer-controlled mannequins were developed in 1967 at the University of Southern California. Medical educator Stephen Abrahamson, PhD, along with anesthesiologist J. Samuel Denson, MD, collaborated with a group of engineers from the Sierra Engineering and Aerojet General Corporation to create Sim One. This prototype device was a computerized, adult-size mannequin that featured breathing, heart sounds, functional pupils, and an anatomically correct airway. It was used for airway management training for anesthesia residents from the late 1960s through the 1970s, with a noted benefit of training without placing patients at risk. Ultimately, however, Sim One did not gain acceptance and the program was terminated. For the next 3 decades, simulation in medical education remained relatively dormant.
The Growth of Simulation in Medicine
…[N]o 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. —David M. Gaba, MD
The Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health System, published in the year 2000, drew attention to the perils of the health care system, highlighting the human and financial costs of medical errors. The period following the IOM report witnessed a resurgence of simulation in medicine as a response to the reinvigorated emphasis on patient safety. Government and medical institutions began to embrace simulation as a means of improving health practitioner and team performance to improve outcomes. In 2001, the Agency for Healthcare Research and Quality (AHRQ) published an analysis of patient safety practices and dedicated a chapter to the potential benefits of simulation.
With the publication of increasing evidence that simulation could be applied to patient safety, it began to find its way into the language of accreditation and certification. The Accreditation Council for Graduate Medical Education has embraced simulation as an effective training method and now mandates that simulation resources be available for programs such as anesthesia and surgery, and more programs are following suit. In 2008, Accreditation Council for Graduate Medical Education program requirements mandated having available simulation resources for 3 out of 159 residency requirements; as of today, that number has grown 10-fold, to 30.
A body of pediatrics literature demonstrating the benefits of simulation has been published. This knowledge has been used to improve skills ranging from complex resuscitations to lumbar puncture (LP) and has demonstrated applicability to inpatient and outpatient settings.
For example, the literature on pediatric outpatient emergencies shows that offices are frequently ill-equipped to manage an emergency. In 2000, the American Academy of Pediatrics Committee on Pediatric Emergency Medicine published Childhood Emergencies in the Office, Hospital, and Community: Organizing Systems of Care. This resource highlights how preparation of the staff, office environment, and community are crucial for delivering high-quality emergency care and advises that simulated mock scenarios or codes are an essential part of an office emergency preparedness plan. Currently, many resources provide the necessary tools for providing simulation education in the field of pediatrics.
Simulation is increasingly used in the health care field. In 2004, the Society for Simulation in Healthcare was established by professionals who use simulation for education, testing, and research in health care. Members now include physicians, nurses, allied health and paramedical professionals, researchers, and educators from around the globe, and the society hosts an annual meeting. Since 2006, the AHRQ has been funding simulation research as part of its safety mission. This research has expanded our knowledge on how to effectively use simulation in a variety of clinical settings. Additionally, the AHRQ in collaboration with Society for Simulation in Healthcare created the Healthcare Simulation Dictionary to provide uniform terminology and definitions for users of health care simulation. In response to demand, the medical simulation equipment industry has blossomed, and currently products that can simulate virtually any situation encountered in medicine are available. With the development of not only the technology but the technique of simulation, it has become apparent that for health care, as in other high-stakes industries, simulation has found its place.
This chapter provides a broad overview of simulation in health care—the associated terminology, available resources for health care education, and techniques for providing this mode of training.
The term simulator refers to the equipment, such as a simulated arm for venipuncture, a computerized mannequin that replicates human physiology, or a virtual reality computer with programming designed to practice laparoscopic surgery. Simulation is an educational technique described by the IOM in 2010:
The act of imitating a situation or a process through something analogous. Examples include using an actor to play a patient, a computerized mannequin to imitate the behavior of a patient, a computer program to imitate a case scenario, and an animation to mimic the spread of an infectious disease in a population.
Simulation-based medical training is a systematically designed program that provides information, demonstration, and practice- based learning activities that are supported by the concept of deliberate practice.
A simulation center is an area designed to provide some or all of the aforementioned modes of simulation. It can range in size from a 60 m2 room to a 3,000 m2 building replicating a hospital with fully equipped patient rooms, clinics, and operating rooms. Such centers provide opportunities to practice all facets of medicine, depending on the learning goals. Spaces can be fashioned to appear like an emergency department or clinic office and may be wired with cameras and microphones so that learner actions and statements can be recorded and reviewed for evaluation and feedback. Some centers may use a control room adjacent to the simulation area, separated by 1-way mirrors, that allows the facilitator to observe and control the scenario without being in the room with the learner. If high-fidelity mannequins are used, they are controlled from this room via computer, and facilitators communicate with role players in the scenario by 2-way radio. There may be conference areas for viewing live simulations and debriefing, as well as storage areas for equipment. Multidisciplinary centers provide the best opportunity for cross-training among health professionals and building camaraderie.
In situ simulation comprises simulation activities embedded in an actual clinical environment. The advantage of in situ simulation is that medical scenarios can be practiced in the working environment, thereby providing the closest approximation of reality. Such simulation is excellent for team training, because all members of the medical staff can participate. Another advantage of in situ simulation is that it provides the ability to test the working environment for conditions that can predispose a person to make an error.
For example, a prospective randomized controlled trial was performed to evaluate the effect of a simulation-based intervention designed for emergencies in the pediatric office. Thirty-nine practices were involved, with 20 in the intervention group and 19 serving as controls. The intervention involved 2 mock codes delivered by the investigators in the office (in situ), where staff responded using their own equipment and local emergency medical services. After the mock code, the investigators debriefed the staff, reviewed existing emergency equipment, and assisted with developing a resource manual designed for emergencies. A post-intervention survey was distributed 3 to 6 months later that included items on the following areas: purchase of new emergency equipment or medications; receipt or updating of basic life support, pediatric advanced life support, and advanced life support certification by staff members; and development of written protocols for emergencies. The control group received no intervention and completed the same survey.
Intervention practices were more likely than control practices to develop written office protocols (60% vs 21%; P = 0.02), and staff in intervention practices were more likely to be current on life support certifications by the time of the post-intervention survey (118 vs 54; P = 0.02). No significant differences existed between the 2 groups in terms of the purchase of new equipment or medications. Satisfaction with the simulation exercise was evaluated as well. At the time of the post-intervention survey, 90% of staff felt the exercise was useful for their practice, and 95% felt that the program should be continued.
Although in situ simulation is an effective tool, it does have shortcomings. In a busy hospital or clinic environment, staff may feel overburdened by having to perform extra tasks during work hours that may be perceived as unnecessary. It is the responsibility of the person organizing a simulation practice session to ensure that patient care is not compromised during the activity; it is also important to build a culture of patient safety in which staff feel a responsibility to provide excellent individual and team function in a well-prepared environment.
Medical Simulation Resources
Resources available for simulation in health care can be categorized into 1 of 5 areas: mannequin based, screen based, virtual reality, task trainers, and standardized patients (SPs) (Box 18.1). How these tools are used depends on the educational needs.
Mannequins are lifelike representations of human beings and range in size from a preterm neonate to a full-size adult. The spectrum of functionality spans from a simple form, such as Resusci Anne, to a high-fidelity mannequin. A high-fidelity mannequin is computer driven and has features that represent human physiology, such as breathing, heart sounds, and blood pressure. These mannequins are technology dependent and often expensive and require expertise in maintenance and operation. Mannequins are typically used for mock codes, which can be applied to almost any health care setting, such as an office, inpatient ward, or operating room.
Box 18.1. Resources for Medical Simulation Training
•Mannequin: simple or computer driven
•Screen-based simulation programs
•Virtual reality programs
Screen-based simulated programs are more affordable and logistically easier than a mock code. Unlike a mock code, which often requires the coordination of more than 1 person, screen-based simulated programs can be performed by an individual at any location with a computer. Software programs are available that contain libraries of clinical scenarios in which patient history, examination findings, image studies, and laboratory tests can be represented graphically. Users can select diagnostic and therapeutic options as they work through the case and generate a record of performance. Immediate feedback is provided by preprogrammed software or an instructor at a later time.
Task trainers are three-dimensional representations of body parts that allow the user to improve technique or develop psychomotor skill in many areas, such as intravenous line insertion, LP, or bag-valve mask. Task trainers exist for nearly every procedure and discipline, with options ranging from preterm neonates to adults. Some trainers provide visual, auditory, or printed feedback to the learner based on the quality of the performance. For example, when practicing bag-valve mask on a baby head, an airway connected to inflatable lungs allows learners to visualize the effectiveness of their technique. Task trainers are especially useful for practitioners to gain familiarity with the equipment being used, whether they are first learning to use the equipment or refreshing their skills after a period of nonuse.
Virtual reality and haptic systems use the most sophisticated computer programming for procedural practice. Virtual reality refers to the re-creation of environments or objects as a complex, computer-generated image. Haptic systems provide the capability of tactile learning, and these programs can provide detailed feedback on procedural skill based on the kinetic actions of the user. Typically, virtual reality and haptic systems are used with a task trainer; most of the products available are for vascular access, surgical procedures, bronchoscopy, or endoscopy. Evidence shows that virtual reality is superior to traditional training; it is likely that simulation-based medical education will further incorporate virtual reality in the future. Currently, virtual reality programs are relatively cost-prohibitive and limited in scope; however, this may change as programming and options continue to develop.
Standardized patients have been used in graduate medical education for years. An SP is an actor playing a role and provides trainees an opportunity to practice communication, physical examination skills, or history taking. Although SPs typically play the role of a patient, they can also play the role of a family member or a fellow health practitioner.
Hybrid simulation, which combines 2 modes of simulation for a more realistic experience, is an excellent opportunity to provide a multifaceted learning experience. For example, when creating a scenario for a child with diabetic ketoacidosis (DKA), a mannequin and an SP can incorporate scripts written for DKA as well as for a mother who must be told that her child has a new diagnosis of diabetes mellitus. Learners have the opportunity to both apply their knowledge in assessing and treating DKA and use their skills in having difficult conversations. Afterward, feedback is provided to the learners about their medical knowledge, decision-making skills, and communication skills. The term confederate is sometimes applied to role players who work together with the instructor in scenarios.
The Culture of Simulation
This section describes the elements that are needed when designing and delivering education using simulation. But before these steps are illustrated, it is important to discuss the culture of simulation learning and how it fits with the current culture of medicine.
Traditional medical education emphasizes the importance of error-free practice, with intense pressure to achieve perfection during diagnosis and treatment. Furthermore, when mistakes are made, the psychological toll for the practitioner cannot be underestimated. It is often said that there are 2 victims in the case of a medical error: the patient and the health professional. Reports of provider depression, substance abuse, and suicide highlight the need for engen-dering a productive rather than destructive response to medical errors, which is 1 of the central aims of simulation. The technique of practicing technical skills or decision making skills in an environment absent of the “shame and blame” response can assist in developing healthy reactions to mistakes, in which the factors leading to the error are objectively reviewed and analyzed and improvements instituted. When a mistake is made, the goal is to change the thinking from what the repercussions will be to how health professionals can better themselves to improve care for their patients. As the practice of medicine is an art, so is the practice of becoming a better health professional.
The learning environment for simulation education activities must connote a safe learning environment in which mistakes can be made without reproach. In fact, simulation is an area in which it is desirable for health professionals to make mistakes so that the practice of improvement can occur. It is the responsibility of the facilitators to explicitly state this to help create an atmosphere conducive to constructive discussion.
Simulation activities also provide an opportunity for health professionals to train together and build effective communication skills and team camaraderie. The training of health professionals— nurses, physicians, medical or physician assistants—generally occurs in parallel, which can have the unintended consequence of poor communication between team members. This potentially can create an environment that may not always be conducive to fair and open discussion of mistakes, which is necessary if optimal learning and improvement are to occur. When delivered with creativity and enthusiasm in a nonthreatening environment, simulation can provide a venue for building effective relationships between practitioners while imparting educational benefits.
Steps for Delivering Simulation Learning
Developing simulation activities requires multiple steps and careful planning to achieve learning goals (Box 18.2). Health professionals are often busy and have little spare time, so in addition to making simulations accessible, the educational product must be sound and worth the time spent. Learning events that are not well planned or delivered can have an adverse effect on an individual’s perception of simulation education, which can have a negative effect on that person’s learning. The first step in delivering simulation learning is the creation of a mock code or scenario, followed by deliberate practice, a concept of instruction that is applicable to scenario or procedural training.
Mock Scenario Development
The first step in creating a scenario is to identify what needs to be improved; this may be related to medical knowledge, technical skill, communication, team function, or a combination of these. Adverse as well as routine events in the office or hospital setting often provide opportunities for learning and improvement and can set the educational framework.
The case study provided in the beginning of the chapter, for example, highlights a situation in which a mock code could be helpful in improving performance. Practicing a mock scenario of anaphylaxis can address multiple needs: teamwork, communication, locating and operating equipment, performing proper advanced life support techniques, and disposition. After a scenario is developed, it can be practiced by the office staff until performance standards are met.
When writing a mock code or scenario, the first task is to create succinct learning objectives. Writing clear objectives is an underappreciated skill and is a crucial part of any educational program. Good objectives are important because they focus teaching and enable the evaluation of the effectiveness of the activity. A helpful way to start thinking about objectives is to begin with the phrase, “By the end of this session, the learner will be able to…” followed by the learning objective. Objectives should be specific and measurable and use words that are open to few interpretations. For example, the objective, “By the end of the session, the learner will understand the complications of bag-mask ventilation.”, is open to many interpretations, whereas the statement, “By the end of the session, the learner will be able to list the complications of bag-mask ventilation.”, is open to fewer interpretations.
Box 18.2. Steps for Providing Simulation-based Medical Education
1. Determine learning needs.
2. Create learning objectives.
3. Create learning lesson.
a. Script, if performing mock scenario.
b. Simulated patient history and physical examination, laboratory data, images, and case progression.
c. Consequences of anticipated interventions and disposition.
d. Identification of required equipment and space.
e. Identification of role-players.
4. Session delivery.
a. Create a safe learning environment.
b. Deliberate practice.
a. Advocacy inquiry.
b. Plan for improvement.