Best Practices in Simulation Plann At the recent International Conference on Residency Education, several speakers emphasized the importance

of planning when using expensive simulation labs. Residents who train exclusively on high fidelity simulators frequently complain about the complexity and confusion of learning in this manner. I decided to write an article about the best way to plan the use of 4-step progressive simulations.

Preplanning a. Begin by analyzing what competencies should be taught in this manner. Dangerous, painful, rare and embarrassing procedures make the best candidates. Determine what level of competency is required depending on the level of the resident. Setobjectives for each stage. b. Create learning activities including written instructions for each level of the progressive process described in the following document. Train preceptors to provide the necessary role modeling. c. Create assessment tools appropriate for each level. d. Train raters to use the assessment tools.

1. Intentional Role Modeling An experienced preceptor demonstrates (without comment to the trainee) the complete procedure including interactions with patients/families and team members. This provides the student with an understanding of the goal of training including completion time, explanations given to the patient, safety measures etc. This step may involve watching a video if an experienced preceptor is not available for observation. 2. Low Fidelity Simulation

Low fidelity simulations use learning resources such as videos, animations and virtual reality with written procedural guides. Ideally this will involve a self-directed process whereby the learner learns the basic step by step mechanics and can repeatedly use the required resources until they believe they have reached an understanding of the objective. Assessment at this stage uses multiple choice and listing questions; either paper based or online with a pass mark of >80%. Learners must have the option to retest at this stage. 3. Mid Fidelity Simulations

Mid fidelity simulators are the body parts task trainers that expose students to the tools used to complete procedures in a portable, minimally complex manner. Again students practice with minimal supervision or peer support until they feel confident to undergo formal testing. Direct observation by raters or a lab supervisor followed by a feedback session is the usual test at this stage. Students should be allowed to retest after returning to the simulation if they dont demonstrate proficiency. The student now has the basic knowledge and tool proficiency to move to the interactive level. 4A. Interactive Hybrid Patient Simulation

Hybrid simulations are used for simple procedures which might be painful or embarrassing for patients to have beginners practice. Simulated body parts are attached to standardized patients who act out pre-arranged scenarios and

provide feedback to the learner during the debriefing. More expensive than midlevel task trainers, this level allows for the inclusion of interaction skills. Direct observation is the standard assessment. 4B. Interactive High Fidelity Simulation

The most expensive and complex type of simulators are the full body mannequins that require participants to practice technical + communication skills in complex scenarios. In some cases, participants may experience planned and unplanned disaster scenarios. Ideally the mannequins themselves provide immediate feedback about how well the patient is progressing because of the participants actions. Debriefing with a skilled preceptor is required after each session. Video observation by trained raters is the standard summative assessment. History of simulation in healthcare The first medical simulators were simple models of human patients] Since antiquity, these representations in clay and stone were used to demonstrate clinical features of disease states and their effects on humans. Models have been found from many cultures and continents. These models have been used in some cultures (e.g., Chinese culture) as a "diagnostic" instrument, allowing women to consult male physicians while maintaining social laws of modesty. Models are used today to help students learn the anatomy of the musculoskeletal system and organ systems. Type of models Active models Active models that attempt to reproduce living anatomy or physiology are recent developments. The famous Harvey mannequin was developed at the University of Miami and is able to recreate many of the physical findings of the cardiology examination, including palpation, auscultation, and electrocardiography.

Interactive models More recently, interactive models have been developed that respond to actions taken by a student or physician.] Until recently, these simulations were two dimensional computer programs that acted more like a textbook than a patient. Computer simulations have the advantage of allowing a student to make judgements, and also to make errors. The process of iterative learning through assessment, evaluation, decision making, and error correction creates a much stronger learning environment than passive instruction. Computer simulators

3DiTeams learner is percussing the patient's chest in virtual field hospital Simulators have been proposed as an ideal tool for assessment of students for clinical skills. For patients, "cybertherapy" can be used for sessions simulating traumatic expericences, from fear of heights to social anxiety. Programmed patients and simulated clinical situations, including mock disaster drills, have been used extensively for education and evaluation. These lifelike simulations are expensive, and lack reproducibility. A fully functional "3Di" simulator would be the most specific tool available for teaching and measurement of clinical skills. Gaming platforms have been applied to create these virtual medical environments to create an interactive method for learning and application of information in a clinical context. Immersive disease state simulations allow a doctor or HCP to experience what a disease actually feels like. Using sensors and transducers symptomatic effects can be delivered to a participant allowing them to experience the patients disease state.

Such a simulator meets the goals of an objective and standardized examination for clinical competence This system is superior to examinations that use "standard patients" because it permits the quantitative measurement of competence, as well as reproducing the same objective findings. Modern medical simulation The American Board of Emergency Medicine employs the use of medical simulation technology in order to accurately judge students by using "patient scenarios" during oral board examinations.[1] However, these forms of simulation are a far cry from high fidelity models that have surfaced since the 1990s Due to the fact that computer simulation technology is still relatively new relative to flight and military simulators, there is still much research to be done about the best way to approach medical training through simulation. That said, successful strides are being made in terms of medical education and training. A thorough amount of studies has have shown that students engaged in medical simulation training have overall higher scores and retention rates than those trained through traditional means. The Council of Residency Directors (CORD) has established the following recommendations for simulation 1. Simulation is a useful tool for training residents and in ascertaining competency. The core competencies most conducive to simulation-based training are patient care, interpersonal skills, and systems based practice. 2. It is appropriate for performance assessment but there is a scarcity of evidence that supports the validity of simulation in the use for promotion or certification. 3. There is a need for standardization and definition in using simulation to evaluate performance. 4. Scenarios and tools should also be formatted and standardized such that EM educators can use the data and count on it for reproducibility, reliability and validity. Training The main purpose of medical simulation is to properly educate students in various fields through the use of high technology simulators. According to the Institute of Medicine, 44,000 to 98,000 deaths annually are recorded due primarily to medical mistakes during treatment.[3] Other statistics include:

225,000 deaths annually from medical error including 106,000 deaths due to "nonerror adverse events of medications" 7,391 deaths resulted from medication errors

If 44,000 to 98,000 deaths are the direct result of medical mistakes, and the CDC reported in 1999 that roughly 2.4 million people died in the United States, the medical mistakes estimate represents 1.8% to 4.0% of all deaths, respectively. A near 5% representation of deaths primarily related to medical mistakes is simply unacceptable in the world of medicine. Anything that can assist in bringing this number down is highly recommended and medical simulation has proven to be the key assistant. Examples The following is a list of examples of common medical simulators used for training. Advanced Cardiac Life Support simulators Partial Human Patient Simulator (Low tech) Human Patient Simulator (High tech) Hands-on Suture Simulator (Low tech) IV Trainer to Augment Human Patient Simulator (Low tech) Pure Software Simulation (High tech) Anaesthesiology Simulator (High tech) Minimally Invasive Surgery Trainer (High tech) Bronchoscopy Simulator Battlefield Trauma to Augment Human Patient Simulator Team Training Suite Harvey mannequin (Low tech) Advantages Studies have shown that students perform better and have higher retention rates than colleagues under strict traditional methods of medical training. The table below shows the results of tests given to 20 students using highly advanced medical simulation training materials and others given traditional paper based tests. It was found that high technology learning students outperformed traditional students significantly.

E-Learning vs. Textbook Learning

Mode of Learning

Mean Test Score on Multiple Choice Test 4.03 / 5 (80.6%) "B"

Time to Complete Module 2830 minutes

E-Learning (N=20) Traditional Paper Based Significant Difference

3.05 / 5 (61%) "D"

2830 minutes

Yes (p < .001)

N/A

In addition to overall better scores for medical students, several other distinct advantages exist not specifically related to training.

Less costly Time efficient Less personnel required Many automated processes Ability to store performance history Track global statistics for many linked medical simulators Less medical related accidents

Medical Simulation There is a lot of discussion at the University of Saskatchewan about the use of medical simulation in health science education. To understand the decisions being made in this area, you need to understand that there are four distinct categories of simulation: 1. Physical Simulators 2. Human Manipulated Physical Simulators 3. Virtual Simulators 4. Virtual Environment Simulators Physical Simulators Physical simulators are reusable mannequins that students practise skills on such as physical examinations, injections and other invasive treatments. Using this type of simulator provides initial practice when willing patients are in short supply or when practise could be invasive, unpleasant or painful to patients. Once the student has developed an acceptable level of skill, they complete their

learning with human patients. Below you can see some examples of physical simulators manufactured by Kyoto Kagaku Co. Ltd., which were recently displayed at the university.

Human Manipulated Physical Simulators A more sophisticated level of simulator is a full body mannequin that can be manipulated by a human operator located behind a two-way mirror. This type of simulator can answer questions, raise limbs as well as be examined/draped/treated. This provides students with a more holistic simulation

in which they role-play interactions with the patient. The draw back here is a high initial cost as well as an ongoing expense of an operator. Virtual Simulators Virtual Simulators use 3D animation to teach parts of the body (Guide to a Healthy Heart) or to teach steps in a procedure (Sim Praxis video ) Costs to create these simulations can be very high, therefore, they are often purchased as CDs with a textbook or accessed through sponsored online sites. See also The Visible Human Virtual Environment Simulators The Virtual Environment Simulators are computer-based medical scenarios that usually include a 3D model of a location, equipment, personnel and patients that students enter with an Avatar. They work well for What if? case studies such as disaster training, pandemic planning, problem solving and modeling of unusual diagnosis that students might not encounter in their clinical experience. Costs of initial production can be lowered by using already existing virtual worlds such as Second Life, a virtual world with a higher population than the prairies. Cost per student is frequently minimal. USES OF SIMULATION IN MEDICAL EDUCATION Studies in cognitive psychology inform us that the recall of information and its application are best when it is taught and rehearsed in environments similar to workplace. The healthcare professions are heavily task- and performance-based where non-technical skills, decision making and clinical reasoning are important alongside integrity, empathy and compassion. Most of these attributes are difficult to teach and assess in the traditional classrooms. Enhanced patient safety on one hand has to be the ultimate outcome of any medical curriculum while on the other hand, it itself can be potentially compromised in an apprenticeship-based model of medical education. A range of simulation techniques are very well placed to be used alongside clinical placements. These can be employed to enhance learning of healthcare professionals in safe environments, without compromising the patient safety, while maintaining a high degree of realism.. It enhances the students understanding Simulation-based learning is used to promote medical students' mastery of communication skills, medical interviewing, physical examination and basic clinical procedures. Students and tutors both recognize the effectiveness of simulation-based learning in medical education.

Virtual patient education will help to prevent the medical errors There are very few medical schools that would not routinely use such simulation as a standard part of their curriculum. This is not because they are cost effective (although they are) but rather because they have been shown to reduce human error in performing these clinical skills and provide a safe environment for doctors to learn such procedures without endangering real patients. Simulation has taken many forms in Medicine including: (1) Computer-based simulations; (2) Standardised patients widely used in OSCE training and examination; (3) Virtual environments; (4) mannequins such as Resuscitation Annie, and (5) so-called "high fidelity" simulations resembling as much as possible the actual clinical situations. These forms of simulation have been used to teach the important skill of clinical decision-making as well as technical procedures.