Simulation as a Teaching Tool in the ICU

1. Simulation as a teaching tool in the ICU: The Human Factor perspective José M. Nicolás, MD. PhD. Intensive Care Unit. Hospital Clínic of Barcelona, Spain.

2. What we pursue? 2

3. High Reliability Organisations (HRO)

4. Work at ICU as a High Reliability Organisation • We work under uncertainty and changing situations. • Other industries aviation, nuclear power stations, army too. • Joint Commission commitment to HRO model. High reliability organisations, work at risk with the potential to generate large-scale damage, but they a chive a balance between effectiveness, efficiency and security. They minimize errors through teamwork, awareness of the potential risk and continuous improvement. 4

5. Define the problem to understand the solution 5

6. • IOM Institute of Medicine: To err is human. • 98.000 deaths/year medical error. 8th death cause. 6 Some interesting information America, C. on Q. of H. C. in, & Medicine, I. of. (2000). To Err Is Human: Building a Safer Health System

7. 7 Errors in critically-ill patients St.Pierre, M., Hofinger, G., Buerschaper, C., & Simon, R. (2011). Crisis Management in Acute Care Settings: Human Factors, Team Psychology, and Patient Safety in a High Stakes Environment. Springer.

10. “Food for thought” Errors detected Errors solved Mean Error Time Expert 18 15 0,4 h Residents 13 8 1,5 h Students 8 2 3,0 h Errors detected and solved in 10 h of UCI care Patel, V. L., & Cohen, T. (2008). New perspectives on error in critical care. Current Opinion in Critical Care, 14(4), 456–459.

11. 11 errare humanum est Lucius Annaeus Seneca Busto de Séneca. Museo del Prado

12. What are the causes? 12

13. Conflicts at the ICU: actors Fuente: Fassier T, Azolulay E. Cur Op Crit Care 2010. ICU: “Ineffective Communication Unit”

14. Joint Commission on Accreditation of Healthca- re Organizations. Sentinel event data root causes by event type. 2013.

15. • Error ≠ lack of Knowledge • The 70% of medical errors are related with Human Factors 15 Human Factors Helmreich RL, Fousbee CH. Why crew resource management? Empirical and theoretical bases of human factors training in aviation. In: Wiener EL, Kanki BG, Helmreich RL, editors. Cockpit resource management. San Diego: Academic Press Inc; 1993. p. 1–41.

16. "Human factors refer to environmental, organizational and job factors, and human and individual characteristics, which influence behaviour at work in a way which can affect health and safety". 16 Human Factors Health and Safety Executive. Human factors/er- gonomics. Introduction to human factors

17. 17 Human Factors Rall M, Oberfrank S. Human factors and crisis resource management: improving patient safety. Unfall- chirurg. 2013;116(10):892-9.

18. 18 Human Factors Rall M, Oberfrank S. Human factors and crisis resource management: improving patient safety. Unfall- chirurg. 2013;116(10):892-9.

19. 19 Problem Root Cause Analysis Solution

20. SOLUTION: Learning 20

21. Circle of Learning

22. Acquisition of clinical competency Does Shows Knows how Knows Does Shows Knows How Knows Miller GE. Academic Medicine 1990

23. Learning process What we remember Degree of involment Read Listen See how to Discusion Keynote Simulate Practice real life passive active

24. ¿What is medical simulation? Simulation is the use of one or several devices (simulators) to emulate a realistic situation of a patient care with the purpose of training or to evaluate.

25. ¿Why a simulated ICU? Learning shoud be done in the real place or a realistic one. Advantages: – Avoids any risk on the patients. – Allows training in complex and sporadic events.. – Reproducible, standarixed and may be evaluated.

26. 26 Learning by simulation

27. SOLUTION: Technical skills and decision taking? 27

28. Basic technical skills

32. Complex technical skills

33. Skills with animals

34. Simulated patients

35. Simulated patients

36. Decision taking with Microsimulation

37. Skills in processes: Bacteriemia “Zero”

38. Skills in processes: Ebola

39. Skills in processes: Ebola

40. 40 errare humanum est perseverare diabolicum Lucius Annaeus Seneca Busto de Séneca. Museo del Prado

41. 41 PROBLEM 98000 Medical error CAUSES 70% Human Factor SOLUTION Training HF and NTS

42. SOLUTION: Non-Technical Skills Training 42

43. America, C. on Q. of H. C. in, & Medicine, I. of. (2000). To Err Is Human: Building a Safer Health System

44. • Error arising primarily from aberrant mental processes – Forgetfulness – Inattention – Poor motivation – Carelessness – Negligence, and recklessness • Humans are fallible • Errors are to be expected, even in the best organizations. • Humans are not perverse 44 PERSON APPROACH BLAME CULTURE SYSTEM APPROACH SAFETY CULTURE • Countermeasures – Reducing unwanted variability in human behaviour – Disciplinary measures, threat of litigation, retraining, naming, blaming, and shaming • Countermeasures – We cannot change the human condition, we can change the conditions under which humans work Reason J. Human error: models and management. West J Med. 2000;172(6):393-6.

45. Trajectory of the error 45 System Approach: Swiss Cheese Latent Failures Active Failures MISHAP Defenses Reason J. Human error: models and management. West J Med. 2000;172(6):393-6. Hazards

46. UB-CRM TEAM TRAINING ACRM MED Teams Team STEPPS DOM GITT MTM MTT 46 Non Technical Skills Training Baker, D., Gustafson, S., & Beaubien, J. (2007). Team training in health care: A review of team training programs and a look toward the future. Adv Pat Saf. The Comprehensive Textbook of Healthcare Simulation. (2013).

47. • Medicine: The principles of individual and team behavior in normal situations and crisis focus on skills dynamic decision making , interpersonal behavior, and team management . • It is a system that makes optimal use of all resources and equipment, the available procedures, and people to promote patient safety. 47 What is CRM? Gaba DM. Crisis resource management and teamwork training in anaesthesia. Br J Anaesth. 2010;105(1):3–6.

48. 48 Crisis Resource Management Call for help Anticipate and plan Define a leader CR M Know the envirome nt Use all available informatio n Focus attention wisely Use all available resources Use cognitive adis Define roles Distribute the workload Effective comunica tion Crisis Resource Management Diagram. ©2008 Diagram: S.Goldhaber-Fiebert, K. McCowan, K. Harrison, R. Fanning, S.Howard, D. Gaba

49. 49 Crisis Resource Management Patient Safety due to the Human Factors application though CRM Team Working Situational Awareness Decision Making Task Management Communication Verbal and Non Verbal Rall M, Oberfrank S. Improving patient safety in air rescue: the importance of simulation team training with focus on human factors/CRM. Air Rescue Mag. 2013;3:35-40.

50. How we train with CRM principles? 52

51. ADULT LEARNING THEORY • Shön. Reflective Practice – Reflection IN action. DURING. • It is based on the ability to learn and develop continuously through creativity, applying current and past experiences and using reasoning as unexpected events occur . – Reflection ON action. AFTER. • We reflect on the factors that have contributed to the incident happened, if the actions taken were appropriate and how it may affect this situation to practice in the future. 53

52. 54 How we train CRM – HNT – FH? SIMULATION CULTURAL CHANGE

53. 55 Simulation course/session

54. Place for simulation

55. Setting intro and theory

56. 58 Case briefing

57. Perform the scenario

58. 60 How we achieve cultural change? DUR.THE SCENARIO Reflection IN action. Shön DUR. DEBRIEFING Reflection ON action. Shön

59. • Crisis management • Training – Leadership and comunication – Decision Making! enviroment. (Kind of hospital, available resources) – Security routines. Check-list – Situational awareness – Process of information • Experience real enviroment. MEDICAL GOALS • Use of electromedicine in clinical contest (Monitoring, VM, DF) • Protocols: ALS, ATLS, STEMI, ARDS, EGDT, bz • Technical skills. 61 DURING THE SCENARIOS HNT – FH - CRM Reflection IN action. Shön

60. Behavioral Assessment Tool (BAT) • Evaluates 9 aspects of CRM.

61. Debriefing is the soul of simulation

62. • Reflective learning – Study the frame (mental model) actions and results. – Decision making medical and non medical. – Error and how to mitigate after mishap. – Proceedings and healthcare processes: identify risk situations and pourpose changes. • Analisys of situation through CRM. DEBRIEFING • Cultural sensibilitation directed to patient safety. • Analisys cause • Training the ability to emit and receive objective criticism and self-criticism 64 Reflection ON action. Shön

63. 65 How we change culture through DEBRIEFING? TOOL: DEBRIEFING BLAME CULTURE PATIENT SAFETY CULTURE

64. • Methodology “Good Judgement”: – Learning without fear : safe, not punitive. – Premises: The student is smart and wants to do the right thing . We all make mistakes . – Criticism is accepted. • Debriefing phases: – Description: Step by step of what happened. – Analysis and Analogy: " pearls" and points relevant parallels reality. – Application: what you take home. 66 Debriefing: Methodology and phases Rudolph, J. W., Simon, R., Dufresne, R. L., & Raemer, D. B. (2006). There’s no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simulation in healthcare : journal of the Society for Simulation in Healthcare, 1(1), 49–55

65. Impact on clinical care. Scientific evidence

66. Technical skills at ICU Studies Results Improving Delivery of Continuous Renal Replacement Therapy: Impact of a Simulation-Based Educational Intervention. Mottes T, et al. Pediatr Crit Care Med 2013 RRCT, duration of hemofilters goes from 42,5 h to 59,4 h after simulation of technical skills. Use of simulation-based education to improve outcomes of central venous catheterization: a systematic review and meta-analysis. Ma IW et al. Acad Med 2011 Ffewer tries of venous cathetherization SMD -0,58 Pneumotórax RR 0,62 A prerotational, simulation-based workshop improves the safety of central venous catheter insertion. Sekiguchi H, et al. Chest 2011 Errors in CVC placements lowers from 22,8% a to 16,2%. Arterial pucture drecreases from 4,2% to 1,5%.

67. Adherence to clinical processes at ICU Studies Results An educational course including medical simulation for early goal-directed therapy and the severe sepsis resuscitation bundle: an evaluation for medical student training. Nguyen HB, et al. Resuscitation 2009 Intervention groups achieved 94% vs 77% in early goals of sepsis treatment. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Wayne DB et al. Chest 2008 After simulation CPR was prerforment according AHA standards(68% vs 44%). Use of simulation to assess electronic health record safety in the intensive care unit: a pilot study. March CA et al. BMJ Open 2013 Simulation facilitates error identification in the ICU clinical record.

68. Non-technical skills at ICU Studies Results Nontechnical skills assessment after simulation-based continuing medical education. Morgan PJ, et al. Simul Healthc 2011 Improves scores in simulation by 5% per sessión, by withouth any effect from debriefing. Short simulation training improves objective skills in established advanced practitioners managing emergencies on the ward and surgical intensive care unit. Pascual JL, et al. J Trauma 2011 Training by only half day with 5 scenarious simulation it is enough to improve leafdership, efectiveness and communication. Effect of crew resource management training in a multidisciplinary obstetrical setting. Haller G, et al. Int J Qual Health Care 2008 A CRM-based program improves efectiveness and teamwork.

69. Outcome of the criltically-ill patient Studies Results Use of simulation-based education to reduce catheter-related bloodstream infections. Barsuk JH et al. Arch Intern Med 2009 A simulation program for CVC placing reduces catheter-related bacteriemia (0,50 vs 3,20 cases/ 1000 catheter-days). Performance of medical residents in sterile techniques during central vein catheterization: randomized trial of efficacy of simulation-based training. Khouli H, et al. Chest 2011 A simulation program for CVC placing reduces catheter-related bacteriemia from 3,4 to 1 cases / 1000 catheter-days; and decreased length of stay by 1.4 days. Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital. Riley W, et al. Jt Comm J Qual Patient Saf 2011 A decrease in perinatal mortality by 37% was observed after a simulation program.

70. Liam Donaldson,2004 Alianza Mundial para la Seguridad del Paciente Key points

71. Change from blame culture to patient safety culture. 73 Key points Perform training programs • Adult learning theory. • Train non-tech. skills. CRM • Explore mental frames.

72. 74

Simulation as a Teaching Tool in the ICU

Dr.Mahmoud Abbas

Simulation as a Teaching Tool in the ICU