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© 2014 David M. Gaba, M.D.
2014 Winter Anesthesia Seminar
Simulation in Anesthesia:
What, why, when, who, how?
David M. Gaba, M.D.
Associate Dean for Immersive and SimulationSimulationbased Learning and Professor of Anesthesia,
Stanford University
Director, Patient Simulation Center of Innovation
at VA Palo Alto HCS
© 2014 David M. Gaba, M.D.
Disclosures
No disclosures of commercial financial interest
in last 12 months
You should know:
I have 3 jobs that pay me to work on simulation in
healthcare (Stanford, VA, EIC of journal
Simulation in Healthcare)
I am on BOD of Soc Sim in Healthcare (SSH) &
Treasurer of Adv Initiatives on Med Sim (AIMS)
I am on ASA Sim Editorial Board
I teach ACRM1,2,3 & MOCA Sim Courses
© 2014 David M. Gaba, M.D.
Learning Objectives
Articulate 7 or more of the 11 dimensions of
simulation
Describe the different modalities of simulation
Look at how simulation can present highhigh-intensity
cases with challenging (even rare) clinical
situations that demand dynamic decisiondecision-making
and team management, to better understand and
teach crisis management and patient safety
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© 2014 David M. Gaba, M.D.
What is Simulation?
• A “technique” NOT a “technology”
–For interactive and often
“immersive” activities that rere-create
experiences of a realreal-world
environment
To amplify or replace actual experiences
“Even better than the real thing”
© 2014 David M. Gaba, M.D.
Simulation is Probably PrePre-Historic
• Likely a preparation or surrogate for
hunting or war
Full Immersion
Simulation
“The Real Thing”
Photos via “Adobe Photoshop Time Machine”
© 2014 David M. Gaba, M.D.
Why Was Anesthesiology
Pioneer For Simulation?
• Anesthesiologists are riskrisk-averse
- Anesthesia is not therapeutic
• Cognitive profile matches that of
industries that use(d) simulation
• Adverse event training has high salience
• Anesthesia attracts “nerds” and
“techno--geeks” (like me, Schwid, Good, etc.!)
“techno
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© 2014 David M. Gaba, M.D.
Why Use Simulation?
Pathology or Crises “On Demand”
• Simulators allow the planned
presentation of diverse cases, e.g.
–Common conditions & diseases
–Time
Time--critical and lethal events;
high intensity situations
–Rare or variant conditions
© 2014 David M. Gaba, M.D.
Simulation Allows Things That Are
Impossible in Real Life
• There is no risk to a patient; there
is no time pressure for clinical
efficiency
• Simulation allows start / stop /
pause & restart to a prior state
• Errors can be allowed to occur
without immediate intervention
© 2014 David M. Gaba, M.D.
11 Dimensions of Simulation
Application in Health Care
• Purpose/goal of simulation
- Education ⇔ Training ⇔ Assessment ⇔ Research
• Unit of participation
- Individual ⇔ Team ⇔ Work Unit ⇔ Hospital
• Knowledge, skill, or behavior addressed
- Knowing ⇔ Doing ⇔ Deciding ⇔ Teamwork
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© 2014 David M. Gaba, M.D.
11 Dimensions of Simulation
Application in Health Care
• Clinical domain(s)
domain(s)
- Clinic ⇔ Ward ⇔ CathCath-Lab ⇔ OR/ICU/ED
Anesth/EM
/EM
- Psych ⇔ Int Med / Peds ⇔ Surg/
Surg/Anesth
• Discipline(s
Discipline(s)) of health care personnel
- Clerk ⇔ Allied
Allied--Health ⇔ Nurse ⇔ MD ⇔ Execs
• Experience level(s
level(s)) of participants
- K-12 ⇔ Univ ⇔ Prof School ⇔ Trainee ⇔ Staff
© 2014 David M. Gaba, M.D.
11 Dimensions of Simulation
Application in Health Care
• Patient age
- Neonate/Infant ⇔ Child ⇔ Adult ⇔ Elderly
• Technologies and techniques
RoleRoleComputer
Virtual
play ⇔ Screen ⇔ Reality
⇔
Computerized
Mannequin
© 2014 David M. Gaba, M.D.
11 Dimensions of Simulation
Application in Health Care
• Site of simulation
- Home ⇔ Skills Lab ⇔ Sim Ctr ⇔ Actual Worksite
• Extent of direct participation
Remote
Obs &
InIn-person Fully
⇔ Interact ⇔ Hands on ⇔ Immersive
Obs
• Feedback/Reflection
– Neonate/Infant ⇔ Child ⇔ Adult ⇔ Elderly
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© 2014 David M. Gaba, M.D.
Types of Simulation
• Verbal, rolerole-playing, storytelling
• ComputerComputer-screen simulation
including virtual patients
• Part
Part--task &
procedural
trainers
© 2014 David M. Gaba, M.D.
Types of Simulation
• Standardized patient actors
• Multiplayer Online
Virtual--worlds (MOG)
Virtual
• Computerized mannequins
© 2014 David M. Gaba, M.D.
Technological Simulation is Necessary
in Anesthesia
• In settings such as anesthesia most
training goals require a
technological simulator
- Actors don’t like receiving
drugs, intubation, cardiac
arrests, etc.!
- Verbal simulation only goes so
far
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© 2014 David M. Gaba, M.D.
OnOn-Screen Simulators
© 2014 David M. Gaba, M.D.
© 2014 David M. Gaba, M.D.
Advanced Virtual Technologies
Mixed Reality
Simulation
CAVE
Head mounted
display VR
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© 2014 David M. Gaba, M.D.
Part-task Trainers
PartVascular Access
© 2014 David M. Gaba, M.D.
Part-task Trainers
PartIt pays to play with your food!
© 2014 David M. Gaba, M.D.
CVP Simulation
(MOVAT)
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© 2014 David M. Gaba, M.D.
Part-task Trainers
PartBronchoscopy
Stanford Residents Use Both Systems on
Thoracic Anesthesia Rotation
Not Free
Free Online Bronchoscopy Simulator
© 2014 David M. Gaba, M.D.
Airway Management Simulation
Multiple Trainers; Multiple Tools
© 2014 David M. Gaba, M.D.
Part--task Trainers
Part
Echocardiography (TTE & TEE)
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© 2014 David M. Gaba, M.D.
Simulators provide the
usual monitor data streams
© 2014 David M. Gaba, M.D.
Scenarios can be
challenging medically,
technically, and in terms
of teamwork
© 2014 David M. Gaba, M.D.
Face Validity
of Simulation
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© 2014 David M. Gaba, M.D.
Debriefing
Reflection on what transpired
• Often similar duration
as the simulation
scenario (15 – 40 min)
• Led by experienced,
trained, facilitator
• Self, group, expert critique of “performance”
not “performer”; discuss alternatives & their
pros & cons
© 2014 David M. Gaba, M.D.
Diverse Applications of
Simulation for Anesthesiology
• Education (students)
•Training (housestaff
&
experienced)
• Research
• Quality and Risk Management
• Performance Assessment
© 2014 David M. Gaba, M.D.
Simulation in Anesthesia
Education of Students
• Introduces students to arena of high
dynamism & intrinsic risk
• Knowledge, skills, attitudes & behaviors
needed for this arena are different than
those emphasized in medical school
• Recruiting tool for those interested in
anesthesia
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© 2014 David M. Gaba, M.D.
Potential Impact of Simulation
on Patient Safety – Training (HS, BCA)
• Improve actual critical clinical skills
- Dynamic decision making
- Therapy selection
- Psychomotor skills of execution
• Simulation
Simulation--based behavioral training
could improve critical behavioral skills
- Team management, communication
© 2014 David M. Gaba, M.D.
Simulation for Integrated Medical & NonNon-technical Skills
Team
Management
Dynamic
Decision
Making
© 2014 David M. Gaba, M.D.
Potential Impact of Simulation
on Patient Safety -- Research
• Simulation
Simulation--based research &
development can help to study &
improve processes of care,
care, such as:
- Clinical protocols
- Human
Human--machine interactions
- Performance shaping factors (e.g. fatigue)
- Cognitive aids/emergency manuals
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© 2014 David M. Gaba, M.D.
Quality Management & Risk
Management & Systems Safety
• In
In--situ simulation for “systems probing”
- InIn-situ – simulation in actual pt. care areas
- “Systems probing” – looking for what
works well in the “system” and what latent
problems are there
• If you fix a systems problem it may be
fixed for EVERYONE (no training needed)
© 2014 David M. Gaba, M.D.
Simulation for Performance Assessment
in Anesthesiology?
• Not currently used in U.S. for highhigh-stakes
assessment (but used in Israel)
• Has been used for formative assessment
(residents); considerable ongoing research about
performance assessment
• In 2017 ABA will start OSCEs in 1˚exam
- Objective Structured Clinical Exams
- Nature of OSCEs not yet set. Not fullfull-blown simulations,
but will not be just technical skills
© 2014 David M. Gaba, M.D.
MOCA Simulation Course: Curriculum
Requirements Set by ABA & ASA
Simulation Editorial Board
• Every 10 year Maintenance of
Certification in Anesthesia (MOCA)
cycle requires attending a qualifying
simulation course for Part IV of MOC
At a site that is ASA endorsed
by the ASA (ASA Simulation
Editorial Board)
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© 2014 David M. Gaba, M.D.
MOCA Simulation for Part IV–
IV– Practice
Improvement
• Curricula oriented to managing
challenging situations (crises) as
individual and team
• Includes scenarios of hypoxemia,
cardiovascular compromise, etc.
• Physical recreation of real OR , PACU,
etc.
© 2014 David M. Gaba, M.D.
MOCA Simulation -- First Two Years
McIvor W, Burden A, Weinger WB, Steadman R; 2012, JCEHP 32:236-242
583 diplomates at 27 centers
Agree or strongly agree with following
Met learner expectations
Nonthreatening learning environment
Simulations realistic
Debriefing enhanced learning
Course content relevant to practice
What I learned will change my practice
(98%)
(99%)
(98%)
(98%)
(99%)
(94%)
Fraction Responding
AGREE or STRONGLY AGREE
Similar data from ABA for >3000 diplomates, 2014
Relevance
Change practice
Recommend
+ experience
(partial)
2013 was a milestone year for first cohort (2008) who is required to complete simulation:
Year 5 of 10-year cycle in which one Part 4 activity is due
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© 2014 David M. Gaba, M.D.
MOCA Simulation
Practice Improvement Plans (PIPs)
& FollowFollow-up Reports
Steadman RH, Burden AR, Huang YM, Gaba DM, Cooper JB: Practice
Improvements Based on Participation in a Simulation Program for Maintenance of
Certification in Anesthesiology Anesthesiology, 2014 (Submitted)
• 634 participants sampled from 1,261 (1/2010 – 12/2012)
• 1,982 Practice Improvement Plans (PIPs) &
634 FollowFollow-up Reports analyzed with:
- Word count
- Coding of PIP for
» Theme
» Target of improvement (self, others)
» Measurability
© 2014 David M. Gaba, M.D.
MOCA Participants Took
Practice Improvement Plan Seriously
• Participants mostly wrote far more in their
plans than the minimum needed
Followup
PIPs
Steadman RH, Burden AR, Huang YM, Gaba DM, Cooper JB: Practice Improvements
Based on Participation in a Simulation Program for Maintenance of Certification in Anesthesiology
Anesthesiology, 2014 (Submitted)
© 2014 David M. Gaba, M.D.
PIP Content and Nature of
“Practice Improvements”
Category (N; % of “Improvements”)
1. System (820; 33%)
Equip/Meds, Education, Checklists, Policy, Simulation
2. Teamwork (737, 30%)
Commun, Leadership, Sit Awareness, Resources, Help
3. Knowledge (699, 29% )
Guideline, Funct/Loc, Application, Policy, Literature
Steadman et al, submitted
92% of improvements
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© 2014 David M. Gaba, M.D.
PIP Content and Nature of
“Practice Improvements”
Steadman et al,
submitted
Completed: Fully
Fully/Partially/No
/Partially/No 79% / 16% / 6%
74% / 26%
Measurable: Yes / No
Target of Plan
Self
+ Other Anesth Professionals
+ Non
Non--Anesthesia Physicians
+ Non
Non--Anesth NonNon-physicians
(e.g. Nurses, Pharm)
89%
50%
16%
26%
© 2014 David M. Gaba, M.D.
Summary about MOCA Simulation
• Highly intense exercises
replicating clinical realities;
detailed debriefings
• > 3000 participants; Evaluations
profoundly positive toto-date,
despite cost & hassle
• Stimulates practice improvement,
often aimed beyond merely the
individual participant
© 2014 David M. Gaba, M.D.
MOCA Simulation Status
• 43 centers in 25 states – currently 4 in CA
(UCLA, Irvine, Stanford, UCSF) -- More in CA in future?
• MOCA Simulation tuition is significant ($1500 - $2000)
- Instructors (1 - 3 per 5 participants); technical staff (esp. if weekend)
- Facility & equipment; CME costs; Univ. Overhead “Tax”
- Direct costs (food, handouts)
- When all costs considered, only some sites “break even”
• Travel required for some participants
• Throughput is an issue (2˚ to intensity & faculty ratio;
most faculty are busy clinically themselves!)
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© 2014 David M. Gaba, M.D.
Anesthesia Simulation for MOCA
First among many?
• Anesthesiology is the first specialty to have
simulation for MOC
• Others are planning it in various forms:
- Emergency Medicine
- OB/GYN
- Etc.??
© 2014 David M. Gaba, M.D.
The Simulation Vision Is a (many)
DecadeS
Decade
S-long Proposition
• The Vision is of training that is:
- Comprehensive & Integrated
- Continuous – for individuals, teams,
work units
- Coupled with performance
assessment
- Over an entire career; embedded in
work processes
© 2014 David M. Gaba, M.D.
(Simulation) Training Must Be
For a Lifetime (cumulative effect)
• Career
Career--long combination of
modalities as individuals & teams,
repeatedly cycling through:
- Didactics & seminars
- OnOn-screen simulators & “virtual
worlds”
- Courses in dedicated sim center
- InIn-situ simulations & drills
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© 2014 David M. Gaba, M.D.
Does it Work? CRM/TeamCRM/Team-Training
Intervention Evidence is Still Inconclusive
Zeltser MV, Nash DB
Am J Med Qual,
Qual, 2010; 25: 13
13--23
© 2014 David M. Gaba, M.D.
{Incidentally} What is the Evidence for
Simulation in Commercial Aviation?
• There is mandatory yearly training
& checking of flying performance
- Studies can be grafted onto these
activities
• Yet, nothing like Level 1A evidence
that it saves planes or lives (T3)
No randomized trials; they would
be unethical to conduct -- pilots are
“1st ones at the scene of an accident”
© 2014 David M. Gaba, M.D.
Translational Research Levels
Simulation Education Research
McGahie et al, SSH Rsch Summit; Gaba
1
2
3
Performance during simulation (many)
Performance during clinical care (few)
Outcomes in patients (efficacy) (very very few)
3’ Cost-effectiveness in patients (cost-efficacy)
4
Dissemination (can it be done by others?)
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6
Adoption (will others actually use it?)
Population health impact (if they do, what impact will it
actually make?)
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© 2014 David M. Gaba, M.D.
Outcome Measurement (T3) is
Tractable When:
• Simulation intervention is
circumscribed;
AND
• Outcome is easily measured;
AND
• Outcome moderately
common
Example:
Infection rate
after CVC
insertion
© 2014 David M. Gaba, M.D.
Outcome Measurement is
Difficult When…
• Event is rare (e.g. MH, card arrest)
• Outcome is subtle & hard to measure
(e.g. cognitive function)
• Behavior/skill is complex (e.g. teamwork)
• Intervention is complex (e.g. CRM sims)
• Many confounds between intervention
& outcome (e.g. most inpt. arrests die even with
excellent care)
© 2014 David M. Gaba, M.D.
The Pharmaceutical Analogy for
Simulation: A Policy Perspective
(Gaba D: Sim
Healthc; 2010,
5:55:5-7)
• Who would study an antianti-hypertensive by:
- Using a low dose of the study drug
- Dosing occasionally to only a few subjects
- Ignoring the exacerbating factors
» e.g. stress, drug use, salt intake
- Following subjects for only a short time
• And then expect a major change in outcome??
But…that’s what we’ve done with simulation!
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© 2014 David M. Gaba, M.D.
Applications of Simulation
Interventions Have Been Limited
• Infrequent
• Often lowlow-intensity curricula
• Little reinforcement in real work
• No coupling to performance assessment
• In only a few disciplines/domains
• Small studies & short time horizons
© 2014 David M. Gaba, M.D.
Real Test of Simulation Needs a
Long Time Horizon
• Current studies chip away at small
questions (this is good work, but….)
• The REAL question is: Does
simulation improve quality when there is:
–Long
Long--term adoption
–Comprehensive, integrated model
–Career
Career--long
–Training & assessment
–Evaluated over long time horizon
© 2014 David M. Gaba, M.D.
Pharmaceutical Analogy:
Who Pays for Proof?
• In clinical trials, often the manufacturer
- Huge research budgets, many trials but few
successes is “usual”
- Huge profits for successful drugs
• Simulation community (industry / centers):
- Tiny margins [few centers break even], not
used to expensive trials with few successes
- No “blockbusters” even if trials are
successful
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© 2014 David M. Gaba, M.D.
Who Pays for the “Proof”?
“The Government”??
• For some diseases govt. funder does pay
for large and long trials
- Current funding for simulation research
comes from quality & safety but with tiny
relative budget
- No federal agency seriously addresses
clinical education research
- To
To--date small $$ & short, limited studies
© 2014 David M. Gaba, M.D.
Anesthesiology is
About Saving Lives
Just Do It!
And whoever saves a life, it is as though he
had saved all mankind
(appearing in various forms in
the Talmud, Sanhedrin 4:5 and the Quran 5:32)
© 2014 David M. Gaba, M.D.
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