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The Role of Simulation in Improving Patient Outcomes

Akira Nishisaki, MD, MSCE, and Ellen S. Deutsch, MD

It has been more than 12 years since the Institute of Medicine published To Err Is Human,¹ which raised public awareness and called for attention to safer health practices, including teamwork and simulation training. Simulation-based education is becoming standard in medical and nursing school curriculums and in on-the-job training in many hospitals.^2,3 A recent meta-analysis showed that the number of publications describing simulation-based intervention increased substantially after 2006.⁴

Simulation, Simulator, Simulation Training

Earlier literature used the terms simulation, simulator, and simulation training loosely and interchangeably, leading to confusion among readers. As simulation and education research and science have progressed, terms have been more clearly defined.

Simulation is defined as a strategy or technique to mirror or amplify real clinical situations with guided experiences in an interactive fashion.⁵ The degree of perceived realism is referred to as fidelity. The degree of fidelity, which seems to influence the effectiveness of simulation-based education, has 3 components^6,7: (1) physical fidelity (how manikins or task trainers look and feel real to learners), (2) conceptual fidelity (how the re-created simulated environment makes sense to learners), and (3) emotional or affective fidelity (how the re-created simulated situation evokes an emotional response in learners similar to that in a real clinical situation). The early descriptor high-fidelity simulator simply means that the manikin has a capability to provide physical cues (signs) such as palpable pulses or chest rise for spontaneous breath or in response to effective bag–valve–mask ventilation. This type of highly sophisticated manikin produces only one important component of fidelity: physical fidelity.

Simulation is often used as an educational intervention. There are, however, other uses of simulation in healthcare, such as diagnostic probes (eg, conducting a safety check of a new neonatal ICU using simulated patient admission and a simulated code event), credentialing and documenting competence (eg, using standardized patient stations to objectively assess medical students’ clinical skills), and desktop modeling to predict responses (eg, using a mathematical formula to predict patient response to a certain intervention). This chapter focuses on the use of simulation as an educational strategy.

Simulator refers to a physical object or representation on which the full or partial task is replicated during the simulation.⁸ These include whole-body simulators with some physical and/or electronic cueing features (eg, pulses, chest rise, breath and heart sounds), task trainers with or without cueing features, and flat screen simulators (virtual reality simulators) with or without haptic technologies.⁹

Simulation training refers to an educational intervention that uses simulation to enhance learning. In healthcare, simulation training is often integrated into curriculums in professional schools and is used in orientation training for new postgraduate physicians.² For identified healthcare hazards and latent errors, simulation-based education is often adapted as one of many targeted interventions. In this chapter we discuss why simulation training is often used to identify and remediate problem-prone situations, what steps should be taken to develop and implement simulation training, and how we evaluate training effectiveness. We further discuss potential solutions to enhance the effect of simulation training.

Why Simulation Training Is Often Used

There has been a substantial increase in the medical knowledge and skills that medical trainees and providers must master, yet work hours dedicated to training are limited. Traditional education using classroom didactics and bedside education with a “see-one, do-one, teach-one” approach failed to meet those demands. Furthermore, with tighter restriction of trainees’ work hours, each trainee’s exposure to educational cases has decreased over time. For example, pediatric residents have decreasing exposure to tracheal intubation in neonatal ICUs and in the delivery room.¹⁰ To address this, supervising bodies such as the Accreditation Center for Graduate Medical Education emphasize outcomes-based education and reporting of outcomes. Simulation training supports the acquisition of skills based on the needs of learners, rather than patients, and without direct risk to patients. Simulation training can be incorporated into an educational curriculum for acute care skills with targeted educational outcome measures at different levels: performance in simulation, clinical performance, behavior at the bedside, patient outcomes, and patient safety.

Steps to Develop and Implement Simulation Training

Simulation training is often sought as a solution for sentinel events or other serious patient safety events and for root and apparent cause analyses. Specific methods enhance simulation training as an intervention for quality of care and patient safety improvement.^11,12 By taking the steps outlined in Table 1-1, administrators can appropriately allocate educational and human resources to maximize return on investment. Organizational and provider buy-in and engagement in simulation training are ensured.

The first step is the problem identification and general needs assessment. Problem identification often requires systematic analysis such as root or apparent cause analysis. It is critical to perform a needs assessment from a simulation training perspective. It often starts by asking the following question: To what extent did clinical and behavioral skills of medical providers contribute to a particular patient safety event? A good example is a medical mistake where an epidural anesthesia continuous infusion is inadvertently connected to intravascular infusion pump tubing and infused intravenously. The most effective solution would be to introduce a “hard stop” mechanism to completely eliminate the possibility of connecting any epidural line to intravascular tubing. This can be done by making the type of epidural tubing and connectors specific for the epidural system. Educational intervention would not be as effective because this specific medical mistake did not derive from lack of education but from omitting an appropriate step that would automatically mitigate poor attention to details. This type of mistake is hard to eliminate by educational interventions. The second step is to perform a comprehensive needs assessment of the targeted learners. The educational needs assessment is defined as “a systematic process to identify gaps between the current conditions and desired conditions in learners.”¹² In this step, simulation educators can evaluate the true needs and collect necessary data to develop simulation training objectives, content, and activities. The third step is setting goals and objectives. A goal is a broad educational objective for simulation-based intervention, and objectives are specific measureable metrics for the simulation training. Objectives should include 5 basic elements: (1) who (2) will do (3) how much (how well) (4) of what (5) by when.¹² For “will do,” it is strongly recommended that clinical educators use observable action verbs that are subject to fewer interpretations. For example, “Understand the importance of 30 seconds of hub scrub” is not a good objective, because “understanding” cannot be directly measured. Define, describe, and demonstrate are much better words to use for objectives, because they have fewer interpretations for educators. The fourth step is developing educational strategies. Those strategies include different types of simulation training such as multidisciplinary simulation or psychomotor skill training using task trainers. Several educational strategies can be combined to address patient safety events. The fifth step is implementation. This step requires clinician educators to plan necessary resources and justify the investment in the phases of educational intervention. The sixth step is providing evaluation and feedback to learners. Educators should constantly evaluate the effectiveness of the intervention using actual patient-level process and outcome results and should modify the intervention based on the results. The evaluation should include assessment of return on investment for the simulation-based intervention.

How to Evaluate Training Effectiveness

Recently, the Society for Simulation in Healthcare conducted a multidisciplinary consensus meeting to develop a research agenda.¹³ A modification of the traditional Kirkpatrick levels of training evaluation was put forth to be used as training outcome measures:

1. Reaction (provider’s confidence level)
   
2. Learning (skill measures in simulation settings)
   
3. Behavior (clinical process in healthcare settings)
   
4. Organization (patient-level and hospital-level outcomes)

A recently conducted meta-analysis used this classification and reported simulation training outcomes as knowledge, skills, behaviors and patient outcomes.⁴ In this meta-analysis, skill evaluations in simulation settings were further classified as time skills (time to complete a certain task), process skills (process measures to complete a task in simulation), and product skills (outcomes such as success or failure to achieve a task in simulation). Behavior assessment in clinical settings was further divided by time and process. The levels of training effectiveness are also described from a translational research bench-to-bedside concept (Table 1-2).^14,15 In this model, promoted by McGaghie et al,¹⁴ 4 levels of translational outcomes exist: Tl (simulation setting), experimental studies in simulation laboratories; T2 (clinic/bedside), patient care practice (process measures); T3 (patient outcomes and community settings), patient level outcomes and overall effect on patient care in community settings; and T_value (return on investment or cost-effectiveness), the association of simulation interventions to achieve safer and more efficient care that benefits patients, providers, and systems.

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