Reducing Sepsis with Simulation

  Healthcare can be tough. We try to do a lot with limited resources.

What if you could do something that made a life saving difference about one time in every eight patients? Would it be even better if you knew that it was saving the system money?

The golden intersection of providing better care, in a cheaper manner is a rarity in medicine. It seems to be too good to be true. However, we know that goal directed sepsis care can attain both of these criteria.

Collectively, we have known since the early 2000’s that the algorithmic approach to sepsis care has a remarkable ability to save lives. Studies have shown that treating as few as 6 – 8 patients with goal directed sepsis care can result in a life saved. The problem has always been translating the knowledge into performance in the hospital setting. Preliminary work at the University of Alberta (Brindley et al) published as letter to CJEM editor in 2007 showed that this knowledge translation can be accomplished with simulation.

Elaine and I attended an impressive seminar in San Diego given by a group from Mercy Hospital in the Dignity Health System. They were faced with an impressive task. Educate hundreds of staff on a limited budget and show improved outcomes combined with cost savings. They were tasked with reducing sepsis mortality within the organization by 5%. They had a 60 month time frame and an overall budget of $1.7 million dollars (that sounds like a lot – but includes the cost of replacing people during their training time!)

The group came up with a program of online lectures and high fidelity simulation. They tested everyone pre and post hi fidelity activities. There was notable staff improvements in confidence, knowledge of the criteria and on fluid management. There was also an overall greater recognition of sepsis within the organization with call volumes to the screening team doubling in the 6 months after training was completed.

What were they able to accomplish in the review after the program roll out?

Mortality cut by 25% Estimated 1296 lives saved Est $50 million (yes million!!) dollars saved – in an organization with approximately 300 inpatient beds!!!

Or to see a few more examples of successful programs using simulation to train staff about sepsis at other centres click here. That seems to be time and money well spent! Simulation is a powerful learning tool that can be translated directly into favorable patient and economic outcomes. ….not to mention that it is fun 🙂

Stay tuned for more…….

Kish

Forward Looking Evaluations…..

Now that we have the keys to our new Simulation Centre, it is time to shift our thinking to what’s next. How will we maximize the value that our centre can add for our patients, staff and students?

A recent paper that I’ve been writing has required me to look backwards and examine how the discourse around simulation has developed and how it has evolved. So why have we been quite slow to adopt simulation within healthcare compared to the airline industry, engineering and the military to name a few? What’s held us back?

One of the major reasons is that until recently there hasn’t been strong scientific evidence to suggest that simulation changes outcomes at the bedside…. Even the meta-analysis that Kish recently reported on was able to highlight only ‘moderate effects for patient related outcomes’…. remembering though that it did find ‘large effects for outcomes of knowledge, skills and behavior’.

So what can we do differently in our lab and what’s my challenge to each of us as educators?

I believe one place to start was highlighted in a recent article by M. Kaas (2011), Evaluation of Simulated Learning: Looking Backward & Forward. In the article Merrie suggests that she has noticed that evaluation of a simulation experience usually comes as an ‘afterthought’ – once we’ve already designed our simulations. The focus of the evaluation is more on the success of simulation as a teaching strategy rather than on the learning that can be applied to future clinical situations.

Is the technology a method of achieving the outcomes, or does the technology become the experience? 6 months after this simulation, what do I want the learner to know? How can we develop forward-looking evaluations for simulation? Merrie offers, that by starting backwards with the learning outcomes, we can keep our attention on the critical content and not on the technology.

So what was her advice on how to go about this? Well in her practice she suggests she has redefined her outcomes and:

Rather than evaluate the performance skills and knowledge just learned in the simulation, I am addressing specific skills and knowledge students need to have to be successful in a variety of clinical situations and working with the simulation lab staff to provide more practice and feedback opportunities. I am also now incorporating student reflections to help them integrate knowledge, feelings, and values into their practice. During simulation debriefing sessions, the students and I discuss future clinical problems that the simulation prepared them for or not (p.253).

I think Merrie offers some good advice for us as we are starting out.

We have an opportunity in our centre to perhaps do things a little differently… and I believe our centre presents us with an opportunity for more than just a ‘moderate’ change to patient related outcomes.

Your thoughts?

Laureen

Proud New Sim Centre Owners…..

As you’ll see from the pictures below – we are now the proud owners of a Simulation Centre. As of April 5th, the final inspection was completed and we were handed the keys to our centre. Not that the work is by any means done, but certainly we’ve reached a significant MILESTONE.

There are so many people and groups that I need to thank as we move forward -especially our project team, the RQHR for donating the space and the C of Medicine and the HRF for the funding….

April will be a busy month as we install all of the technologies, set up the mannequins and move in.

An official grand opening and the announcement of the centre’s major sponsor is planned for late May… but if you find yourself on Level O-D, please do stop by. Stay tuned – it will soon be your turn to start using and posting on the value you’ve seen from training in our new centre.

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Thanks as always for your support & interest in the project.

Laureen

The Finish Line is Now In Site >>>>>>

Good morning simulation community,

As you’ll see from this week’s construction walk through – we are closing in on our goal. We remain on target to have the keys to our centre on APRIL 5th. Then our colleagues from housekeeping will be by to do a major clean (thanks to the housekeeping group for this as I understand its  A LOT of work). After that…. it’s all tech, all the time – while we spend the month with the group from EMS (Educational Management Solutions) installing our software and viewing components.

Centre furnishings will also be arriving mid-April.

Work is underway with the HRF (Hospitals of Regina Foundation) to plan our grand opening; where we’ll finally get to thank our donor, RQHR and the College of Medicine for their belief in and support of this project. We also have a number of open houses planned for the spring and summer – so we hope you’ll stop by.

FYI, the phone is already ringing to book the centre, so if you have an upcoming educational session where your learners could benefit from hands on skill practice, practice, practice….. please give us a call at 3683.

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Thanks for stopping by. Find one of us if you have questions…..

Laureen

Does Simulation Make a Difference?

It’s a difficult question… the answer complicated. If you want the quick answer, skip to the bottom. Otherwise, enjoy the read

Simulation is becoming an important part of medical education. In the US, agencies such as the AHRQ have devoted entire funding blocks to simulation research to try to determine the effect of simulation on patient safety and physician skill.

It is generally accepted that simulation enhances learner engagement and allows for repetition of skills in a non threatening environment. It also allows for the opportunity to showcase rare clinical events with relative ease. Despite all of these seemingly positive attributes, evidence for simulation in education was/is somewhat lacking.

I had the privilege of attending a session at IMSH  by Dr David Cook (Mayo Clinic Medical School) and Dr Rose Halata (University of British Columbia). Their group has published the largest study to date outlining the evidence for simulation ( JAMA Vol 306 Sep 7 2011). This is the first large meta-analysis published on the topic. They scanned over 10,000 articles narrowing the search to 609 studies involving over 35,000 participants (students, nurses, physicians, paramedics) with the goal of answering the following question:

 To what extent are simulation technologies associated with improved outcomes versus no intervention?

The results are interesting. About 4% of the studies showed little or no benefit to using simulation with the remaining 96% of studies showed varying degrees of positive effects. The most marked effects were noted in the areas of: knowledge, time to complete a task, overall result (known as “product skills”), and behaviors. Of the 32 studies that looked into the effect on patient care, the results were mixed  – still showing modest improvement, but 2 studies showing a negative effect. This is somewhat surprising, but is likely confounded by the large heterogeneity (difference) found between the study groups and less defined outcome measures.

It is quite impressive to see the effect that simulation has on the above noted areas. Rarely does a meta-analysis yield such striking results. It is even more impressive if one considers the variables that are in play,and the nature of the participants and their learning experiences. Despite these confounding variables, simulation statistically outperformed the other interventions.

 Although this study is affected by the same biases of any meta-analysis such as study size bias, study selection bias and Simpson’s Paradox, it should be applauded for its sheer scope. Clearly determining the effect of simulation on learning is a monumental task.

What is quite clear, however, is that simulation is an inherently effective method of teaching many groups of learners and that it is here to stay. As more literature becomes available, this distinction will become even more clear.

So….

Does simulation make a difference?  YES

Stay tuned for further updates …..

Kish

That’s a lot of cable….

We have lots to tell you about simulation, but the team has been busy ‘doing’ and ‘preparing’ over the past 2 weeks rather than writing. So we’ll catch up soon….

From the latest pictures, you’ll see we have color, flooring and the grid for the ceiling now in place. The mill work is scheduled to arrive next week. Now we move on to all of the technical components – pulling cable and finding destinations for all that wire you see Kish holding.

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We are scheduled to move in early April and that’s when we’ll be installing the centre software and AV equipment. A grand opening and centre tours are in the planning stages.

Stay tuned.

Laureen

What’s Been Happening?

In case you’ve been waiting or wondering….. here are the latest snapshots from the construction walk through February 15th, 2012.

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With the number of bookings that we already have for the centre, we are glad that the project remains on schedule.

Thanks for stopping by.

Laureen

What do spy movies & simulation have in common????

 

I love spy movies. It’s a guilty pleasure. Despite the fact that they all seem to have the same plot, I keep coming back for more. The common thread of all of these movies (besides explosions and car chases) is the alteration of a character’s reality by someone else. This change in reality forces the hero to confess, get caught, etc.

Simulation is just like this. We can alter the reality that a learner experiences in order to accomplish an objective. This is termed ‘fidelity’. Simply defined, fidelity is the degree of realism experienced by a learner. This can be done using high-tech means via virtual reality and patient simulators or low tech via something as simple as an orange to practice IM injections.

One would think that the higher the fidelity, the better learning experience that occurs. Deep and realistic environments can be immersive and engaging. High profile athletes often practice on the same field before the big game to get the feel of the turf and the acoustics of the building. In fact, the New York Giants even incorporated a break in the practices exactly the length of Madonna’s half time performance so they would know what the rest before the second half would feel like (it worked – they won the Superbowl).

Interestingly, that is only part of the picture. For learners just being introduced to a subject, high fidelity can be distracting from the objective at hand. Just think about learning to luge…… Practicing on an Olympic track would be futile (not to mention dangerous) before the basics were mastered.

So it seems that fidelity can be a double-edged sword: immersive, engaging and memorable on one hand – distracting and overwhelming on the other.

At IMSH this year there were many abstracts on the topic of fidelity. We know that simulation is very effective at teaching medical knowledge, skills and behavior. The jury is still out on when to incorporate higher fidelity and when to use low fidelity approaches. We will monitor this debate in the literature at the sim center and aim to provide the appropriate activities given the objectives at hand.

Exciting stuff! Stay tuned for more…

Kish.

Kish and Elaine are back from IMSH…..

I’m turning blogging duties over to Kish for the next while as he has lots  of great things to tell you about IMSH this year……. like we needed to get Kish even MORE excited about life LOL.

Elaine and I just had the privilege of attending IMSH 2012. The International Meeting for Simulation in Healthcare was held this year in San Diego California. This is the second IMSH that I have attended (the prior one was held in New Orleans last year). I was very excited and eagerly counted down the days until the conference opened.

This year didn’t disappoint. Over 2900 delegates from 21 countries! There were over 250 educational sessions, lecture and workshops. Every conceivable occupation was represented from Doctors, Nurses, RTs and EMTs, to Military Personnel, technical support and programmers. This brought together the most famous names in simulation in a fun, supportive environment. Canada was well represented with teams from most provinces and a strong showing from the West. Representatives from BC and Alberta gave fantastic presentations on research and ongoing projects.

Keynote addresses were given by some distinguished faculty. Dr Paul Haidet from Penn State gave the opening address on “the Jazz of Team Communication” where he compared interpersonal communication to jazz music. Both need some structure but only flourish with some freedom. Dr Josef F Schmid who is the flight Surgeon and lead for medical information at the Johnson Space Center, gave the second major plenary. He described what it is like to be the “family doctor” for astronauts as well as some of the major logistical problems that they encounter. He also discussed the use of simulation and why it is important we experience what our patients do. (He gets to fly around in fighter jets!!)

Choosing an itinerary at IMSH is a formidable task. There are literally hundreds of sessions, workshops, and discussions. The best educators in the world give these sessions, and choosing only a few courses is a difficult task. Its so difficult, that it’s the first conference that I have been to that encourages the use of an interactive web app combined with a smart phone to find your way around!!! I attended sessions focusing on interactive learning, video editing, crisis resource management, debriefing skills and sepsis education. There were many incredible speakers and sessions. I can’t wait to share what I have learned. Stay tuned for more posts!

Kish

Another photo opportunity…

Good progress has been made since we did our last walk through. The construction team tells me we start painting next week.

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Thanks for stopping in again.

Laureen