Sophisticated Clinical Simulation Program Raises the Bar

"Sim Baby" is having a very bad day on the operating table. The tiny manikin wails like a baby, and its tiny belly rises and falls beneath the mint green hospital gown. A pulse-oxygen clip on a finger sends off a steady red blinking light.

 

Yesterday, Sim Baby played a small patient who was in for a neck cyst removal but then suddenly went into cardiac arrest. Today, she is a 1-year-old child with Down Syndrome who is having tubes placed into her ears. But as soon as the anesthesiology residents place the mask on the baby, the simple procedure becomes complicated.

 

At a control monitor in another room behind a one-way window, Lianne Stephenson, MD '03, an assistant professor of anesthesiology at the University of Wisconsin School of Medicine and Public Health (SMPH), points the mouse and clicks. Suddenly Sim Baby is seizing on the table.

 

"Is that a seizure? That sure looks like a seizure," says senior resident Ashley Jensen, MD, as she discusses whether to stop the procedure. But the seizure ends, and all is good, until Stephenson clicks the "severe brady" button, to simulate bradycardia, the slowing heart rate that may accompany inhaled anesthesia or undiagnosed heart problems associated with Down Syndrome.

 

The residents debate and then administer atropine, and Sim Baby recovers, only to suddenly start retracting its chest, signaling that its larynx is in spasm. The residents struggle to intubate the baby, and are successful, despite the fact that Stephenson has programmed the airway to constrict.

 

Later, in the debriefing room, they talk through their actions, whether they were transparent in communicating their thoughts with each other during the exercise and what other choices they could have explored. Stephenson, a fellowship-trained pediatric anesthesiologist at American Family Children's Hospital, and the residents trade tips, anesthesiology war stories and advice about how to be more prepared next time.

 

"What I like best about simulation is that medicine is normally so busy, we rarely get time to sit down and talk through these judgment calls," Stephenson says. "We can also practice identifying and treating conditions such as malignant hyperthermia, which an anesthesiologist might never encounter but should be prepared for."

 

Since Sim Baby is made of vinyl, no actual patients are harmed in the learning process. As Richard Page, MD, chair of medicine at the UW School of Medicine and Public Health, likes to say, "The beauty of simulation is that you can have the post mortem without the mortem."

 

Welcome to the new, $6 million UW Health Clinical Simulation Program, which celebrated its grand opening November 1, 2011. The gleaming new 6,500-square-foot facility located on the first floor of UW Hospital and Clinics has been in the works for two years.

 

The program is modeled on those at Stanford University, Mayo Clinic and the University of Pittsburgh, but may be in a class by itself when it comes to flexibility. Each of the six rooms can be set up in varying configurations of beds occupied by a variety of high-tech manikins.

 

Improving the Quality of Care

 

Video: The UW Health Clinical Simulation Program opens its new facility.

Perhaps the strongest advocate for the program is K. Craig Kent, MD, chair of the Department of Surgery at the School of Medicine and Public Health, who made building a simulation program a priority when he arrived in 2008 from New York Presbyterian Hospital and the Weil Cornell Medical School.

 

"There are many arguments in favor, but most important is that simulation is at the forefront of improving quality of care," Kent says. Given metrics that guide ratings of a hospital's quality, the old days of "see one, do one, teach one" learning on the job are long gone.

 

As a vascular surgeon, Kent has seen how a simulation program can improve effectiveness.

 

"When I put in a carotid artery stent, there may be 18 steps in the process," he says. "It helps if you practice that four or five times before the first time you perform the procedure on a patient. The value of that is incalculable."

 

Actually, Kent has conducted research that showed the value of simulation for residents who had never before participated in a catheter intervention. Those who practiced first in a simulated learning experience received higher grades from their mentors, and performed better on measurable surgical statistics, according to a 2006 study Kent published in the Annals of Surgery.

 

Simulation is part of the future of surgery, Kent says, explaining that very soon, not only will residents have to prove their skills on simulators before they can be board certified, veteran surgeons will also have to perform well on simulations to be re-certified.

 

The same is already true in anesthesiology, where specialists must engage in simulation drills to be re-certified. Robert Pearce, MD, chair of the Department of Anesthesiology at the UW School of Medicine and Public Health, says there are currently 27 programs in the United States that provide training that satisfies the Maintenance of Certification in Anesthesiology (MOCA) requirements, and he expects the School of Medicine and Public Health to join that group.

 

"Anesthesiologists have driven advances in simulation because of the strong focus of our specialty on patient safety," he says. Pearce likens simulation training in rare medical events to the way airlines train pilots by programming info from "black boxes" retrieved from crashes so that the new pilots can learn from the disasters of the past.

 

"It is useful for training in events that don't happen often, but that you want to practice so you can respond quickly, the same way the pilots responded in the 'Miracle on the Hudson' airplane crash," Pearce says.

 

George Keeler, MBA, the UW simulation program manager, agrees, adding that simulation is one area in medical education in which mistakes are encouraged, so people can learn from them. For example, one simulation includes a scenario in which the patient is given the wrong type of blood from the blood bank and team members are judged on how quickly they realize the error and respond.

 

Interdisciplinary teamwork simulations are key, Keeler says, because research suggests that 70 percent of health care errors are due to miscommunication.

 

The Wisconsin Idea in Action

 

The program is a joint project of UW Hospital, the School of Medicine and Public Health and the UW Medical Foundation. The William S. Middleton Veteran's Hospital, the Madison Fire Department and others have also supported the program and will be active participants.

 

Jon C. Gould, MD '96, spent several years planning the program and served as its first medical director before he left the School of Medicine and Public Health this summer to become chief of general surgery at the Medical College of Wisconsin.

 

Gould says he became convinced of the benefits of simulation after he returned from fellowship training in laparoscopic surgery and wanted to share what he had learned with new residents. Gould was so commited to building the UW Simulation Program that he organized his classmates from the Class of 1996 to donate to it.

 

Supporters of the simulation program can be found throughout the School of Medicine and Public Health faculty.

 

"It's the future of medical training, and we will be leaders in that future," says Page, a cardiologist who envisions physicians and care providers from around the state coming to campus to train and be certified.
"Both UW Health and the SMPH take our role as the state's teacher very seriously," he says. "This is the Wisconsin Idea in action."

 

The new simulation program will allow many types of research, because each of the main rooms has six nodes that gather and pull together data that can later be evaluated.

 

But Kent says that some of the most important aspects of simulation involve the human element - evaluating the ability of people to work together as a well-honed team, and assessing their interactions with patients and families.

 

"One of the most difficult days for a young physician is the first time he or she has to tell a family that their loved one didn't make it," Kent says.

 

He has watched as residents evaluated film of each other interacting with actors playing bereaved family members and witnessed how they learned from each other, and from their own mistakes.

 

"This is the type of experience that helps you learn the art of medicine, and ultimately become a better doctor," Kent says.

 

Kent envisions the simulation program giving the School of Medicine and Public Health the ability to train surgeons in new devices and procedures, saying it may draw practitioners from around the country for training.

 

The training aspect is also true for trauma and emergency medicine. UW Hospital trauma coordinator Amy Stacey, NP, says the simulation program will be used for teaching Advanced Trauma Life Support (ATLS) courses.

 

She especially appreciates the ability to simulate a fast-moving trauma situation, in which a large team of physicians and nurses from a variety of specialties work together on a single patient. It will be good for training new trauma residents at UW Hospital, but also important for physicians who come to Madison from around Wisconsin for ATLS courses.

 

"As a level-one trauma program, we are required to offer outreach learning to our referring facilities, and we have people coming in from around the country for these courses," Stacey says. "For example, simulations can be very valuable to a hospitalist who may be the only physician on site at night in a small community hospital and who doesn't get to see some of these situations on a regular basis."

 

Simulation Benefits Research

 

The program is also building research ties, such as the one with Robert Radwin, PhD, a UW biomedical engineering professor. He works at the "CAVE" that's part of the Living Environments Laboratory in the new Wisconsin Institutes for Discovery.

 

The CAVE lets scientists create 3D virtual operating rooms to test how people interact while delivering patient care. Radwin creates virtual surgical and medical procedures for improving healthcare tools and devices, including a simulation of an ER trauma bay. The ideas created in virtual space at the CAVE may later be tried out at the simulation program space at the hospital.

 

Besides "Sim Baby," the simulation program offers a whole family of teaching manikins. These range from single-purpose training torsos such as "Chester Chest" and "Peter PICC Line" to more complex devices, such as the "HeartWorks" torso that allows cardiologists, anesthesiologists and cardiothoracic surgeons to practice taking ultrasound images (echocardiography), either through the chest wall or down through the esophagus.

 

These ultrasound views of the heart show up on the screen, which also includes an online teaching text about cardiac physiology.

 

Sophisticated Teaching Tools

 

Probably the most sophisticated manikins are the Meti HPS (human patient simulator) models. These manikins can respond to drugs (they react based on reading a scan of the drug's barcode), can "breathe" in anesthesia gases and expel carbon dioxide, and react to exams with thumb twitches and pupils that automatically dilate and constrict depending on the light.

 

The cousins of the HPS manikins, models named i-Stan and 3GMan, react with visible cyanosis in the nail bed, chest flail, realistic secretions from the nose and mouth, and trismus, or lockjaw, just to make placing that airway tube extra difficult.

 

Physicians from around the state can look forward to meeting the sophisticated teaching tools as the UW Simulation Program soon shifts into high gear.

 

Just don't call them "Dummies." With their high-tech training features and human-like responses, a better name for Sim Baby and her relatives might be "Smarties."

 

By Susan Lampert Smith

This story appears in the fall 2011 issue of Quarterly.

Date Published: 11/16/2011