Best Evidence Practical Guide on Simulation in Healthcarepassh.org/uploads/3/5/4/4/35444078/plenary3_evidence_hyun.pdfBest Evidence Practical Guide on Simulation in Healthcare Hyun

Best Evidence Practical Guide on Simulation in Healthcare

Hyun Soo Chung, MD, PhD

Associate Professor, Department of Emergency Medicine

Director, Yonsei University Clinical Simulation Center

Yonsei University College of Medicine

Yonsei University Severance Hospital

[email protected]

AMEE Best Evidence Practical Guide on Simulation in Healthcare

Ivette Motola, MD, MPHAssociate Professor of Emergency Medicine

University of Miami Miller School of Medicine

Director, Division of Prehospital and Emergency Healthcare

Gordon Center for Research in Medical Education

International Meeting on Simulation in Healthcare

January 13, 2015

Hyun Soo Chung, MD, PhDAssociate Professor

Department of Emergency Medicine

Yonsei University College of Medicine

Yonsei University Severance Hospital

Luke Devine, MD, MHPE, CHSELecturer

Division of General Internal Medicine

Mount Sinai Hospital

University of Toronto

Learning Objectives

• Review an effective approach to curriculum integration of simulation in healthcare education.

• Explain the importance of feedback and deliberate practice to effective learning using simulation.

• Describe how a mastery learning model leads to skill improvement and retention.

Overview

• Where are we now in simulation in healthcare education?

• Why this guide?

• A walk through the guide

Where are we now in simulation in healthcare education?

• Please refer to Paul Phrampus lecture slides from yesterday’s keynote speech.

I am a Good Guy from

Pittsburgh !

Why this guide? - Formula: Effective Use of Simulation

Training

Resources

Trained

Educators

Curricular

InstitutionalizationX X =

Effective

Simulation-based

Healthcare Education

Issenberg, SB. The Scope of Simulation-based Healthcare Education.

Simulation in Healthcare. 2006.

SIMULATED ENVIRONMENTSimulators

CLINICAL ENVIRONMENT

Identify learning need

Simulatorbasedpractice

Reapply skill

Review

Further practice as needed

Patients

Clinical

supervision

Teachersupport

Continue

Why this guide? - Educational & Professional Context

Why this guide?

International group of individuals, universities &

organizations committed to the promotion of

best evidence medical education

What are the features / uses of high fidelity simulations that lead to effective learning?

SB Issenberg et al. Medical Teacher 2005;27(1):1-28.

Why this guide?

Why this guide?

• Goal: To ‘operationalize’ the features from BEME into a practical, up to date guide for healthcare educators

• Provide information on current approaches relating to the day-to-day work of the healthcare educator

Why this guide?- Sections

• Curriculum Integration• Feedback in Simulation• Deliberate Practice• Mastery Learning• Range of Difficulty • Capturing Clinical Variation• Individualized Learning• Approaches to Team Training• Future Directions of Education Using Simulation

A walk through the guide

• Curriculum Integration• Feedback in Simulation• Deliberate Practice• Mastery Learning• Range of Difficulty • Capturing Clinical Variation• Individualized Learning• Approaches to Team Training• Future Directions of Education Using Simulation

Curriculum Integration

• “The simulation experience must be planned, scheduled, implemented and evaluated in the context of the broader curriculum”

• Critical to the success and effectiveness of SBHE

• Most powerful outcomes are achieved by having an organized and systematic approach to the incorporation of simulation in an existing or new curriculum

Curriculum Integration- Process

Plan

Develop

ImplementEvaluate

Revise

Curriculum Integration- Examples

Feedback

• Specific information given to a trainee about the comparison between observed performance and a standard, given with the intent to improve the trainee’s performance

• The “heart and soul” of simulation-based training

Feedback

Without a post-event reflective process,

what the participants have learned is largely left to chance,

leading to a missed opportunity for further learning,

and making the simulation encounter less effective.

The 3 P’s of Feedback

Plan

•How & when

•Consistent with learning objectives of session

•Feedback checklists/tools for facilitators

•Leave time for “emergent” objectives

Prebrief/ Prepare

•Pre-event preparation of learners

•Rules and Expectations

•Learning objectives

Provide Feedback/

Debrief

•Ensure simulator feedback meets goals (physiologic, verbal, haptic)

•Feedback during session

•Post-event Debriefing

Debriefing Models

• Plus/Delta

• Debriefing with Good Judgment (Reactions/Analysis/Summary)

• GAS (Gather/Analyze/Summarize)

• Crisis Resource Management

• TeamSTEPPS

• Korean model (?)

“Typical” Korean Student

• Overly submissive & humble

• Forbearing or yielding passivity

• Learn not to ask any questions

• Poor student-teacher interaction

• Few active students (externship abroad)

• Culturally embedded in strict neo-confucianism & authoritarian hierarchy

“Culture”

• Symbols

• Heroes

• Rituals

• Values

Hofstede’s Cultural Dimensions

Helmreich RL. Culture at Work in Aviation and Medicine. 1998

Chung HS. Simulation in Healthcare. 2013

Power Distance

Power Distance

During Debriefing…

• Negative feedback

• Scolding

• Learners favor feeding

You should

not make

that kind of

error!!

Individualism-Collectivism

Individualism-Collectivism

I hope this is

not a foolish

question?!

What might

the others

think of me?

During Debriefing…

• Passive

• Quiet

• Overly conscious

Uncertainty Avoidance

During Debriefing…

• Teacher focuses on the errors

• Students refuse to accept differences and/or changes

Chung HS. It is time to consider cultural differences in debriefing. Simulation in Healthcare. 2013

Deliberate Practice

• Repetitive Practice + Rigorous Skills Assessment + Feedback

• Coined by Ericsson in instructional science research

• Highly motivated learners• Identify well–defined task• Appropriate level of difficulty• Focused repetitive practice• Measurements that yield reliable data• Informative feedback• Opportunity to correct errors• Advancement to next level / skill

Acad. Med. 2004;79(Suppl):S70-81

Deliberate Practice

Acad Med 2011;86:706-11.

Acad Med 2011;86:706-11.

Study N Population Competency Assessed Randomized Trials

1. Wayne, et al, 2005 38 IM Residents Advanced Cardiac Life Support

2. Ahlberg, et al, 2007 13 Surg Residents Laparoscopic choleystectomy

3. Andreatta, et al, 2006 19 Surg Residents Laparoscopic skills

4. Korndorffer, et al, 2005 17 Surg Residents Laparoscopic suturing

5. Korndorffer, et al, 2004 20 Med Students Laparoscopic camera navigation

6. Van Sickle, et al, 2008 22 Surg Residents Intracorporeal Suturing

Cohort Studies

7. Issenberg, et al, 2002 98 IM Residents Cardiology skills

8. Barsuk, et al, 2009 18 Neph Fellows Dialysis catheter insertion

9. Butter, et al 2010 108 Med Students Cardiac auscultation

Case-Control Studies

10. Wayne, et al, 2008 78 IM Residents Advanced Cardiac Life Support

Pre-Post Baseline Studies

11. Wayne, et al, 2008 40 IM Residents Thoracentesis skills

12. Barsuk, et al, 2009 41 IM Residents Central venous catheter insertion

13. Barsuk, et al, 2009 103 IM Residents Central venous catheter insertion

14. Stefanidis, et al, 2006 18 Surg &Residents Laparoscopic suturing

Statistics for Each Study

Study Correlation and 95% CILower Upper

Correlation Limit Limit p-Value

0.81 0.70 0.88 0.0000.80 0.56 0.91 0.0000.67 0.40 0.84 0.0000.62 0.29 0.82 0.0010.52 0.17 0.75 0.0060.51 0.17 0.74 0.005

0.78 0.73 0.82 0.0000.61 0.29 0.81 0.0010.59 0.47 0.69 0.000

0.51 0.29 0.68 0.000

0.80 0.72 0.86 0.0000.79 0.70 0.86 0.0000.77 0.71 0.82 0.0000.71 0.55 0.83 0.000

0.71 0.65 0.76 0.000

Favors Traditional Clinical Education

Favors SBME with DP

-1.00 -0.50 0.00 0.50 1.00Overall Effect Size

Randomized Trials1. Wayne, et al, 20052. Ahlberg, et al, 20073. Andreatta, et al, 20064. Korndorffer, et al, 20055. Korndorffer, et al, 20056. Van Sickle, et al, 2008

Cohort Studies7. Issenberg, et al, 20028. Barsuk, et al, 20099. Butter, et al 2010

Case-Control Studies10. Wayne, et al, 2008

Pre-Post Baseline Studies11. Wayne, et al, 200812. Barsuk, et al, 200913. Barsuk, et al, 200914. Stefanidis, et al, 2006

Deliberate Practice Meta Analysis

Mastery Learning

• Critical component of competency-based education

• Goal: All learners consistently achieve objective level of mastery performance

• Time: variable

Mastery Learning

• Model:

• Establish assessment and minimum passing standard;

• Baseline assessment;

• Clear objectives, units in increasing difficulty;

• Engagement in educational activity;

• Testing for mastery;

• Advancement to the next training level; or ongoing practice

• Essential Components

• Outcomes

• Increasing level of Difficulty

Source: Barsuk JH, Cohen ER, Caprio T, et al. Simulation-based education with mastery learning improves resi

dents’ lumbar puncture skills. Neurology 2012; 79(2): 132-37. Reprinted with permission of Wolters Kluwer Heal

th.

Clinical skills examination (checklist) pre-and final posttest performance of 58 first-year simulator-trained i

nternal medicine residents and baseline performance of 36 traditionally trained neurology residents. Thre

e internal medicine residents failed to meet the minimum passing score (MPS) at initial post-testing. PGY

– postgraduate year.

Mastery Learning of Lumbar Puncture Skills

Range of Difficulty and Clinical Variation

• Learning optimized with stepwise progression to increased levels of difficulty and complexity as mastery achieved

• Shift the learning curve

• Train for rare events

So much complexity in the healthcare, thus too many

things to learn!

I have already worked 80 hours this week! No more

working for me!

Hospital is only interested in how many “profitable” patients I see!

And I get promoted through my research publication, not by

teaching a lot!

I do not have the luxury to devote my time to teaching!

I’m not just old, but have DM,

HTN, ESRD, MI, stroke, and have a forearm fracture!

Are you sure you can handle me?

Range of Difficulty

• Cognitive load and complexity of intervention must be appropriate to learner level

Level Population Tasks Example

11st year medical s

tudentIdentify finding “I hear a fourth heart sound.”

22nd year medical s

tudent

Correlate finding with und

erlying patho-physiology

“This fourth heart sound is cau

sed by an increased after-load

on the left ventricle.”

33rd year medical s

tudent

Generate a differential dia

gnosis

“Possible causes are aortic sten

osis, hypertension, etc.”

42nd year internal

medicine resident

Make a management decis

ion

“Order an EKG, consult a speci

alist, initiate medical therapy.”

Example: Cardiac Bedside SkillsThe University of Miami developed a multi-year cardiac bedside skill curriculum in

which the difficulty of each task increases with each stage of training.

Cardiac Finding: A simulator presents a fourth heart sound at the apex.

Simulation as a Solution

• Medical error reduction and patient safety

• Learner-centered, individualized learning

• Outcomes-based education

• Needed exposure to range of clinical cases

• Studying human factors

• Supplant animal and live-tissue models (as technology & tissue fidelity continues to improve)

• Accreditation and Licensure

Terima kasih

ありがとうございます

謝謝

Salamat po

धन्यवाद्

شكرا جزيل

MahaloThank you

Danke schon

唔該