Simulation Improves Quality and Safety

Children's Hospitals Today, Winter 2009

by Sallie Strang
Director, Communications

Simulation-based training began in the aeronautics field and graduated to state of the art at NASA with the training of astronauts. Today, children’s hospitals are perfecting their own applications of this learning methodology to meet the training needs of health care providers and to improve quality and safety in patient care. These profiles of simulation training programs provide a glimpse into three different aspects of simulation education at children’s hospitals – mannequins, role-playing actors and PC-based simulation programs.Lou Halamek with simulation equipment

As a young boy, Lou Halamek sat entranced watching televised Apollo astronauts carry out exercises honed to precision through months, even years, of practice in realistic flight simulators. Years later as a college baseball pitcher, Halamek followed a rigorous, intense practice schedule, honing his skill under realistic conditions, first, to identify weaknesses and, then, to remedy them. Then as a new physician specializing in neonatology, Halamek discovered a missing link in his medical education – practice. “We were expected to do arterial sticks on real patients without much practice on realistic models,” says Halamek, lamenting that this methodology does not serve patients well, especially pediatric patients and their families. But how to get this practice? How to pinpoint the weakness and then practice, practice, practice for the time when things do go wrong.

A fortuitous encounter brought Halamek together with the man who wrote simulation protocols for the Apollo program, teaching astronauts how to be ready when things go wrong. A few hours of intense discussion made Halamek an advocate for simulators in the medical setting.

Today, Halamek is an attending neonatologist in the neonatal intensive care unit at Lucile Packard Children’s Hospital at Stanford in Palo Alto, CA; he runs the fellowship training program in neonatal-perinatal medicine in the department of pediatrics at Stanford University and is the founder and director of the Center for Advanced Pediatric and Perinatal Education (CAPE), the world’s first training center dedicated to fetal, neonatal, pediatric and obstetric simulation. And Halamek is committed to the incorporation of technology into medical education, especially technology that can improve performance. He has brought into sync the training techniques from three loves in his life: space travel, baseball and medicine.

At CAPE, multidisciplinary teams work through simulated clinical scenarios captured on videotape and played back during debriefings. Simulation-based team training exercises are also strategically rolled out within Packard Children’s. By identifying and remediating both human and system weaknesses, the approach that proved successful at NASA is helping change the culture at Packard Children’s.

CAPE programs also serve as a national model. Since 1997, its NeoSim program has enhanced cognitive, technical and behavioral skills necessary for successful resuscitation of the neonate. The success of NeoSim has led to its adoption as a model for change by the American Academy of Pediatrics Neonatal Resuscitation Program, the national standard for delivery room resuscitation. To date CAPE has trained provider and instructor teams from most of the 50 states and more than 20 foreign countries.

Halamek, like many of his colleagues in simulation education at other institutions, strives to move simulation from novelty to standard operating procedure. In addition to performance and patient safety improvements, he also points to the return on investment for the institution. “In health care we know that the opportunity to fail increases when low volume couples with high risk. The ability to practice in a safe environment where no patients can be harmed is extremely valuable. Replacing lectures and passive learning with active, immersive experiences can reduce not only the time required but also the cost of training. The most learning often comes from the debriefing discussion,” says Halamek. “Both educators and trainees gain more from the simulation exercise.”

Learn more about CAPE and the simulation program at Packard Children’s.

Standardized Patients Enhance Learning

Mary Cantrell, director of the PULSE Center (Pediatric Understanding and Learning Through Simulation Education) at Arkansas Children’s Hospital in Little Rock, says debriefing is the heart of the education process. To support her emphasis on debriefing, Cantrell describes a scenario designed for new residents who had never worked in the emergency department. As residents responded to an emergency code and worked to resuscitate SimBaby, a trained “mother,” loud and upset, lingered in the ED room. An attending physician tried to console the distraught and distracting “mother” by staying at her side during the encounter.PULSE Center at Arkansas Children's Hospital

In the debriefing immediately following the scenario, the physician asked the residents if they were bothered by the mother’s distracting behavior and why they had decided to let her remain in the room. One resident confessed that the mother certainly added to the stress in the situation, but because the mother was at the physician’s side that connoted permission to stay, so he could not ask her to leave. The discussion then centered on who has ultimate control in the room; could a resident actually trump the attending to make the environment more conducive to care?

“Situations like these,” says Cantrell, “are safe environments for learners. It is open and receptive and allows them to step back and evaluate their own behavior.” Cantrell is a big advocate for using SPs – standardized parents/patients/physicians – who are trained to simulate the actions of real people and add another dimension to the world of simulation.

“Children,” Cantrell says, “walk in with an entourage. And we are interested in treating the whole entourage.”

The PULSE Center at Arkansas Children’s opened in February 2007 with the objective of structured clinical instruction. Since then, it has been a busy place with a multidisciplinary slew of clients including: nursing units, ER fellows and physicians, clinical care fellows, anesthesiologists, pediatric residents, transport team, adolescent medicine, PICU, cardiac ICU, ECMO (a machine that diverts blood flow and provides oxygenation allowing heart and lungs to rest and heal), security guards and pediatric chaplains.

Working with social workers and academy trained security guards, the PULSE Center focused on scenarios involving SPs representing a homeless person, divorced parents in a bad relationship, and a teen threatening suicide and becoming violent. Child life workers helped develop scenarios similar to actual incidents. Pediatric chaplains were able to identify gaps in the training of new recruits because the simulation exercises “gave them the ability to watch like they have not been able to watch before.”

“Everyone who participates in simulation training is intelligent and well trained and wants to improve,” says Cantrell.

Learn more about PULSE at Arkansas Children’s or learn more about standardized patient educators.

Computer Programs Boost Competency

Kathleen Ventre, M.D., medical director of the George and Esther Gross Clinical Simulation Program at Primary Children’s Medical Center in Salt Lake City, adds yet another dimension to simulation education. She uses innovative, interactive computer technology in orientation and continuing education programs for hospital staff.

The Primary Children’s simulation center opened in September 2006 and has serviced more than 2,000 participants. The center incorporates both computer screen-based simulation and high fidelity mannequin-based simulation in its overall clinical simulation program.

In January 2007, Ventre’s team posted an innovative simulator on hospital computer terminals that allows interactive pediatric resuscitation training at the patient point of care. “We were introducing simulation in the daily life of health care workers,” Ventre says.

The computer-based simulator portrays realistic pediatric emergency scenarios that require quick decisions. The trainee works independently on the computer and is able to monitor the results of his or her actions on the computer screen by watching dynamic photographic images of the simulated patient and a real-time, audible cardiac monitor display. The software also generates a score of overall performance during the scenario. “Watching teams handle arrest scenarios with mannequins makes evaluating individual competency difficult. The PC is a key element in objectively and effectively assessing competency,” says Ventre. “It is an integrated part of multipart simulation training.” After demonstrated knowledge of protocol is established on the computers, the student moves on to the mannequin lab for the second phase where training focuses on team-based behavioral skills.

For residents and fellows whose time in the hospital is strictly regulated, the computer program offers the benefit of availability outside the hospital.

The computer-based point of care simulations supplement the program’s formal Pediatric Advanced Life Support (PALS) curriculum. For nurses or anyone PALS certified, quick reference cards serve as standard cognitive aids, but these depend on familiarity to find the right card when an emergency occurs. The computer program teaches PALS certified providers to navigate this card system efficiently. This system has benefited nurses, physicians, emergency medical services and transport personnel, respiratory therapists, and pharmacists.

Ventre ask a crucial question: Once health care providers obtain initial resuscitation training, how quickly do newly acquired skills begin to degrade? She doesn’t have a quantitative answer to this question. However, integrating the computer training program into the daily routine of health care workers can influence quality improvement in skills acquisition and maintenance; this is especially important for care givers who handle emergency cases infrequently.

Ventre, a critical care physician, introduced the hospital to computer program development and studies begun by Howard Schwid, M.D., anesthesiologist at the University of Washington School of Medicine. Schwid’s research concentrates on developing both mannequins and PC-based programs. Ventre has worked with Schwid to develop, test and launch pediatric-specific computer programs at Primary Children’s.

Learn more about simulation education at Primary Children’s.