Researchers look at benefits and applications of medical simulation

Emergency medicine physicians and simulation experts from Rhode Island Hospital discuss the benefits of advanced medical simulation in five manuscripts appearing in the November 2008 issue of Academic Emergency Medicine (now available online).

The articles describe how simulation centers, along with new portable simulation technology, offer unique training opportunities for dynamic, complex and unanticipated medical situations in acute care fields. At the same time, the authors show how to guide team training and create new tools to measure teamwork effectiveness.

New advances are taking standard simulation techniques and manikin technologies currently used in simulation centers to a portable platform. In the first article, "Educational and Research Implications of Portable Human Patient Simulation in Acute Care Medicine," the researchers describe the adaptation of simulation techniques and manikin technologies for portable function. These new programs can relieve some limitations of traditional simulation, with an emphasis on the effects on acute care and disaster training. For example, mobile portable simulation allows on-site training in highly specialized clinical practice such as critical care transport medicine. Progressive simulations, i.e., longer-duration events that follow a simulated patient through sequential care environments, are also highlighted. These create an opportunity to study healthcare systems integration, continuity of care and transitions as well as the medical care delivered at each point of care. Lead author Leo Kobayashi, MD, notes, "Areas of education and research in acute care medicine are expanded by portable simulation's introduction of new topics, fresh perspectives and innovative methods."

The second article focuses on team performance in emergency medicine − "Defining Team Performance: Methodology, Metrics and Opportunities for Emergency Medicine." Rhode Island Hospital physicians Marc Shapiro, MD, and Gregory Jay, MD, PhD, led a consensus panel which identifies that "teamwork is a complex construct requiring metrics broad enough to capture the cycles of performance and yet sensitive and precise enough to assess a single behavior. No single measure can capture overall individual or team performance; it is helpful to measure both team process and outcomes to avoid the pitfalls in relying on 'one single inadequate criterion.'"

With this in mind, the panel reviews existing team performance metrics in health care, proposes a scientific methodology for simulation-based training (SBT) (including development of simulation scenarios and evaluation tools), and focuses on leadership as a target for SBT team training. Four core principles are proposed for effective team training and assessment:

1. Team-based competencies must be established in advance for effective training and assessment.
2. Carefully crafted simulation scenarios must be offered for guided teamwork practice.
3. Team performance, strengths and weaknesses must be objectively diagnosed.
4. Feedback must be linked to learning outcomes to develop effective debriefing protocols following a simulation exercise.

In a third article, "Advanced Medical Simulation Applications for Emergency Medicine Microsystems Evaluation and Training," a consensus panel led by Kobayashi and Frank Overly, MD, examines the role of simulation-based exercises in the assessment and improvement of small-scale clinical systems (microsystems) in emergency medicine. The panel suggests that focusing simulation on these microsystems creates distinct benefits: it introduces the possibility of working on higher-order, acute care functions while also enhancing system capabilities to respond to situations that are highly dynamic, unanticipated, incompletely specified, or otherwise problematic. Kobayashi comments, "Quality by design is made possible through use of simulation methods that create an engineered window on the system."

RIH simulation experts were also instrumental in developing two other manuscripts for the consensus conference. Shapiro contributed substantially to "Toward a Definition of Teamwork in Emergency Medicine," while Kobayashi served on the panel that generated "Defining Systems Expertise: Effective Simulation at the Organizational Level--Implications for Patient Safety, Disaster Surge Capacity, and Facilitating the Systems Interface." David G. Lindquist, MD, Mary L. Salisbury, RN, MSN, and Andrew Sucov, MD, are among the additional physicians and staff from the simulation center at Rhode Island Hospital involved in developing the recently published articles.

Led by emergency medicine physicians from Rhode Island Hospital and the Warren Alpert Medical School of Brown University, the region's first simulation center opened in 2002. Since then, the center's staff have served as leaders in simulation-based training for Lifespan and its affiliates, the Alpert Medical School, other health care providers in the community, and at national and international venues.