Hybrid Simulation…using patient actors to enhance simulation

I’ve gotten a bit behind in my posts mostly as I’ve just moved back from New Zealand but I’m hoping to get a few more regular posts. For those who’ve read this blog, you’ll know that I like to highlight innovative approaches to simulation. This post is mostly for those interested in medical simulation…hopefully providing some new ideas.

One of my interests is procedural skill acquisition and how simulation can be used to enhance learning. So when I came across this paper I thought it deserved mention. The authors, from the University of Toronto describe using “hybrid” simulation for teaching knee arthrocentesis among internal medicine residents. Residents went through a procedural skills curriculum where they received teaching and practice performing arthrocentesis. They had to interact with a standardized patient and explain risks/benefits of the procedure. Then they were evaluated on both technical & non-technical skills in a separate scenario. They demonstrated the feasibility of this approach and they showed high ratings of realism among trainees & standardized patients and it functions as a hypothesis generating study for if these acquired skills are translated to the clinical setting.

Great use of hybrid simulation for obstetrical scenario - live patient actor "giving birth". source: http://www.samuelmerritt.edu/hssc/task-trainers

Great use of hybrid simulation for obstetrical scenario – live patient actor “giving birth”. source: http://www.samuelmerritt.edu/hssc/task-trainers

Hybrid simulation is actually a pretty cool concept. For those are new to this, hybrid simulation combines patient interaction (using a standardized patient) with a bench model (or task trainer) that allows for procedural skill practice. The benefit of this technique is the learner gets to interact with a patient as if they’ll be the recipient of the procedure while also getting to master the technical skills of the procedure.

Using procedural competency as a goal in procedural training, hybrid simulation is an excellent method for integration into a training curriculum. In one definition of competency:

“it refers to a resident’s ability to safely prepare for, perform and navigate the complications of a procedure” (Mourad et al. J Gen Med 2010).

Hybrid simulation will allow the learner to manage each of these aspects. They practice how to prepare for the procedure (both technically and preparing the patient). This will include consenting the standardized patient to the risk and benefits. I think we often forget this key aspect and instead focus on the technical skill. Furthermore, hybrid simulation scenarios can also integrate complications and evaluate the learner as they manage both the technical and interpersonal issues that must be addressed.

Another group at the University of Ottawa has started using OSCEs as a method for evaluating procedural skills which also is quite innovative! I came across an abstract they recently presented and a quick google search revealed a manuscript that further outlines the integration of an OSCE for procedural skills. Definitely worth checking out.

In simulation, we spend thousands of dollars on advanced equipment that is designed to replicate real patient interaction. However, hybrid simulation shows us that we can enhance fidelity even more by using some imagination and combining a task trainer with a live actor.

Another example while I was in Auckland, I ran full trauma simulations with a live patient. At the helicopter base, we had an actor who had suffered a considerable trauma from a motor vehicle accident. Its very impressive to watch a team interact with a “real” patient compared to a manikin. There’s much greater concern with pain and emphasis towards communication of each management step – these are definitely lost during interaction with a manikin.

I think medical educators and those involved in curriculum design need to take the next step as we seek to improve procedural skill teaching in medicine – let’s start integrating live patient actors into our simulations. We’re starting to see that it’s feasible and that some considerable benefit can be ascertained. As we seek procedural competence, we cannot forgot the trainee should be evaluated for their ability to explain and work with a live patient throughout the procedure. Its not infrequent that trainees learn to perform a procedure but they have no idea the complication rate or even what can go wrong! Then when something does actually go wrong they haven’t thought about it. Integration of these  hybrid simulations will only enhance trainee skills and lead to improvements in patient safety – something we’re all working so hard to improve.

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Should the simulated patient die? Pros and cons to acting as the grim reaper

This post discusses a great article about death in simulation and the impact on learning. I’ve learned about the importance of this topic from @jameslhuffman, an ED physician with an interest in simulation. For those interested/involved in simulation, its importance is understated but probably moving forward we’ll hear more about.  I highly recommend that anyone who is regularly running simulations or involved in medical simulation check out this paper. I’ll review some of the highlights below.  This article follows the same topic that I wrote about a few weeks ago regarding the ethics (or impact of being unethical) of medical simulation.

Important to decide how much of a grim reaper you should be as a simulation facilitator

Important to decide how much of a grim reaper you should be as a simulation facilitator

The authors reviewed the literature for evidence about the impact of death during simulation and how it affects learners. I won’t discuss their methods as I really don’t think that’s the important message of the paper – it should be noted it’s simply a literature review rather than anything more detailed or comprehensive (e.g. systematic review or meta-analysis).

Who cares whether the simulated patient dies? Why does this even matter? These are two very reasonable questions and hopefully this review will help to shed some light on why some consideration should be made about the impact of the simulated patient’s life expectancy during the scenario!

The authors outline a few concerns that have been described regarding simulated death:

  • Stressful situations including death may negatively affect learning and memory, as a result the scenario may not achieve its predefined learning objectives
  • Death during simulation may instill negative feelings among learners about simulation (e.g. “every time I do a simulation, the patient dies…I don’t ever want to participate in that again!”)
  • Death of a simulated patient may overtake the other objectives of the scenario and may occupy most of the debriefing 
  • Inability to maintain an environment of psychological safety – learners lose trust in the instructors if too many unexpected and difficult situations occur thus detracting from learning

I think all of these are very reasonable concerns and should be considered when designing a simulation scenario however, I don’t believe (nor do the authors of this review) that death in simulation should be abandoned. It clearly has a role as death in real life is inevitable and we should train and practice how to manage it. In addition, trainees must be exposed to scenarios where regardless of the therapies implemented the patient will inevitably die. This happens almost every day for clinicians involved in acute care medicine.

What I liked about this review is that the authors included some recommendations for educators to consider when designing a scenario.

First, they defined 3 types of simulated death:

  1. Death expected by both the facilitator & the learner – include discussion about end-of-life
  2. Death expected by the facilitator & unexpected learner – may include a planned respiratory arrest that the learner must attempt to manage
  3. Death unexpected by facilitator & the learner – this involves the learner administering a fatal drug or failing to recognize a fatal condition

Depending on what type of death occurs may dictate the implications for debriefing. The following are recommendations that the authors make based on a combination of evidence and experience but in general, they’re quite reasonable. In planning for a death during simulation here are some considerations:

  • Ensure the instructor is prepared for the discussion
  • Ensure the participants have a pre-briefing session that includes mention of the possibility that the simulated patient may die 
  • Simulated death should probably not be used with novice learners
  • Scenarios for advanced learners should include simulated death if clinically appropriate
  • Simulated death shouldn’t be used for punishment (e.g. death shouldn’t occur if a participant administers a noncritical drug) – death should only occur when the learner’s actions lead to a life-threatening consequence in real-life
  • A de-briefing after a simulated death is essential – it must safely address the factors  that led to the patient death with discussion about team dynamics & medical management
  • Acknowledge participant emotions associated with death 

In my opinion, most important however is simply to acknowledge that death during simulation isn’t without consequences. The impact on learners is relatively unknown given the lack of evidence. But we should consider how much stress we place on the learners as it may positively or negatively impact their learning.

Hopefully these considerations will be helpful in evaluating the sim patient’s life expectancy! I found it extremely useful and I acknowledge that the paper is better than any summary I can provide. Here’s the reference below for the article

Simul Healthc. 2013 Feb;8(1):8-12. doi: 10.1097/SIH.0b013e3182689aff. To die or not to die? A review of simulated death. Corvetto MA, Taekman JM. 

A little bit more about the benefits of In-situ simulation. It’s time we practice where we work

In-situ simulation has become increasingly popular and just recently there’s some evidence that it’s achieving the holy grail of simulation…simulation resulting in improved patient-centered outcomes. Intuitively it makes sense that more practice will make us better and probably practice within the exact place that we work, will be good too! Look at an Olympic downhill skier…they train several days in advance of their race on the exact same course as the race. Why? So that they can gain a better understanding about where every difficult turn is located or how they should navigate through a particularly challenging section. I mean, for such a high risk setting, why wouldn’t you practice where you work? Well I think the same can extend to resuscitation medicine. We should practice where we work! And at the very least, it won’t hurt us…and it will probably help. And maybe, just maybe it will benefit our patients too. 

This study was just published in Resuscitation. It’s a prospective study that implemented in-situ simulation in a pediatric setting with their emergency response team and they studied several clinical outcomes in a pre-post study design.

Their results included that after in-situ simulation, deteriorating patients were recognised more promptly and more rapidly escalated to intensive care (median time 10.5/5 h, p = 0.024). Furthermore there were additional trends (though not significant) towards decreased morbidity & mortality – which warrants further investigation.

The authors also note some key features of their team training & human factors considerations that may have contributed to the success of this intervention. Each of these 5 factors are EXTREMELY important for successful in-situ simulation:

(1) Regular training for all team members (4–10 times/year depending on rotation).

(2) Training in real clinical roles in real clinical environment.

(3) Key decision makers (paediatric registrars and charge/deputy charge nurses) from all wards participate in team and team training, building capacity to deal with evolving critical illness on the wards, even if the team as such is not called.

(4) Senior medical and nursing staff from many departments are team trainers – enabling trainers to address issues identified in clinical practice during team training and to facilitate acceptance of team and team training across traditional departmental boundaries

(5) Senior clinical and managerial staff support team and team training (willingness to respond early to calls from team; protected training time).

Finally, I’ve included the study abstract if you’re interested.

Regular in situ simulation training of paediatric medical emergency team improves hospital response to deteriorating patients. U. Theilen et al.  vol 84 (2):218-222

Aim of the study

The introduction of a paediatric Medical Emergency Team (pMET) was accompanied by integration of weekly in situ simulation team training into routine clinical practice. On a rotational basis, all key ward staff participated in team training, which focused on recognition of the deteriorating child, teamwork and early consultant review of patients with evolving critical illness. This study aimed to evaluate the impact of regular team training on the hospital response to deteriorating in-patients and subsequent patient outcome.

Methods

Prospective cohort study of all deteriorating in-patients of a tertiary paediatric hospital requiring admission to paediatric intensive care (PICU) the year before, and after, the introduction of pMET and concurrent team training.

Results

Deteriorating patients were: recognised more promptly (before/after pMET: median time 4/1.5 h, p < 0.001), more often reviewed by consultants (45%/76%, p = 0.004), more often transferred to high dependency care (18%/37%, p = 0.021) and more rapidly escalated to intensive care (median time 10.5/5 h, p = 0.024). These improved responses by ward staff extended beyond direct involvement of pMET.

There was a trend towards fewer PICU admissions, reduced level of sickness at the time of PICU admission, reduced length of PICU stay and reduced PICU mortality. Introduction of pMET coincided with significantly reduced hospital mortality (p < 0.001).

Conclusions

These results indicate that lessons learnt by ward staff during regular in situ team training led to significantly improved recognition and management of deteriorating in-patients with evolving critical illness. Integration of in situ simulation team training in clinical care has potential applications beyond paediatrics.

Cricothyroidotomy training for the pre-hospital setting

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Newest addition to the ARHT simulation centre. Cricothyroidotomy task trainers built from old manikins. Rolled them out successfully last week with our paramedics using them for the first training session.

One of my medical education interests is looking at how we train and practice rarely performed procedures. For these situations, simulation offers an excellent method of training. The challenge, however, is recreating the fidelity of such situations since many rarely performed procedures are quite invasive.  Often we’ll start the training with a task-trainer like model and then progress to a full size manikin. Task-trainers are simulation models specifically designed for one type of procedure. 

In emergency and pre-hospital medicine, the cricothyroidotomy is among the most invasive, time critical yet rarely performed procedures. In addition to the potential technical challenges of this procedure, the decision to perform a cric might be even more difficult.  Identifying a “can’t intubate, can’t ventilate” scenario and then to “pull the trigger” may be one of the hardest cognitive leaps we face in resuscitation.  For example, last week, in the  Auckland emergency department we ran an in-situ simulation scenario for the registrars that required the performance of a cricothyroidotomy. The goal of the simulation was only to perform a cric…in fact, we even gave the registrar team a heads up that the patient would required a cric. Amazingly while we only used a task trainer that didn’t even allow for intubation, the trainees still tried to proceed with intubation. There was considerable reluctance to finally acknowledge that it was a “can’t intubate, can’t ventilate” situation.  I don’t think we train enough to practice taking that cognitive leap to the final step in the failed airway algorithm. Even this short little scenario provided evidence that such scenarios require practice and should be simulated.

This past week at the base we rolled out our cricothyroidotomy task trainers. We constructed our trainers based on a model created by Agnes Ryzynski & Dr. Jordan Tarshis at Sunnybrook Health Sciences Centre. They described the creation of such task trainers using old/broken manikin heads and some innovation using easily found products within the hospital. The value of such a trainer extends beyond its simplicity as it also  maintains good fidelity, it costs less than $30 to make and it recycles old manikin heads! 
Such a trainer might supplement an even lower fidelity construction depending on the setting. At the ARHT, our go-to method for cricothyroidotomy is a bougie-assisted technique which is described in this article and video. We’ve selected this technique based on simplicity in the field and relatively minimal equipment required. But there’s good debate out there whether these should be performed using the needle or surgical approach. Scott Orman (ED physician and blog author for aucklandhems.com) wrote about the topic last week with some great links.

You can see from the pictures, that the paramedics have set up on the left side of the patient. We were trying out different approaches and set ups to find out what works best. Personally, I prefer the right side of the patient. In our setting within the helicopter  we only have access to the patient’s right side. As a result, there may be some benefit to be on the right side. The ergonomics of such a high stakes procedure are probably understated so training in the same way that you’ll perform the procedure is essential. I acknowledge that you might need to be a bit flexible regarding setup but in general, the airway team should be well prepared and anticipate where equipment and personnel will be placed.

Here’s a few more pictures of our training day.

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Next post will have a bit more about the evidence base around cric performance.

 

Deception and misdirection – Is being “unethical” a bad thing during medical simulation?

This week’s post was prompted from a recent set of articles in the journal Simulation in Healthcare. Until recently, I’ve given little thought to purposeful deception during  simulation scenarios. Often scenarios are designed to be somewhat “tricky” with a key learning point. This often takes place by incorporating a random medical fact/concept that the learner may not pick up. For example, the seizing patient in refractory status epilepticus…if the participants took a proper history from the family they would have found out that patient has recently started treatment for tuberculosis. The diagnosis of INH induced seizures would be clinched  But what about when you purposefully try to mess with the participants and actually challenge their personality, their ability to behave as a physician and arguably break the psychological safety that should exist within a simulation? Is this beneficial or does such a scenario inhibit learning? optical-illusion-man

I’d like to review and comment on the articles and editorials published in the most recent edition Simulation in Healthcare. The article is a description about how simulation was used to test/study medical hierarchy during a medical resuscitation.

The authors (pediatric intensivists) implemented a scenario where a young child was critically ill with hyperkalemia resulting in a dysrhythmia and incidental hypophosphatemia. The team leader (who was a confederate) was scripted to order potassium phosphate to replace the low phosphate, however, this would also result in death of the simulated patient. The learners (ICU residents/fellows) had some idea that a team leader (staff intensivist) would appear part way through the case but were unaware that such hierarchy conflict would emerge. The team leader confederate was instructed to comply by not administering the drug only if the team demonstrated repeated or sustained challenges in giving this potentially deadly medication. The authors describe running the scenario 3 times and reported the following responses:

  1. Appropriate, successful challenge of drug administration and team leader complied
  2. Appropriate challenge but delayed resulting in delayed appropriate management
  3. The order was not challenged and the simulated patient died

What are you thoughts after reading this? Do you have a visceral reaction that this was a good or bad idea?

My opinion is that in the right circumstances with trained educators I think this is extremely powerful, useful and should be part of the educational toolbox. There’s an accompanying editorial where the authors have raise multiple concerns about this approach which I won’t reiterate – all of which are valid. Though interestingly they also provide well written counter arguments in anticipation of how others may respond.

Simulation scenarios that address non-medical aspects that can lead to patient harm should be simulated. While I agree that this type of case probably is best administered by an experienced simulation educator with highly skilled participants, I disagree with the editorial which suggests that such scenarios should be avoided. They were concerned that this may cause the participant to think:

“Am I the kind of person who is unwilling or unable to challenge a respected colleague who I think is making bad medical judgments, even when this may result in serious injury to the patient, or even death”

I would argue (like the study’s authors) that with proper briefing regarding the educational purpose of the simulation and adequate de-briefing to explore the cognitive decision points that resulted in the patient’s outcome, then learning can be achieved. The degree of deception should be related to experience level of the participants since junior learners would unlikely benefit from such a difficult scenario. However, increasingly, we recognize that teamwork and crew resource management (CRM) play an important role in how we care for patients. Our non-technical skills and awareness to our own cognitive biases during critical situations has considerable impact on patient outcomes.  It’s inevitable that during critical situations we may face challenging interpersonal interactions or difficult decisions.  We should train by pushing the limits of the team and the system. I acknowledge there are some who are concerned regarding the disregard for psychological safety during such simulations. I argue that with proper approaches that psychological safety can be managed. Furthermore we can do a much better job controlling the psychological safety of a simulation than we can simply leaving learners to fend for themselves during a real-life situation where not only their psychological safety is at stake, but the medical safety of the patient is at risk.

The argument that we should study this more before widespread use is reasonable but I’m not sure that results from one centre will be applicable to others. The validity of such studies remains challenging to say the least. Certainly larger studies will help, but meanwhile simulations including misdirections or deceptions that challenge not only technical knowledge but interpersonal and team dynamics should be supported.

 

Abstract from cited article above 

Case & Commentary: Using Simulation to Address Hierarchy Issues During Medical Crises. Calhoun AW et al. Simul Healthc. 2013; 8(1):13-19

Medicine is hierarchical, and both positive and negative effects of this can be exposed and magnified during a crisis. Ideally, hierarchies function in an orderly manner, but when an inappropriate directive is given, the results can be disastrous unless team members are empowered to challenge the order. This article describes a case that uses misdirection and the possibility of simulated ‘‘death’’ to facilitate learning among experienced clinicians about the potentially deadly effects of an unchallenged, inappropriate order. The design of this case, however, raises additional questions regarding both ethics and psychological safety. The ethical concerns that surround the use of misdirection in simulation and the psychological ramifications of incorporating patient death in this context are explored in the commentary. We conclude with a discussion of debriefing strategies that can be used to promote psychological safety during potentially emotionally charged simulations and possible directions for future research. (Sim Healthcare 8:13Y19, 2013)

 

 

 

 

 

 

 

 

 

In-situ Simulation: The 10 commandments

This past week, I had the opportunity to present to the Auckland Trauma Forum about the in-situ simulation and its value within trauma training. I believe however that it’s value extends far beyond trauma training. We’ve been using it at the helicopter base and in the ED. The pediatricians and obstetricians have recognized its utility as well especially given

ten-commandments-2296856

the rare but high risk scenarios they may encounter.  As a result, I thought it would be appropriate to put up a post on the topic.  I’ve titled this “the 10 commandments” however, please feel free to disagree, challenge or critique my list…I just though the title sounded better that “a list of 10 things to consider while doing/planning in-situ simulation”.

Increasingly, educators are recognizing that in addition to traditional simulation (which occurs in a simulation centre), in-situ simulation provides benefits that are unattainable elsewhere. For those new to the concept, one definition of in-situ is

simulation that is physically integrated into the clinical environment

This quote is from a must-read for anyone interested in in-situ simulation. (Patterson et al. chapter on In-Situ simulation in the book “Advances in Patient Safety: New Directions and Alternative Approaches)

And now for the 10 Commandments of In-Situ Simulation (in no particular order…except maybe the first one or two).

1. Always run an in-situ simulation with well defined goals and objectives (and ensure participants have been briefed). I don’t think this needs elaboration

2. Always ensure there’s a debriefing period that’s adequate. This goes for all simulation but in-situ can easily be derailed especially if you’re using the on-call team and a sick patient arrives. Have a contingency plan for a debrief later on.

3. Use in-situ simulation to improve teamwork and coordination especially in acute care settings and high-risk situations. This will lead to improved patient outcomes (my opinion…data is promising). New data suggests the value of in-situ simulation includes improving teamwork and communication but may also lead to patient-oriented benefits.

Debriefing after a successful simulation. We have 3 different personnel here - doctor, paramedic and crewman. Truly multi-disciplinary.

Debriefing after a successful simulation. We have 3 different personnel here – doctor, paramedic and crewman. Truly multi-disciplinary.

4. Use in-situ simulation as a method of testing the ergonomics of your current clinical setting (current state analysis). We NEVER do this in medicine. I bet the next time you go into your resus room that you’ll find 10 things that are placed or designed in non-user friendly manner. Maybe the monitor isn’t easily visible. Maybe the chest-tube tray is just a big S***show everytime you open it…leading to delayed placement. Running simulations in your own work environment then evaluating it can be helpful! A study in one ED found that their response to life-threatening arrhythmias was horrible after running unannounced in-situ simulations…but it lead to improvement!

5. Separate in-situ simulation equipment from real equipment: We use identical equipment at the helicopter base for our in-situ simulation as we do in our real work. This is the benefit of in-situ simulation (we practice with the same equipment we work with). However, mixing equipment inadvertently can be dangerous. Imagine a ventilator purposefully tampered for a simulation that somehow ends up being used for a real patient. BAD. We label everything with big red tags “Defective – training gear”. Whatever you decide, just make sure everyone is aware. Sometimes you may want to use real equipment in the sim, but have someone responsible to ensure its appropriate re-integration into the clinical environment.

6. Notify others that in-situ simulation is in process: nothing worse than starting an in-situ simulation in your resus room and someone, unaware to the exercise, activates a code blue with personnel running from all ends of the hospital only to find that its just a simulation. This can be remedied by notifying others in the clinical environment via email/posters and signs.

7. Maximize learning for on-duty personnel by running an in-situ simulation: There are huge benefits of incorporating teaching for your on-call team while they’re at work anyways. Why bring people in on their day off to train when you can use down time during the day to run a sim in their own work environment! It’s efficient from a cost and time perspective. Who knows…maybe that failed airway drill run earlier in the day will prepare them for something later on!

No better way to see what its like to intubate in a helicopter then to actually practice...in the helicopter. A sim centre just isn't good enough for this objective. Notice our paramedic is in full gear too!

No better way to see what its like to intubate in a helicopter then to actually practice…in the helicopter. A sim centre just isn’t good enough for this objective. Notice our paramedic is in full gear too! Plus we can assess ergonomics of patient positioning. 

8. Multi-disciplinary is key for In-situ simulation: We work with large teams from all different specialties all the time. Engage your colleagues – not just fellow physicians but nurses, respiratory therapists, etc…

9. Seek departmental support to run in-situ simulation regularly: This doesn’t just mean one department…we rarely work in isolation during high risk/acute care situations. Often trauma or medical resuscitations require multiple teams so get support to gather teams from more than your own department.

10. Be creative! We don’t practice often enough the situations that can lead to bad outcomes. Wouldn’t it have been great if you had practiced running a resus in CT before you brought that trauma patient who crashed there? While initial decision making may have been an issue…maybe the fact the suction was missing could have been identified had an in-situ sim been run!

Bonus (#11): In-situ simulation is a fantastic way to test out new equipment/cognitive aids. We love new toys in medicine but rarely do we try them out other then when the rep comes in, gives us lunch and before we know it the new equipment is in use. This isn’t safe but despite our efforts we often escape bad outcomes. We should test run new equipment especially those used in high risk clinical settings. In addition, while I’m a huge fan of checklists or cognitive aids…I dont think these should just be implemented without some in-situ testing. Maybe the RSI checklist needs some tweaking…or maybe it doesn’t read well when it’s used in a time-sensitive manner. Get your team accustomed to using before you need it for that next failed airway.

Any feedback…I welcome hearing it!

Medical error…an unbelievable story

This past year (2012) was apparently aviation’s safest year ever!

I’m not sure the same can be said for medicine. I don’t know if we have similar global data as aviation but my guess is that we haven’t made the impressive strides our pilot friends have made.  While considerable efforts are being made to improve patient safety, medical errors continue and often despite identified solutions.

I wanted to share this amazing & shocking video (see below), narrated by Martin Bromiley who is the husband of a woman (Elaine Bromiley) who died as a result of medical error during a routine surgery in the UK (around 2007). Martin is a commercial pilot and using his experience with crisis resource management, teamwork and critical decision making he sought to determine what factors lead to his wife’s death. More impressively, he developed efforts and programs within the NHS based around human factors.  Listening to Martin speak is quite remarkable and for a man who has suffered a such devastating loss, he has made an amazing effort to make medicine safer. His efforts should be congratulated and shared. Watching this video provides powerful evidence that educators must incorporate simulation that elicits stress among the participants. In medicine, we should practice scenarios where clinicians must function and make decisions in a high-stress environment. This must be implemented with caution however, as there is some emerging evidence (and another study) that when stress levels are too high, trainees may experience cognitive overload that actually inhibits learning.

Should medical simulation be regulated?

In short reply to the title of this post: No, not unless we plan to deprive learners of valuable educational opportunities.

At a recent simulation course that I attended, one session ended with a discussion about the need to regulate simulation. One of the instructors for the day was suggesting that simulation be conducted only by individuals well trained and experienced in medical simulation. He advocated for a need to implement regulation and accreditation for simulation activities. Furthermore he voiced about low fidelity simulation and just anybody out there thinking they can conduct a simulation scenario.

Do we need approval from a governing body to run a simulation scenario? In thinking we do may lead to unintended harms such as clinical errors that may have been prevented by simulation (while we wait for the appropriate regulation)

I approached him afterwards and listened a bit more to his perspective. He described concern about some technology that would facilitate a “lower” fidelity simulation scenario. In his opinion training in an environment  that isn’t identical to the actual work environment might lead to the participant acting inappropriately or being unable to manage in the real world since they may only become proficient using the machines available during simulation. In other words, if you teach people on one machine this may result in error if they’re faced with another machine in their actual work environment. He cited the Tenerife airport disaster as an example whereby simulation could be harmful. This devastating incident occurred when two jumbo jets collided on a runway in the Canary islands.

Despite the pilot being extremely experienced, he had just recently returned from a prolonged period where he had been instructing in the flight simulator. There’s some speculation that this may have contributed. Whether “too long” in the flight simulator and not enough real flight time played a role is difficult to determine. Is it possible that he picked up bad habits in the simulator and subsequently brought these back to his real work environment?

I agree that there is potential for harm in simulation. A recent report from Toronto described a critical event of an anaesthetic canister overheating (unintended) during a simulation scenario. There’s also reports of in-situ simulation equipment being accidentally brought into live use. Such events mandate safety for participants as paramount and that processes are in place to prevent mixing simulation-grade equipment into real life. However, to suggest that eager, enthusiastic clinicians who want to initiate simulation must pass tests or wait until policies are implemented or even receive some type of accreditation risks stifling valuable education. Holding the key to the simulation door in an ivory tower, available only to those who are pass the “test” is irresponsible and impractical.

We have implemented simulation into medicine as a means to improve care, practice critical events and work as a team. If we are to wait for accreditation and have only select individuals conduct simulation, then we are doing a disservice to our trainees and our patients. We should encourage teachers who wish to run scenarios to do so, even if they can’t use the latest most expensive high-fidelity manikin. To suggest that there’s considerable risk by training in a non-identical training environment is crazy. If you can’t train using high-fidelity, would it be better to just read about the procedure and practice on a real patient? Oh wait, this is what we’ve done for years and simulation was implemented to help reduce the harms of such an approach.

If accreditation or regulation will become part of simulation, the process should not inhibit the creativity of clinicians who have generated amazing learning opportunities (often with very little). Waiting for the “most appropriate” policy or procedure to be implemented will only expose our trainees and patients to further threats, errors and harms.