Patient Simulation

What This Chapter Is About: An Overview

“Simulation training in all its forms will be a vital part of building a safer health care system” [p. 55]. Sir Liam Donaldson, CMO Annual Report (2008)

In concert with other modalities, simulation can improve patient safety by informing personnel about best practices, guiding established clinical practice, and strengthening human performance. Unfortunately, simulation in health care is still not used as widely and systematically as needed, compared to its use in other high-risk/high-reliability industries. From the authors’ point of view, anesthesia professionals, anesthesia departments, and health care organizations need to strive to embrace the use of simulation for the many purposes mentioned in this chapter. Simulation, in combination with human factors training (CRM, see Chapter 6 ), has the potential to substantially improve the quality and safety of health care.

Anesthesiology has pioneered the field of simulation in health care. The rather new, mannequin-based patient simulators have been in regular use in anesthesiology since the early 1990s. Over the last two decades, there have been many technologic advances in simulation and a wide variety of applications of simulation in anesthesiology have been developed in the domains of education and training, research, system and equipment probing, and assessment. Considerable collective experience has already been achieved with simulation devices, sites, pedagogy, and assessment rubrics. What was once an arcane and small niche activity has expanded enormously. Simulation can be thought of like playing a musical instrument: almost everybody can somehow coax a tone out of it, but to play it well and use it optimally can only come about after considerable practice.

This chapter aims to provide the reader—whether a simulation participant or a novice or experienced instructor—with a solid and nuanced understanding of many aspects of patient simulation in anesthesiology and other parts of health care.

Modern simulation with advanced teaching concepts and the integration of human factors training (CRM) is much more than traditional basic life support and advanced cardiovascular life support (“megacode”) training. Modern simulation team training is academically demanding, personally stimulating, and involves many disciplines and lines of thinking. As a simulation instructor, you are operating at the core of our profession!

Simulation in Anesthesia: Why Is It Important?

See one—do one—teach one? Read one—do one—teach one? Many decades ago anesthesiology trainees might have been “given a long leash” (inadequately supervised) and asked to gain experience by “sink or swim,” often with a clinical population of indigent patients. Using actual patients in this way as if they are expendable “simulators” is unethical, and the presumed learning experiences were extremely uneven. In the last few decades unacceptable practices have been eliminated, but it increasingly begs the question of how can clinicians at all levels of experience feel the difficulties of patient care, including managing very difficult situations, without putting patients at undue risk? How does someone go from a total novice to a fully competent independent anesthesia professional? And of increasing importance, how can clinicians—during both initial and recurrent training—learn and hone skills of dynamic decision making, situation awareness, leadership, communication, and teamwork?

Anesthesiology is a “hands-on” discipline. It is not likely for medical students and residents to learn simply by “looking,” “time passing,” or by “osmosis.” The application of (rare) technical skills, the correct use of medical knowledge and algorithms, as well as the reliable utilization of anesthesia nontechnical skills (see Chapter 6 )—such as teamwork, communication, and leadership behavior—need to be learned and then trained repeatedly. At the same time, experience is no substitute for excellence (see Chapter 6 ). This is especially true for nonroutine events, such as emergencies or rare complications. Not only trainees but also experienced clinicians require continuous education and training of their clinical and nontechnical skills in order to stay current and avoid bad habits or the normalization of deviance (see Chapter 6 ).

Health care, with anesthesiology as the pioneering discipline, borrowed and adapted alternative educational approaches to teach knowledge and gain procedural experience from years of successful service in other industries that faced similar problems. These approaches focused on “simulation.” Simulation is a technique well known in the military, aviation, space flight, and nuclear power industries. Simulation refers to the artificial replication of sufficient elements of a real-world domain to achieve a stated goal. The goals include for example education and training of technical and nontechnical skills, system probing, testing of equipment and supplies, and assessment as well as evaluation of students and personnel. These different topics are covered in this chapter, even though there is a focus on simulation as a training and education tool.

In 2000, the National Academy of Medicine (then the Institute of Medicine) released a report, “To Err Is Human: Building a Safer Health System,” that suggested the use of simulation training in health care in order to reduce preventable errors. The American College of Critical Care Medicine recommended the use of simulation to improve training in critical care. With anesthesiologists being the pioneers for simulation-based training in health care, simulation in anesthesia already has a long tradition. At the same time, its comprehensive and profound implementation has come a long and rocky way over the last decades and, despite many benefits, still needs further implementation and continuous evaluation. Major recognition of simulation in anesthesia by the clinical world is highlighted by the fact that it is now a highly utilized training course for the practice improvement component of Maintenance of Certification in Anesthesiology (MOCA) in the United States. In Australia and New Zealand, it is an integral part of anesthetic training. In their reviews, Lorello and colleagues, LeBlanc and colleagues, and Higham and Baxendale give an overview of simulation-based training in anesthesia. In many parts of the world, including industrial countries, the use of simulation is way behind the United States or Australia.

A fundamental part of the future vision for simulation is that clinical personnel, teams, and systems will undergo periodic and systematic simulation activities across their entire career using various modalities of simulation and for diverse purposes of education, training, performance assessment, refinement in practice, and system probing. This vision is inspired in part by the systems in place in various high-reliability industries, especially commercial aviation and nuclear power (see Chapter 6 ). Needless to say, using simulation as part of the process of revolutionizing health care is more complex than merely attempting to stick simulation training on top of the current system. Moreover, beyond training, simulation may provide indirect ways to improve safety, including facilitating recruitment and retention of skilled personnel, acting as a lever for culture change, and improving quality and risk management activities.

Application of Simulation in Anesthesia and Health Care

Simulation techniques can be applied across nearly all health care domains. A few books are devoted solely to the topic of simulation and its use in and outside of anesthesiology.

In the upcoming section, an overview of the main objectives of simulation in health care and anesthesiology are presented in the following sequence: (1) education and training of technical and nontechnical skills, (2) system probing, (3) testing of equipment and supplies, (4) assessment/evaluation, (5) research, and (6) further purposes.

Use of Patient Simulation for Training and Education

With respect to the first objective—education and training—anesthesiology remains a driving force in the use of simulation in health care, although simulation has spread to nearly every discipline and domain. As used in this chapter, education emphasizes conceptual knowledge, basic skills, and an introduction to nontechnical skills and work practices. Training emphasizes preparing individuals to perform actual tasks and work of the job.

Disciplines successfully applying simulation for training besides anesthesia are, for example, emergency medicine and emergency field responders, trauma care, neonatology and pediatric anaesthesia, labor and delivery, surgery, radiation oncology, intensive care, and infectious disease. Simulation serves almost all resuscitation trainings, which have advanced over the years. Fig. 7.1 gives several impressions of simulation training.

Nearly every anesthesia residency program in the United States offers some cogent simulation training experiences, although the scope, frequency, and target content vary. Other disciplines and other countries may not have adequate simulation training coverage during residency, as evidenced by a study by Hayes and colleagues.

The military and the U.S. Department of Homeland Security also have been heavy users of simulation in health care; simulation has been applied to the initial training of new field medics and to the recurrent training of experienced clinicians and clinical teams. In 2013, a first instructor course for the North Atlantic Treaty Organization (NATO) Special Operations Forces (SOF) was held at NATO headquarters in Brussels to bring together medical experts from the United States SOF, the NATO SOF, and some civilian instructor experts (including authors Rall and later Oberfrank).

Simulation is relevant from the earliest level of vocational or professional education (students) and during apprenticeship training (interns and residents), and it is increasingly used for experienced personnel undergoing periodic refresher training. Simulation can be applied regularly to practicing clinicians (as individuals, teams, or organizations; the latter for example for disaster drills, or for preparing to care for patients with Ebola virus disease ) regardless of their seniority, thus providing an integrated accumulation of experiences that should have long-term synergism. Thus, it is applicable to health care providers with a range of experience, including experts, novices, advanced residents, medical, nursing, other health care students, and even children. Simulation rehearsals are now being explored as adjuncts to actual clinical practice; for example, surgeons or an entire operative team can rehearse an unusually complex operation in advance by using a simulation of the specific patient.

Many simulation centers offer continuing medical education (CME) and training for experienced practitioners, and many aspects of simulation training for residents can be expanded for this purpose. Several studies have shown that experienced anesthesiologists have deficiencies in the management of critical patient situations and make severe errors comparable to those of anesthesia residents. Because crisis situations are rare during routine clinical work, these results are not startling. In addition, experience in terms of years on the job and hierarchy probably do not correspond to expertise and excellence. Crisis management training with patient simulation should be started early in education and training and applied on a recurring basis during practice.

Concerning education of health care professionals about patient safety, patient simulation can be a tool that contributes to changing the culture in an organization bottom-up to create a culture of safety. First, it allows hands-on training of junior and senior clinicians in practices that enact the desired culture of safety based on the principle of high reliability organizations (see Chapter 6 ). Simulation can be a rallying point about culture change and patient safety that can bring together experienced clinicians from various disciplines and domains (who may be captured because the simulations are clinically challenging and show the need of change in direct relation to patient treatment), along with health care administrators, executives, managers, risk managers, and experts on human factors, organizational behavior, or institutional change. For these groups, simulation can convey the complexities of clinical work, and it can be used to exercise and probe the organizational practices of clinical institutions at multiple levels (see section on system probing). Various curricula and recommendations for curricula development for simulation training exist.

Use of Patient Simulation for Research

In regard to the fifth objective—research—simulation-based research falls into two categories: (a) research about simulation—testing or improving the techniques, technologies, and didactics of simulation; and (b) research that uses simulation as a tool to study other things, such as human performance and clinical cognition (see Chapter 6 ), or clinical care processes. Box 7.1 provides a sampling of these types of questions.

Box 7.1

Exemplary Research Issues That Can Be Addressed by Using Simulation

Cognitive Science of Dynamic Decision Making (see Chapter 6 )

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  What is the interaction of precompiled procedural knowledge (Type I thinking) versus deep medical knowledge and abstract reasoning (Type II thinking)?

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  How does supervisory control of observation relate to vigilance, data overload, and visual scanning patterns?

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  What is the information content and utility of watching the surgical field?

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  How are optimal action planning and scheduling implemented?

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  How does reevaluation fail and result in fixation errors?

Human-Machine Interactions

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  What is the distraction penalty for false alarms?

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  Do integrated monitors and displays have an advantage over multiple stand-alone devices and displays?

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  How easy to use are the controls and displays of existing anesthesia equipment in standard case situations and in crisis situations?

Teaching Anesthesia in the Operating Room (see Chapters 4 , Chapters 9 )

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  How much teaching can be accomplished in the operating room without sacrificing the anesthesia crew’s vigilance?

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  How well can faculty members detect and categorize the performance of anesthesia trainees?

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  What teaching styles are best integrated with case management in the operating room?

Issues of Non-Technical Skills/Teamwork on Anesthesiologist Performance

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  How does an anesthesia crew interact during case and crisis management?

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  How is workload distributed among individuals?

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  How do crew members communicate with each other, and how do they communicate with other members of the operating room team?

Effects of Performance-Shaping Factors on Anesthesiologist Performance

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  How do sleep deprivation, fatigue, aging, or the carryover effects of over-the-counter medications, coffee, or alcohol affect the performance of anesthesiologists?

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  Can smart alarm systems or artificial intelligence provide correct and clinically meaningful decision support in the operating room or intensive care unit?

Development of New Devices and Applications: Research Regarding Techniques of Simulation

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  How well can simulations re-create perioperative clinical settings? Can they provoke the same actions as used in real clinical care (ecologic validity of simulators)?

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  How much does debriefing add to learning from simulation? Are specific techniques of debriefing, or combinations thereof, of greater applicability or utility, overall or for particular situations?

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  How do various aspects of simulation scenarios influence aspects of perceived reality, and how do they influence transfer of training into the real world?

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  Does simulation training lead to better clinical practice and improved clinical outcomes?

Regarding research about simulation, some examples would include the design of debriefing approaches such as Debriefing with Good Judgement, Debriefing-Diamant, PEARLS, TeamGAINS, and others ; methods for designing simulation scenarios such as PARTS ; the efficacy of using videos in debriefings ; the creation and maintenance of an inviting learning atmosphere ; the effective design of specific training interventions such as for resuscitation, airway management, and avoidance of catheter-related infections ; and testing of specific training interventions such as for facilitating speaking up, briefings, and feedback.

Patient simulation is now used sometimes to address the medical management of chemical, biologic, or nuclear threats from accidents, weapons of mass destruction, or terrorism. One group in Germany, used simulation to test the constraints of treating patients in full chemical protection gear to optimize the strategies of the German Ministry of Internal Affairs for dealing with terror attacks or chemical plant disasters ( Fig. 7.2 ). Several investigators have performed multidisciplinary studies with combined simulation modalities (script-based simulators, model-based mannequin simulators, and simulated acted patients) to teach the management of victims of an attack with weapons of mass destruction and terrorism. The demand for such training is substantial in nations engaged in active military conflicts or with an ongoing need to prepare for war or terrorist attacks.

Regarding (b) simulation as a research tool, it offers some unique features, and it can be thought of as a complementary window on the clinical world relative to other modalities. It can be applied, for example, when complex phenomena such as medical team processes are studied. Examples are investigations of how teams adapt from routine to non-routine situations and how this adaptation is related to performance, communication processes such as information processing, talking to the room and speaking up, problem-solving and decision-making, and coordination requirements during resuscitation. Important milestones for simulation-based research of both types was the creation by the Society for Simulation in Healthcare (SSH) in 2007 of its flagship peer-reviewed journal, Simulation in Healthcare followed in later years by other peer-reviewed journals (e.g., Advances in Simulation , BMJ Simulation & Technology Enhanced Learning , Clinical Simulation in Nursing ). In addition, for research that is linked tightly to a specific clinical domain, the traditional medical specialty journals have become more welcoming to articles about simulation or that use simulation as an experimental technique.

Cooperation between simulation directors or instructors and psychologists, human factors engineers, or educators has proved useful in research and training. Such collaborations have helped delineate the theoretical foundations of simulation-based experiential learning, improve the understanding of debriefing, and research on work psychology and human performance in health care. Many institutions have integrated psychologists or educators, or both, into their simulation center staff.

History, Development, and Types of Simulators and Simulation

The following section gives a short, non-exhaustive overview about the history and the development of the main simulators in health care and anesthesia. For a more in-depth examination of the topic, the reader is referred to further literature. Particularly the mannequin-based simulators that are in wide use have been well covered in several review articles and a whole book chapter by Rosen written in 2013 is dedicated to the topic in detail. Another comprehensive textbook on the history of simulation in health care tracing it back 1500 years was published by Owen.

• Simulation probably is as old as mankind. Simulation has probably been a part of human activity since prehistoric times. Rehearsal for hunting activities and warfare was most likely an occasion for simulating the behavior of prey or enemy warriors. In medieval times soldiers learned the art of swordsmanship on dummy soldiers. Hundreds of years ago, models were used to help teach anatomy and physiology, and simulators were used to train surgical procedures and to help midwives and obstetricians handle complications of childbirth. Italy was the major source of simulators early in the 18th century, but in the 19th century, dominance in clinical simulation moved to France, Britain, and then Germany. In modern times, preparation for warfare has been an equally powerful spur to the development of simulation technologies, especially for aviation, navy and armored vehicles. These technologies have been adopted by their civilian counterparts, but they have attained their most extensive use in commercial aviation. The aircraft simulator achieved its modern form in the late 1960s, but it has been continuously refined.

• Mannequin-based simulators (MBSs). In 1969, the first electromechanical mannequin-based simulator in modern health care—Sim One—was produced by an aerospace company working with an educator and an anesthesiologist at the University of Southern California. It consisted of a mannequin comprising an intubatable airway and upper torso and arms, and in many respects was years ahead of its time. It was originally used as an aid for students or residents learning to intubate, as well as to induce anesthesia but the project died out in the early 1970s. In the following years, several other mannequin-based patient simulators were developed and introduced in the middle to late 1980s. Noteworthy among others is Harvey, a cardiology mannequin simulator released in 1976, which is able to simulate the arterial pulse, blood pressure, jugular venous wave, precordial movements, and heart sounds in normal and diseased states. In 1986, a team at Stanford, headed at first by Gaba and DeAnda, developed a full-scale simulator called the Comprehensive Anesthesia Simulation Environment (CASE); they used it initially to study the decision-making processes of anesthesia professionals during critical events, but they were also interested in its use for training. Over a few years, with their recognition of the parallels with Crew/Crisis/Cockpit Resource Management (CRM) in aviation this team developed their flagship simulation training course Anesthesia Crisis Resource Management (ACRM, see Chapter 6 ). Newer commercially-available mannequin-based patient simulators have been in use in anesthesiology since about 1995, and considerable collective experience with the devices already has been achieved. Currently, full-size mannequin-based simulation devices are used in most simulation centers (available now, for example, from the manufacturers Laerdal, Gaumard, CAE Healthcare, and others). Such devices allow the simulation of rapidly changing physiology and can support a variety of hands-on interventions (e.g., airway management, vascular cannulation, drug administration, electric countershock, or pacing). Some devices allow the system automatically to recognize injection of specific medications or therapeutic maneuvers, such as cardiac massage, and then—with or without instructor input—to respond in an appropriate manner. Even though highly developed, mannequins still miss important features. Box 7.2 shows desirable features of future MBS systems.

  Box 7.2

  Desirable Features of Future Mannequin-Based Simulator Systems

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    Ability to interface to or to mimic advanced brain monitoring such as: AEP, Auditory evoked potential; BIS, bispectral index; EEG, electroencephalographic; PSI, patient state index.

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    Advanced skin signs such as: change in skin color to cyanotic or pale, improved diaphoresis, change in skin temperature (e.g., as a result of shock or fever), rash, hives, or generalized edema

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    Regurgitation, vomiting, airway bleeding or secretions

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    Physical coughing (currently only sounds are simulated)

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    Realistic convulsions

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    Purposeful movements of extremities

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    Improved or possible support for spinal, epidural, or other regional anesthesia procedures

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    Improved EEG signals (e.g., for BIS, AEP, PSI)

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    Improved intracranial pressure

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    Support for physical central venous and arterial cannulation

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    Improved fetal and maternal cardiotocogram

  Please note: This list contains features that are not currently incorporated. Some features may be under development and could be available after publication of this book. In addition, some features are currently available as third-party or homemade add-ons.

• (Computer) Screen-based simulators (microsimulators). Beginning in the mid-1980s, several screen-based, also called screen-only simulators (microsimulators), were developed by anesthesiologists. These included (1) screen-based part-task trainers that simulated isolated aspects of anesthesia, such as the uptake and distribution of anesthetic gases in the body given different physiologic and physical chemistry situations (e.g., the well-known Gasman program ); and (2) screen-based overall-task trainers that represented nearly all aspects of the patient and clinical environment. Originally, the patient was represented by drawings or animations, but increasingly in these systems the representation of the patient is by photographs or videos. Vital signs appearing on virtual monitors may mimic real clinical devices. Actions are selected typically using a graphic user interface, pointing and clicking on menus and buttons, and using sliders and numeric entry boxes to allow control of most kinds of interventions that clinicians use on a regular basis.

• Part-task trainers and virtual procedural simulators. In the 21st century, advancements in engineering and computer science have stimulated a new era of simulator technology, including:

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    Part-task trainers in the form of anatomic mock-up devices that are made from synthetic material to represent human body parts, such as models that allow training of central line placement, epidural catheter insertion, cricothyroidotomy, or chest drainage. Over several decades, tissue-based simulation—representing some sort of part-task trainer—has become more common, with trainees no longer learning procedural skills using animal models because of cost and issues of animal rights.

  • ▪

    Virtual simulators for surgical and procedural skills (i.e., hardware and software that provide haptic feedback for performing realistic laparoscopic cholecystectomy, bronchoscopy, colonoscopy, echocardiography, and endovascular procedures). In these systems, the synthetic (virtual) environment exists solely in the computer. The real procedure is performed by using a video display that can be recreated by the simulator. The person simulating the procedure interacts with the video display through the eyes (without or with head-mounted glasses) and the ears, and usually the hands, if the simulator features special instruments, instrumented gloves, or sensors. For anesthesia, for example, there exist VR simulators to train the conduct of fiber-optic intubation and regional anesthesia. Two systematic reviews are available for more in-depth information on the general use of simulation teaching regional anesthesia.

• Virtual reality and augmented reality (usually via head-mounted displays). Both immersive virtual reality (VR), which fully integrates the human user into the computer’s world, and augmented reality (AR), which adds computer-generated imagery onto or next to the real-world view, typically use head-mounted displays to either replace ordinary vision or to augment it. Both approaches have been described in the literature, often in prototype or research-only settings. This chapter will discuss only VR and not AR. The authors (DG in particular) have been evaluating commercially available systems for head-mounted display VR. For health care they seem to fall into two categories: (1) visualization of objects or spaces—typically for anatomical structures, or for architectural environments, and (2) physically interactive clinical environments— meaning the clinicians themselves can move with the space and interact directly with each other and the virtually presented patient, essentially the VR equivalent of physical mannequin-based simulation. Visualization applications are much more common and are direct applications of consumer VR hardware and software (e.g., visualizing the human heart in all its detail inside and out instead of, say, the Taj Mahal). Fully interactive VR makes use of commercial head-mounted displays and other gear but is more complex to create the clinical space, patient, and equipment while providing for multiple physical participants to interact with seamless head and body movements.

  Both types of VR are still in quite early stages of practical implementation in health care and how these approaches can best be used in health care remains to be seen, but the tide is now turning away from arcane research or “vaporware” to an era of rapidly improving practical devices and applications. Although Gaba has previously written that VR would soon (by 2020-2025) completely replace all physical simulation, this now seems unlikely in that time frame; in fact, it is likely that VR will join the spectrum of simulation modalities each of which has a set of unique advantages and disadvantages relative to the others.

• Virtual Environment/Virtual World. A related type of virtual simulation is the virtual environment or virtual world. According to Wikipedia, a virtual world is a computer-based simulated environment intended for its users to inhabit and interact through avatars (users’ graphic representation of themselves). Such systems typically allow multiple participants to control their own avatars (including speech) simultaneously over a network and to interact verbally and by virtual physical actions within a commonly perceived virtual environment. This technology currently portrays the virtual world as perspective three-dimensional images (or possibly true 3D) on a computer screen with sound. Virtual worlds are most commonly used for computer games. In a medical virtual world, the patient may be an automated avatar controlled by the computer, or the patient may be an avatar inhabited by a human participant. Kleinert and colleagues published a review of such systems in 2015 and concluded that the development and validation of such simulators will need to be the subject of further research.

• Standardized patients. Standardized patients (SPs; in some countries referred to as “simulated patients”) are actors/role players who are trained to represent a patient’s condition (e.g., symptoms or social situation) and may be trained to score a participant’s performance and to provide informative feedback. Over the last three decades, students increasingly learn skills in medical history taking and physical examinations using SPs. Overviews of the use and implementation of SPs in anesthesia education are available. SP-based simulations are increasingly being used for issues such as disclosure of bad news and other difficult conversation as well as in pain medicine.

• Hybrid simulation. Hybrid simulation means combining different types of simulation modalities during a simulation scenario. It can be used in different ways and serves several purposes: (1) Pairing simulation devices in parallel. This way, a training atmosphere can be established, in which different professions can have credible clinical work for their role. For example, when training the management of complications in the OR with surgeons and anesthesiologists together, it is helpful if both professions have clear functions during the scenario. For example, Kjellin et al. performed a multidisciplinary OR team training, where training was performed in a mock-up OR equipped with a mannequin-based patient simulator and a laparoscopic simulator. Another option is to integrate manufactured life-like surgical models with the mannequin, as used by Weller et al. for multidisciplinary OR team training. (2) Pairing simulation devices in sequence. This way, the best characteristics of each simulation modality can be used in a scenario and create a simulation that is more than the sum of the parts. For example, a scenario can start with a standardized patient/role player presenting in a patient bed or gurney; the simulation can be transferred to a mannequin at a critical point, such as when invasive activities are needed (e.g., intubation or CPR) or when giving birth. Cantrell and Deloney offer suggestions for integrating SPs into high-fidelity simulation scenarios.

Simulation Fidelity and Classification of Simulators

Simulation is becoming more commonly used for education and training purposes as well as for continuing professional development. But people often have very different perceptions of the definition of the term simulation. This highlights the need for definitions of simulation modalities, simulation fidelity, a classification of the relevant technologies and features, and also a brief overview about the methods of teaching.

• Simulation fidelity and simulator capability. In the simulation literature the term fidelity—which means how closely something replicates reality—is often used to refer to specific devices or products. In contrast, the authors believe strongly that this is a misnomer and that the concept of fidelity is a property of the simulation activity and not primarily of the device(s) or products used. That is, fidelity is determined by the number of aspects that are replicated by the simulation (not only physical ones) and the applicable representation of each aspect relative to that of the real world (see subchapter on simulation realism) . The fidelity required of a simulation depends on the stated goals and participant population. Some goals can be achieved with minimal and low fidelity, whereas others require very high fidelity.

• Classification of simulators. For some purposes it is useful to compare the levels or specifics of the particular technological capabilities of simulator devices. There is no universally accepted classification scheme for describing simulators in anesthesia. Any classification involves some overlapping and gray areas. Cumin and Merry describe a classification that is based on the three pillars of (1) user interaction, (2) physiology base, and (3) use. Gaba classifies simulation modalities according to the following scheme: verbal simulation (i.e., “what-if” discussions, storytelling, trigger videos, role playing), SPs, part-task trainers (including realistic mock-up devices and tissue simulation), computer patient (i.e., VR simulation, microsimulators/screen-based simulators), and electronic patient.

  In this chapter, a patient simulator (as opposed to a part-task trainer) is a system that presents an approximation of a whole patient (not only parts of it) and a clinical work environment of immediate relevance to anesthesiologists (e.g., operating room, postanesthesia care unit, ICU, etc.). A patient simulator system contains several components ( Fig. 7.3 ). Some of the currently available features of typical mannequin-based patient simulators are presented in Table 7.1 .

  
  Table 7.1

  Functionality of Typical Current Mannequin-Based Simulator Systems ^∗

  Clinical Area	Features and Functions	Remarks
  Airway	Appropriate pharyngeal and glottic anatomy	The airway often provides an acceptable seal for ETT; the seal for supraglottic airway devices can be variable, but it generally does allow positive pressure ventilation. The facemask seal is variable (plastic on plastic) Cricothyrotomy of modest anatomic realism; the tissue does not feel like real skin and lacks a subcutaneous fat layer; no bleeding occurs; however, the simulation does allow going through the physical steps of inserting a subglottic surgical airway.
  	Placement of facemask, ETT, supraglottic airway devices, Combitube
  	Laryngospasm, tongue and airway swelling, cervical immobility, jaw closure, breakable teeth
  	Cricothyrotomy
  	Transtracheal jet ventilation
  	Bronchial anatomy (to the lobar bronchus level)
  Head	Eyelid movement, pupil dilation, and reaction to light or medications
  	Patient voice and sounds such as coughing and vomiting (through built-in loudspeaker)	A live voice is preferred to the prerecorded audio clips because of higher flexibility in scenarios.
  	Palpable carotid pulses
  	Cyanosis represented by blue light at the edge of the mouth	The blue light is a cue that the patient is cyanotic, but it does not physically replicate the appearance of cyanosis.
  	Tearing, sweating
  Chest	Physiologic and pathophysiologic heart and breath sounds Spontaneous breathing with chest wall movement	Breath and heart sounds through loudspeakers; sounds contain artifacts and mechanical noise. Often sound level depends on position of stethoscope relative to loudspeaker.
  	Bronchospasm
  	Adjustable pulmonary compliance
  	Adjustable airway resistance
  	Pneumothorax
  	Needle thoracotomy and chest tube placement	As for cricothyrotomy the anatomy is not very realistic, but the mannequin may allow performance of these procedures.
  	Defibrillation, transthoracic pacing ECG
  	Chest compressions
  Extremities	Palpable pulses (dependent on arterial pressure)
  	Cuff blood pressure by auscultation, palpation, or oscillometry
  	Modules for fractures and wound modules
  	Intravenous line placement
  	Thumb twitch in response to peripheral nerve stimulation
  	Arm movement	Most current simulators do not provide even limited robotic movement of limbs.
  	Representations of tonic-clonic seizure activity	These representations are cues that lack anatomic reality.
  Monitoring (waveforms or numeric readouts)	ECG (including abnormalities in morphology and rhythm) SpO 2	Most simulators provide a simulated virtual vital signs display; some can interface to actual clinical monitors.
  	Invasive blood pressure
  	CVP, PAP, PCWP
  	Cardiac output
  	Temperature
  	CO 2 (may be actual CO 2 exhalation)
  	Anesthetic gases (may have actual uptake and distribution of agents)
  	Cardiopulmonary bypass	Some simulators include(d) a virtual cardiopulmonary bypass machine.
  Automation and sensors	Chest compressions Ventilation rate and volume
  	Defibrillation and pacing (including energy measurement)
  	Gas analyzer (inspired O 2 , anesthetics)
  	Drug recognition (drug identification and amount)

  CO ₂ , Carbon monoxide; CVP, central venous pressure; ECG, electrocardiogram; ETT, endotracheal tube; O ₂ , oxygen; PAP, positive airway pressure; PCWP, pulmonary capillary wedge pressure; SpO ₂ , saturation of peripheral oxygen.

  ∗ The features listed are each present in some existing simulators, but not all features are present on any single device. Sets of features depend on the device and model.

  In the following, the major education and teaching purposes of main simulator classifications are presented. The presentation is partly based on the idea of the Miller prism (also pyramid or triangle) of clinical competence. For a more elaborate overview the reader is referred to further literature.

• Miller’s learning pyramid. For each simulation a variety of different learning objectives exist. Largely they can be aligned to the Miller pyramid shown in Fig. 7.4 . On the cognition level, simulations can be used to help learners acquire new knowledge and to better understand conceptual relations and dynamics (“knows,” “knows how”). For example, physiologic simulations allow students to watch cardiovascular and respiratory functions unfold over time and how they respond to interventions—in essence, bringing textbooks, diagrams, and graphs to life. The next step on the spectrum is acquisition of isolated skills to accompany knowledge (“knows how,” later “shows how”). Some skills follow swiftly from conceptual knowledge (e.g., cardiac auscultation) while others involve intricate and complex psychomotor activities (e.g., catheter placement or intubation). Isolated technical and non-technical skills must then be assembled into care processes and existing workflow concepts, creating a new layer of clinical practices (“shows how,” later “does”). Over time those assembled skills get integrated into practice and become part of daily performance (“does”). The expert health care professional performs only in the “does” triangle, except when honing old skills or learning new ones. However, there may be a gap between the level of performance that individuals—or teams or work units—“do” compared to the optimal level. Often, clinicians might be able to demonstrate “knows how”—“shows how” without necessarily being able to “do” under all relevant circumstances and occasions. Simulation can be a valuable tool to close such gaps.

  

• Non-technological simulation. Verbal simulations (“what-if” discussions), storytelling, paper and pencil exercises, and experiences with SPs require little or no technology, but can effectively evoke or recreate challenging clinical situations. Similarly, even pieces of fruit or simple dolls can be used for training in some manual tasks. Some education and training on teamwork can be accomplished with role playing or discussion of videos of relevant events.

• (Computer) Screen-based simulators (microsimulators) that present the patient on the screen as drawings, photos, or videos, while allowing clinical actions or changes to be chosen can be used to teach basic concepts and technical material, such as the uptake and distribution of inhaled anesthetics or the pharmacokinetics of intravenous drugs. Such programs are inexpensive and easy to use. They allow the presentation of and practice with the concepts and procedures involved in managing normal and abnormal case situations, mostly targeting the parts of the Miller pyramid referred to as “knows” and “knows how,” commonly for early learners.

• Part-task trainers include artificial (and occasionally animal or human cadaver) models used to teach particular procedural skills, for example intubation, intravenous or intraosseous access, regional anesthesia techniques, thoracic drainage, and use of difficult airway management devices. These target “knows how” and “shows how.” Such trainers are most commonly used with novices having little experience with the procedure, or to retrain experienced personnel in the application of the particular tools.

• Mannequin-based simulators , representing most or all of a patient, can be used to capture the full complexity of the real task domain, including application of clinical skills and clinical algorithms in combination with human-machine interactions and the complications of working with multiple personnel. They can be used to address “shows how” extending into “does,” at least in simulation (see later section on translational research levels). Therefore, MBS are appropriate to teach diagnosis and management of challenging situations as well as non-technical skills and human-factor-based behavior (see Chapter 6 ). These can be used, with different educational approaches, for all levels of learners. For early learners it is common to use a teacher in the room as an advisor or coach, and to control the simulation by “pause and reflect” allowing the scenario to be stopped and continued or restarted as necessary to maximize their learning.

Sites of Simulation

Some types of simulation such as nontechnological ones and those that use videos or computer programs can be conducted in the privacy of the learners’ home or office using their own equipment. Part-task trainers and mannequin-based simulation are often used in a dedicated simulation center, but MBS is increasingly also done “in situ” (in place)—in a real patient room/bed—or “peri-situ” (near the place)—nearby elsewhere in the clinical work unit. For large-scale simulations (e.g., disaster drills ), the entire organization becomes the site of training, or in the case of a “moving” simulation, different parts of an organization become the site of training. If the simulation training takes place outside the organization, but uses the equipment and personnel of the organization, it is called “mobile” simulation.

Often simulation personnel that work in a dedicated center may either also conduct simulations “in situ,” “peri-situ,” “mobile,” and “moving patients exercises” or may mentor others who do so. The advantages and disadvantages of different simulation sites are discussed in each respective section and summarized in Table 7.2 . Sørensen and associates give an overview of the advantages and disadvantages of different simulation sites in a recent publication in 2017.

Dedicated Simulation Center

Many institutions have chosen to construct one or more complete simulation centers in which to conduct a variety of education and training sessions. At a few places entire “simulation hospitals” have been created (e.g., Miami, https://simhospital.sonhs.miami.edu/ ). Some useful websites of simulation centers and other resources are listed at the end of the chapter ( Appendix 7.1 ). The cost structure of a simulation center is a complex issue (see later subchapter). But these programs and their managers in charge have already voted with their feet on the issue of cost versus benefit.

In a dedicated simulation center, one or more simulators may be used, typically in rooms that partially or fully replicate, in a relatively generic fashion, various clinical environments (e.g., operating room, ICU, labor and delivery, emergency department, etc.). Fig. 7.5 and Fig. 7.6 show the floorplan of a medium-sized and a large simulation center. Fig. 7.6 shows the floor plan of the Immersive Learning Center at Stanford University, a pioneering center for health care simulation.

Typically, simulation centers provide a separate control room to allow complex simulations to be presented without an instructor intruding on the simulated case. Fig. 7.7 shows a simulation control room. Many simulation centers have audio-video systems allowing the recording of multiple views during patient simulation. Some centers have computer-based systems to allow annotation of video on the fly and rapid search to the marked portions, but others have found that such mechanisms are not necessary to support debriefing. Dedicated centers typically provide one or more debriefing rooms, often with video replay capability. Ideally a center is located to be easily accessible to a variety of participant populations. Designing, equipping, and overseeing construction of a simulation center may benefit from special knowledge or prior experience.

Universities and hospitals or hospital networks are increasingly constructing very large multidisciplinary and multimodal simulation facilities that often still have anesthesiologists in leadership positions. Often, these kind of facilities combine all the types of simulation and immersive learning in one large unit, including actors playing SPs (usually in clinic settings), mannequin-based simulation, part-task and surgical and procedural trainers, wet and dry work (e.g., plaster casting or procedures on food products), and different forms of VR. Sometimes these incorporate facilities for dissection of cadavers or the use of anesthetized animals but often these are in other pre-existing sites. Some institutions have many simulation centers, associated with different learner populations, in different locales, or featuring different kinds of simulation equipment.

Advantages and Disadvantages of Dedicated Simulation Centers

Simulation in a dedicated center facilitates scheduled training and allows the use of complex audiovisual gear and a variety of simulation and clinical equipment, with substantial storage. Devices can be preset, tested, and ready to go, with briefing and debriefing facilities immediately at hand. In a dedicated center inexpensive discarded, flawed, or outdated clinical equipment and supplies can be safely used. When a center incorporates all modalities of simulation in one place it fosters hybrid techniques, as when an actor playing a standardized patient is combined with a part-task trainer, or when a surgical simulator is combined with a mannequin-based patient simulator.

The main disadvantage of a dedicated center is its cost of construction and outfitting. Moreover, no matter how well equipped it is, it can never replicate the equipment, layout, and clinical processes of any specific clinical workplace. Also, participants know from the very beginning that the activity is a simulation and not the real thing.

Training and Probing Where Clinicians Work

There are several approaches to conducting simulations in or near actual sites of clinical work. By necessity institutions without a dedicated simulation center must use one of these approaches, but they are useful for many other reasons.

In Situ Simulation

In situ simulation is conducted in an actual bed/gurney/bay of a real clinical workplace, such as, for example, OR, ICU, trauma room, postanesthesia unit, or ward. ISS training is often used for complex patient simulation scenarios with experienced single-discipline or interprofessional staff. It is typically used for training in order to create high environmental fidelity and/or to probe procedures or the system (see earlier subchapter “Application of Simulation”). ISS can be a useful training option especially for training in unique workplaces that are difficult to recreate with adequate realism (see later subchapter on simulation realism) in a simulation center or elsewhere, such as a catheterization laboratory, a CT scanner, an ambulance, or an air rescue aircraft ( Figs. 7.8 to 7.15 ).

Rosen and colleagues reviewed the use of in situ simulation in the continuing education for health care professions. They summarized that a positive impact of ISS on learning and organizational performance has been demonstrated in a small number of studies. They also indicated that the evidence surrounding ISS efficacy is still emerging and that existing research is promising.

Most ISS is performed mobile as a temporary setup only for the training sessions. In very few institutions a simulator is permanently installed in a clinical workplace, for example, creating a simulation-specific patient room in the actual ICU.

Advantages and Disadvantages of In Situ Simulation

ISS seems ideal in that it probes and challenges personnel and systems as they actually exist, thus unmasking real issues of patient care. It is available, in principle, to all sites, even those without a dedicated center, and it is conducive to short courses and unannounced mock event drills.

Because it takes place in the actual work unit, it will eliminate travel time to a dedicated center and will put participants at ease. Some substantial disadvantages include potential distractions by ongoing clinical work, lack of privacy, logistics of setup and takedown, reduced availability of AV and simulation equipment, and supply costs (many ISS activities use the unit’s real clinical supplies as needed). ISS can be difficult to organize, schedule, and control. The clinical area planned for simulation may not be vacant or may be needed on short notice. Staff members engaged in the simulation are prone to being pulled into clinical duty, and training sessions may be interrupted. Raemer summarized potential risks of ISS and amplified some of the safety hazards of simulation itself including maintaining control of simulated medications and equipment, limiting the use of valuable hospital resources, preventing incorrect learning from simulation shortcuts, and profoundly upsetting patients and their families. In our experience, patients and families are rarely upset and in fact often are pleased to see that such serious training is going on.

Peri-situ or Off-site Simulation

If simulation is, in principle, worthwhile, then doing simulation anywhere is probably better than not doing it at all. Peri-situ simulation (PSS) means simulating in the clinical work unit, but not in an actual patient room/bay/bed—for example in a conference room, or even hallway of the unit. This may be done when an ISS session is planned but there is no actual clinical spot available, or it may be done this way on purpose. PSS has some of the advantages of ISS in terms of locale, systems, and supplies, but it lacks the ideal realism of an actual bedside. When simulation is done outside a clinical unit (say a nonclinical conference room) or in a public area of a hospital it is referred to as off-site simulation (OSS).

Sequential Location Simulation

This is sometimes called moving simulation and it simulates the patient moving between different sites of care in one scenario, at each stop enacting what might transpire in that location. For example, the patient could be brought to the emergency department by ambulance; assessed and treated; then taken to CT scan, interventional radiology, or OR; and finally transferred to an ICU. Moving simulation may be best accomplished as ISS or PSS, but again, there will be some value to it even if each stop cannot be simulated perfectly. To do it with full veracity requires intensive coordination and complex choreography of simulation equipment and personnel. It is probably only worth it if done occasionally and primarily with a focus on systems probing and improvement. Moving simulations can address different specific issues at each stop, depending on the most important systems probing and learning issues for each.

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