Simulation in Pediatric Anesthesia

Simulation-Based Training in Anesthesia

In a 1987 review of anesthesia training, gaps were identified in decision making and crisis management and diagnostic decisions were found to be relatively static. Today, in the complex, rapidly changing, time-pressured environment of the operating room (OR), anesthesiologists are challenged beyond static decision making, especially when identifying and resolving crises and leading interdisciplinary teams. To reconcile this schism, the anesthesia crisis resource management (ACRM) program was developed based on the commercial aviation model: Crew Resource Management. These investigators established a framework and curriculum to teach individual and team leadership skills, along with effective communication styles. ACRM provided anesthesia trainees with tools similar to those that made the complex dynamic world of aviation safer through decision making and crisis resource management. The development of anesthesia simulators and OR-simulated settings was critical in the implementation and growth of ACRM as trainees and practitioners needed a safe venue to experience cases that challenged them in diagnostic problem solving, fixation errors, and poor teamwork in order to train and gain ACRM skills.

ACRM was an outgrowth of the patient safety movement that began in anesthesia in the early 1980s in America. In the late 1980s, research funding from the Anesthesia Patient Safety Foundation (APSF) supported the early development of several forms of human patient simulators (HPSs). Further publicity and advocacy from APSF propelled anesthesiology to the forefront of specialties in the application and adoption of simulators, with strong patient safety implications through education (residents attempting new skills for the first time on a mannequin), training (teamwork, critical event management, and situational awareness), and research (human performance). Today, simulation in anesthesiology is global, with emphasis not only on medical knowledge and skills training, but also on ACRM, disaster training, debriefing, and patient safety. To maintain status as board-certified anesthesiologists, the American Board of Anesthesiology (ABA) requires candidates to complete the Maintenance of Certification in Anesthesiology (MOCA) program. One of the approved ways to achieve MOCA credit is to complete a simulation-based course at a simulation center endorsed by the American Society of Anesthesiologists. In some institutions, such training is required as a condition of credentialing for practice and insurance coverage.

What Is Simulation?

Simulation is a technique to replace or amplify real experiences with guided experiences that evoke or replicate aspects of the real world. Simulation is enabled by a diverse set of emerging technologies. The application of simulation in the health care field is focused on education and training of clinicians. Education emphasizes knowledge, skills, and introduction to the actual work. Training emphasizes the actual tasks and work to be performed. The term “simulator” is used in the health care field to refer to a device that represents a simulated patient and interacts appropriately in response to the actions of the simulation participant. In aviation, pilots are seated in the cockpit of a flight simulator, whereas in health care, clinicians are in a simulated OR, emergency ward, or patient floor in simulated clinical scenarios, caring for a simulated “patient” experiencing a critical or otherwise challenging event.

Participants in a simulation are “immersed” into a task or setting to the extent necessary to achieve the learning objectives. This may be conducted in a normal classroom or in an environment that extensively replicates the real world. In the latter case, participants and faculty enter into a “fiction contract” such that the instructor prepares an engaging simulation scenario and the participant attempts to care for the “patient” as if he or she were a real person. Most importantly, it is incumbent on those who create and implement the simulation to create sufficient realism to enable the learner to feel the reality of the situation and respond accordingly.

Participants in a simulation scenario experience realism in three distinct domains: physical, conceptual, and emotional . Simulations that address all three domains are more likely to instill the intended learning objectives. A high degree of realism appropriate for the specific learning objectives is central to ensure that the learners become mentally and physically engaged. The physical properties of the simulator (the patient), such as weight, flexibility, tensile strength, and color, are important for developing kinesthetic awareness and muscle memory. For example, the weight of the head and force required to effectively perform laryngoscopy are important for teaching tracheal intubation, whereas the rubbery feel of the mannequin skin is not. Conceptual realism refers to the causal relationships observed in the scenario, such as a decrease in oxygen saturation during a period of apnea or the resolution of hypotension after an appropriate IV fluid bolus. High conceptual reality enhances clinical reasoning and decision making. Finally, emotional and experiential fidelity is achieved when participants experience familiar and authentic feelings, such as “emotional activation,” anxiety, stress, fear, or excitement. Ultimately, realism in simulation is perceived as “an exciting simulation that captures the imagination, triggering physiologic responses and execution of ingrained clinical algorithms.” Although realism is important, it has been said that “when learning is the focus, the flawless recreation of the real world is less important.” It is necessary to find circumstances that help participants learn, rather than circumstances that exactly mimic a clinical situation. The degree of realism desired for a successful simulation education program is an amount sufficient to achieve the intended learning outcomes.

Technologies Used in Simulation

Partial Task Trainers

Partial task trainers are mannequins or models (e.g., suturing board, intravenous [IV] arm, airway head) designed to allow participants to practice clinical skills and tasks ( Fig. 53.1 ). They should be reliable, robust, and medically meaningful. Usually they represent a portion of a person rather than the whole. Although many are simple devices designed for learning or practicing a specific procedure (e.g., suturing, IV insertion, arterial line placement, laryngoscopy, cricothyrotomy, or intraosseous access), some are coupled with computers, robotic interphases, and digital graphics to provide sophisticated partial task simulators designed for learning or practicing more involved procedures (e.g., bronchoscopy and endoscopy, endovascular catheterization, or laparoscopic skills). These models are particularly useful for teaching invasive, risky, and rare procedures (e.g., emergency cricothyrotomy, transvenous pacing, or pericardiocentesis), complex psychomotor skills requiring repetitive training (e.g., ultrasound-guided central venous catheterization or awake fiberoptic intubation), or those that are safe but create increased anxiety for either the learner or the patient and his or her family (e.g., neonatal intubation, urethral catheterization, IV insertion, or arterial puncture). The use of partial task trainers in a simulation environment is conducive for coaching and deliberate practice. Curricula that use these types of devices focus on skills training at varying levels of skill-oriented goals, rather than a particular situation. For example, cricothyrotomy training on a partial task simulator aims to teach the procedure, regardless of the indication (e.g., angioedema, burns, obstructing mass, or hemorrhage). Specific partial task trainers used for simulating aspects of pediatric interventions include products to learn or practice lumbar puncture, peripheral IV insertion, intraosseous needle insertion, laryngoscopy and intubation, umbilical vein and artery catheterization, and cardiopulmonary resuscitation (see Video 53.1 ). In the context of skills training, there is strong evidence that simulation-based mastery learning can improve patient outcomes. Although there are partial task trainers commercially available for many invasive procedures, simulation education faculty and operations specialists frequently design and produce “low-cost” models to teach practice procedures—for example, managing obstetric and neonatal emergencies in Mexico and postpartum hemorrhage in rural Africa.

Human Patient Simulators

An HPS is a representation of the human body constructed on a mannequin, typically made of plastic and metal, without a bony skeletal frame. Although popularized in the 1990s, the first mannequin-based simulator (SimOne) was developed at University of Southern California in the 1960s and was intended to facilitate medical education and training. Adult HPSs became commercially available in the early 1990s; the first high-fidelity pediatric simulator was introduced in 1999. The METI PediaSIM (CAE Healthcare, Sarasota, FL) represented a child between 5 and 7 years of age. Two models of integrated infant HPSs became available in 2005: the METI BabySIM and the Laerdal SimBaby (Laerdal Medical, Stavanger, Norway) ( Fig. 53.2 ). Both models exhibited standard vital signs and variable airway features (e.g., tongue swelling and laryngospasm), breathing patterns and sounds (e.g., retractions to illustrate upper airway obstruction, breath sounds [wheezing], and pneumothorax), cardiovascular features (e.g., heart sounds and peripheral pulses [diminished or absent]), and others (e.g., abdominal sounds and distention, and fontanel bulging). Both infant simulators produce a variety of monitor signals and allow extensive treatment interventions (e.g., intubation, laryngeal mask and nasogastric tube insertion, chest compressions, IV and intraosseous cannulation, and thoracocentesis) (see Video 53.1 ). Incorporated into the clinical setting or in a simulation room outfitted with biomedical equipment and teams of health care providers, the HPSs can provide a high degree of clinical authenticity and realism to facilitate participants to fully engage in the care of the simulated patient. Typically, participants in simulation scenarios reflect on their performance during the simulation, for the purpose of sustaining and improving their practice with an instructor, in the process termed debriefing (see Video 53.2 ).