In the first of a series of articles on medical simulation centers, Group Editor Marty Kauchak reports the quest for patient safety and other requirements are fueling the community’s demand for these facilities.

Simulation allows healthcare profession members to learn and enhance many skills for individual and team procedures before they step into the operating room. The rapidly evolving simulation market provides doctors, nurses and other healthcare professionals with cost-effective and high- fidelity part-task trainers to complement the array of more expensive, heritage full-task training devices prevalent throughout the community. At the same time, cutting edge Web-based instruction, virtual worlds and other forward-leaning technologies are being introduced into the continuum of academic and professional learning. Hospitals, medical schools and other institutions in the private and public sectors allow their professionals to learn and rehearse an increasing list of procedures in the virtual domain – not on an actual patient – at medical simulation centers. These venues typically have classrooms, virtual operating rooms, after- action review (debrief) stations and other facilities to allow learners to use technologies throughout their continuum of instruction.

In an accompanying feature article in this issue, John Schaefer, M.D., further explores the realm of possibility with networked simulation, discussing HealthCare Simulation of South Carolina.

In a series of building block-type articles, MEdSim will highlight the latest developments in medical simulation centers. This initial story looks at how the burgeoning, underlying demands for simulation are fueling the requirements for these facilities to serve as brick-and-mortar venues for learning. In follow on articles we’ll look at returns on investment (ROI) and the business case for these facilities, the technologies that populate the centers and other topics.

Understanding Simulation Centers

The healthcare profession, in relation to the military, civil aviation and other high-risk communities, is belatedly embracing simulation. The other sectors have used part-task trainers, full mission simulators and other devices for decades to help its members learn and enhance their ability to operate aircraft, vehicles and ships, and perform other skills – prior to conducting the task. In a positive development, simulation is becoming a foundation of healthcare providers’ culture of learning.

The majority of this activity is occurring at simulation centers. These facilities are built and equipped to allow individuals and teams to be immersed in increasingly rigorous training scenarios – without using live patients.

These venues are being built at a quickening pace. During a one week period this September, MEdSim’s sister editorial resource <> reported the opening of two centers and the donation of $7.1 million to open another facility in 2013.

The surging interest in medical simulation centers is a global phenomenon. Indeed, the embryonic Sidra Medical and Research Center’s Clinical Simulation Center in Qatar, promises to be one of the leading facilities in the world [Medical Simulation Centers Transforming International Healthcare Landscape MEdSim issue 2.2012].

Two center leaders described their state-of-the-art facilities.

Cate Nicholas, Ed.D., MS, PA, the Director of Simulation Education and Director of the Standardized Patient Program at the Clinical Simulation Laboratory, University of Vermont/ Fletcher Allen Health Care, told MEdSim, that her simulation laboratory is built on a distributed model with more than one physical location.

Part of the laboratory’s infrastructure includes a virtual hospital. “This has six inpatient rooms, one with an attached bathroom; a multipurpose room which can be transformed into an OR/ER/MICU[medical intensive care unit]/ PICU [pediatric intensive care unit] or SICU [surgical intensive care unit] based on the needs of the faculty; two debrief rooms – one small and one large which accommodates up to 35 people; a task-trainer room which holds 16 people or more; and a virtual reality room which has a number of devices – a simulator for robotic training, a colonoscopy/endoscopy machine and arthroscopic machine.”

Another attention getter is the diverse learning audiences served by this center, providing another indication of the interest by the private and public healthcare sectors in the technology.

Nicholas, who is also a physician’s assistant, pointed out the Clinical Simulation Laboratory (CSL) is jointly supported by the University of Vermont Colleges of Medicine, and Nursing and Health Sciences, and Fletcher Allen Health Care, and serves multiple learning audiences. A partial list of the more than 20,000 healthcare professionals who will annually use the laboratory includes aspiring doctors, nurses and allied healthcare professionals at UVM colleges; faculty staff at the university; and staff doctors, nurses and other community professionals, as the EMT programs. The CSL also provides educational support for the Vermont Air and Army National Guard.

The Burlington, Vermont-based simulation community leader noted her learners’ particular interest in part-task trainers is to develop specific clinical skills. “These devices are getting an incredible amount of use across the continuum of medical school training and across the health care continuum – they are being used quite extensively.

Also of note, the Clinical Simulation Laboratory’s has a video capture system that supports the recording, replaying and debriefing of simulation scenarios.

One of the community’s newest simulation centers is the Simulation Lab at Kishwaukee (Illinois) Community Hospital, part of KishHealth System. The lab is outfitted with a computer control room and a mock patient room that houses iStan, a wireless simulated patient equipped with fully operational functions including bleeding, tears, and other fluids “iStan also has realistic physiology and responses including EKG rhythms,” DurRay Sanchez-Torres RN, BSN, the Clinical Development Coordinator of the Simulation Lab, pointed out. Healthcare providers are able to run scenarios, making decisions in real time, communicating with and treating iStan as an actual patient. Medications are given through IVs, oxygen is delivered through the nose and mouth, and catheters are inserted, creating a training environment like no other, as iStan speaks and reacts as a human being would to whatever stimulus is presented,” Sanchez-Torres added.

The Primacy of Patient Safety

Simulation centers and their enabling technologies are an important investment for any size host institution.

Three data points on the cost of these facilities may be gleaned from facility openings through this summer. This July, CHRISTUS St. Michael Health System unveiled its new 5,200 square-foot, $1.2 million Simulation Center in Texarkana, Texas. Earlier in June, the University of Texas in San Antonio opened a new $3.9 million Simulation Center and Clinical Learning Lab for its School of Nursing, and in Australia a $1.3 million mobile simulation center is expected to revolutionize the way clinical training is delivered in regional and remote areas of New South Wales.

Even in an era of increasing medical costs and competition for resources, medical sector decision makers are investing in simulation centers – and with compelling reasons.

In medical simulation, the training imitates reality, offers almost limitless opportunities to have things “go wrong”, allows practitioners to safely demonstrate how to “do things right”, and provides corrective feedback as a guide to future action, Connie Lopez, MSN, CNS, RNC-OB, CPHRM, the National Leader for Simulation-based Education & Training in the National Risk Management and Patient Safety section at Kaiser Permanente, observed.

She added, “Simulation-based education provides an opportunity to practice a variety of clinical situations where error is more likely to occur. At Kaiser Permanente, medical simulation-based training effectively targets commonly elusive educational objectives: practice without risk, curricular standardization, and pedagogic efficiency.”  The Kaiser Permanente investment strategy in simulation at all eight of its regions also helps illustrate the surging interest in simulation across healthcare specialties.

Simulation-based programs at Kaiser Permanente are now offered in: labor and delivery, anesthesia, operating rooms, neonatal/ pediatric intensive care units, medical/surgical units, general and interventional radiology, adult and pediatric procedural sedation, ambulatory surgery and procedural centers, clinics and emergency departments. “These programs are constantly evolving and we are looking at other high-risk areas where simulation can be utilized,” Lopez pointed out.

At the association level, the American College of Surgeons’ Division of Education has embraced simulation across the spectrum of education and training programs and has established an accreditation program for simulation centers. .

Following up on Lopez’s theme, Ajit Sachdeva, M.D., FRCSC, FACS, the director of the ACS division, told MEdSim that patient safety was at the top of his list of requirements for using simulation.

“There are things that we need to do to train people in simulated environments so they can perform in a much more effective way in real environments and provide safe care of the highest quality,” Sachdeva said.

Sachdeva noted the ACS views simulation as a way to promote excellence and expertise in surgery. “That comes through the repeated, deliberate practice, which requires a fair amount of training in simulated environments. We can change the slope of the learning curve by doing this.” He emphasized learning tasks may be completed in a  more concentrated manner through simulation while it takes considerable time to gain expertise in the real operating room environment.

Additionally, Sachdeva said the achievement of cognitive, judgment and technical skills may be effectively assessed and documented against pre-established standards in a simulated environment.

“We also can expose our learners to diseases and conditions that are unique and uncommon, so they are prepared for and can deal with the unexpected,” he remarked.

The National Patient Safety Foundation (NPSF) views simulation through the prism of its very- focused mission: improving the safety of the healthcare system. To support the mission, the foundation has become a unique proponent of simulation – recognizing its value as an educational tool to assist healthcare professionals as they learn and apply patient safety techniques.

The NPSF’s efforts in this sector have been led by Jeff Cooper, Ph.D., a long-time advocate of medical simulation and a community subject matter expert. “Jeff and our board have made us quite familiar with the value of simulation as a learning tool and the place that it has in improving safety practices,” Diane Pinakiewicz, the foundation’s president, told MEdSim.

At an early point in the foundation’s existence, it also believed that simulation had tremendous value as a safety enabler – allowing the health care professional to practice a procedure before performing the steps in real time. “The discipline of anesthesia was able to improve its safety profile through the use of simulation,” Pinakiewicz recalled. “What we realized was that simulation had broader application to safety across disciplines.”

The Lucian Leape Institute, a think tank based at NPSF, also endorsed simulation in its report Unmet Needs: Teaching Physicians to Provide Safe Patient Care. Pinakiewicz pointed out that the report framed simulation as a “critical component of medical school training.”

The NPSF’s president also noted that the healthcare community’s awareness and understanding of the value of simulation to support individual and team training has been shaped, in part, by the experience of aviation and other high-risk industries that have used simulation for decades.

“Using simulation to practice new procedures while presenting no risk to patients is invaluable to improving patient safety. If you have the capability to learn in a scenario where you are safe and protected from potentially hurting someone, and are able to learn from trial and error without affecting a patient, that has value,” she said. And while some of the returns on investment or other outcomes of simulation use may be hard to quantify, using this technology to learn and rehearse, and learn experientially and not just didactically, result in more effective skills and teamwork to get the job done.

Cate Nicholas

connie lopez, Kauchak, MEdSim4
From top: Dr. Ajit Sachdeva, American College of Surgeons; Cate Nicholas, University of Vermont/ Fletcher Allen Health Care; Connie Lopez, Kaiser Permanente. Image Credit: American College of Surgeons; Raj Chalwa/UVM Medical Photography; Kaiser Permanente.

Team Building and Beyond

Much like their counterparts in the military and civil aviation sectors, medical professionals can also build team skills in a simulated environment. Kaiser Permanente’s Lopez noted that her colleagues have used medical simulation to support our "teams of experts becoming an expert team." She continued, “Through the use of simulation in the medical training environment any health care provider or medical center team has the potential to improve and maintain collaborative teamwork and communications skills in addition to improving patient safety and clinical outcomes.”

Indeed, MEdSim has noted the buzz at recent conferences – on the exhibition floor and in break-out sessions – about systems and strategies designed to replicate the successes of institutions such as Kaiser Permanente that build and enhance team performance through simulation.

Sachdeva, too has noted this development, but added a hint of caution for his colleagues. “People sometimes get so focused on team training that they do not sufficiently address the needs of the individual. If the individual does not have the requisite skills, no amount of teamwork is going to cut it – people on the team can only compensate for so much. Our approach has been to focus on excellence at the individual level, excellence at the team level, and excellence at the systems level. All three domains must be addressed effectively through simulation.”

At the end of the day, medical simulation centers are a business and must remain financially viable.  Roger Smith, Ph.D,, examined this topic in greater depth in his MEdSim feature article Surgical Education, Research and Business Design, Issue 1.2012. At a more elementary level, CEOs and other “shareholders” of organizations that invest in simulation labs, look for ROIs from their expenditures. MEdSim readers gained insights into ROI in a groundbreaking article on the topic ROI: What is it and does it really matter? by Don Combs, Ph.D., Issue 2.2012.

While ROI will be discussed in more detail in follow-on articles, the concept is included in this discussion because of its linkage to patient safety.

The Clinical Simulation Laboratory is achieving an impressive ROI by improving processes, in addition to teaching and enhancing individual skills. In one instance, Fletcher Allen Health Care, the University of Vermont’s teaching hospital, is dramatically reducing the infection rate for central line insertion procedures. “We were invited into the discussion because we have central line insertion mannequins,” Nicholas said, and continued, “The key here was a total system review. Simulation had something to contribute – it was a piece of the pie. We were able to become part of a new, required training for first-year residents prior to them entering the medical intensive care unit. At the most recent follow-up they had zero central line infections with insertion related to those learners coming in – and that’s in one year.”

As part of the system review, the laboratory has also contributed to lower infection rates through collateral improvements in hand washing and other sterilization procedures, electronic health record documentation, and other actions. “I don’t think the simple task of having the learners come in and learn how to put a central line in a simulator made the difference. I think it’s because we got involved with a process review of how do we improve and lower central line infection rates from A- Z, and we took that system and replicated the process in the simulation lab,” Nicholas reflected. [Editor’s note: See related University of Washington central line study in this issue.]

The simulation laboratory is helping improve two other internal processes;  skin surveys to avoid bed ulcers in hospitalized patients and preventing patient falls.

In what promises to be a watershed development in healthcare’s use of simulation,providers of malpractice insurance for healthcare professionals are reducing their rates for members who demonstrate levels of competency through simulation. While several insurance providers in this sector declined MEdSim’s invitation to provide on-the-record or on background insights on the impact of these technologies on their rates, the ACS’s Sachdeva corroborated anecdotal evidence we have received on the topic at conferences and other venues.

One of the community's newest simulation centers is the Simulation Lab at Kishwaukee (Illinois) Community Hospital. Image Credit: KishHealth System.
One of the community's newest simulation centers is the Simulation Lab at Kishwaukee (Illinois) Community Hospital. Image Credit: KishHealth System.

“The insurance companies have been watching the advances in the field of simulation. They have realized that validated and effective methods for teaching and assessment can be very useful to ensure that individuals acquire and demonstrate specific levels of competence, proficiency and expertise. In some cases, they have started offering small reductions in insurance malpractice premiums, which is a very positive trend,” Sachdeva said.