By Roy Phitayakorn, Wilton Levine, Emil Petrusa, Bethany Daily, Ersne Eromo, Denise Gee, Maureen Hemingway, Rebecca Minehart, May Pian-Smith, and James A. Gordon
Making It Real Development and integration of in situ simulation operating rooms into the real operating room environment.
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imulation is any artificial construct that represents a real-world process. Technology-enhanced simulation in modern health care is growing exponentially, but the basic concept of “practice” to enhance real-world performance in medicine dates back centuries. For example, in the 1600–1700s, birthing simulators were built from human bones, leather, wood, and wicker to train midwives how to manage common birthing emergencies [1]. Today, simulation sessions can be loosely categorized into three formats: 1) imaginative scenario-based work (paper or tabletop simulations), 2) individual versus team-based manikin simulations or standardized patient-based simulations, and 3) specific task-based trainers. Modern surgical simulation focuses largely on the latter two approaches and is typically differentiated from other forms of medical simulation by the use of specific surgical models or tasks during the simulation. However, despite the rapid growth of simulation in health care, operative training models that replicate the practice of surgery remain underdeveloped. Currently, there is a robust discussion in the simulation community regarding center-based versus in situ simulation locations. Center-based simulation typically occurs outside of a patient care facility. These centers are flexibly designed to accommodate a wide variety of participants from all health care groups, as well as different patient care settings [i.e., inpatient wards, outpatient clinics, emergency department bays, radiology imaging suites, or operating rooms (ORs)]. While such flexibility Digital Object Identifier 10.1109/MPUL.2015.2428298 Date of publication: 14 July 2015
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allows for a wide range of participants and settings, it often limits exact replication of any one particular environment’s physical space and equipment. In situ simulation is defined as simulation in the learners’ actual work environment. Advantages of in situ locations include lower equipment and overhead costs, ability to train more participants in a given amount of time, enhanced simulation realism, identification of latent system errors, and improved convenience for both the learners and faculty [2]. However, in situ locations generate unique logistical and organizational challenges. In this article, we describe our experience in integrating simulation into the existing OR complex at Massachusetts General Hospital (MGH). We hope this description fosters increased medical collaboration with engineering communities, not only with respect to the advancement of realistic surgical modeling, but also in designing integrated systems to serve both clinical and educational needs in the health care environment.
Surgical History of MGH The MGH in Boston currently performs over 37,000 operations a year where more than 1,000 medical students, residents, and fellows learn. Inside the MGH Bulfinch Building is the Ether Dome, which is the site of the first public demonstration of ether anesthetic for a surgical operation in the United States. On 16 October 1846, William T.G. Morton, a Boston dentist, successfully administered ether to Gilbert Abbott, which allowed MGH cofounder, Dr. John Collins Warren, to painlessly remove a tumor from Mr. Abbott’s jaw.
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This landmark event at MGH started a long A New Vision for OR Training While the cognitive and tradition of performing operations that select The vision for the new in situ OR simulateamwork experiences members of the public and medical commution suites was to provide a physical space in our simulations are nity could observe from a platform surroundto conduct high-fidelity OR team training ing the OR table. This open environment simulations; to allow practice opportuniquite realistic, there ceased with increased understanding of germ ties for individual operative skills; and to remain technical theory and the importance of sterility to pretest new OR devices, procedures, and poligaps that present vent surgical infection. However, in 1939, MGH cies. This vision was integrated with overall challenges unique to designed enclosed surgical observation decks institutional goals of discovering latent orgathe in situ simulation for the opening of the ORs in the White Buildnizational risks, supporting residency trainenvironment. ing. These former “state-of-the-art” two-story, ing and nursing education programs, and sealed observation decks overlooked several promoting the continued professional develOR theaters (see Figure 1). Except for the one opment of health care providers through overlooking OR#5, these historical decks were ultimately high-quality educational offerings. We also recognized that closed, and most were demolished. In 2012, a wing of new ORs the ultrahigh-fidelity nature of this simulation space would opened in the MGH Lunder Building, allowing three of the be an ideal laboratory to develop and test new assessments original White Building ORs, including OR#5 and its observaof individual and teamwork performance within an OR tion deck, to be used for simulation training. environment. july/august 2015 ▼ ieee pulse 11
FIGURE 1 The historical observation deck at MGH. (Photo courtesy of MGH Archives and Special Collections.)
These questions helped us develop guiding principles and The concept of creating simulation training opportunities policies to ensure that the in situ simulation supplies, equipwithin an active OR complex presented exciting opportunities as ment, and processes were “sealed” and that no training equipwell as important challenges. In addition to its inherent authenment or processes “leaked” into the real ORs. To this end, we ticity, the idea of an in situ surgical simulation space had definite created OR simulation policies, a standardized orientation for historical appeal, harkening back to MGH’s use of observation all simulation participants, reviewed simulation safety protogalleries as an educational tool. Financially, there were also real cols at the beginning of each session, installed cost savings to using existing facilities rather than explicit signage for all simulation spaces, and building a brand new surgical simulation center. Despite the rapid attached “simulation-only” labels for all supAlso, OR staff participating in simulation sessions growth of simulation in plies and equipment. As an additional fail-safe saved considerable time by eliminating travel to to avoid cross-contamination of any “mock” an off-site training locale. The participants could health care, operative elements into the real-world environment, then return promptly to their clinical responsibilitraining models that we stocked and maintained only clinicalties, thereby increasing overall employee producreplicate the practice grade equipment, supplies, instrumentation, tivity for their departments. of surgery remain and medications in each simulation room. We However, utilization of the existing physiunderdeveloped. worked closely with our perioperative biocal OR space did not allow for renovations typimedical engineering and pharmacy groups cal of an off-site simulation center (removing/ to ensure that these elements are maintained moving walls, adding one-way mirrors, etc.). regularly and match the real ORs. We also carefully designed In addition, management of the operational workflow of an several engineering work-arounds of the existing phone/overin situ simulation center internal to a live operating suite was head intercom, anesthesia machine, manikin, clinical monicritical. Some of the critical questions considered included the toring, and computer systems, so that our training activity following: Would all equipment used in the simulation center would not interfere with routine OR operations. The observabe part of the active OR inventory? Would equipment ever be tion deck acts as a control area to operate the manikin and used that was not part of the active OR inventory? How would other simulation elements; it also provides an opportunity for sterile supplies be maintained? Would we use real or simulated individuals to view the proceedings, out of sight of the simulamedication vials? If using real medication vials, how would tion participants. we balance this against the ongoing national medication shortSimilarly, we worked closely with our perioperative inforages? How would actual patients presenting for surgery and mation technology group to create patient names and medical passing through the hallway adjacent to a simulation perceive record numbers that would only be used for the patients in the their experience? What would happen if a simulation parsimulation scenarios. This opened up the potential capabilticipant left the simulation environment to obtain help from ity to track supplies, equipment, and medication costs for the nonsimulation participants? 12 ieee pulse ▼ jluy/august 2015
simulated patients, just as we would in a real case. We also worked with the MGH Laboratory for Computer Science to create a radio-frequency identification badge reader system that allowed simulation participants to sign in for each simulation session with a simple badge swipe. This system allowed us to easily see who was assigned to take care of a simulated patient for that session documented in our OR computer systems. The simulated patient also appeared on the real OR schedule so that the OR community could see when the rooms were being used and what “operation” the teams were going to perform. These entries served to highlight the concept of continuous education as a key element of daily operations and emphasize the connection between simulation and actual patient care.
Training Experience and Future Needs We started using our new in situ simulation ORs for operative training in late 2012. Since that time we have conducted nearly 400 OR simulations for many specialties, including general surgery, pediatric surgery, burn surgery, laryngology, oral maxillofacial surgery, urology, obstetrics and gynecology, orthopedics, thoracic, and cardiac surgery. Our multidisciplinary approach has included surgeons (attending/resident physicians), anesthesia providers (attending/ resident physicians and certified registered nurse anesthetists), registered nurses, and surgical technologists, which helps to enhance and enrich the educational opportunities. Over 1,000 health care staff have participated in OR simulation experiences as a partial fulfillment of various curricula and continuing education initiatives including medical malpractice discounts, continuing education credits, Accreditation Council for Graduate Medical Education milestone achievement, Anesthesia Crisis Resource Management curriculum, and the American College of Surgeons and the Association for Program Directors in Surgery National Surgical Skills Curriculum. While the cognitive and teamwork experiences in our simulations are quite realistic, there remain technical gaps that present challenges unique to the in situ simulation environment. Only close collaboration with inventors and engineers will yield high-fidelity surgical models that can be fully integrated into an already complex operative environment. For example, our manikins were not originally designed for regular positive pressure ventilation from an anesthesia machine, so several modifications were made to ensure adequate pulmonary compliance to avoid false alarms from the anesthesia machine for low tidal volumes/pressures and air leaks. The manikins were also modified to prevent internal damage from irrigation fluids, sharp cutting instruments, or simulated blood. Various surgical models, such as an abdomen for laparoscopic operations and a bleeding tumor, had to be engineered and placed on top of the manikins due to lack of internal space. New modifications are continually needed to create OR situations that are realistic enough to engage the surgical team (surgeons, scrub technologists, circulator nurses, and anesthesiologists) without being excessively bulky or damaging to the manikin. In particular, computerized algorithms that
could mimic ventilator characteristics and response to medications would remove the need for pumps and bellows within the manikin’s thoracic and abdominal cavities. The removal of this equipment would enhance internal space within the manikin and allow direct internal integration of surgical models to enhance the scenario realism and the overall engagement of surgical teams. In the future we hope to make simulation staffing and resources even more accessible to surgical teams as part of their routine OR workday. Previous research on the effectiveness of dress rehearsals prior to actual surgery has been shown to benefit teams who routinely practice with simulation [3]. We also feel that in situ simulation allows teams to practice in their own environment as opposed to traveling to a simulation center. This benefit appears to enhance accessibility and overall learner satisfaction with the simulation sessions. In summary, the development and integration of three in situ simulation ORs into the working OR clinical environment has required advanced vision, creative use of OR space, and ongoing collaboration across hospital services. Beyond their profound educational value, these rooms have provided robust opportunities to refine OR policies and procedures, enhance the OR safety culture, and support collaborative research opportunities, all of which help us to continuously improve patient care. We are currently exploring the development of simulation-based credentialing metrics that could be incorporated in the Joint Commission processes. We look forward to expanding our work with engineering communities to help advance the field of surgical simulation modeling and operations. Roy Phitayakorn, Wilton Levine, Emil Petrusa, Bethany Daily, Ersne Eromo, Denise Gee, Maureen Hemingway, Rebecca Minehart, May Pian-Smith, and James A. Gordon are affiliated with the MGH Learning Laboratory; Department of Surgery; Department of Anesthesia, Critical Care, and Pain Medicine; and Perioperative and Patient Care Services; all at Massachusetts General Hospital, Boston. For questions or more information regarding the content of this article, contact Director of Surgical Education Research Roy Phitayakorn, M.D.:
[email protected].
References [1] A. A. Wilson, “New synthesis: William Smellie,” in The Making of Man-Midwifery: Childbirth in England 1660–1770. London: Univ. College London Press, 1995. [2] K. M. Ventre, J. S. Barry, D. Davis, V. L. Baiamonte, A. C. Wentworth, M. Pietras, L. Coughlin, and G. Barley, “Using in situ simulation to evaluate operational readiness of a children’s hospital-based obstetrics unit,” Simul Healthc. vol. 9, no. 2, pp. 102–11, Apr. 2014. [3] J. D. O’Leary, O. O’Sullivan, P. Barach, and G. D. Shorten, “Improving clinical performance using rehearsal or warm-up: an advanced literature review of randomized and observational studies,” Acad Med., vol. 89, no. 10, pp. 1416–22, Oct. 2014.
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