# Presentation: 479160

## John C. Messenger, MD, FACC
Associate Professor of Medicine
Division of Cardiology
Director, Cardiac Catheterization Laboratories
University of Colorado Denver

- Associate Professor of Medicine
- Division of Cardiology
- Director, Cardiac Catheterization Laboratories
- University of Colorado Denver

**Simulation Training to Improve Heart Attack Care for Rural Hospitals**

- 2008 AHRQ Annual Meeting

## Background

- Multiple therapies have been demonstrated to improve survival in patients suffering a heart attack--acute myocardial infarction (AMI).
- Published guidelines, endorsed by multiple medical societies, are now update almost yearly.
- Despite this, the rates of guideline-recommended treatment adherence for AMI care are suboptimal in many healthcare settings
- Rates lower in rural hospitals versus urban
- Effective dissemination and education of rural providers may play a role in this.

## Background

- CRUSADE Registry Data
- Association between hospital processes of care and outcomes among patients with AMI
- Better adherence to guideline-based treatments for heart attack patients  Better Clinical outcomes

- Peterson ED et al.  *JAMA *2006; 295(16):1912-20.

## Why a Rural Hospital Setting?

- Rural hospitals have not been specifically targeted in recent national quality campaigns
- No mandatory reporting requirements for AMI quality measures
- Care teams appear to differ from urban hospitals
- Low volume AMI centers

**Notes:**
While national campaigns have aimed at increasing awareness about the use of guideline based therapies for AMI, often in conjunction with cardiologists, rural hospitals have not  been specifically targeted.

## Rural Health Care and AMI

- Acute Myocardial Infarction
- Small Numbers=limited opportunities to care for these patients
- 3% of pts were discharged home from the ED despite a final diagnosis of MI in rural hospitals
- No mandatory QI programs for AMI care
- Unknown which quality improvement methods work best for AMI care in the rural setting
- Unknown which educational programs are effective

- Westfall JM et al. *Ann Fam Med*  2006;4:153-158

**Notes:**
Due to the relatively small numbers of AMIs seen in many rural hospitals compared to urban hospitals, there are likely limited opportunities to care for patients with AMI, which may make recognition and guideline-concordant management of AMI more challenging for rural health care providers.   In addition, the low rates of  AMI in most rural hospitals might limit the effectiveness of quality improvement programs that have been successfully employed in larger urban settings. As a result,  it is important to develop innovative approaches aimed at improving AMI care in rural hospitals where a significant proportion of AMI patients are hospitalized nationwide. 

## How do healthcare providers learn about changes in care?

- Read journals with updated scientific statements
- “Throw-away” magazines on medical topics
- Attend annual or semi-annual meetings of professional societies with didactic lectures
- E-mails sent with links to educational websites
- Local continuing education programs
- Lunch or dinner programs with speakers
- Word of mouth through practices/hospitals

## Human Learning: Level of Interactivity

**Why Use Simulations?**

**Interaction** is associated with learning achievement and retention of knowledge
- Participants **learned faster** and had **better attitudes** when they used an interactive instructional environment

**	**_**Retention**_
**Teach Others****	****90%****	****Collaborative Simulations**
**Learn By Doing**	**75%****	****Simulations**
- Discussion Groups	50%	Web Seminars, IM, chat
- Demonstration	30%	Animation
- Audio Visual	20%	PowerPoint Slides
- Lecture	5%**	**Streaming media
*Source: Andersen Consulting*

- Najjar, L. J. (1998). Principles of educational multimedia user interface design.  *Human Factors*, 40(2), 311-323.

**Notes:**
Studies have documented that simulation training provides retention of knowledge and skill that equals real life scenarios.  Significant increased performance versus traditional teaching technologies.

## Pilot of a novel educational program

- Use medical simulation as a platform for education in rural hospitals:
- Embed an up-to-date didactic curriculum
- Create a ‘realistic’ setting
- Exposure to rare events
- Team training
- Cover the spectrum of care
- Create a safe environment to practice and teach
- Take education to rural hospitals

**Notes:**
The use of medical simulation has been proposed as a strategy for educational training that holds promise in many fields of medicine and might be particularly useful in rural settings.  It allows training for rarely encountered events in a safe setting. Pictured here are participants at Lincoln Community Hospital in Hugo, CO training on an acute myocardial infarction scenario on the SimMan as part of our training program.
As one of the handful of serious emergency medical conditions that rural providers see infrequently,  simulation based training may be a model for helping rural providers recognize and treat AMI patients more effectively. 

## Medical Simulation

- Training tools developed to imitate:
- Anatomic regions
- Clinical tasks
- Real patients
- Real-life circumstances in which medical care is rendered

- Issenberg SB and Scalese RJ.  *Persp Biol Med*, (51)1:31-46, 2008

**Notes:**
What is medical simulation? There have been many definitions provided by authorities.  Drs. Issenberg and Scales have simplified it to be tools that are developed to imitate real patients, anatomic regions or clinical tasks or to reflect real-life circumtances in which medical care is rendered.  A wide range of  simulation tools will be discussed today by myself and the other presenters to follow. 

## Spectrum of Simulations 

- Lower Cost  		       Higher Cost

**Computerized Case Scenarios**

**Programmed Patient Training**

**Surgical “Box” Trainer**

**Mannequin based Simulation—**
**SimMan****TM (Laerdal) or METI HPS**

**Anesthesia OR Simulations**

**VR Surgical Simulations—**
**MIST-VR, ES3, GI Mentor, etc**

**High-Fidelity Endovascular**
** ****Simulators**

**Flight Simulators for Airline Industry**

**Case Scenarios with role playing**

**Notes:**
There is a broad spectrum of simulations that have been developed for use in the medical community.  These range from relatively inexpensive simulations such as role playing to expensive, high-tech immersive environments such as those used in the flight industry.  Despite the differences in cost, simulations along the spectrum have been demonstrated to be effective in training and evaluation. 

## Recommendations from IOM

- Use simulators to ensure that clinical training is _safe_ for patients
- Develop simulators for use in skills assessment
- Use simulation technology to improve _individual_ and _team performance_ through interdisciplinary team training
- Use simulation for problem solving and recovery from problems — “crisis management”

*To Err is Human: Building a Safer Health System*, Institute of Medicine, Committee on Quality, National Academy Press, 1999

**Notes:**
Recommendations from the IOM state very clearly that not only should simulation-based training be incorporated, but that it has to be developed with patient safety as the goal.  It is safe, it provides an avenue for both individual and team training, and it is cost effective.

## Features and Uses of Medical Simulations That Lead to Most Effective Learning

- Feedback
- Repetitive Practice
- Range of Difficulty
- Multiple learning strategies
- Clinical variation

- Controlled environment
- Individualized learning
- Defined outcomes and benchmarks
- Simulator validity and realism
- Curricular integration

- Best Evidence Medical Education (BEME) Collaboration
- Issenberg SB et al. *Med Teach* 27(1):10-28, 2005

**Notes:**
Dr. Issenberg and colleagues summarized the features and uses of medical simulations that lead to most effective learning from a review of the literature in the nest-evidence medical education curriculum.  Many of these factors will be discussed by today’s speakers and we tried to included them in the design of our simulation program. 

## Goal of Rural Hospital Simulation Project 

- Implement a novel training program aimed at improving adherence rates to guideline-recommended treatment of AMI in rural hospitals in order to improve clinical outcomes.
- Incorporate most recent guidelines
- Directed at appropriate levels for EMS, Nursing, Physicians
- Encourage team training as it really occurs in the management of AMI
- Provide for interaction and practice
- Incorporate immediate and summative feedback on performance
- Take education and training to rural providers to maximize benefit

**Notes:**
The overall goal of our simulation pilot project was to develop and implement a novel training program aimed at improving adherence rates to guideline-based care for patients with acute myocardial infarction in rural hospitals, and thus improve outcomes.  This involves incorporation of recent guideline updates, directed at all provider levels acknowledging that the team make-up in rural settings differ from other hospitals.  We focused on providing team training, encouraging all members to help with guideline based care.  The simulations were designed to provided interactive environments.  Expert feedback was provided during and after each scenario.  Importantly, all education was provided on site at each of our five participating hospitals.  

## Project Objectives

- Evaluate acceptance and effectiveness of a simulation-based educational program
- Focus on recognition and management of AMI patients presenting to rural hospitals
- Assess the state of AMI care in rural hospitals in Colorado before and after simulation training

**Notes:**
The specific objectives of this project are to assess rural healthcare providers acceptance of the utility and effectiveness of simulation training for AMI care.  In addition, we aim to assess the state of AMI care in each hospital before and after the simulation based training to assess the effectiveness of this type of training on rates of adherence to guideline based care.   

## Our Team

- Multidisciplinary group
- University of Colorado Denver
- Cardiologists
- Family Medicine
- Rural Health Nursing
- Colorado Foundation for Medical Care
- Medical Simulation Corporation
- Funded by AHRQ

**Notes:**
Our team encompasses physicians and nurses from the University of Colorado Denver with expertise in cardiology, rural healhcare as well as outcomes research. Participating partners in this project include the Colorado Foundation for Medical Care, our regional CMS quality improvement organization as well as Medical Simulation Corporation, the provider of the simulator services used in this project.  This project is funded by the Agency for Healthcare Research and Quality as part of it recent simulation research portfolio.

## Target Audience

- Rural Healthcare Providers
- Physicians
- Nurse practitioners
- Physician assistants
- Nurses
- ER technicians
- First responders/EMS

**Notes:**
The target audience for simulation training in this program was broad, reflecting the make up of teams in rural hospitals.  Unlike urban hospitals, EMS providers often render care in the emergency departments as the physician may not be on site immediately.  The team members in rural hospitals often have multiple roles.  Physicians have a varied backgrounds with providers from family medicine, internal medicine and emergency medicine evaluating patients without on-site cardiology support.
Multidisciplinary training is the goal in this project.

## Rural and Critical Access Hospitals in Colorado

**100 miles**

**Notes:**
This map represents the state of Colorado and its 39 rural or critical access hospitals.  Five hospitals volunteered to participate in this prject as represented by the red circles.  This included Yuma Community Hospital, Wray District Hospital, Southwest Memorial Hospital in Cortez, The Memorial Hospital in Craig and Lincoln Community Hospital in Hugo, CO. These hospitals range in size from 10 bed to 25 beds.  

## Project Outline

- Simulation-based training
- On-site training with physicians from UCD
- Formal didactic curricula using simulation
- Recognition of AMI
- Guideline-based treatment of AMI
- Recognition of life-threatening complications of AMI
- Focus on core quality measures and “best practices”
- Pre and Post training assessment of AMI management
- Survey of participants regarding utility of simulation training
- Retrospective and prospective chart review of AMI patients at participating hospitals

**Notes:**
Simulation based training was performed on-site with a simulator proctor as well as one to two experts in AMI care.  The faculty provided feedback for each group during and after simulation training.  In addition, the faculty presented a 30 minute formal didactic curriculum featuring the most recently updated AMI guidelines as well as focusing on the core measures and “best practices” of hospitals that have high rates of guideline-recommended care.  This project also involves the assessment of care in these hospitals that is ongoing.

## Simulation Training

- Use of SimManTM, with four AMI scenarios
- Touch screen interface with introduction to the simulator by the proctor
- Proctor records orders/instructions
- Team training with 3-5 participants per group
- MD, RN, EMS

**Notes:**
The simulation training consists of four case scenarios including patients with different types of heart attacks as well as several infrequently encountered complications such as cardiac arrest, shock and abnormal heart rhythms that require emergent treatment by participants.  Prior to the participation, the simulation proctor goes through an introductory case to familiarize participants with the simulator and its workings. Each scenario has a pre-brief introducing the case, then participants can talk with the patient, with scripted answers provided about the patients condition, past medical history and medications. The participants can review electrocardiograms, interpret labs and x-rays and provide medical care as they would in the ED.  All of the treatments and actions are recorded for review and analysis.   Pictured above is the simulator layout as used in this project, featuring a mannequin, a touch screen and monitor for vital signs as well as a computer screen for post-simulation questions. 

## Components of the Scenarios

- Brief introduction to each case on computer
- “Patient” can be interviewed and examined by participants
- Continuous heart rhythm and vital sign monitoring
- Labs, X-ray, EKG’s available for interpretation by participants
- All treatments recorded, with pharmacology algorithms built in to simulation
- Simulated adverse events occur in each case requiring appropriate treatment

**Notes:**
Each case starts with a brief history displayed on a computer screen.  The simulation starts with the patient arriving in the ER.  The team needs to evaluate the patient, monitor the patient, order tests and interpret the findings.  All treatments are recorded.  Medications have normal effects on vital signs, EKG’s and patients.  The patient or simulator gives verbal clues if appropriate care is not rendered.  Simulated adverse events occur with each case requiring specific treatment. 

## Example of Simulated Case

**Notes:**
This picture is from the training program at Wray District Hospital.  This training consists of a team of a nurse practitioner with three nurses that cover the inpatient unit and emergency department.  They are reviewing the initial electrocardiogram of a “patient” presenting with chest pain during one of the scenarios. 

## Simulation Implementation

**Notes:**
This is a picture of the debriefing review software that is used in going over cases.  It includes a log of activity during the case noted in the left hand side, a video of the operators to capture verbal instructions in the bottom right as well as the real time vital signs and heart rhythm during the specific time of the simulation in the top right.

## Components of the Simulation Training Program

- Each scenario with 4-5 post-simulation questions
- guideline recommended care
- risk assessment and reperfusion therapy
- Expert feedback during simulations provided by faculty during and after each case
- Following the simulation training, review of didactic curriculum on updated AMI management guidelines for 2008 performed
- Post training assessment of the simulation training program by participants

**Notes:**
Following each scenario, there are multiple choice questions assessing knowledge about guideline recommended care.  These focus on correct diagnosis, appropriate medical treatments and evaluation of treatment algorithms regarding need for further studies or consideration of reperfusion therapy.  Expert feedback was provided during scenarios using a pause of the simulation and following each scenario.  Following simulation training, a review of the 2008 guidelines on AMI care were reviewed to reinforce knowledge.  At the conclusion of the training program, evaluations were completed by participants. 

## Participants in Simulation Training Program

- 95 healthcare professionals at 5 rural hospitals

**Notes:**
Ninety-five participants underwent simulation training at five rural hospitals.  The graph demonstrates the distribution among medical specialties.  We were able to train most of the nurses and physicians at each hospital.  We also were able to train many EMT’s that work with each rural hospital. 

## Healthcare Provider Evaluation of Simulation Training

- Questions:
- Simulated cases realistic and engaging
- Requires critical thinking skills
- Using this system confidence and skills can be improved
- Useful for on-site training of healthcare providers

- Proportion
- Strongly Agree or Agree
-        98%
- 	   99%
- 	   98%
-   98%

-   Proportion Strongly Agree
-      85%
- 	  86%
- 	  65%
-  87%

**n=85 respondents**

**Notes:**
Following the simulation training, Likert-scale questionnaires were completed by participants.  There were a total of 11 questions covering a broad range of questions regarding the simulation program.  Overall, the response to questions was uniformly favorable.  Important questions assessing the realism of the simulations, requirement for critical thinking during the simulated cases, the utility of this program to increase confidence and skills and usefulness for on-site training in AMI care was very positive with 98% of individuals agreeing or strongly agreeing with each question.  Importantly, the proportion was very similar among nurses, physicians and EMS personnel. 

## Performance on case-based questions

- Case 1
- Case 2
- Case 3
- Case 4

- 95
- 79
- 90
- 100

**Overall % correct**

- 75-100
- 40-100
- 50-100
- 100

**Range **

***Scores from 18 groups at 5 hospitals**

**Notes:**
Following each case scenario, there were four or five multiple choice questions.  The team was able to answer as a group.  Overall, the groups performed well, but there was a large range of performance noted. 

## Variability in Performance on case-based questions

***Scores from 18 groups at 5 hospitals**

**Notes:**
This slide represents overall performance across all five cases, demonstrating a range of knowledge regarding care of patients with acute myocardial infarction.  The make-up of each individual group likely plays a role, however many of the lower performing groups included physicians.  

## Ongoing Research Efforts

- Determination of quality of care for AMI patients at the participating rural hospitals
- Baseline:  In the period from 1/2007 to 12/2007
- Following Simulation Training:  From 7/2008-6/2009.
- Chart abstraction by CFMC into the ACTION Registry (Duke Clinical Research Institute)
- Allow for benchmarking of AMI care compared to hospitals participating in ACTION.

**Notes:**
Ongoing efforts include retrospective chart abstraction by CFMC to evaluate baseline adherence to guideline recommended care at each of the hospitals in the year prior to simulation training.  Prospective chart review is being performed at each site from the date following simulation training.  The data is being abstracted into the ACTION registry database, managed by the Duke Clinical Research Institute.  This will allow for benchmarking of performance to other hospitals during this time period.  

## Challenges Encountered

- Despite using a commercially available simulator, development time was longer than anticipated.
- While many hospitals were eager to participate, the chart abstraction component of this project limited many due to limited staffing resources
- Tailoring the evidence based guidelines to all levels was more difficult than expected.
- Coordination of training at each hospital took more effort than expected.

**Notes:**
As in any project, there are many challenges, most of which are not suspected before the start.  As is often the case, we found our development time for the AMI case to be longer than expected despite using a commercially available simulator. Pre-existing cases were not robust enough to use.  Second, it took longer to recruit hospitals to participate.  This required a change in our approach with a need to partner more closely with CFMC.  Many of the hospitals were interested in participating in the simulation training, but not in the chart abstraction process due to limited personnel and resources.  Finally, developing a training program that was broad enough for all levels took more time than expected. 

## Lessons Learned

- The actual delivery of on-site rural healthcare training was easier than anticipated
- Having on-site faculty to discuss AMI care was well received
- Partnering with CFMC (that had pre-existing relationships with these hospitals) enabled this project
- Provision of CME and CEU credit hours resulted in significant participation at each site

**Notes:**
Interestingly, by partnering with Medical Simulation Co., we were able to deliver on-site training easier than expected.  By having faculty on-site, the ability to provide direct education and feedback was evaluated to be a strength of the program. Partnering with a group such as CFMC, that had established relationships with several of the hospitals, made the project much simpler to perform once we had interested sites. Finally, interest in the program at each site by providers increased dramatically when we introduced continuing education hours.  

## Conclusion

- Use of a novel simulation based training program focusing on AMI care in rural hospitals was felt to:
- Be realistic and engaging
- Require critical thinking skills for AMI care
- Improve confidence and skills in AMI care
- Useful for on-site training
- Education was easily delivered on-site to a large number of participants
- Accepted by physicians, nurses and EMS
- Evaluation of the impact of simulation on guideline-based AMI care is ongoing

**Notes:**
In summary, we found that our simulation based training program to train rural healthcare providers in current management of patients with AMI was felt to be realistic and engaging, require critical thinking skills, improved confidence and skills and was felt to be useful for on-site training by the overwhelming majority of participants. This novel program was delivered on-site in the rural setting, resulting in the ability to train a significant proportion of the staff at each hospital.  It was accepted by all of the disciplines involved in patient care.  We now are in the process of determining if it has the ability to improve adherence to guideline recommended treatment of AMI patients in this setting. 

## Collaborators on this project

- University of Colorado Denver
- Jack Westfall MD, MPH
- Andrew Klein MD
- John Rumsfeld MD, PhD
- Fred Masoudi MD, MSPH
- John Carroll MD
- Michael Kim, MD
- Cathy Jaynes RN, PhD

- Medical Simulation Co.
- Amy Ketron
- Shannon Gettings
- Colorado Foundation for Medical Care
- Deb Chromik
- Niki Hyde
- Nancy Borgstadt

## Questions/Comments