Simulation Director Envisions Greater Use For Training Tool (2012)

BI&amp;T What's the growth been like for simulation in healthcare?Joseph T. Samosky Simulation-based training in healthcare has been experiencing explosive growth over the past decade. In 2000, there were about 100 clinical simulation centers in the United States. Today, there are more than 1,000. Our field's main conference, the International Meeting on Simulation in Healthcare, had more than 3,000 attendees this year from 37 countries, and 86 companies exhibited. The recognized benefits and successes of simulation are leading to national initiatives to promote it. As of last year, all anesthesiology residents in the United States are required to have at least one simulated clinical experience annually. And in 2009, with the creation of the national SimLEARN program, simulation-based training was established across the entire Veterans Administration hospital system.BI&amp;T Why is the use of medical simulation growing?Joseph T. Samosky Simulation offers advantages for training and assessment from the level of the individual, to teams, to entire systems: It can save lives, time, and costs. Growth is being driven by a body of research that shows simulation- based learning improves performance in actual clinical practice, by the desire to enhance patient safety and increase the efficiency and effectiveness of healthcare training, and by the increasing recognition that if effective alternatives exist to using patients as “teaching material”— particularly during the earliest stages of training— then it's simply the ethically right thing to do. To paraphrase one of my former mentors, “Where do you want to be on your surgeon's learning curve— number 3 or number 200?”BI&amp;T What's the one thing simulation can do in terms of medical device development that can't be done any other way?Joseph T. Samosky In a simulation, you can assess the effectiveness of a new device design, or train and assess life-critical skills involving the operation of a medical device—all without exposing patients to risk. Sensor-rich simulators can provide objective measurements of performance that are often impossible to provide in the real clinical environment. And you can make mistakes in a simulation —without hurting a patient—learn from them, and rise higher on your learning curve before you treat a living, breathing, pain-feeling human being.BI&amp;T The aviation industry has been using simulations for decades. Do you see parallels between the aviation industry and what the healthcare industry is doing?Joseph T. Samosky Healthcare has explicitly looked to the aerospace and aviation industries for years for inspiration in developing simulation- based training. Simulation researchers from Stanford have sought input from NASA Ames Research Center on simulation debriefing methods.The 2009 emergency landing in the Hudson River of an Airbus A320 by Captain Chesley Sullenberger and his crew is frequently referred to in the healthcare simulation community as exemplary of how simulation can contribute to saving lives—in this case, for low-incidence, but very high consequence events. Healthcare simulation is also drawing inspiration from the amply demonstrated successes in many other fields where life-critical performance is required and simulation is used routinely, including military training, operating nuclear power plants, piloting supertankers, and firefighting.BI&amp;T Tell me about the Simulation and Medical Technology R&amp;D Center. When did it start? What is its mission?Joseph T. Samosky In 2007, I moved from Harvard/Massachusetts General Hospital in Boston to the University of Pittsburgh to create a technology development center for medical simulation. After two years of recruiting students and staff, obtaining space and developing funding, we formally launched the center in January of 2010.We strive to provide an engaging, resource-rich environment for collaboration and hands-on prototyping, to lower barriers to innovation and enable creative translation of ideas into prototypes. We aim to promote an “inventive community” of faculty researchers, student scholars, clinicians, and industry partners whose synergy will create next-generation technological solutions for critical needs in healthcare.Our fundamental mission is to improve patient care and enhance patient safety. We specifically aim to do this by creatively bringing together the disciplines of design, engineering, and clinical medicine to invent enabling technologies for simulation-based healthcare training and new, “smart” medical devices. The center serves as both a multidisciplinary “idea workshop” and an incubator for innovation and prototyping.BI&amp;T So you develop both simulation technologies and medical devices?Joseph T. Samosky The two areas are closely related. First, there is overlap in the technologies frequently employed in both: sensors, information displays, embedded processors, control system software, and user interface designs.Equally important, when investigating the development of a new simulation-based training system, we may back up a step, look at a problem from a systems engineering perspective and ask, “Wait, why is this procedure being done this way, with this device?” Perhaps we should be developing a better device or procedure, one that is less prone to error, rather than a training method for the old one.To draw an analogy from aviation: Suppose you have a plane with a hole in the wing. You could develop a training program for how to fly a plane with a hole in the wing. Or, you could fix the hole. Sometimes in healthcare, we need to recognize that we need to fix the hole in the wing.BI&amp;T How many simulation and medical device projects is the center involved in at any one time? How many projects have there been since the center started?Joseph T. Samosky We typically have from five to seven projects active in various stages of development. These can range from a “quick hit” one-semester student project to rapidly build a low-cost demonstration-of-concept prototype, to multiyear efforts involving a multidisciplinary team of engineers, designers, clinicians, and industry partners.We've developed 20 research prototypes in the Simulation and Medical Technology R&amp;D Center to date, in areas ranging from very specific applications like medical device training (defibrillators, dialysis machines), endotracheal intubation, IV drug administration, peripheral nerve blocks, and pressure ulcer prevention, to more general-purpose platform technologies like sensors for touch, spatial tracking of user gestures, and a system that uses augmented reality display to provide interactive “X-ray vision” for simulated procedures. We were recently honored to receive the first place technology award at the 2012 International Meeting on Simulation in Healthcare, the principal conference in our field, for development of an automated drug simulant recognition system that enables a simulator to sense injected or infused simulated drugs and respond automatically.BI&amp;T Does the center's work focus on improving/tweaking devices and technology currently in use at hospitals or is the focus on helping to bring entirely new devices and technologies into such facilities?Joseph T. Samosky Both. Our approach is fundamentally user-centric, so we begin with the needs of clinicians, medical educators, and device developers, and try to work forward to an effective technological solution. We try to be as agile as possible; in some cases, we work to improve existing systems. In other cases creative reimagining and re-engineering may be appropriate.BI&amp;T Describe the origins of a typical project. Where does an idea come from? Who is involved in the research? How do you approach technology innovation?Joseph T. Samosky Ideas can come from many different sources. My PhD training was in the medical engineering program of the Harvard- MIT Division of Health Science and Technology (HST) which was wildly interdisciplinary. That experience reinforced in me the value of casting a very broad net when looking for both interesting problems and solutions.A good, inspiring idea can be a clear, well-motivated clinical problem or an innovative technology that meets a real need. Converging the two in just the right way is an exciting challenge. Just getting clinicians and engineers to talk to each other in terms each can understand is often the essential first step!From the clinical side, we may identify problems ourselves or problems may be presented to us from one of our many collaborators. Perhaps a nurse in a dialysis unit is looking for a better way to train operation of a dialysis machine. Or a quality improvement unit at a local hospital wants to address a specific patient safety issue. Some of our staff and students are engineers who also do part-time work in clinical environments. We have also mined malpractice events and adverse event records to identify targets for enhanced training. This directly led to a current project that will use augmented reality visualization projected onto a full-body mannequin simulator to provide a trainee with “X-ray vision” during simulated Foley catheterization, hopefully reducing the incidence of premature balloon inflation leading to urethral trauma.For design and engineering ideas, we again try to look broadly. I encourage my staff and students to look for ideas and inspiration in their daily experience of well-designed consumer devices, interactive media, movies, theater and the dramatic arts, and cutting-edge technologies from other fields such as robotics, autonomous systems, human computer interfaces (HCI), automotive technology, film special effects, computer games, and flight simulation. We regularly present our findings— we call them Cool Things of the Week (CTOTW)—at our weekly meetings. Recent examples have included a connector-less inductive battery charging system in a Braun toothbrush—that later inspired a design for a battery charging system for a syringe auto-injector—a touchscreen that gives tactile feedback, a solar-powered 3D printer, and novel gesture-based user interfaces based on the Microsoft Kinect and Nintendo Wiimote devices.BI&amp;T What about medical device manufacturers? Do they turn to the center for help? If so, what are they seeking?Joseph T. Samosky We have just recently begun to have discussions with several device manufacturers, and we envision some very exciting possibilities for ways simulation can aid device design, evaluation, and training. We also envision ways that advanced sensing, information displays, and automation technologies can make devices themselves smarter, more effective, and safer.As one example, one of our major current projects is what we call Virtualized Medical Device Personal Trainers, or “V-Devs” for short. The analogy is a personal trainer at a gym— someone who works at your side to assess your technique, provide immediate feedback, and guide you to correct performance.Our V-Devs use touch screens to emulate device front panels and sensorized physical peripherals—like defibrillator paddles or dialysis machine cartridges—that can be manipulated like their real counterparts, but provide measurement of user performance. The multitouch interface displays a photo-realistic view of the device's front panel. Using intuitive gestures, like on an iPhone, you can press buttons, turn knobs, navigate menus, and read displays. But there are also physical peripheral devices that plug into the touchscreen computer—these enable hands-on interaction with parts of the device that require more complex and realistic physical manipulations.We are currently developing the personal-trainer capabilities of V-Devs by implementing built-in personal performance assessment and intelligent tutoring systems that can automatically provide learner-customized instruction, assessment, and feedback. Our goal is to enable convenient, on-demand learning and skill assessment whenever and wherever needed.BI&amp;T What is a specific example of a virtual medical device you've developed?Joseph T. Samosky We've developed a virtual defibrillator that we informally call the “V-Zoll.” Two paddles plug into the touchscreen tablet computer. As soon as they are plugged in, the tablet “becomes” an emulator of a defibrillator. The user can apply the paddles to a person's chest, and the front-panel display shows a simulated ECG. You can set the energy level, charge the defibrillator, and administer a “shock.” No shock is actually delivered, however, so the device is safe to use by students or with standardized patients—actors used for medical training. The paddles sense key aspects of performance: They detect the pressure being applied and can sense their location on the body. All of this data is recorded for later review and debriefing.BI&amp;T What do you see as the future of simulation training—either for training on simulated patients or medical device training?Joseph T. Samosky First, I am very interested in exploring the design space of ways that simulators can offer capabilities beyond what even actual clinical experience can provide—ways that simulators can be “even better than the real thing.” For example, in simulation we can pause or accelerate time, provide objective sensing of a user's actions in ways not feasible in the real clinical environment, or enable the exploration of “what-if” scenarios, all with the ability to hit the reset button and try again if a mistake is made.Our research team is also working to develop turnkey, on-demand, 24/7 training systems. Simulators that could be located in the break room of a hospital unit, for example, so that if a resident or nurse has a half hour free at 2 a.m, he or she could walk up to the simulator and quickly receive focused, experiential practice— and a key advantage is that this can be supervised, guided practice, even in the absence of a human instructor, because the simulator has a rich array of sensors, performance-assessment metrics and automated tutoring capabilities built in.Patient-specific simulation is also a grand challenge for our field. Imagine walking into a simulation room in a hospital unit early in the morning before you are about to round on Ms. Jones. You don't just practice a generic case on the simulator; you download Ms. Jones—or at least everything in Ms. Jones's electronic medical record—into the simulator. Perhaps you missed that she is allergic to a drug and you administer that drug in the simulation. You now may need to practice how to respond to anaphylactic shock. And you probably won't make that mistake when you actually treat Ms. Jones later that day.BI&amp;T Let's talk specifically about the work of the center in promoting patient care and safety with smart medical devices. By way of example, can you talk about a particular device and how work in the simulation center impacted that device's design or function?Joseph T. Samosky Last year, an undergraduate bioengineering student contacted me and said that he wanted to work on a senior design project with me in the center. His father had been in the hospital and had a chest tube in place, and this student had time and again observed nurses coming in to monitor the chest tube drainage container. They sometimes had to get down on their hands and knees to read the level, made marks manually with a Sharpie on strips of tape attached to the device, and in some cases one nurse couldn't interpret the marks another had made. He felt there had to be a better, more automated way of monitoring chest tube output.This led to a year-long senior design project in which we developed PleurAlert, an enhanced chest tube drainage container that electronically senses fluid volume, automatically detects critical alarm conditions, and provides the ability to automatically send alerts to a nurse's cell phone as text messages. PleurAlert adds “smart behavior” to a traditionally passive medical device. It can graphically display trends over time, has the potential to interface to the electronic medical record, and most importantly can “call for help” if a sudden increase in flow occurs, for example, due to hemorrhage.This project was a great example of a first-hand clinical observation leading to an exploration of design and engineering solutions and the rapid development of a working prototype. We've now filed a patent application and are working to further refine the system and move it toward commercialization.BI&amp;T Has the center done anything specifically related to the issue of medical alarms? That seems to be a growing concern—clinicians overwhelmed by too many devices with too many alarms, the result being some alarms are ignored and patient safety is compromised.Joseph T. Samosky Alarm fatigue is a very important problem. Our PleurAlert project is one example of our trying to explore an alternative to the typical auditory alarm. We didn't want to create yet another “machine that goes beep,” and we didn't want a broadcast alarm, where no one in particular is directly accountable. By sending a message to a nurse's cell phone, the intent was to explore whether conveying specific, actionable information to an could enhance there has to be If the nurse respond to the text message a of time, a be or a broadcast alarm may need to be but the goal be to the of broadcast What about devices and Has the center done any work in that If so, could you T. Samosky We have our Medical Device Personal system to devices. nurses in correct operation of devices is a critical for patient safety. We with a device to develop a specific a that the device's control unit, and an attached physical peripheral that the The peripheral have sensors to detect actions such as correct of the and of the And both the touch and unit could display and feedback. You could use this system on your time, without an instructor, to practice, and assess your in correct device of the most capabilities of simulation is what I to as consequence a virtual on a we to just the front panel. 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