Chapter 75: Simulation and Education in the ICU

Critical care medicine (CCM) specialists face emergencies every day and are required to make decisions in a short span of time. These decisions have a great impact on patient outcomes and physicians may require years of experience in order to be competent in handling such situations. This process poses a real challenge for CCM physicians undergoing training.

As Confucious said: “I hear and I forget, I see and I remember, I do and I understand.” Similarly, Edger’s cone of experience emphasizes the importance of learning by doing. But, does that mean that physicians in their initial learning curve will continue to learn by doing procedures and executing management plans on patients? If we were patients, would we want a physician’s first ever procedure to be on us? Would it not be better to practice on a model before we practice on a real patient? That is where simulation comes into play.

Simulation is defined as something that is made to look, feel, or behave like something else. Simulation training gives physicians exposure to different case scenarios in a shorter period of time, and imparts knowledge, experience, and skills to deal with them confidently. Learning could be passive such as listening to lectures or active whereby the learner participates verbally by giving comments or physically by participating in the simulation.

Knowles¹ described the adult learner as a self-directed learner who attaches more meaning to learning through experience than through passive learning, is more interested in learning things applicable to real life, is problem-oriented and performance-centric, and always seeks feedback in order to become more efficient. His principles of the ideal way to teach an adult learner have been included in simulation training.

Models simulating the brain, heart, airway, and other body organs have been used to teach human anatomy for many years. Medical science has come a long way from using those models to using today’s high-fidelity simulation models that can talk, breathe, and have palpable pulses. Simulation-based training has been used in other high-hazard professions, such as aviation, the nuclear industry, and the military, to maximize training safety and minimize risk. Health care has lagged behind in simulation applications for a number of reasons, including cost and resistance to change.²

Review of literature shows that flight simulators have been utilized in training since the 1920s. Around the 1960s, the practice of using standardized patients for the training of medical students was started. ResusciAnnie and Harvey for cardiology examinations were developed at the same time that cardiopulmonary resuscitation (CPR) was introduced. The concept of virtual reality was introduced by the entertainment industry in the 1960s via Morton Heilig’s Sensorama. Virtual reality entered the medical field through simulated endoscopies in the 1990s. With advancement in computer technology in the 1990s, software-based simulators were developed, leading to the extensive use of simulators in anesthesia.³

Before 1990, anesthesiologists were not provided formal training in crisis management, although they were suddenly called upon to manage life-threatening crises. Due to this gap in training, Dr. Howard and Dr. Gaba in the 1990s developed a course in anesthesia crisis resource management (ACRM) analogous to courses in crew (cockpit) resource management (CRM) conducted in commercial and military aviation. Two model demonstration courses in ACRM were conducted using realistic anesthesia simulation systems to test the feasibility and acceptance of this kind of training.⁴ Subsequently, simulation was started to be used by many different subspecialties, including critical care, pediatrics, emergency medicine, and obstetrics/gynecology.⁵ Around the year 2000, Laerdal introduced a computer-controlled patient simulator mannequin–SimMan, with very realistic features and feedback responses, and subsequently developed more advanced high-quality human simulators. Haptic devices were also used to simulate laparoscopic procedures.

The main advantages of simulation training are as follows:

• Provides an opportunity to get hands-on experience of real-life scenarios on mannequins before dealing with patients.

• Enables learning of common procedural skills.

• Enables practicing rarely used procedures.

• Enables learning of leadership skills.

• Helps with crew crisis/resource management.

• Enhances communication skills.

• Provides feedback for enhancing the learning process.

Steadman et al⁶ conducted a study for training, based on either SIM (learning by simulation) or PBL (practice-based learning), to 31 fourth-year medical students in acute care management; the SIM group performed better than the PBL group (mean PBL 0.53 vs SIM 0.72, P < 0.0001). They concluded that SIM was superior to PBL for the acquisition of critical assessment and management skills.

Studies from aviation literature have shown that simulation reduces the number of training hours required to reach a proficiency level compared with other methods of training. Generalizing their results to health care, we can postulate that SIM will be of great help to produce efficient, skillful health care providers in a shorter period of time.⁷

This concept is adapted from the aviation literature and involves implementing the gathered knowledge/skills in real-life scenarios (Figure 75–1). Baldwin and Ford⁸ define the transfer of training as the application of knowledge and skills gained from training to real-life situations outside training and the maintenance of that transfer over a certain period of time. Later, Ford also mentioned that the factors affecting the transfer of training include trainee characteristics (ability, personality, motivation), training design (learning, sequencing, job relevance of training content), and the work environment (transfer climate, social support from supervisors and peers). Learning does not necessarily equate ability to perform tasks “on the job.” If that learning occurs in a simulated environment and does not result in transferable skills, then the training will be of no use.⁹ Assessment of this transfer would be by evaluating the trainees’ performance in real-life scenarios.

1. Standardized patient simulator: It simulates a person acting as a patient reproducing the history, symptoms, and mien in response to the learner’s questions and physical examination. It has been used for years in different scenarios such as the clinical skills examination for USMLE, and recently in palliative care simulations for end-of-life discussions,¹⁰ among others. It is mainly used to evaluate and improve communication skills. It is also being used in institutes in the early mobilization program wherein the multidisciplinary ICU staff members are being trained to mobilize patients on a ventilator by using a standardized patient hooked up to the ventilator.

2. Part task trainers are life-like models of body parts used to enhance procedural skills such as airway management, line placements (Figure 75–2A), chest tube insertions, cricothyroidotomies, and intubations (Figure 75–2B).¹¹

3. Hybrid simulators consist of life-like body parts attached to a standardized patient.

4. Advanced task trainer: It consists of a body part model linked to a computer; it is used for procedures such as bronchoscopies (Figure 75–3) wherein the practitioner inserts the instrument into the body part and the computer screen displays the internal anatomy as maneuvers are performed. The system is programmed to respond to stimuli (ie, irritation by coughing if adequate analgesia is not given).

5. High-fidelity simulator (Figure 75–4): A mannequin simulator that very closely mimics real-life responses. It manifests all the physiologic characteristics—breathing, talking, having palpable pulses, and responding to the learner’s intervention. Simulation training is carried out on such simulators with real equipment.

6. Screen-based computer simulator: A computer screen projecting a patient’s history, vitals, details of various medications, for example. It responds realistically to the learner’s interventions.

7. Virtual reality simulators: Generally used in surgical fields for a 3-dimensional view of masses/polyps, etc, for laparoscopy, for colonoscopy, etc.

Simulation is not intended to replace the need for learning in a clinical environment, but through improved preparation, it enhances the clinical experience and improves patient care; thus, it is important to integrate it with clinical practice.¹²

The success of a simulator program is not determined primarily by the type of simulator used but more by the enthusiasm, skill, and creativity of instructors, as well as the time and effort devoted to preparing and performing credible simulation scenarios.¹³

The intensivist has to work as part of a team that includes the nursing staff, respiratory therapist, physical/occupational therapy staff, and other consultants. All medical practitioners can derive benefits from simulation training, not only acquiring knowledge and clinical skills,¹⁴ but also improving team performance and developing leadership skills¹⁵ (Figure 75–5).

Simulation helps physicians improve their performance in highly stressful and life-threatening situations. The diagnosis and management of various shock scenarios, acute coronary syndromes, tachy/bradyarrhythmias, status epileptics, respiratory distress, anaphylaxis, metabolic disturbances, trauma, and post-surgical/cardiothoracic cases can be taught through simulation.

In the study by Sandahl et al,¹⁶ the participants reported that simulation training had increased their awareness of the importance of effective communication for patient safety. However, they caution that the observed improvements will not last, unless organizational features such as staffing rotation and scheduling of rounds and meetings can be changed to enable use of the learned behaviors frequently in the work environment.

Tukey and Wiener¹⁷ in their study surveyed pulmonary and critical care program directors and found that many fellows currently occupied do not get the opportunity to gain proficiency in pulmonary artery catheterization (PAC), and proposed that fellowship training programs should consider alternate means of training fellows in PAC data interpretation, such as simulation.

With advanced technologies such as ultrasound being used for most ICU procedures, simulation plays an important role in giving trainees skills and confidence to perform procedures. Barsuk et al¹⁸ showed that simulation-based mastery learning increased residents’ skills in simulated CVC insertion, decreased the number of needle passes when performing actual procedures, and increased residents’ self-confidence.

The types of airway handling techniques that can be taught in simulation range from the simple (bag and mask ventilation) to the complex (direct laryngoscopy intubations, glidoscope-guided intubations, tube exchangers, bougie use, cricothyrodotomies, and percutaneous tracheostomy tube insertions). In a study with medical residents of basic airway management, Kory et al¹⁹ showed that scenario-based training with a computerized patient simulator was more effective in training medical residents than the traditional experiential method.

For pulmonary and critical care fellows, simulation allows practicing how to introduce and maneuver the bronchoscope in the simulated airway, thus allowing development of skills before the actual procedure is done on a real patient. The advanced task trainer for bronchoscopy produces natural patient reflexes such as coughing, and responds to sedation and analgesia like a real patient. It helps the new learner to get familiar with the basic techniques of holding and maneuvering the bronchoscope from the upper to the lower airways. If done first on an actual patient, a novice bronchoscopist could expose the patient to untoward events such as hypoxia or hypotension. These simulators may also allow training for bronchoscopic biopsy, brushing, and ultrasound.

Kennedy et al²⁰ performed a meta-analysis on studies evaluating simulation-based flexible or rigid bronchoscopy training compared to no intervention. In comparison with no intervention, simulation training was associated with large benefits in terms of skills and behaviors (pooled effect size, 1.21 [95%CI, 0.82-1.60]; n = 8 studies). They concluded that simulation-based bronchoscopy training is more effective than no intervention and also found that comparative effectiveness studies were few.

Burden et al²¹ collected data for catheter-related bloodstream infection incidence (CRBSI), the number of ICU catheter days, mortality, laboratory pathogen results, and costs pre- and postintervention, which was simulation-based central venous catheter insertion training. They found that the CRBSI incidence and costs were significantly reduced for 2 years postintervention.

Mechanical ventilation can be taught by using either screen-based computer simulators or high-fidelity simulators. The screen projects the ventilator screen with waveforms and ventilator settings and pressures. It gives arterial blood gas values and creates scenarios with different airway and ventilation issues. It responds to learner intervention by appropriate changes in arterial blood gases.

It is obvious that the patient and their family members in the ICU require emotional support and other comfort measures. An intensivist must conduct family meetings to keep them updated about the patient. They may have to deal with varying responses from the family members. Given the patient’s severity of illness, they may also have to discuss end-of-life issues. As mentioned before in this manuscript, simulation is now being used in this field.¹¹ A standardized patient can act as the patient. Family members’ responses can also be simulated. This tool can also be used to evaluate residents’/fellows’ baseline communication skills as well as to teach these skills effectively.

A study done by Efstathiou and Walker²² indicated self-perceived improvements in knowledge, skills, confidence, and competence when dealing with challenging end-of-life care communication situations. A comparison of pre- and post-intervention scores revealed a statistically significant positive change in the students’ perceptions about their level of knowledge (P < 0.02).

Now with early mobilization being implemented in major institutes, physical and occupational therapies are increasingly being followed by the ICU interdisciplinary team. More patients on ventilators are being mobilized out of bed. This could possibly result in more adverse events such as accidental extubations, circuit disconnects, hemodynamic compromise, and falls. So, it is essential that the rehabilitation services staff be trained to anticipate and act on these issues by calling for help early or taking more precautions with tubing and pumps attached to the patients.

Ohtake et al²³ showed that incorporating simulated, interprofessional critical care into a required clinical course improved physical therapist students’ confidence in dealing with technical, behavioral, and cognitive performance measures, and was associated with high student satisfaction; using simulation to introduce students to the critical care environment may provide encouragement and increase their interest in this area.

1. Pacemaker and defibrillator: Simulation training will enable health care professionals to better operate the machinery used in this field. Running a scenario on a simulator with different brady/tachyarrhythmias scenarios will give health care providers hands-on training with different equipment so that they are prepared and trained for real-life scenarios. Knowledge of resuscitation algorithms is not sufficient to help patients if operators are not familiar with how to use vital equipment.

2. Continuous renal replacement therapy (CRRT): With the technological advancement, there is also a need to train the involved staff in the operation of the new equipment, and the operator should be comfortable with troubleshooting alarms. Mencía et al²⁴ developed a device and proposed that it may be very useful for training health care professionals in CRRT management, thus avoiding risk to patients.

3. Extracorporeal membrane oxygenator circuit (ECMO): The use of ECMO has increased in recent years. Simulation in ECMO can be used to train surgeons, anesthetists, critical care physicians and nurses, and perfusionists.

Simulation with standardized patients during a mass disaster can be used to train health care professionals to be mentally and physically ready. Also with emergency rooms being overcrowded with many sick patients during a disaster, the ICU team should be ready to absorb the very sick patients and provide additional care in unfamiliar settings outside of the ICU. In order for the team to react properly to these kinds of emergencies, simulation training is necessary.

A medical error is a preventable adverse effect of care, whether it is harmful to the patient or not. Medical errors are one of the main causes of significant morbidity and mortality. They incur a cost burden on the society and health care industry. Medical errors hurt patients physically, economically, and psychologically. They may also cause feelings of inadequacy and guilt in the provider. Decreasing medical errors to improve patient safety is of high importance.

Some of the measures to reduce medical errors and increase patient safety, as suggested by Kohn et al,²⁵ are to support projects aimed at achieving a better understanding of how the environment affects the ability of the provider to practice safely. Another recommendation is funding researchers and encouraging organizations to develop, demonstrate, and evaluate new approaches to improve provider education in order to reduce errors. Simulation training can be used to fulfill both these purposes. Errors may occur in a team care environment as a result of nontechnical factors (eg, communication), and specific simulation-based training protocols have been developed for enhancing team performance.^16,26

With the age-old practice of apprenticeship training in the medical field being questioned in light of increased priorities for patient safety, simulation training seems to be a useful tool to help reduce medical errors through training and improve safety. Simulation training allows practitioners to make errors and learn from them in a controlled, simulated environment. This experience can prepare them to face real-life scenarios with confidence and minimize actual errors.

Crew resource management, defined as effective utilization of all available equipment and people to carry out safe, efficient flight operations,²⁷ is a term introduced in the aviation industry during a NASA workshop in 1979. It was designed as a training program to improve air safety and reduce the increasing number of fatal accidents attributable to human error.²⁸ When errors were analyzed, they were mainly attributed to failure of interpersonal communication, leadership, and decision-making. The same principle can be applied to the medical field where it is called crisis resource management (CRM). Health care industry has now recognized the importance of this training and is slowly and steadily incorporating it into different subspecialties. The traditional medical curriculum does not lay emphasis on nonclinical skills such as communication, leadership, and team building. Now, with human errors being linked to inadequate nonclinical skills, importance has been given for developing and maintaining these skills by simulation training.

How can one evaluate and measure CRM skills? Two validated scales in critical care are the Ottawa Global Rating Scale (GRS) and Mayo High Performance Teamwork Scale (MHPTS).²⁹ In their study, Kim et al³⁰ had first- and third-year residents participating in two simulator scenarios, recreating emergencies in acute care settings, and were evaluated using the Ottawa GRS by three different evaluators. With his results, Kim found acceptable inter-rater reliability and validated the Ottawa GRS to evaluate CRM performance during high-fidelity simulations.

Malec et al³⁰ performed a study to develop and evaluate a scale for assessing teamwork skills in simulated settings. He developed the MHPTS and found that it provides a brief, reliable, and practical measure of CRM skills that can be used by participants in CRM training to reflect on and evaluate their performance as a team.

CRM involves leadership, problem solving, situational awareness, resource utilization, and communication skills. CRM is extremely important for patient safety but is not covered in the traditional learning curriculum. In order to master CRM skills, one has to practice them repeatedly in simulated sessions. Figure 75–6 illustrates how simulation helps improve different skill sets to achieve patient safety.

Debriefing, a term used more often in military scenarios, is a very important component in simulation training. As shown in Figure 75–7, simulation training first involves creating a simulation case scenario (with all pertinent medical details and specific educational goals), then introducing the learner(s) to the simulated scenario, giving them the time to perform a task, and then debriefing them after the scenario is completed. The debriefing should involve the learner’s self-evaluation (ideally after viewing a video recording of their performance), and the instructor’s feedback (a powerful educational tool). The aim of debriefing is to make learners realize both their strengths and areas that could be improved in an encouraging, healthy manner. Also, during this time the instructor should evaluate and address individual and team performances and gives positive and negative reinforcement as appropriate.

Critical care practitioners are increasingly using simulation training. Traditional learning with books and lectures continues to provide a basic fund of knowledge. Simulation helps reinforce and consolidate the knowledge gained from traditional learning. Additionally, simulation helps health care providers develop hands-on clinical and nonclinical skills such as CRM skills. CRM skills cannot be learned from a book or in a lecture hall. Due to the low prevalence yet high complexity of many disease processes encountered in critical care, critical care performance depends on time-sensitive decision-making, safe procedural skills, and good staff teamwork to ensure positive clinical outcomes. However, the opportunities for young trainees to be present and actively participate during these critical moments are increasingly low. Training in critical care using simulation can make medical education more effective and interesting, providing real benefits to patients. Simulation training enables immediate self-evaluation and provides critical feedback, essential for skill development. Simulation training, in all its forms, should be an integral part of the education of all providers who work in the ICU.