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ADF Health 2009 - Volume 10 Number 1

Simulation training

Simulation training for ADF surgical and intensive care teams: a pilot study

• J. Vassiliadis 1, R. Mallett 3, S. O’Regan 1, K. Harrison 4, A. Rehak 1, S.J. Neuhaus 2

Introduction

Medical simulation in training is accepted practice in many areas of health and it has been demonstrated that group behaviour and improvement in team performance occurs with training. 1-11 Difficulty in obtaining realistic team-based medical experience prior to specialist health teams arriving in a battlefield environment makes medical simulation an attractive option for military training.

Military medicine faces similar challenges in all countries: to train medical personnel in peace for the realities of war or conflict. In Australia what corporate experience there is, resides in civilian practice and with Australian Defence Force (ADF) health specialists, who are almost exclusively reservists and who volunteer at times of need. As a result, groups of people who may have never worked together are placed in situations where they are required to work as an effective team in a very short period of time and under difficult and challenging circumstances. Sub-specialisation in medicine in Australia means that there are few specialised ‘trauma surgeons’ who routinely performs resuscitative or damage control surgery. Combat injury patterns from current operations are different from most civilian trauma. Combat trauma is characterised by multisystem blast, burns or ballistic injuries. These are complex injuries and successful outcomes require collaborative and multidisciplinary management.

The training gap both in skills and team-based training is significant. As Moses et al state:

‘Military medical personnel have almost no chance during peacetime to practice battlefield trauma care skills… With some of today’s training methods disappearing the challenge of providing both initial and sustainment training for medical personnel is becoming insurmountable’ 12.

Simulation can provide a risk-free simulated learning environment where medical teams train across a range of medical procedures including trauma surgery. These ‘hands-on’ training opportunities in a simulated environment help teams to ‘train in peace as we would practise in war’ 2. The military environment is a complex and dynamic working environment in which crises develop both on the battlefield and in the operating/medical theatre. These may lead to danger or adverse outcomes – both to the medical personnel and to their patients. Once a crisis has developed, sound medical knowledge or military protocols may not be enough to resolve it. Military medical personnel must be equipped to recognise, avert or manage impending crises. This requires training in Crisis Resource Management (CRM) 1. Although the relevance of such training models is increasingly recognised by the health community 13, to our knowledge no formalised curriculum or course exists in the ADF that provide these skills to senior specialist clinicians. However, sophisticated combat medical simulation centres do exist in the US, Israel and elsewhere.

Parallels exist with the airline industry which also functions in a high risk environment. Research in that industry has identified that most airline disasters are not due to equipment failure, but due to human error and failures in decision making, communication and leadership 14. As a result, a flight simulation- based curriculum called Crew Resource Management was developed to teach the necessary teamwork and leadership skills 15. Crew Resource Management training is a requirement for all Australian and US flight crews. Medical Crisis Resource Management (CRM) has developed out of the principles of aviation CRM 1.

Medical CRM was identified as a core requirement of the mission specific training for specialist ADF surgical and intensive care teams deploying into a multinational facility within the Middle East Area of Operations. This paper addresses the recent simulation experience used to enhance the operational readiness of Surgical and Intensive Care teams (AUSMTF-1 and 3) prior to their deployments to Afghanistan.

Methods

Study Design and Population. This report is based on a follow-up survey given to participants after completing the Military Emergency Crisis Management (MECM) course at the Sydney Clinical Skills and Simulation Centre (SCSSC), Royal North Shore Hospital. The ADF personnel who participated in the two courses included twelve specialists (made up of anaesthetists, intensivists and surgeons), seven medics and ten nurses. All the specialists were reservists. All medics and some nurses were full time members of the ADF. Each of them gave informed consent prior to participating and the study was granted ethics approval by the Northern Sydney Area Health Service.

Overview of the MECM Course. All the participants were provided with pre-reading that outlined theories of communication, team leadership, teamwork, graded assertiveness and CRM. This reflected the brief given to the course director, in regards to the AUSMTF needs and the construct of the mission specific training.

The course began with a brief introduction to the background and goals of MECM. The course director emphasised to the participants that the goal of MECM was not to evaluate each participant’s performance but to focus on understanding the key CRM principles (Table 1) and the human factor principles of leadership, teamwork, decision making and error identification and prevention.

The participants were introduced to a structured approach for thinking when confronted with any emergency. This included a risk/benefit evaluation of the plan of management and developing a contingency plan.

In order to emphasize the applicability and importance of the CRM principles (Table 1), the participants viewed an 8 minute video of a flight simulator re-enactment of an actual commercial airline crash. It contained examples of simple avoidable errors, made by the pilots and an air traffic controller which led to the disaster. The course director then used the video as a basis to discuss and explore CRM, team work and error. The participants were subsequently orientated to their simulated field hospital and mannequin simulators (METI High Fidelity Patient Simulator and Laerdal Simman).

In keeping with adult learning principles, a multimodal instructional approach was employed. The group took part in a desk activity exploring the issues of managing a mass casualty incident. This was followed by six high fidelity simulated case based scenarios. The participants took part in the scenarios in teams of four or five, assuming their usual roles in a deployed environment. (Fig 1 - 3). One of the nurses in each of the scenarios was a faculty member and wore a headset to allow private communication with the scenario director in the control room. (Fig 4).This ensured that each case met its planned learning objectives. Groups who were not involved remained in a separate room to observe via a video link.

Fig 1. Anaesthetic and surgical teams preparing the manikin for surgery

Fig 2. Manikin moulaged to simulate severe burns

Fig 3. Surgical team performing damage control surgery on simulated bleeding abdomen

The scenarios were structured to simulate the unique circumstances of the combat environment, which included a realistic laparotomy model, which required the surgeon to perform 4-quadrant packing and control ongoing bleeding. This proved to be a good model for reinforcing the principles of damage control surgery and ensuring that the team were each aware of their competing needs and priorities.

Fig 4. Confederate member of faculty wired up to communicate with the course director

The director, a trained facilitator, concluded each scenario when the objectives of the scenario had been met and there was sufficient material for constructive debriefing. Participants, observers and instructors then debriefed each scenario together for about 20 minutes. The debriefing had several aims: to discuss the clinical, CRM and human factor issues raised by the scenarios, and then to consider how the lessons learned might be translated into their clinical practice.

Data Analysis. At the conclusion of the MECM course all the participants completed a post course evaluation. The evaluation consisted of a 5-point Likert Scale ranging from a score of one (strongly disagree) to five (strongly agree). The mean and standard deviation were calculated for each response.

Results

Twelve ADF Reserve Medical Specialists, 10 nurses and seven medics took part in the two courses. The results of the post course appraisal that were completed by the participants are summarized in Table 2. The participants considered the course very useful pre-deployment training: it provided teamwork opportunities and allowed them to understand each other’s roles and capabilities. They particularly valued the realism of the clinical scenarios. The participants appreciated the chance to debrief and discuss the challenges of their future deployment.

Discussion

Deploying medical personnel have a crucial need for crisis management team training. Currently no formal training exists to prepare health personnel for the potential stress of the deployed military environment and mission.

The MECM course allowed participants to develop skills in communication, error recognition and prevention, teamwork and graded assertiveness in a safe learning environment. They practised key skills in highly realistic simulated clinical scenarios. This led to productive, frank discussion and debriefings.

Team performance improved successively over the course of the six simulated scenarios. Attitudes towards individual and team performance became more positive during the course of the training. By the end of the course the participants felt more competent in responding to medical emergencies and also more comfortable with their co-participants. These findings are consistent with Chen and Kanfer’s 16 multilevel team model . Those researchers claim that effective team performance is more than ‘throwing a group of people together with a common purpose’: each team member must understand their own, and others’ roles in order for the process to be effective. The MECM pre deployment courses aimed to expand on this model and allow the participants to experience the value of scripted roles. It was designed to facilitate an understanding of the roles, responsibilities and skills of their colleagues and the impact of this on improving team performance and outcomes. It achieved those goals. The greater understanding within each team helped motivate and empower them and positively influenced their attitude to successfully respond to a medical/ surgical emergency.

Medical simulation allows participants to experience team training in procedural and communication skills. This MECM course provided fully immersed medical simulation. The focus was not on medical procedures or knowledge, but rather on establishing a level of commitment and collective experience in each team. This enhanced their ability to make complex management decisions. The two teams were highly trained and experienced civilian professionals who were about to deploy. Their deployment would be to an unfamiliar environment and setting and, in a multinational environment that could challenge their perceived roles, responsibilities and clinical management practices. High fidelity simulation allowed us to create scenarios which would be considered unique in civilian practice .They would be impossible to recreate without simulation. The participants had the opportunity to learn by experience 17 and reflection 18, both are key components of adult learning theory 19 .They are also crucial for effective teamwork in challenging deployments. Learning occurs in a simulated environment which imitates, but does not duplicate reality. Participants are afforded opportunities to try out new strategies without risking adverse patient outcomes. They can also discuss outcomes in a safe, ‘no blame’ environment.

Few opportunities exist in a military environment for health personnel to formally debrief after a clinical case. Collegiate discussion about the conduct, management and potential for improved performance results in better clinical outcomes 6. The ability of a military health specialist to deliver ‘best practice’, often under very difficult circumstances 20, depends not only on their technical skill, but good teamwork. Simulation training assists this process 21.

One goal for the course was to convince participants of the value of a ‘team time out’. This meant a preliminary brief discussion with all the team members about the proposed clinical approach and each person’s role .In civilian practice, team members often tend to work in isolation and assume that other team members understand their expected contribution. We placed value on good communication, preparation and planning-qualities which would be of particular value to medical teams in a deployed environment. In a multinational environment using unfamiliar equipment and different cultural expectations, clear communication becomes even more vital.

The command and leadership elements of the group witnessed how the team established its working dynamic and how it functioned under simulated stress. This provided valuable information and insight into further training and skills that may be required before a team is deployed. Individuals should not be chosen for remediation unless a particular behaviour or management concept is deemed unacceptable or dangerous. When necessary, this should always be done privately.

The results of this pilot study show that MECM was well accepted by the participants and indicated that this type of training was likely to benefit pre deployment medical teams.

Limitations

Despite the small size of this study, we believe the positive response to crisis management team training in the MECM course warrants further investigations at our institution, as well as others. Our study did not evaluate long term crisis management knowledge, skills and attitude retention after training. Further study needs to be address how frequently medical teams should train in MECM and whether the lessons learnt in the simulated environment are transferable to the military environment. Most of the participants had little prior exposure to high fidelity simulation. Future studies would need to investigate how the learning experience for participants is affected as their familiarity with simulation is increased.

Conclusions

The positive results from this initiative were encouraging. Given the proven success of other simulation- based team training courses in the medical and aviation industries, further development and investigation of simulation based crisis management training for pre deployment military medical teams is indicated.

The MECM course is ideally suited to meet the ADF’s needs because it delivers realistic and relevant training. Simulation is increasingly being incorporated into lower order health training (e.g. team based resuscitation) However the needs of a specialised surgical and intensive care health team are qualitatively different, with less emphasis needed on technical competency and more on nontechnical and communication issues. The MECM training has demonstrated a new way of delivering operationallyfocused health training to military specialist health teams. The training is cost effective and can potentially increase the experience and confidence of specialist health teams in dealing with complex combat environments.

Acknowledgements

The authors would like to acknowledge the support of HQ 17th Combat Service Support Brigade and Colonel Georgeina Whelan, Command Health Officer, HQ Forces Command for their support.

References

1. Howard S, Gaba D, Fish K, Yang G, Sarnquist F. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 1992; 63: 763-770.
2. Nielsen PE, Goldman MB, Mann S, et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomised controlled trial. Obstet Gynecol 2007; 109:48-55.
3. Dunn E, Mills PD, Neily J, et al. Medical team training: applying crew resource management in the veterans’ health administration. Jt Comm J Qual Patient Saf 2007; 33:317-325.
4. Morey JC, Simon R, Jay GD et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the Medteams project. Health Ser Res 2002; 37: 1553 – 1581.
5. Thomas EJ, Taggart B, Crandell S et al. Teaching teamwork during the Neonatal Resuscitation Program: a randomised trial. J Perinatol 2007; 27:409-414.
6. Robertson B, Schumacher L, Gosman G et al. Simulation – Based Crisis Team Training for Multidisciplinary Obstetric Providers. Sim Healthcare 2009; 4:77-83.
7. DeVita M, Schaefer J, Lutz J, et al. Improving medical emergency team (MET) performance using a novel curriculum and computerised patient simulator. Qual Saf Health Care 2005; 14:326-331.
8. Gaba DM, Howard SK, Fish KJ, et al. Simulation based training in Anaesthesia Crisis Resource Management (ACRM): a decade of experience. Simul Gaming 2001; 32: 175 -193.
9. Blum RH, Raemer DB, Carroll JS, et al. A method for measuring the effectiveness of simulation-based team training for improving communication skills. Anesth Analg 2005; 100:1375-1380.
10. Kim J, Neilipovitz D, Cardinal P et al. A pilot study using high fidelity simulation to formally evaluate performance in the resuscitation of critically ill patients: The University of Ottawa Critical Care Medicine and high fidelity simulation, and Crew Resource Management I study. Crit Care Med 2006; 34:2167-2174.
11. Morgan PJ, Pittini R, Regehr G, et al. Evaluating teamwork in a simulated obstetric environment. Anesthesiology 2007; 106:907-915.
12. General Accounting Office in Moses G, Magee JH, Bauer JJ, Leitch R. Military medical modelling and simulation in the 21st Century. Stud Health Technol Inform 2001;81:322-8.
13. Flin R, Yule S. Patterson Brown S, Rowley D, Maran N. The Non- Technical skills for Surgeons (NOTSS) System Handbook, v 1.2 University of Aberdeen and Royal College of Surgeons of Edinburgh.
14. Helmreich R, Merritt A, Wilhelm J. The Evolution of Crew Resource Management Training in Commercial Aviation. Int J Aviation Psych 1999; 9: 19-32.
15. Wiener EL, Kanki BG, Helmreich RL. Cockpit Resource Management. New York: Academic Press, 1993
16. Chen G, Kanfer R. Towards a systems theory of motivated behaviour in work teams. In: Shaw B, ed.: Research in Organizational Behavior: An Annual Series of Analytical Essays and Critical Reviews. Vol. 27. New York: Elsevier; 2006: pp. 223-267.
17. Dewey J. Thinking in education. In: Barnes LB, Christensen CR, Hansen AJ, eds. Teaching and the Case Method. 3rd ed. Boston, Mass: Harvard Business School Press; 1994, pp.9-14
18. Schon DA. The Reflective Practitioner: How Professionals Think in Action. New York, NY: Bantam Books; 1983
19. 1. Bloom B. S. (1956). Taxonomy of Educational Objectives, Handbook I: The Cognitive Domain. New York: David McKay Co Inc.
20. Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? M J Shapiro1, J C Morey3, S D Small2, V Langford3, C J Kaylor, L Jagminas1, S Suner1, M L Salisbury3, R Simon4, G D Jay1 Quality and Safety in Health Care 2004;13:417-421.
21. Error Reduction and Performance Improvement in the Emergency Department through Formal Teamwork Training: Evaluation Results of the MedTeams Project. Morey, John C.; Simon, Robert; Jay, Gregory D.; Wears, Robert L.; Salisbury, Mary; Dukes, Kimberly A.; Berns, Scott D. Quality of Care Health Services Research. 37(6):1553-1581, December 2002.

LCDR John Vassiliadis MBBS, FACEM is Deputy Director of the Sydney Clinical Skills and Simulation Centre and Staff Specialist in the Emergency Department at Royal North Shore Hospital in Sydney. He has a special interest in trauma and disaster medicine and is an EMST instructor.

LTCOL Richard Mallet is an instructor at the Australian Command and Staff College, Weston Creek, ACT. He is a science graduate with graduate diplomas in management and logistics management.

FLTLT Stephanie O’Regan has been the Simulation Coordinator at Royal North Shore Hospital since 2004.She has been a nursing officer in emergency medicine for over 20 years and holds Masters Degrees in Health Services Management and Health Science (Education).

Dr Ken Harrison FANZCA is a specialist anaesthetist who is Manager, Education and Disasters NSW Careflight as well as a Visiting Anaesthetist at Liverpool Hospital and a Staff Anaesthetist at Westmead Hospital in Sydney. He is Deputy Director of MRU Ambulance Service NSW.His interests are in trauma, disaster medicine and education.

Dr Adam Rehak FANZCA is a specialist anaesthetist and Senior Simulation Instructor at the Sydney Clinical Skills and Simulation Centre, Royal North Shore Hospital, Sydney.

Colonel Susan Neuhaus enlisted into the Australian Regular Army in 1987 and is currently a Reserve General Surgeon and Senior Advisor Health, HQ 17 CSS Brigade. She has served in Cambodia, Bougainville and Afghanistan, is a graduate of Australian Command and Staff College (Reserve), past Commanding Officer of the 3rd Health Support Battalion and previous Editor of ADF Health. She was awarded the Conspicuous Service Cross in 2009.

Authors

1. Sydney Clinical Skills and Simulation Centre John Vassiliadis MBBS FACEM, Deputy Director, Simulation Clinical Lecturer, Northern Clinical School, University of Sydney LCDR RANR Stephanie O’Regan RN, BNurs, MHSM, MHSc (Ed), Simulation Coordinator, FLTLT RAAF Adam Rehak, MBBS FANZCA, Senior Instructor
2. Colonel Susan J Neuhaus MBBS, PhD, FRACS, CSC HQ 17 CSS BDE, Randwick Barracks, RANDWICK, NSW, Clinical Associate Professor of Surgery, University of Adelaide, Adelaide, South Australia
3. Lieutenant Colonel Richard Mallet, Bsc, Grad Dip Log Mangt, Grade Dip Mangt. Instructor, Australian Command and Staff College, Weston Creek, ACT
4. Ken Harrison MBBS FANZCA, Manager, Education and Disasters Careflight.