Critical Care for Dummies Teaching Critical Patient Assessment

Critical Care for Dummies: Teaching Critical Patient Assessment Using High Fidelity Human Patient Simulators UNIVERSITY OF MISSOURI Family & Community Medicine Jack Wells MD MHA Luke Stephens MD University of Missouri Family and Community Medicine

Objectives • Gain an understanding of simulation as a teaching tool • Gain an understanding of simulation program development, implementation, and assessment • Gain an understanding of simulation scenario development • Discussions/ recommendations for improvement UNIVERSITY OF MISSOURI Family & Community Medicine

The Need • Patients can (and do) become unstable on the floor • FM Residents perceived to be fearful of critical care/ code situations § Residents own perceptions § Nursing perceptions UNIVERSITY OF MISSOURI Family & Community Medicine

The Need: Why is this? • FM not perceived to be a “critical care” specialty • FM often approaches from a “presumption of wellness” • Closed ICU: Patients managed by critical care when critical; by FM when stable • Tiger Team: University Hospital in-house rapid response team for critical patients on the floor § “Whew!” phenomenon § We are still the doctor! UNIVERSITY OF MISSOURI Family & Community Medicine

The Need: Why is this? Result: • Residents at end of PGY 1 year have limited exposure to critical patients • likely to have less exposure in the future with hour restrictions We have a rural hospital training facility § No critical care rapid response team § No team, period! UNIVERSITY OF MISSOURI Family & Community Medicine

The Need: Reality • Our mission is to train family physicians to practice in Rural Missouri • Rural Missouri is NOT the University Hospital, with unlimited resources readily available • Several of our graduates do inpatient work/ ED work with little prior critical assessment exposure. • Many of our graduates practice in rural areas where there may not be specialty backup UNIVERSITY OF MISSOURI Family & Community Medicine

The Need: Reality • Our residents should be able to recognize clinical decompensation earlier rather than later. • Our residents should have the skills and confidence to initiate resuscitation in an unstable patient and prevent further deterioration. • Our residents should be comfortable managing a multidisciplinary team in resuscitating a potentially or actively unstable patient. UNIVERSITY OF MISSOURI Family & Community Medicine

Do You Feel Lucky…? Given all of the specialty backup and staffing in the university setting, it is very possible for our graduates to complete their training without ever having been required to assess, stabilize, or manage a critically ill patient… OR… they might have to do it at ANY TIME on call, particularly in the rural hospital UNIVERSITY OF MISSOURI Family & Community Medicine

Residents: Why do we have to do this? Q: How many feel supremely confident in evaluating, stabilizing, and managing unstable inpatients? Q: How many feel supremely confident working in and leading multidisciplinary teams to evaluate, stabilize, and manage unstable patients? UNIVERSITY OF MISSOURI Family & Community Medicine

A: Not many… How do we know this…? They told us so… UNIVERSITY OF MISSOURI Family & Community Medicine

Resident Survey I feel confident in my abilities to evaluate hospitalized patients that have become unstable 59% don't feel confident in ability to evaluate unstable pts. UNIVERSITY OF MISSOURI Family & Community Medicine 72. 7% do not feel confident in ability to stabilize unstable patient

Resident Survey I feel confident in assuming a leadership role in managing a team to assess and stabilize an unstable patient 68. 2% do not feel confident in leading a resuscitation team UNIVERSITY OF MISSOURI Family & Community Medicine I have been required to manage critically ill patients on the floor during my inpatient block rotations. 54. 5% have been required to manage critically ill patients

In Other Words… The majority of our residents did not feel well prepared to perform critical tasks that over half of them have been required to do! UNIVERSITY OF MISSOURI Family & Community Medicine

Our Conclusions • A knowledge gap exists • We have the resources to fill that gap with our sim center • We can fill that knowledge gap by § Teaching needed skill sets not offered elsewhere § Practicing those skills with feedback and self assessment § Allowing learners to fail in a safe environment, and learn from those failures UNIVERSITY OF MISSOURI Family & Community Medicine

Simulation Lab • High Fidelity Human Patient Simulator § Respirations § Pulses § Pupils react § Respond physiologically to meds/ ventilation/ CPR § They even talk! Diabolical instructors can change responses “on the fly” UNIVERSITY OF MISSOURI Family & Community Medicine

Development • Identification of a need: Perceived lack of skills/ confidence • Faculty champions: Drs. Wells and Stephens • Faculty buy-in: “Run with it!” • Resident buy-in: Knowing what they don’t know • Sim lab facility and staff: Tremendous resource! UNIVERSITY OF MISSOURI Family & Community Medicine

Development • Intuitively: Sounds like a good idea • Do we have any evidence to support a course like this? § Literature § Resident input UNIVERSITY OF MISSOURI Family & Community Medicine

The Proof • What has been tried in the past? § Trends in the literature • What has been successful § Common principals for success § Does it actually reduce harms § Will residents find this useful/enjoyable UNIVERSITY OF MISSOURI Family & Community Medicine

The Why • Why longitudinal § ACLS data • 41 IM residents (PGY 2) achieved the MPS on only 1/6 ACLS scenarios at 1 year from ACLS training (Wayne et al. , 2005) § boot camps • Why Simulation § Standardize the resident experience § annual ACLS events of 54. 1 per facility. (Peberdy et al. , 2003) • Why do it on the busiest service that you have § No better time; “the gang’s all here” § Frame of reference UNIVERSITY OF MISSOURI Family & Community Medicine

Issenberg, 2005 • Literature review from 1969 to 2003 to assess “What are the features and uses of high-fidelity medical simulations that lead to the most effective learning? ” • Qualitative data synthesis of the “best available evidence suggests that high fidelity medical simulations facilitate learning under the right conditions” UNIVERSITY OF MISSOURI Family & Community Medicine

UNIVERSITY OF MISSOURI Family & Community Medicine

UNIVERSITY OF MISSOURI Family & Community Medicine

G UNIVERSITY OF MISSOURI Family & Community Medicine y og 35% 30% 25% 20% 15% 10% 5% 0% ro l sx ia Type of Residencies Involved U ro eu N l sx es th es An CT ta en D IM T no t 2 in < . . . 0 10 ab st > 00 -1 0 -5 41 0 -4 31 0 -3 21 0 11 -2 11 51 s ar ye ar s ye te d lis > 2 th s on m s ks hs on t m ee on th m 1 - 12 6 - 6 3 - 2 1 - k ee w w 1 4 1 - < on e N 70% 60% 50% 40% 30% 20% 10% 0% EN y lo g di o d YN B/ G O ix e M y er . . . ed rg Su Ra al er en M ne ic i ed M nc y er ge Em ily m Fa Time between Training Sessions Number of Participants 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% n=48

The Right Conditions 1. Feedback (47%) 2. Repetitive Practice (39%) 3. Curriculum Integration (25%) 4. Range of difficulty level (14%) 5. Multiple learning strategies (10%) 6. Capture clinical UNIVERSITY OF MISSOURI variation (10%) 7. Controlled Environment (9%) 8. Individualized learning (9%) 9. Defined outcomes or benchmarks (6%) 10. Simulator Validity(3%) Family & Community Medicine Issenberg et al. , 2005

IMPLEMENTATION UNIVERSITY OF MISSOURI Family & Community Medicine

The players • Residents( 12 -12 -12) § ACLS/ PALS/BLS/NRP as PGY 1 and PGY 3 § ATLS or Rural Critical Care training as PGY 2 § PGY 1 (8 months) • 4 months of IP adult medicine § PGY 2 (6. 5 months) • 2 months of IP adult medicine (Sr. ) • 2 months of Rural IP/Sx • 1 m of CICU, 1 m of MICU § PGY 3 (2. 5 months) • 2 months of FMIB (Sr. ) UNIVERSITY OF MISSOURI Family & Community Medicine

The training • Simulation sessions § Adult inpatient service residents (n=4) attend • • 2 teams, 1 -on call, 1 -covering Other 4 residents are post-night float or at clinic 2 PGY 1’s and 2 PGY 2/3’s ~1700 discharges in 2010, ~5 admissions/day 2 sessions every Thursday, 3 -4 pm (15 -30 mins/session) 6 -8 sessions in PGY 1 year 3 -4 sessions in PGY 2 and PGY 3 year § Replaces 15 -30 minutes of possible patient care time per week UNIVERSITY OF MISSOURI Family & Community Medicine

Scenario Development: What Do We Teach? • Scenarios have been designed by Dr. Wells § Basic design is for a unstable or decompensating patient (“not codes”) § Residents are not made aware of cases prior to sessions • “Can’t miss” conditions § Lack of an adequate airway Hypoxia/ Hypoventilation Hypoglycemia Malignant Ventricular Arrhythmias Shock: septic, hypovolemic, anaphylactic, cardiogenic, PE, etc. § These items mandate immediate intervention and § § UNIVERSITY OF MISSOURI Family & Community Medicine correction

Scenario Development: What Do We Teach? • “Heartburn” conditions § Residents surveyed; top requests: Respiratory Failure New onset seizure Altered Mental Status Chest pain Irregular heartbeat, tachycardia with RVR Combative Patient Hypertensive emergency UNIVERSITY OF MISSOURI Family & Community Medicine

UNIVERSITY OF MISSOURI Family & Community Medicine

Implementation: Didactics • Didactic lectures § beginning of the academic year for intro/explanation § additional teaching opportunities/ workshops given later in year to address trends or gaps seen during sessions • Orientation for incoming new residents UNIVERSITY OF MISSOURI Family & Community Medicine

Didactics • Initial session on critical assessment § “Resuscitation” not just CPR/ACLS § Preventing “bad getting worse” § Recognizing downward trends and acting § Presumption of illness; “O-M-I” “O-M-G” § Systematic approach to evaluation “A-B-C-D -E-F-G-H”; emphasis on reassessment § ACLS protocols followed as cases require UNIVERSITY OF MISSOURI Family & Community Medicine

Didactics • Team Functioning § Designated team leader § Individual tasks § Closed loop communication § All members free to speak up in a respectful orderly fashion, regardless of level of training UNIVERSITY OF MISSOURI Family & Community Medicine

ASSESSMENT UNIVERSITY OF MISSOURI Family & Community Medicine

Assessment • Immediate: § Feedback immediately following the session in debriefing. § Video playback and debriefing in real time • Ongoing: § All sessions are scored using a scoring tool § Scorer comments recorded, trends identified § Used to determine opportunities for focused instruction, learner progress UNIVERSITY OF MISSOURI Family & Community Medicine

UNIVERSITY OF MISSOURI Family & Community Medicine

Scoring: Summary of scoring UNIVERSITY OF MISSOURI Family & Community Medicine

Scoring Trends: Most Frequent Comments UNIVERSITY OF MISSOURI Family & Community Medicine

Assessment: Survey #2 Second survey of residents to determine improvement in perceptions, worsening of perceptions, or no changes. UNIVERSITY OF MISSOURI Family & Community Medicine

Post Training Survey Says… I feel confident in my abilities to evaluate hospitalized patients that have become unstable I feel confident in my abilities to stabilize hospital patients that have become unstable First Survey 59% NOT CONFIDENT Second Survey 90% CONFIDENT UNIVERSITY OF MISSOURI Family & Community Medicine First Survey 72% NOT CONFIDENT Second Survey 68% CONFIDENT

Post Training Survey Says I feel confident in assuming a leadership role in managing a team to assess and stabilize an unstable patient 60. 00% I have been required to manage critically ill patients on the floor during my inpatient block rotations. 100. 00% 90. 00% 50. 00% 80. 00% 40. 00% 70. 00% 60. 00% 30. 00% 50. 00% 20. 00% 40. 00% 30. 00% 10. 00% 20. 00% 10. 00% Strongly Agree Disagree Strongly Disagree 0. 00% First Survey 68% NOT Confident Second Survey 55% Confident UNIVERSITY OF MISSOURI Family & Community Medicine 1 2 First Survey Second Survey YES NO NO

Survey Results • Residents feel more confident than prior to training § Result of training, hubris, false sense of security, later in the academic year, all of these? • When evaluated by PGY, PGY 2 had more confidence in evaluation but still not confident in initiating and leading resuscitation • PGY 1 had more confidence, but they haven’t done it for real yet • PGY 3 supremely confident, not always borne out by team performances UNIVERSITY OF MISSOURI Family & Community Medicine

CONCLUSIONS & NEXT STEPS: What Have We Learned So Far and Where Do We Go From Here? UNIVERSITY OF MISSOURI Family & Community Medicine

What Have We Learned So Far: The Good… • Everyone learns something § Attitudes often more positive post-session • Teams invested in the outcome § Gets real pretty quickly • Exposes knowledge gaps § Residents are willing to learn § Residents recognize the utility of the experience UNIVERSITY OF MISSOURI Family & Community Medicine

What Have We Learned So Far: The Good… • Residents feel more confident than they did prior to the training • Residents are better prepared for critical care rotations, rural hospital environment § Anecdotal stories of successes on the floors/ ER/ ICU UNIVERSITY OF MISSOURI Family & Community Medicine

What We Have Learned So Far: The Not So Good… • Keeping it real: artificial environment § Learners often have preconceived ideas about what to expect • Exposes knowledge gaps § Some residents defensive • The more we rely on technology, the more chances there are for disappointment! • Time constraints/ Logistics § Inpatient service can be hard to break away from § Multi D learners a challenge to schedule UNIVERSITY OF MISSOURI Family & Community Medicine

Next steps • Development of simulation case curriculum § Start slow with single intervention cases § Build with more complex cases as the year progresses § More regular incorporation of multi disciplinary learners. UNIVERSITY OF MISSOURI Family & Community Medicine

Final thoughts • Simulation is an effective learning tool • Simulation, along with feedback, didactic support, and repetition can increase residents confidence in their performance • We are learning as we develop this project UNIVERSITY OF MISSOURI Family & Community Medicine

Final Thoughts • Residents seem to appreciate the opportunity to practice difficult situations before they have to deal with them on the floors. • Expensive sim labs are really cool, but not mandatory to teach this material UNIVERSITY OF MISSOURI Family & Community Medicine

Acknowledgements • Family and Community Medicine, University of Missouri-Columbia, School of Medicine • Bob Bell, PA • Susan Meadows, librarian of FCM UNIVERSITY OF MISSOURI Family & Community Medicine

References • • • Issenberg SB, Mc. Gaghie WC, Petrusa ER, et al. Features and uses of highfidelity simulations that lead to effective learning: a BEME systematic review. Med Teach 2005; 27: 10 -28 Peberdy MA, Kaye W. Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14, 720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. 2003; 58: 297308 Wayne DB, Butter J, Siddall VJ, et al. Mastery Learning of Advanced Cardiac Life Support Skills by Internal Medicine Residents Using Simulation Technology and Deliberate Practice. J Gen Intern Med 2006; 21: 251 -6 UNIVERSITY OF MISSOURI Family & Community Medicine

Questions ? UNIVERSITY OF MISSOURI Family & Community Medicine