In the immortal words of, among others, Slayer.
Apologies for the delay (as usual), there’s always a delay, and I’m always sorry. Mae culpa, mae culpa, mae maxima culpa
That being said, I’ve received enough positive feedback, comments, mentions, likes, retweets, pokes, shrugs, swipes right, whatever one does on LinkedIn, and even a good old fashioned e-mail to allow myself to consider the ideal that there is more to this blog than me simply howling into the void.
Many, many, many heartfelt thanks for the motivation and encouragement. Let’s get on with it, shall we? (Yes!) I promise to stop blogging when y’all eventually carry me around shoulder high singing hosannas and chanting my name as the saviour of modern simulation, or when I get bored, either feels like a natural end.
In this blarticle (blog/article) I’m going to be presenting a simulation concept I have been instrumental in co-creating with my excellent work colleague and future rock star John Karlsson of Akademiska University Hospitals Clinical Training Centre.
It’s called SMART simulation.
The mechanics and content of SMART are currently undergoing some form of copyright protection process, so I can’t share the material or programming but I can describe the concept.
S.M.A.R.T simulation - Full Metal Packet
“This is our SMART concept, there are many like it but this one is ours…”
SMART is an acronym for Simulation Made Accessible via Resource-Saving Training in-situ.
I’m aware that we’re not the first people to use SMART as an acronym, and that there even exists at least one another SMARTSim.
The great thing with acronyms is that you can change them, let’s refer back to popular heavy metal combo SLAYER, who were so kind as to welcome us back at the beginning of this article. Slayers name *CAN* be an acronym for Satan Laughs As You Eternally Rot *OR* it *CAN* be an acronym for Sings Lovely And Yes, Even Rhymes. You can adapt the acronym to fit the content (or the recipients of the content)
Originally SMART stood for Simpad, Manikin And Relevant Training, which sounds maybe a little more elegant and easier to understand but is then constrained to the use of Laerdals SimPad (more of which later). We found, however, that one of SMARTS strongest features was its modular nature, that we could use the SMART concept as a framework for any event that would benefit from a briefing and a debriefing.
As expressed in a previous blarticle, we run a lot of simulation, meaningless figures abound that I am unwilling to pluck out of the air but it’s a *loooooooooot* We run so much simulation that the resources of our centre are stretched trying to keep up with demand. Running in situ (point of care) simulations in the relevant hospital departments helps take the weight off of the physical resources of the centre and conveys with it the intrinsic benefits that in situ simulation delivers (more on this here, and everywhere else, another time) However, in situ simulation also demands human resources in the form of trained simulator instructors and operators, of whom we have a finite number.
So, saturation point for simulation? No more resources to commit without a drop in quality and for some we go back to being that place in the cellar that ward staff visit once a year (at best!) and play with scary dolls?
Well we could loan out a simulator to the staff responsible for teaching on the ward. But then we have *no* control over what is delivered during the teaching session. This isn’t something that is attractive for us as a centre charged with delivering learning that has the raising of patient safety as its core value.
In short, we don’t want to say no to people who want to engage with simulation, so we need to find a way to make simulation accessible without it losing its meaning.
As we see it, the barriers to simulation include the following preconceptions
- A technologically advanced simulator is not something one can just pick up and use as a teaching resource without prior experience
- Debriefing a group of potential strangers according to Crew Resource Management (CRM) guidelines is not a job for the faint hearted and if mishandled can lead to as much harm as good.
- Simulation is HEAVY on resources, sending 10 members of staff down to the clinical training centre for a half day has the potential effect of removing a weeks worth of ward work
Being a successful simulation instructor or simulator operator could be said to require a set of skills that are if not unique, then *highly* specialised and reliant on experience. So how to translate that?
The vast majority of requests we have to deliver simulation are with specific CRM based goals as the preferred learning points (rather than practical/psychomotor skills) Starting with the preferred learning goals of the target group sounds pedagogically healthy and worthwhile, so let’s do that.
For entry level instructors, there exists a preconception that CRM as a concept can be clumsy and hard to get to grips with. One of the reasons for this is that the central principles of CRM can mean different things to different people, and another is that there are so damn many. Cognitive theory suggests we as humans can only effectively think about seven things at once, so how are we considering the impact of a dozen or more CRM principles on an active group of people with a view to debriefing them? Is it even possible?
The Ace of Spades
We have broken down the introduction of CRM principles and the corresponding debriefing into a card game *gasps from the audience, someone in Denmark just fainted, cries of “No!, you can’t DO that!”
“Oh but,” puts on sunglasses, turns to camera, “we did…”
Each card set has a theme (Communication, Effective Teamwork etc), and there are maybe 4-6 cards in each set. Upon each card is the title of one of the CRM principles (Closed loop communication for example), and on the back of each card is a description of that principle and how it might translate into actual work duties.
The card set forms the basis of an introduction to the simulation session. Once the principles and descriptions have been discussed and agreed upon, it’s time to meet our patient.
All our S:M:A:R:T patients are gender neutral, there’s even a word for a gender neutral person in the swedish language, hooray for a progressive society.
(Nearly) all our S:MA:R:T patient cases can happen whenever, to whomever and wherever. It’s up to the educator delivering SMART to add some finesse to the case if it needs to be made more relevant to a specialist ward or unusual healthcare environment.
The cases are medically straightforward, with the ideal that time spent in the debrief discussing the medical aspects of the case is time spent NOT discussing or reaching the CRM based learning goals.
Drive, she said
Driving a simulator is easy, it’s simply a matter of having 100% focus on the patient's vital statistics (SpO2, Heart rate, Blood Pressure etc) with respect to both the patient's underlying sickness (which you have expert knowledge of) and the actions and interventions carried out by the team of participants, and translating these actions and interventions into realistic physiological responses as displayed on the patient monitor and via the simulator. Simultaneously you are voice acting the patient's symptoms and emotions.
Did I say it was easy, well it is easy to do a bad job, far too easy. So how do we make it easy to do a better job?
As outlined in the previous blarticle “Programming People - Part 1” there are broadly speaking two approaches to driving a patient case on the simulator. “On the fly”, making things up as you go along, an approach that does not suit an inexperienced simulator operator, and Hard Wiring, an approach whose rigidity doesn’t suit a flexible simulation package like SMART
With SMART, we have programmed physiological responses linked to on screen button presses on a mobile device, with the buttons marked according to known likely medical interventions.
It works like this, the participants administer oxygen, the operator presses a button named “Administer Oxygen” or something similar and the physiological response to oxygen administration happens in the background over time. The participants raise the rate of oxygen delivery, there is a button for that with the physiology programmed in. Fluids? Drugs? Tipping the bed? For each likely intervention there is an appropriate button linked to a physiological response.
The patient's condition is preprogrammed to deteriorate over time, with choosable levels of severity of disease state.
For each case, one of the “Participant Action” buttons is red, and is considered the key treatment to allow the case to progress positively and the patient to begin to normalise. For example, the programmed allergic shock case requires the intervention of an EpiPen or similar. Once this intervention has taken place, the red button is pressed and the patient normalises over time.
Simple, elegant, SMART. A physiologically correct patient case that is easy to drive and focuses on the actions of the participants.
“But how does the patient feel?” I hear you ask
As outlined in another previous blarticle (see how its all coming together, long term readers?), patients are, surprisingly, people, as well as fleshy objects, and how they feel has an affect on how they react to treatment.
Scroll a little right on the SMART programmed mobile device to the Symptoms button to find the answers. Pressing this button will display different things according to which phase of treatment/sickness the patient is in. The information is provided in a pop up on the mobile device and includes key phrases the patient might say at this point, and the answers to questions the simulator itself can’t deliver (capillary refill, patient temperature, how warm does the skin feel etc etc)
After running the scenario, the participants are invited to take part in a debriefing. The debrief itself is based on the previously discussed CRM card set and introduces a specially prepared “board game” in order to define, structure and focus the debriefing towards the discussion of the chosen goals, rather than a general roundtable agreement that “good things are better than bad things”
Participants later receive a web based survey in which they may submit further reflections and feedback.
How is this solving the resource problem?
The ward personnel in charge of education come to us for a half days “Smart-Instructors education” course, after which they receive a crown and sceptre and are allowed to book the SMART package (Course material, card game, SMART-programmed simulator)
We have enjoyed huge success delivering SMART using Laerdals Resusci Anne Simulator (RA Sim) and Laerdals SimPad mobile device. The RA Sim is a medium fidelity simulator, that is to say it has pulses, it breathes, you can take its blood pressure. Its ability to be driven by the SimPAd mobile device also makes it very attractive as part of a physical, collectable/deliverable simulation package.
The (newly crowned) SMART instructor collects the package themselves and then delivers the session (often it needs two instructors) back at their own department in the hour long gap between two work shifts. Scheduling education under this hour means that NO patient hours are lost and as a SMART simulation session lasts 30 minutes (10 min intro, 10 min medical case, 10 minute SMART debrief) we can deliver two sessions.
This is the end, beautiful friend
Simplified CRM structured and focussed to deliver specific teaching goals.
Absurdly easy to drive simulation.
Flexible and light on resources.
Sure, it’s simulation LITE, in a way, but it punches way above its weight by directly addressing preconceptions about simulation.
We don’t see SMART as a way out of full scale simulation rather than a way into full scale simulation. We see it as one of the ways in which we don’t have to say no anymore.
After a successful pilot scheme, we launched our own SMART instructors course and are delighted to say we have now more than 40 SMART instructors across our local authority. Which, in context, is 40 plus more people engaged in delivering simulation in Uppsala Län than there was 6 months ago, boom!
Feedback has been overwhelmingly positive, both first hand and via the web survey. One overheard comment at the last course was how this was potentially going to make a MAJOR difference to patient safety, and how EVERYONE should become a SMART instructor.
I was struck by a certain feeling at that point which I can only describe like this...
Remember the film JAWS, when Roy Schneiders character is tossing rubbydubby/chum/fishheads off the back of their vessel and The Shark appears for the first time, revealing its true size?
The look on his face, and the phrase “I think we are going to need a bigger boat”
Exciting times at Simulated Towers!
Till next time, whenever that is, and whatever that is about, stay simulated!