Lecture presented by Dr Jose Maria Nicolas at e-ICU Egypt conference held at Cairo Egypt on 3and 4 December 2014.Organized by Scribe(www.scribeofegypt.com)

1. Simulation as a teaching tool in the ICU:
The Human Factor perspective
José M. Nicolás, MD. PhD.
Intensive Care Unit. Hospital Clínic of Barcelona, Spain.

2. What we pursue?
2

3. High Reliability Organisations (HRO)

4. Work at ICU as a High Reliability Organisation
• We work under
uncertainty and
changing situations.
• Other industries
aviation, nuclear
power stations, army
too.
• Joint Commission
commitment to HRO
model.
High reliability
organisations, work at risk
with the potential to
generate large-scale
damage, but they a chive
a balance between
effectiveness, efficiency
and security. They
minimize errors through
teamwork, awareness of
the potential risk and
continuous improvement.
4

5. Define the problem to
understand the solution
5

6. • IOM Institute of Medicine:
To err is human.
• 98.000 deaths/year
medical error. 8th death
cause.
6
Some interesting information
America, C. on Q. of H. C. in, & Medicine, I. of. (2000). To Err Is Human: Building a Safer Health System

7. 7
Errors in critically-ill patients
St.Pierre, M., Hofinger, G., Buerschaper, C., & Simon, R. (2011). Crisis Management in Acute Care Settings: Human
Factors, Team Psychology, and Patient Safety in a High Stakes Environment. Springer.

8. 8
Errors in critically-ill patients
St.Pierre, M., Hofinger, G., Buerschaper, C., & Simon, R. (2011). Crisis Management in Acute Care Settings: Human
Factors, Team Psychology, and Patient Safety in a High Stakes Environment. Springer.

9. 9
Errors in critically-ill patients
St.Pierre, M., Hofinger, G., Buerschaper, C., & Simon, R. (2011). Crisis Management in Acute Care Settings: Human
Factors, Team Psychology, and Patient Safety in a High Stakes Environment. Springer.

10. “Food for thought”
Errors
detected
Errors
solved
Mean Error
Time
Expert 18 15 0,4 h
Residents 13 8 1,5 h
Students 8 2 3,0 h
Errors detected and solved in 10 h of UCI care
Patel, V. L., & Cohen, T. (2008). New perspectives on error in critical care. Current Opinion in Critical Care, 14(4), 456–459.

11. 11
errare
humanum est
Lucius Annaeus Seneca
Busto de Séneca.
Museo del Prado

12. What are the causes?
12

13. Conflicts at the ICU: actors
Fuente:
Fassier T,
Azolulay
E. Cur
Op Crit
Care
2010.
ICU: “Ineffective Communication Unit”

14. Joint Commission on Accreditation of Healthca- re Organizations. Sentinel event data root causes by event type. 2013.

15. • Error ≠ lack of
Knowledge
• The 70% of
medical errors
are related with
Human Factors
15
Human Factors
Helmreich RL, Fousbee CH. Why crew resource management?
Empirical and theoretical bases of human factors training in avia- tion. In: Wiener EL, Kanki BG, Helmreich RL, editors. Cockpit
resource management. San Diego: Academic Press Inc; 1993. p. 1–41.

16. "Human factors refer
to environmental,
organizational and job
factors, and human
and individual
characteristics, which
influence behaviour at
work in a way which
can affect health and
safety".
16
Human Factors
Health and Safety Executive. Human factors/er- gonomics. Introduction to human factors

17. 17
Human Factors
Rall M, Oberfrank S. Human factors and crisis re- source management: improving patient safety. Unfall- chirurg. 2013;116(10):892-9.

18. 18
Human Factors
Rall M, Oberfrank S. Human factors and crisis re- source management: improving patient safety. Unfall- chirurg. 2013;116(10):892-9.

19. 19
Problem
Root
Cause
Analysis
Solution

20. SOLUTION: Learning
20

21. Circle of Learning

22. Acquisition of clinical competency
Does
Shows
Knows
how
Knows
Does
Shows
Knows
How
Knows
Miller GE. Academic Medicine 1990

23. Learning process
What we remember Degree of involment
Read
Listen
See how to
Discusion
Keynote
Simulate
Practice real life
passive
active

24. ¿What is medical simulation?
Simulation is the use of one or several devices
(simulators) to emulate a realistic situation of a patient
care with the purpose of training or to evaluate.

25. ¿Why a simulated ICU?
Learning shoud be done in the
real place or a realistic one.
Advantages:
– Avoids any risk on the
patients.
– Allows training in complex
and sporadic events..
– Reproducible, standarixed
and may be evaluated.

26. 26
Learning by simulation

27. SOLUTION: Technical skills
and decision taking?
27

28. Basic technical skills

29. Basic technical skills

30. Basic technical skills

31. Basic technical skills

32. Complex technical skills

33. Skills with animals

34. Simulated patients

35. Simulated patients

36. Decision taking with Microsimulation

37. Skills in processes: Bacteriemia “Zero”

38. Skills in processes: Ebola

39. Skills in processes: Ebola

40. 40
errare
humanum est
perseverare
diabolicum
Lucius Annaeus Seneca
Busto de Séneca.
Museo del Prado

41. 41
PROBLEM
98000
Medical
error
CAUSES
70%
Human
Factor
SOLUTION
Training HF
and NTS

42. SOLUTION: Non-Technical
Skills Training
42

43. America, C. on Q. of H. C. in, & Medicine, I. of. (2000). To Err Is Human: Building a Safer Health System

44. • Error arising primarily from
aberrant mental processes
– Forgetfulness
– Inattention
– Poor motivation
– Carelessness
– Negligence, and recklessness
• Humans are fallible
• Errors are to be
expected, even in the
best organizations.
• Humans are not perverse
44
PERSON APPROACH
BLAME CULTURE
SYSTEM APPROACH
SAFETY CULTURE
• Countermeasures
– Reducing unwanted variability in
human behaviour
– Disciplinary measures, threat of
litigation, retraining, naming,
blaming, and shaming
• Countermeasures
– We cannot change the
human condition, we can
change the conditions under
which humans work
Reason J. Human error: models and management. West J Med. 2000;172(6):393-6.

45. Trajectory of the error
45
System Approach: Swiss Cheese
Latent Failures
Active Failures
MISHAP
Defenses
Reason J. Human error: models and management. West J Med. 2000;172(6):393-6.
Hazards

46. UB-CRM
TEAM
TRAINING
ACRM
MED
Teams
Team
STEPPS
DOM
GITT
MTM
MTT
46
Non Technical Skills Training
Baker, D., Gustafson, S., & Beaubien, J. (2007). Team
training in health care: A review of team training programs
and a look toward the future. Adv Pat Saf.
The Comprehensive Textbook of
Healthcare Simulation. (2013).

47. • Medicine: The principles of individual and
team behavior in normal situations and
crisis focus on skills dynamic decision
making , interpersonal behavior, and team
management .
• It is a system that makes optimal use of all
resources and equipment, the available
procedures, and people to promote patient
safety.
47
What is CRM?
Gaba DM. Crisis resource management and teamwork training in anaesthesia. Br J Anaesth. 2010;105(1):3–6.

48. 48
Crisis Resource Management
Call for
help Anticipate
and plan
Define a
leader
CR
M
Know the
envirome
nt
Use all
available
informatio
n
Focus
attention
wisely
Use all
available
resources
Use
cognitive
adis
Define
roles
Distribute
the
workload
Effective
comunica
tion
Crisis Resource Management Diagram. ©2008 Diagram: S.Goldhaber-Fiebert, K. McCowan, K. Harrison, R.
Fanning, S.Howard, D. Gaba

49. 49
Crisis Resource Management
Patient Safety due to the Human
Factors application though CRM
Team
Working
Situational
Awareness
Decision
Making
Task
Management
Communication
Verbal and Non Verbal
Rall M, Oberfrank S. Improving patient safety in air rescue: the importance of simulation team
training with focus on human factors/CRM. Air Rescue Mag. 2013;3:35-40.

52. How we train with CRM
principles?
52

53. ADULT LEARNING THEORY
• Shön. Reflective Practice
– Reflection IN action. DURING.
• It is based on the ability to learn and develop
continuously through creativity, applying current
and past experiences and using reasoning as
unexpected events occur .
– Reflection ON action. AFTER.
• We reflect on the factors that have contributed to
the incident happened, if the actions taken were
appropriate and how it may affect this situation to
practice in the future. 53

54. 54
How we train CRM – HNT – FH?
SIMULATION CULTURAL
CHANGE

55. 55
Simulation course/session

56. Place for simulation

57. Setting intro and theory

58. 58
Case briefing

59. Perform the scenario

60. 60
How we achieve cultural change?
DUR.THE SCENARIO
Reflection IN
action. Shön
DUR. DEBRIEFING
Reflection ON
action. Shön

61. • Crisis management
• Training
– Leadership and
comunication
– Decision Making!
enviroment. (Kind of
hospital, available
resources)
– Security routines. Check-list
– Situational awareness
– Process of information
• Experience real
enviroment.
MEDICAL GOALS
• Use of electromedicine in
clinical contest
(Monitoring, VM, DF)
• Protocols: ALS, ATLS,
STEMI, ARDS, EGDT, bz
• Technical skills.
61
DURING THE SCENARIOS HNT – FH - CRM
Reflection IN
action. Shön

62. Behavioral Assessment Tool (BAT)
• Evaluates 9 aspects of CRM.

63. Debriefing is the soul of simulation

64. • Reflective learning
– Study the frame (mental
model) actions and results.
– Decision making medical
and non medical.
– Error and how to mitigate
after mishap.
– Proceedings and
healthcare processes:
identify risk situations and
pourpose changes.
• Analisys of situation
through CRM.
DEBRIEFING
• Cultural sensibilitation
directed to patient safety.
• Analisys cause
• Training the ability to
emit and receive
objective criticism and
self-criticism
64
Reflection ON
action. Shön

65. 65
How we change culture through
DEBRIEFING?
TOOL:
DEBRIEFING
BLAME
CULTURE
PATIENT
SAFETY
CULTURE

66. • Methodology “Good Judgement”:
– Learning without fear : safe, not punitive.
– Premises: The student is smart and wants to do the
right thing . We all make mistakes .
– Criticism is accepted.
• Debriefing phases:
– Description: Step by step of what happened.
– Analysis and Analogy: " pearls" and points relevant
parallels reality.
– Application: what you take home.
66
Debriefing: Methodology and phases
Rudolph, J. W., Simon, R., Dufresne, R. L., & Raemer, D. B. (2006). There’s no such thing as
“nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simulation in
healthcare : journal of the Society for Simulation in Healthcare, 1(1), 49–55

67. Impact on clinical care.
Scientific evidence

68. Technical skills at ICU
Studies Results
Improving Delivery of Continuous Renal
Replacement Therapy: Impact of a
Simulation-Based Educational
Intervention. Mottes T, et al. Pediatr Crit
Care Med 2013
RRCT, duration of hemofilters goes
from 42,5 h to 59,4 h after simulation
of technical skills.
Use of simulation-based education to
improve outcomes of central venous
catheterization: a systematic review and
meta-analysis. Ma IW et al. Acad Med
2011
Ffewer tries of venous
cathetherization SMD -0,58
Pneumotórax RR 0,62
A prerotational, simulation-based
workshop improves the safety of central
venous catheter insertion. Sekiguchi H,
et al. Chest 2011
Errors in CVC placements lowers
from 22,8% a to 16,2%. Arterial
pucture drecreases from 4,2% to
1,5%.

69. Adherence to clinical processes at ICU
Studies Results
An educational course including medical
simulation for early goal-directed
therapy and the severe sepsis
resuscitation bundle: an evaluation for
medical student training. Nguyen HB, et
al. Resuscitation 2009
Intervention groups achieved 94%
vs 77% in early goals of sepsis
treatment.
Simulation-based education improves
quality of care during cardiac arrest
team responses at an academic
teaching hospital: a case-control study.
Wayne DB et al. Chest 2008
After simulation CPR was
prerforment according AHA
standards(68% vs 44%).
Use of simulation to assess electronic
health record safety in the intensive care
unit: a pilot study. March CA et al. BMJ
Open 2013
Simulation facilitates error
identification in the ICU clinical
record.

70. Non-technical skills at ICU
Studies Results
Nontechnical skills assessment after
simulation-based continuing medical
education. Morgan PJ, et al. Simul
Healthc 2011
Improves scores in simulation by
5% per sessión, by withouth any
effect from debriefing.
Short simulation training improves
objective skills in established advanced
practitioners managing emergencies on
the ward and surgical intensive care unit.
Pascual JL, et al. J Trauma 2011
Training by only half day with 5
scenarious simulation it is enough to
improve leafdership, efectiveness
and communication.
Effect of crew resource management
training in a multidisciplinary obstetrical
setting. Haller G, et al. Int J Qual Health
Care 2008
A CRM-based program improves
efectiveness and teamwork.

71. Outcome of the criltically-ill patient
Studies Results
Use of simulation-based education to
reduce catheter-related bloodstream
infections. Barsuk JH et al. Arch Intern
Med 2009
A simulation program for CVC
placing reduces catheter-related
bacteriemia (0,50 vs 3,20 cases/
1000 catheter-days).
Performance of medical residents in
sterile techniques during central vein
catheterization: randomized trial of
efficacy of simulation-based training.
Khouli H, et al. Chest 2011
A simulation program for CVC
placing reduces catheter-related
bacteriemia from 3,4 to 1 cases /
1000 catheter-days; and decreased
length of stay by 1.4 days.
Didactic and simulation nontechnical
skills team training to improve perinatal
patient outcomes in a community
hospital. Riley W, et al. Jt Comm J Qual
Patient Saf 2011
A decrease in perinatal mortality by
37% was observed after a simulation
program.

72. Liam Donaldson,2004
Alianza Mundial para la Seguridad del Paciente
Key points

73. Change from blame culture to patient safety culture.
73
Key points
Perform training programs
• Adult learning theory.
• Train non-tech. skills. CRM
• Explore mental frames.

74. 74