Neonatal Simulation Center

DETAILS OF SIMULATION TRAINING AT STONY BROOK UNIVERSITY’S
DIVISION OF NEONATAL MEDICINE

At Stony Brook

With the use of the Simulation lab, standardized patients and the high fidelity SimNewB, our goal is to improve quality of care, patient safety and patient outcomes through experiential learning.

Through Simulation, the Division of Neonatal Medicine aims:

1. To standardize and control training

2. To improve procedural competency

3. To provide the opportunity to learn in a safe environment

4. To afford the opportunity to debrief and repeat as necessary to reach competency

5. To evaluate the competency and knowledge gains

6. To improve patient outcomes

In collaboration with Dr. Shanthy Sridhar, Director of Neonatology and Patricia Mele NNP-BC, a variety of scenarios in treating compromised newborns are rehearsed.  These include simulations on delivering “bad news” to the family when necessary, and resuscitation of the full term and pre term newborn in a simulated emergency setting. 

For our fellows, the training provides an education in required management skills needed to attend to NICU patients.  These include skill building in team leadership, communication and team response.  With simulation, we provide a safe learning environment with the ability to video your performance and debrief with faculty. The learner gets immediate feedback and repeat scenarios as needed.

We currently have 6 neonatal fellows, 18 pediatric residents, 7 neonatal practitioners, numerous NICU nurses, anesthesia residents and medical students that will be able to participate. Patrician Mele is a DNP candidate for 2009 and a 23 year veteran in neonatal resuscitation as an NNP. She has been an AAP/ NRP instructor since 1990 and received formal training in simulation with SimBaby, SimNewB, standardized patients and the debriefing session.

GENERAL BACKGROUND ON SIMULATION EDUCATION (Patricia Mele, NNP, DNP)

Limitations on Duty Hours Reduce Opportunities to Learn Procedures

In 1989 the Bell Commission released significant code revisions (New York State Hospital section code 405) affecting medical training programs which limited house staff officers to an 80 hour work week. The maximum shift of 24 consecutive hours was adjusted by the Commissioner of Health of New York State allowing a 3 hour period to be added to on-call for transfer of information, education, but does not include direct patient care.  The ACGME (2007) has also limited work hours, specifying the frequency of overnight calls, consecutive hours the resident can work and necessary time off. Continuous on site duty including in-house call may not exceed 24 hours. Residents may remain on duty for up to 6 additional hours for didactic education, transfer of care and out-patient clinics. These restrictions are not limited to the United States and have been implemented globally.

The impact of the reform has transformed medical education. Young physicians have the essential scientific knowledge, but limited exposure to sub-specialty areas and sometimes critical clinical situations (Douglas, 1990). This not only has a significant impact on continuity of care but also diminishes opportunities for observing, performing, and mastering necessary invasive procedures. The change in medical education to allocate more time spent in primary care areas has also grossly limited the exposure to intensive care areas, such as the neonatal intensive care unit (Douglas, 1990).  This reform has intensified the need for nurse practitioners to provide medical care, as well as perform invasive procedures in this patient population. The neonatal nurse practitioner student’s residency is limited to 600 clinical hours. Thus, the opportunity for the nurse practitioner student to get enough exposure to perform invasive procedures to become proficient is often unrealistic.

CURRENT APPRENTICESHIP MODEL IS NOT EFFECTIVE

Historically, most clinical training to the graduate is not methodical and truly an apprenticeship process. Development of simulation scenarios will allow increased exposure to procedures and will enable the development of competence in the performance of specific techniques (Bradley, 2006; Devita, 2005; Gaba, 2004; Grenvik, 2004). A well know education model, “The Miller Triangle” is a model which embodies cognitive and behavioral steps that an individual progresses through to achieve knowledge to perform a skill (Carr, 2003; Miller, 1990)).  Miller’s triangle of learning demonstrates four levels of competence; knows, knows how, shows how, then does. This education process is analogous to the popular apprenticeship classically used in medical training. These layers can be used in simulation education as long as authenticity is used to reflect the real life scenario (Schuwirth, van der Vleuten, 2003).

Anesthesia was the first sub specialty in medicine to embrace simulation (Bradley, 2006; Grenvik, 2004; Schaefer, 2001,). From there other areas of medicine, such as surgery and emergency have moved toward simulation to expose trainees to improve effective response time, communication, and highly skilled procedures (Dayal, 2004; Devita, 2005; Lighthall, 2003; Mayo, 2004; Seymour, 2002). Several studies support that trainees are more comfortable doing procedures as the apprentice after being exposed in simulation (Britt, 2007; Dayal, 2004;, Lighthall, 2003) Studies have also reported that there is an increase in success rate of placement and decrease in the number of attempts in placing carotid stents and swan central lines in adult patients after simulation (Britt, 2007; Dayal, 2004). Devita 2005, has shown an improvement in medical emergency and crisis response time from multidisciplinary team simulation scenarios.

HISTORICAL ASPECTS OF SIMULATION EDUCATION

The roots of simulation education can be traced to flight simulation on the ground during WWII to train fighter pilots. Civil aviations, NASA and nuclear power stations continue to be significant users of simulators for personnel training (Grenvik, 2006). As in medical error, mistakes in these fields may have devastating consequences. Simulation can also be found in home video games where countless games are used to simulate challenges for entertainment. We have come a long way since the Norwegian publisher and toy manufacturer Asmund S. Laerdal introduced the life-sized and realistic  in appearance“ Resusci –Anne” in 1960.  Basic life- saving programs (BLS) have used “Annie” to train millions of students, professionals and civilian providers.

Simulation education in medicine is relatively new and rapidly expanding. Simulation can recreate real- life scenarios in a pre- planned and safe environment that can be reproduced and adjusted over and over as needed. There is a decreased risk to patients and tasks can be created on demand and tailored as needed. Planned novel or infrequent events can be recreated (Bradley, 2006; Gaba, 2004; Grenvik, 2004; Issenberg, 2005). Recent technology has been brought to the medical field and enabled advanced simulation education in medical training. Along with the expansion of simulation education, there is an increasing need for quality research. Many authors have demonstrated that using simple task simulators to the most complex computerized  mannequins can  improve trainees confidence level, enhance experiences and improve outcomes (Issenberg, Mcgahie, Petrusa, Gordolong, Scalese, 2005). In theory, the use of different clinical scenarios could be unlimited. Simulation education in the neonate has yet to surface in the literature. Laerdal has recently released the SimNewB^tm which is a high fidelity newborn simulator. The “baby” can simulate simple airway scenarios to complex full neonatal codes requiring ongoing assessment and intervention, some of which include several invasive skills. The SimNewB^tm   can be used along with the current American Academy of Pediatrics Neonatal Resuscitation Program (NRP) guidelines to teach newborn resuscitation (AAP, 2007).

Many newborn scenarios requiring quick response and clinical expertise will be simulated in training health care givers. These skills were previously mastered by long hours of residency training.  Simulation will now expose the trainee to the procedure or scenario and allow for critique, debriefing and repeated scenarios as needed without harm to the patient. There are also numerous products that are partial task simulators which, are low fidelity simulators, but provide the simulation for a specific procedure such as, IV access, foley catheterization, lumbar punctures and intubation. Although a spectrum of technology and computerized training can be recreated to simulate real life situations, more evidence is needed on the cost and validity of these education methods. (Bradley, 2006; Britt, 2007; Long, 2005; Schaefer, 2001). Using simulation for education is costly, labor intensive and can be extremely time consuming. Therefore, quality research is needed to evaluate the effectiveness of this method of education in medicine. (Gaba, 2004; Issenberg, 2005)

REFERENCES

Accreditation Council for Graduate Medical Education (2007) retrieved July 21, 2008 from
http://www.acgme.org

American Academy of Pediatrics Neonatal Resuscitation Program (2008) NRP Instructor Upate17(1): 4 retrieved on August 15, 2008 from http://www.aap.org/nrp/newsletter/2008/spring

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