Simulation Center Specialized Training

Each case based learning exercise is developed by first describing the health state changes that would normally occur in a patient. This scenario algorithm follows all realistic health state changes and allows the trainers to vary the patient response based upon the participant's treatment or the pathophysiological responses caused by the disease or injury. Next detailed Learning Objectives are derived from the exercise, including baseline and advanced topics. The scenario is expanded by including patient background and history, which the participant will derive directly from the patient or from their chart. Details from additional lab test and results for the entire course of the scenario are created to respond to the expected requests from the medical staff. The use of ventilation therapy (oxygen regulators and ventilators) is available for each case as required. Additional equipment such as an electrocardiogram or Foley Catheters are included and tested with the scenario. The scenario scene is created, which may include Moulage, the art of adding makeup or blood or fluid lines to the patient for realism. We test the scenarios to develop a smooth flow, as well as the creation of the instructor note set creating a patient personality profile to focus questions and attention to proposed changes in the patient condition. Finally, we include both appropriate and inappropriate drug treatment protocols to assure that anticipated responses are correct. Detailed checklists are prepared, in concert with the case, for the Facilitators and Preceptors to follow and assess the performance of their participants.

Among the reasons this project is justified are:

1. Each station at the FAU CSSC is capable of handling between four and eight participants for optimal training. Our Centers have the ability to replicate cases that might take months or years to occur in the normal hospital clinical environment. These cases can be created and repeated for consistency and preparation. The result will be reduced morbidity rates and improved patient outcomes.
2. FAU has two Training Centers, one at the Boca Raton Campus in the Research Park and a second facility on the grounds of St. Mary's Hospital at the Palm Healthcare Pavilion on 45th Street West Palm Beach. These facilities provide an easier access to the Southern area hospitals and the Northern area as well. FAU has already demonstrated superior training staffed by simulation personnel with backgrounds in Medicine, Nursing, Emergency Response Services, and technology. Our staff of physicians includes Cardiologists, Internal Medicine, Trauma and General surgery, Pediatrics, and Anesthesia. The Center is also staffed with experienced personnel that have developed and executed extended medical, disaster and emergency training and remediation.
3. The FAU CSSC provides state of the art training facilities for Healthcare Professionals to practice interdisciplinary communication essential to improve patient care and treatment and insure the highest level of patient safety, including Pre-hospital, Hospital, and Post-Hospital based personnel. By providing video and audio capture of the sessions in real-time, the participants have a documented capture of their activities, which is essential in aiding the debriefing of the participants. The Centers can pre-record the sessions utilizing preceptors from FAU using standard protocols, so the participants have a model to compare and contrast their own performance.
4. By utilizing advanced A/V technology, the CSSC creates “golden master” videos depicting the appropriate medical encounter or can create vignettes that depict incorrect interaction or treatment. The standardized patients use these to prepare for their participant encounters. The students/participants utilize these to compare their own actions to the “correct” approach to patient care.

The CSSC are used to introduce medical students to complex Vital Sign assessment on the mannequins or standardized patients. They utilize venipuncture trainers to learn to draw blood. Suturing techniques are taught using skin pads and appropriate medical equipment. They utilize the Intubation Heads to learn intubation protocols. They learn to practice physical examinations and assessments on Rectal, Pelvic, breast and testicular skill trainers. They learn cardiac sounds using the Harvey Simulator. They are exposed to advanced medical cases, such as, Cardiology, Pulmonary, Infectious Disease and Renal Disorders at the Simulation Centers. These detailed cases focus on key learning objectives and teachable moments during hands on case based learning with the mannequins or with standardized patients.

The medical students are exposed to case based learning throughout their medical training. In the CSSC, the initial focus is on “Critical Thinking Methodology”. From the first interaction with the simulation center, the students are taught to think through a broad range of potential differential diagnosis, and then narrow their diagnosis based on information or evidence from history and physical examinations. In this manner, we reinforce the teaching concepts throughout the curriculum. At the CSSC, we may have the students ascertain the condition of their patient through a thorough focused physical examination, requiring the turning of their patient and a complete head to toes examination to determine root cause of a patient condition. The mannequin patients respond in real time, giving the students the sense of realism in responding to patient treatment. If they prescribe the wrong dosage or amount of medication, the mannequin patients will respond accordingly and they learn firsthand about the consequences of incorrect medication. The mannequin patients respond interactively with the students, as the exercise is managed remotely from outside the room. The exercises are videotaped and provided as a debriefing and memory record for the students. The students utilize these recordings to perform self-assessment, peer evaluations and identify issues with their own performance.

The typical case evidence based scenario is developed in conjunction with Program Director for the particular discipline. The objective of the simulation scenario is to use the case as a vehicle to bring together all of the elements of their didactic and self-directed learning experiences. The scenario is developed by outlining the learning objectives, primary and secondary that the Director wants to emphasize. The case describes the environment, mannequin setup or standardized patient dress, any props or Moulage (makeup) required to make the patient seem more realistic (insertion of a pacemaker with scar and bandage covering), diagnostic studies (CBC, ECG, Chest x-ray, 12 lead, BMP, etc.). The case includes any medications that the patient had been taking and any distracters (socks covering foot ulcer, stage three sacral decubitus covered by patients shorts). The scenario then includes the physical pertinent positives, vitals including heart and lung sounds as appropriate. The Preceptors have a chart that assists their leading the medical students through possible etiologies and differential diagnosis. We map out the flow of potential mannequin patient changes, including those with positive and negative results, depending upon the diagnosis, or treatment provided by the students. We then can reset the case flow, restart the scenario, and provide the correct treatment with the corresponding expected results. The scenario plan includes specifics for the debriefing and has the key objectives or take away points that the students need to review before the conclusion of the case. The cases contain facilitator (directors of the case from outside of the simulation room providing the voice and system responses for the mannequins) notes and key words or phrases to respond to medical student queries.

The FAU CSSC is actively engaged in training starting in the very first semester through the fourth year of our medical student education. The simulation center has been inculcated into the curriculum at the newly expanded Clinical Skills Simulation Center.

Each Training Session that is offered is comprised of hands on scenarios, followed by a debriefing session, led by Hospital supervisors or proctors. Each scenario is evidence based matching institutional/learner objectives needs which may include focusing on heart sounds, breath sounds, intubation or respiratory therapy and patient psychosocial needs. Prior to the start of all the cases, FAU presents an introductory examination of the Human Mannequin Simulators so that the nurses become familiar with their vital signs and responses. Prior to the start of the cases, the nurses may be given charts that relate to the specific patients to which they will respond. The Training Sessions can be a single session attended by a group of nurses from the same practice area, or may comprise a series of Training sessions over a period of weeks, focusing on different aspects of the same practice area (e.g. Telemetry, Medical Surgical, Emergency Room, Critical Care, Labor & Delivery, etc.). The following table represents a sample of some of the cases the Simulation Center has already created:

Critical Care

• Acute Coronary Syndrome
• Pulmonary distress
• Neurological/Renal Disease
• GI distress/Multisystem failure
• Integrated Simulation - Putting it all together

Emergency Department

• Assessment Skills related to Cardiovascular disease
• Pulmonary disorders - identification and assessment
• Multi-system failure - identification and assessment
• Renal disorders - identification and assessment
• Pediatric ACS - identification and response
• Triage - multi-system failures and response
• Integrated Simulation - Putting it all together

Mother/Baby

• Normal Labor and Delivery
• Breech Birth
• Cesarean Delivery
• Neonatal Airway management
• Neonatal Complications

Pediatric/Pediatric Intensive Care

Each incoming class of residents will receive BLS/ACLS/PALS (as appropriate) training at our training centers. In addition, we have teamed with St. Mary’s Hospital and provided ATLS training as appropriate. The FAU CSSC utilizes a baseline assessment program to identify areas of potential focused education for each class of residents. As part of this assessment, the CSSC developed clinical stations utilizing customizable skill station identification and Heart Sound “HARVEY” Simulators to present various clinical findings for a patient. The Residents are required to describe the diagnosis and prescribe the next steps in treatment. The Residents answered multiple-choice questions regarding each simulated patient. In addition, FAU created numerous distinct cases and each PGY 1 - 3 performs an assessment and treats their patient on an individual participant basis. Various simulation methods and scenario combinations are used. For example:

• "Alternating Medical Scenario” - The residents will attend to mannequin patients on an individual basis, assess the patient’s condition, and prescribe the appropriate treatment for each case. The resident will then complete each exercise by completing their admitting orders as appropriate for the patient.
• “Group Medical Scenario” - A group case is created, for example, an Acute Coronary Syndrome assessment where the Residents would be grouped together with senior and junior members as part of the same team. A facilitator would be present and manage the cases remotely while interacting with the individual Resident by providing the remote voice of the patient. Also present would be a Preceptor who provides labs and other pertinent clinical information upon request, but offers no assistance in treatment. Both the facilitator and the Preceptor use checklists to annotate the activities of the individual Resident. In addition, the entire event would be videotaped for later review. Summary findings may be presented to the Attending staff at their respective Hospitals for review and remediation. Additional training is available to address issues demonstrated through resident performance.

Additional training for residency programs has been created to match many disciplines. Currently, our training includes both our Internal Medicine, Surgical Residency, Emergency Medicine, Psychiatry, and other specialties are also under development. We currently have cases written for Cardiology, Pulmonary, Infectious Disease, Renal and Multi-system Failure, Shock and Stroke, Pediatrics, Labor and Delivery, and neonatal conditions. We have skill training for surgery, with the inclusion of sonogram and ultrasound-guided central line placements, “box”, and high fidelity virtual reality trainers for laparoscopic skills enhancement.