Human patient simulation has come a long way since the days of the first resuscitation manikin in 1960. In fact, healthcare simulation has really evolved into a high-tech science at the beginning of the 21st century. Today, the medical simulation industry offers a multi-billion dollar plethora of high, mid, and low fidelity options from task trainers with and without feedback, to virtual reality computer modules, and wearable task trainers, to full body responsive, high-fidelity patient simulators. Yet, the challenge becomes how to determine which equipment will “do the job” the most effectively and facilitate the achievement of increased learning outcomes. This HealthySimulation.com article discusses the steps involved in this process and ideas to consider along the way.
When building a healthcare simulation scenario or even a lab session in which learners will practice healthcare skills, one must always start from the end and work backward. What does the healthcare educator hope the learners will take away from the experience? What knowledge, skills, and attitudes are expected to be learned, practiced, or assessed in the session?
These questions will inform the educator and/or simulationist about what kinds of equipment may be needed. The detail is not yet obvious at this stage. This involves only a high-level pass at what the overall theme of the scenario or session will be. An example could include that, “the learner will develop the knowledge, skills, and attitudes (KSAs) to effectively manage intravenous fluid therapy.”
After the creation of a high-level basic learning outcome, the next step is to develop or identify approximately three specific outcomes related to the primary outcome. In the role of a simulationist, One may develop these learning outcomes for hospital staff attending patient simulation. In another role, they may receive the learning outcomes from the faculty developing the curriculum.
Either way, this step is necessary in order to determine the fidelity required. As an example, one of the three specific outcomes will be to successfully insert a peripheral IV catheter using evidenced-based standards of practice. The healthcare career learners are also expected to communicate effectively with the patient and build upon all of the previous KSAs they learned (such as hand washing, patient identification, safety, etc.).
How to Apply Objectives to Healthcare Simulation Equipment
Once determined that the learners will need to insert an intravenous catheter to accomplish the objective, they must next determine the best way to facilitate that. In this process, standards of practice, safety, and governing factors (such as policies and procedures) must be taken into consideration.
For example, does the facility routinely allow and encourage learners to practice on humans? What guidelines are in place to protect the health and safety of everyone involved? Is this the wisest method? In most instances the answer is no, however, a handful of programs find this acceptable. If allowed, this would be the highest level of fidelity.
One might additionally consider a high-fidelity human patient simulator. There are several on the market that has IV arms already attached. This method may appeal to the healthcare simulation educator as they can “hide” behind the scenes and allow the healthcare learners to engage with the simulated patient while performing the task.
The equipment available and how the effect on the performance of the skill must also be considered. Some patient simulators utilize rubber, like tubing in channels on the arm (one or both arms), and require a filled bag to create the positive pressure to mimic a venous flash into the cannula.
Some fidelity is lost at that point by both the fill bag presence and the feel of the rubber-like vein that may or may not be in the correct anatomic location under the silicone rubber skin. The arms on manikin not being very flexible which inhibit proper positioning should be a consideration as well.
Additional Options
Another option is to use a simple task trainer IV arm. There are several types and manufacturers available. Most utilize the same rubber-like tubing in a channel under the arm skin and require fill and drain bag system as described above. The fidelity or lack thereof is clearly understood in this case.
The method is appropriate if the learner is not expected to engage in an immersive patient interaction experience. This method would be extremely difficult to suspend disbelief with a voice coming from a body that is not connected to the arm. Therefore, the task trainer method is most appropriate when the skill is isolated and repetitive, and not necessarily when a scenario is needed.
A wearable task trainer is another option. Avkin makes one that works well for this. This device will allow a standardized patient, faculty member, or healthcare simulationist to wear the device. The device safely accepts the IV catheter insertion while allowing the learner to engage in simulated patient interaction.
This trainer has limited venous access site choices but they are anatomically correct and the feel of the veins is more realistic than the other task trainers or patient simulator veins mentioned above. The trainer also gives a reliable venous flash while the filled bag remains hidden from the learners.
Virtual Reality Options
There are several virtual and blended reality simulators available in recent years. These can be coupled with a task trainer that will provide feedback. One recognizable such device is a laparoscopy trainer. In this case the objective is usually to become accustomed to working with tools in a small space via a camera as one would within the human body. The feel of the actual organs is not immediately important for this objective. The orientation of left vs. right, and moving the instruments with accuracy is the main goal.
Blending Equipment: Code Blue Simulation
I recently conducted multiple cardio-pulmonary resuscitation scenarios with RN and PA students. I chose the Laerdal Resusci Anne QCPR manikin with a feedback device. In this scenario, the teams of learners were required to perform high-quality CPR with Advanced Cardiac Life Support. The feedback device was essential, and learners relied on the feedback to determine their effectiveness and clear improvement could be seen.
The PA learners were simultaneously expected to also intubate the patient using an endotracheal tube. The QCPR manikin offered the best fidelity and compression/ventilation feedback for the learners but did not offer the ability to intubate. In order to provide the best opportunity for the practice of intubation during a code, the learners continued to perform compressions on the QCPR manikin but an intubation torso task trainer was slipped into the bed beside the manikin.
The PA learners continued to communicate with the team about when to stop compressions for chord visualization or when there was a difficulty. The lack of scenario fidelity was more than made up by the ability of the team to practice all of the skills well side by side. Defibrillation was accomplished using ShockLink by Laerdal which enabled various rhythms to be displayed on a real defibrillator.
The patient started in an unresponsive state so there was no patient voice needed in this scenario. Feedback from learners and faculty was overwhelmingly positive. Improvement was readily evident as the scenario was repeated and learners switched roles. No one was bothered by the use of two torsos in the patient’s bed, and they appreciated the anatomic fidelity and feedback.
Consider the Cost
Addressing the outcomes when creating a scenario or laboratory session is vital. As the educator or simulationist, these individuals must work to ensure that the equipment available best meets this need. One must also consider cost, wear and tear, and reliability.
High-fidelity patient simulators are expensive. Many facilities do not have the budgets to purchase or replace this type of equipment regularly. Many simulators have “died” under the hands of well-performing compressors during CPR. Most of the high-fidelity full-body patient simulators on the market, while advertised as having the ability, are not durable enough to withstand the rubbing and compressing of eager and nervous learners for very long before the wires and internal mechanisms wear out.
When thinking about task trainers versus high fidelity patient simulators, consider the goal. How important is anatomic fidelity? While IV arm task trainers are much less costly, if it is important for learners to engage with a “patient” while performing the skill, consider a mid-fidelity option such as that offered by Avkin.
The same holds true for skills such as endotracheal intubation, nasogastric tube insertion, and many other skills. Beginning with the end in mind will help inform a decision on the most appropriate and most cost-effective equipment to meet the healthcare simulation need.
Disclaimer: Views expressed here are solely those of the author and do not represent those of any employer or organization.
