Effectiveness of Human Simulation Training for Medical Crisis Management Skills

The use of Medical Emergency Teams (METS) for handling in-hospital medical crisis decreases mortality and improves patient safety. Adverse in-hospital events occur in about 4-17% of hospital admissions. Of these, 70% are thought to be preventable. The most serious adverse in-hospital event is unexpected cardiac arrest which carries a mortality rate of 50-80% [1]. One approach to reducing this adverse event is the use of METS. Unlike traditional cardiopulmonary resuscitation teams, which respond to cardiac arrests, METS respond to medical crises early on and aim to prevent the progression of problems into unstable situations. The implementation of METS have been found to decrease the number of unexpected cardiac arrests, intensive care unit transfers and in-hospital mortality [1]. Bellomo et al. further found that the implementation of a MET not only decreases hospital mortality but also decreases incidence of post-operative complications [2]. As an integral part of the MET, a critical care physician must have the communication and leadership skills to effectively manage the team, the cognitive skills to adequately assess/judge the situation and guide plan of actions, and the psychomotor skills to perform necessary procedures.

Existing methods for teaching medical crisis management are inadequate. The instruction of medical trainees in the management of acute medical crisis is often done through didactic teaching, problem based learning, and apprenticeship. It is not uncommon for a trainee's first experience managing medical crisis to be on a real patient who is experiencing a real medical crisis with significant consequences. This form of training is limited and clearly sub-optimal for many reasons. Didactic training and problem based learning may be useful in instilling medical knowledge but is often inadequate in teaching the communication skills and critical thinking that is involved in managing medical crises. Further, the urgency and complexity of medical crisis is not well understood without first-hand experience. In general, although medical crises are relatively common, trainees get limited opportunities for the repetition required to hone their management skills. Some medical crises, such as respiratory distress with difficult airway, are extremely rare and will not often be experienced by most trainees. Moreover, when they do occur, trainees may not have enough supervision and hence do not receive appropriate feedback. Thirdly, clinical apprenticeship does not provide for standardization of training and feedback for the trainees. Lastly, most trainees are not allowed to view the consequences of the errors made while managing medical crises as most supervisors will intervene to prevent patient injury or harm [3-6].

HST can be used as an educational tool for teaching medical crisis management. Simulation training has been used in other fields, such as aviation and the military, to train people to do complex tasks with potentially dangerous consequences [7-13]. A curriculum using HST may be a useful at surpassing some of the limitations of traditional training noted above[14]. The full body human simulator such as Laerdal's Sim Man, can be programmed to present a wide range of physiologic conditions and physical exam findings. Using this human simulator, a wide variety of medical crises can be programmed to recreate real-life situations. The human simulator also allows the re-creation of clinically important but rare situations. The human simulator will also allow trainees to manage medical crises repetitively until a satisfactory level of proficiency can be reached.

Most importantly, HST allows trainees to repetitively experience dangerous situations and practice their crisis management skills. Trainees can now benefit by seeing their management errors run their course without placing patients at risk. HST allows for providing immediate feedback. This technology is portable and hence allows for trainees from various institutions within a particular region to have standardized training and feedback. The 1999 Institute of Medicine Report, "To Err is Human," challenged the medical community to confront the issue of medical error. One innovative approach that was mentioned for performance improvement and healthcare training was the use of human simulators [15].

Human Simulators are a valuable and valid performance evaluation tool. Human simulators have long been used in the field of medicine for evaluation. In particular, the field of anesthesia has taken the lead in terms of using advanced full body simulators for resident and physician training and evaluation. Instructors in the field of anesthesia have used human simulators to re-create dangerous and complex intra-operative crises to help their trainees acquire, test, and practice skills of crisis resource management without placing patients at risk [16-18]. By using evaluation techniques such as videotaped review and checklists, anesthesia instructors have been able to assess the behavioral and technical performances of trainees[18-21].