Respiratory therapy departments and academic programs continue to expand the use of simulation devices, like manikins, in order to strengthen patient care.

By Phyllis Hanlon

Simulation manikin

In the early 1960s, cardiopulmonary resuscitation (CPR) programs incorporated the use of Resusci-Anne to provide hands-on training in reviving someone whose heart had stopped beating. In the ensuing years, nursing programs, anesthesiologists, respiratory care departments, and other medical professionals have found value in using manikins to perfect procedures and teach patient care without endangering human lives.

Today, technology has brought these inanimate human replicas to “life,” and training programs across the country are adopting the use of simulators/manikins to enrich the educational experience, create a strong clinical foundation, and enhance professional confidence.

Types of Simulators

Dara Legacy, MS, RRT, RCT, program director of respiratory care at Orange Coast College in Costa Mesa, Calif, will be the first to admit how lucky her program is. She works in a “Human Simulation Lab,” equipped with three simulators, which enable her to recreate a wide variety of clinical scenarios for the first- and second-year level students she teaches.

Legacy’s program uses METI simulation, by CAE Healthcare, which has been customized according to specifications from the school. “METI incorporates specific features to mimic a patient in the ICU,” she said.

The program’s star attraction is “Big Kevin,” a lifelike simulator tethered to the wall that runs on carbon dioxide, nitrogen, and oxygen piped in from exterior tanks. He is housed in a room that resembles an intensive care unit. A crash cart set up next to the bed enables students to practice advanced life support techniques. The program also has a portable model and an infant, “Baby Hoagie.” The simulators breathe, have heart and lung sounds, talk, blink, and wheeze, and can be programmed for a variety of medical conditions. “One has nail beds and lips that go cyanotic,” Legacy pointed out.

Lectures take place on Wednesday with lab on Friday, which gives students time to digest the classroom instruction. Depending on the lesson for the week, students might have to practice ventilation management, monitor heart rate rhythm, insert arterial lines, or measure pulmonary and cardiac pressure and saturation, according to Legacy.

The MUSE software system allows Legacy to design and deliver different case scenarios to the simulator via computer. “The program comes with generic cases, like a gunshot victim, an alcoholic, someone with COPD. You can build your own case scenarios and name them what you want,” Legacy noted. “We use pulmonary fibrosis and have built-in pathology. Sometimes I combine cases, based on lectures. Students need to know all the problems, even if they are not common to that geographic area. Students have to use critical thinking skills.”

Real-Life Scenarios

During the hands-on application, students are expected to determine how to treat the patient as if they are in an actual clinical setting.

“The student sees the monitor with heart and respiration rates and blood pressure, but can’t see what I’m doing. These monitors are in real time, and the students have to get used to reading them to choose the proper treatment,” Legacy said. “For instance, the simulator might need to be intubated. The student might have to connect him to a vent and witness him getting return volume. Then they have to manipulate to get the right blood gases.”

Working with groups of one to three students, Legacy provides scenarios that test students’ classroom knowledge. “I might tell them they just got a call from the ER, which has a critical trauma patient. The students have to do an assessment, figure out what modality to use, and do it in the proper order,” she said.

In one of the exercises, Legacy asked the students to put the portable simulator on a transport ventilator with all the necessary supplies and wheel him across the campus. “I had him crash, go into Code Blue. The students hadn’t put the right supplies on the cart so the patient ‘died.’ This teaches them that they have to treat the patient properly or they will die,” she said.

In another situation, a patient may be on a ventilator, but experiencing a problem. The student has to change the mode so the patient responds, Legacy explained. Or the patient could be getting better and needs to be weaned off the ventilator, she added. “The student needs to call the physician for orders and then act appropriately.”

Student and Patient Benefits

Johns Hopkins opened its Medicine Simulation Center in March 2008 and began using simulation during its annual staff training days for respiratory care in January 2009. Julie S. Perretta, MSEd, RRT-NPS, CHSE, manager of the Manikin & Procedural Skills Program and lead simulation educator at Johns Hopkins, emphasizes that incorporating simulation as a learning strategy makes good sense.

“It decreases the risk of harm to patients as a by-product of training. It shortens the learning curve and gives learners permission to make mistakes and then learn from their errors,” she said. “It also gives the same learner multiple opportunities to practice until he or she achieves mastery of a skill or process, and it can standardize training and orientation in a way that’s virtually impossible when using a traditional clinical training model.”

In some cases, simulation—in conjunction with reading materials and online learning modules—can replace much of the didactic education. “If necessary, it can also augment or even replace less effective clinical rotations, such as when there are not enough neonatal clinical sites, or students are not allowed to be involved in high-acuity or low-volume patient populations,” Perretta added.

Moreover, a simulation program can teach 60-plus residents the proper technique for placing a central line in one afternoon, a task that would take weeks in a clinical environment, according to Perretta. She added that the ability to both standardize and vary a manikin’s behavior helps to hone a student’s skills.

“I can program a manikin to behave the exact same way for all 130 of my respiratory therapists, so we are consistently and reliably providing the same experience and validating skills under the same circumstances,” she explained. “But I can also increase or decrease the patient’s complexity during lower-stakes simulation experiences, so that people are not functioning outside of their comfort zone, known as the zone of proximal development, which has been shown to make it difficult—if not impossible—to learn and master new knowledge and skills.”

Perretta noted that simulation serves multiple purposes from teaching new healthcare providers new procedures/skills and assessing the quality of learning to validating skills before graduation and training for low-volume, high-risk patient events. Additionally, simulation facilitates interdisciplinary team training and usability testing of new equipment, documentation systems, and protocols before hospital-wide release. New techniques can be researched safely through simulation and can be an integral part of the investigation or root-cause analysis of adverse patient events, she pointed out.

Multisensory Experience

Ed Dellert, senior vice president of Clinical Education, Informatics and Research with the American College of Chest Physicians (ACCP), pointed out that advanced technology drives home engagement with the educational process. He pointed out that, during the last 5 years, schools have had to rethink their curricula, realizing the necessity of incorporating simulation into their programs to attract the top students.

A majority of today’s students have spent years engaged in a variety of game systems that provide a multisensory experience, Dellert explained. “These residents and fellows in training are learning bronchoscopy [and other techniques] and are transferring these experiences into more serious activities. They are using devices with the same techniques. This is a form of simulation,” he said.

Since simulators can replicate rare events, they provide an opportunity for practitioners to enhance and update seldom used skills. “A practitioner may see a certain situation only once, but simulation can make this a valuable experience,” said Dellert. “It’s a good practice to reinforce these skills periodically.” Patients will have the benefit of knowing that the healthcare professionals who treat them have the most updated training, he added.

Programs usually work together with manufacturers to create specialized simulators that fit their particular needs, creating a clinical pathway, said Dellert. “The manufacturers reach out to simulation programs for scenario development. For instance, if a situation involves a 60-year-old Caucasian male who was a smoker, the simulator should be able to monitor oxygen levels during a procedure. By creating a pathway in response to a scenario, you can determine what capabilities the simulator should have,” he noted. “The more lifelike it is, the more ideal it is. You try to figure out how to make things come to life in clinical practice.”

Evaluation Tools

Unlike other programs that use simulators as an adjunct to classroom teaching, the joint program at East Los Angeles College and Santa Monica College uses simulation as an evaluation tool, according to Salvador Santana, director of clinical education at East Los Angeles College. The simulators help to educate students about low-frequency/high-risk inpatient procedures. “We use simulators for noninvasive ventilation, BiPAP simulation, and nasal tracheal suctioning,” he said. “Simulation helps to increase competency.”

Santana explained that the 50 students in his program complete a 3-hour practice run with the simulator and then return in 7 days to take a 30- to 40-minute test. “The students want to see test results. The simulators assess their level of competence,” he noted.

Since East LA College is short on space, Santana’s program borrows simulators from the school’s nursing program, which has SimMan, manufactured by Laerdal Medical, and the Hal Tetherless Patient simulator, by Gaumard Scientific. Santana’s program currently uses the simulators sparingly due to required clinical practice hours, but hopes to make some changes. “In the future, we are considering the use of simulators in lieu of clinical hours,” he said.

Specialty Simulators

Several manufacturers offer different types of simulators that address unique needs and are designed for use in specialty situations. At Johns Hopkins, Perretta tries to incorporate simulators that have the characteristics necessary to teach patient assessment, decision-making, psychomotor, and teamwork skills that a healthcare professional will need to function in a high-acuity, fast-paced environment. “We incorporate partial task, or skills, trainers, full body patient simulators, virtual reality simulators, computer-based simulations, standardized patients, and teaching associates,” she said, noting that the last two are “real humans.”

Rebekah Cavanaugh, Global Product Manager, Patient Monitoring at Covidien, explained that certain systems are used primarily in the operating room as well as in intensive care units. She said Covidien’s “BIS Titration SimulatOR was developed as a creative learning exercise for anesthesia professionals to explore BIS-guided anesthesia titration during an animate simulation of surgery procedure. The BIS SimulatOR is designed to provide the user with the ability to increase their technological proficiency with the BIS brain monitoring platform in a safe, virtual environment.”

This program becomes interactive when downloaded to a computer. Data provided by the simulator reflect the user’s activity, whether intubating the patient, adjusting anesthetic levels, or performing some other function, according to Cavanaugh. The simulator issues information on goals and desired ranges and components to assist the user as he navigates through the simulated case.

Clinical Teaching Tools

Simulators used in training programs and at schools typically teach students how to intubate, monitor vital signs, and place a central line. However, Joel M. Brown II, RRT, FAARC, clinical manager, Christiana Care Health System in Newark, Del, indicated that respiratory care professionals working in a clinical setting want to derive efficient ways to apply procedures in pulmonary situations. Achieving this goal sometimes poses a challenge, since many simulators fall short in accurately replicating lung function. “For pulmonary mechanics, you need to modify the simulator to your particular population. We want to see graphics on the vent and know what they mean and how to make adjustments,” he said.

Brown noted that Christiana Care also uses CAE Healthcare’s Meti Human Patient Simulator and Laerdal’s SimMan. To evaluate lung function, he adds the high fidelity ASL 5000 Breathing Simulator from IngMar Medical, which closely mimics the human lung and its functions; he noted, though, that controlling two machines can be challenging. “It’s the standard test lung we use in the lab. Lungs in simulators alone can only go so far with regard to realism,” he said. “Most therapists who do simulation for clinical reasons usually modify the lung to look real.” Although the ASL5000 serves as a good test lung that replicates neonatal and adult respiratory situations, including coughs, exhalation, and apnea sounds, it does have one drawback. Brown said, “It’s a box. So you lose the high-fidelity response of seeing a patient. There is no emotional response.”

At Christiana Care, a centralized laboratory allows respiratory care therapists to become involved with other departments within the hospital. “We are integrated with everyone else. It’s a multidisciplinary effort. We don’t operate in a silo,” Brown said. “You lose the ability to learn from others when you are not centralized. Respiratory therapists maintain a relationship with the staff in the simulation lab.”

Brown added that the 130 respiratory therapists at Christiana Care find using simulation is the ideal way to improve clinical confidence while not endangering patients.

Prepurchase Checklist

David M. LaCombe, Americas Regional Portfolio Director, Emergency Care, Laerdal Medical, emphasized that hospitals should develop a clear understanding of the desired performance before investing in any educational intervention, including simulation. Given the hefty price tag—simulators can range from a few thousand dollars to more than $100,0000, depending on technology and options—getting buy-in from administrators and other stakeholders is critical.

“Hospitals seeking to integrate simulation into training should make an analysis of their institution’s education and implementation infrastructure and culture,” he said. “A CEO or COO contributes to the decision-making and should answer some questions. Who will operate the simulator? Do they have the time? Do they know what the hospital wants? Do they have the authority to engage others? You have to have follow-through to get value out of the purchase.”

Programs should be aware that, although the simulator market is not regulated, government users, such as the military and Department of Veteran Affairs, issue precise requests for proposal, which drive the marketplace to respond to meet the government’s needs, according to LaCombe. “Simulation manufacturers test their own simulators to ensure the products meet the user and technical requirements. Manufacturers often use marketplace clinical and educational subject matter experts to validate the quality and functionality prior to release,” he added. “Private organizations, such as the Society for Simulation in Healthcare and the American Society of Anesthesiologists, develop standards on accreditation of simulation centers and certification of simulation instructors.”

In many cases, manufacturers provide training and customer education and support. Major manufacturers offer warranties that include preventative maintenance, loaners, and service, according to LaCombe. He pointed out that software platforms may have to be updated from time to time and that life expectancy varies, depending on usage. For instance, programs that perform frequent invasive procedures, such as IV chest tube insertions, may have to replace the simulator skin more often. “High-end users, like the military, make the investment up-front and get replacement skin as part of the original package,” he added.

Training programs, schools, and clinical departments that have incorporated simulation into their educational curricula and professional development initiatives unanimously recommend the practice. Legacy has seen firsthand the benefits of using simulators at Orange Coast College and wholeheartedly endorses the practice. “I notice a difference between students in my program and those from other schools without simulation,” she said. “My students are very comfortable treating real patients.” RT

Phyllis Hanlon is a contributing writer for RT. For further information, contact [email protected]