Students from UAB's schools of Nursing, Medicine, Health Professions and the College of Arts and Sciences practice teamwork and the complex communication required in high-pressure care environments in an extended ICU simulation. (Photo by Charles Prince.) Students from UAB's schools of Nursing, Medicine, Health Professions and the College of Arts and Sciences practice teamwork and the complex communication required in high-pressure care environments in an extended ICU simulation. (Photo by Charles Prince.)

Ever ready: Simulation accelerates learning, innovation across UAB's health enterprise

September 29, 2015
By Matt Windsor
From training for rare emergencies to improving interprofessional education and advancing research, simulation is playing a growing role at UAB.

When a patient with Ebola-like symptoms arrived at UAB Hospital’s emergency department in early August 2015, a trained team was waiting. It didn’t matter that UAB had never admitted an Ebola patient before, or that none of the staff had treated anyone with the highly infectious disease. After an estimated 2,500 hours of training, the hospital’s 60-person response team had rehearsed every step, from the most effective layering of personal protective equipment to the fastest route between the ambulance bay and the dedicated treatment room in the emergency department.

The training began soon after the first confirmed Ebola case in the United States in October 2014. Hands-on exercises quickly revealed ways to improve on published protocols. “You could see, ‘that’s not going to work,’” said Marjorie Lee White, M.D., vice president for Clinical Simulation in the UAB Health System and director of UAB’s Office of Interprofessional Simulation for Innovative Clinical Practice (OIPS). “You can’t send in an X-ray technician, or a lab tech or dietetics, when the patient is quarantined, so we had to teach the team members all of those additional patient care tasks. We were able to adapt our patient care protocols based on our simulations in a really rapid cycle.”

The August patient turned out to have malaria, not Ebola. But UAB clinicians were ready for that as well. The hospital’s Ebola team has now been re-formed as the all-purpose Rapid Infectious Outbreak Team.

Simulation - nursing studentsNursing students participate in an OB/GYN Clerkship simulation. Photo by Brian Mezzell.

Interprofessional expertise

Like airlines and nuclear power plant operators before them, major academic medical centers such as UAB are embracing the power of simulation — using constant practice to reduce common errors, and prepare for events that staff rarely see. Simulation expertise “is becoming a necessity,” said Will Ferniany, Ph.D., CEO of the UAB Health System. “If we’re going to be a state-of-the-art university and health system, we need to have these facilities for training our students and staff.”

That’s why the OIPS was formed, in 2014. White, a pediatric emergency physician who has been involved in simulation for more than a decade, acts as quarterback of UAB’s widespread simulation enterprise, which trains everyone from undergraduate nursing majors to specialty units such as UAB’s OB/GYN surgery teams. Over the past six years, “we have embedded an interprofessional simulation experience in every year of medical school, and every semester of the BSN program in the School of Nursing,” White said.

At the UAB Center for Patient Safety and Advanced Medical Simulation in Quarterback Tower and the UAB School of Medicine Simulation Sandbox, interprofessional simulations have involved students from the schools of Health Professions, Nursing and Medicine, as well as social work students from the College of Arts and Sciences. Students from the School of Dentistry and School of Optometry have also participated in simulation experiences designed for them, White notes.

From July 2014-June 2015, the UAB Office of Interprofessional Simulation for Innovative Clinical Practice facilitated 474 events with more than 7,500 participants, for a total of 87,155 simulation hours.

Enhancing communication

In one large training exercise, “we turn the sim center [in Quarterback Tower] back into the medical ICU that it once was,” said Chad Epps, M.D., associate director of the OIPS and director of Simulation in the School of Health Professions. “We bring in students from all these different professions and they run a two-hour shift, just like a real unit.” The simulation includes six advanced “high-fidelity” robotic mannequins playing the parts of patients with a range of complications, along with a host of faculty and staff in other roles, including grieving family members.

“The students find that very beneficial,” Epps said. “They learn a lot about each other, and what each profession does and doesn’t do.” Afterward, the OIPS staff lead a debriefing for all the learners, followed by discipline-specific debriefings. The response from students is always the same, said Jacqueline Moss, Ph.D., R.N., professor and assistant dean for Clinical Simulation and Technology at the School of Nursing: “They like simulation, and they want more of it.”

Moss recently received an Innovation and Development Award from UAB’s Center for Teaching and Learning to test a new approach to simulation education. “We’re going to be teaching medical students and nursing students how to give feedback on performance during a simulation in a direct, honest, nonthreatening way,” Moss said. “We’re going to see if that really changes the quality of their communication with one another.”

Ongoing communication training is also vital to experienced staff, explains John B. Woods, M.D., assistant professor in the Department of Obstetrics and Gynecology and director of OB/GYN Simulation. “Communication errors are one of the biggest reasons for adverse events, so it’s important that we practice communication skills as a team,” Woods said. “Using ‘in situ’ simulations conducted in the team’s own space, we’re able to test a lot of the processes associated with rare obstetric emergencies in the actual practice environment.”

Using multiple modalities for education

Health education programs across UAB are making increased use of multiple forms of simulation, Epps says. For example, students in the School of Health Professions’ physician assistant program do weekly simulation training during the fall of their second year, where they practice clinical scenarios but also focus on “nontechnical” skills such as communication and working effectively in a crisis situation. Meanwhile, students in the school’s genetic counseling program train with “standardized patients” — actors who help the students practice interview skills and the tough work of breaking difficult news to families.

The OIPS conducts regular training sessions, and has established a partnership with the internationally renowned Center for Medical Simulation (CMS) at Harvard University. In August, 21 faculty and staff members participated in a weeklong interprofessional simulation instructor training course at UAB taught by CMS faculty — the second time the Harvard group has led the course at UAB. The participants “are now experts in the use of clinical simulation as a teaching tool,” White said.

 Faculty and staff learn to implement simulation in their own classes in regular Facilitator Development Courses led by the OIPS. <i>Photo by Charles Prince.</i>Faculty and staff learn to implement simulation in their own classes in regular Facilitator Development Courses led by the OIPS. Photo by Charles Prince.

Simulation research 

The OIPS also is engaged in numerous research studies to validate the effectiveness of simulation training. “The existing research shows that practice, and perfect practice, makes for better patient outcomes,” White said. What is less clear is the ideal dose of simulation training. “How often should you practice inserting a central line, or CPR — or responding to a rare type of emergency?”

The OIPS is examining these questions, White notes. She and other UAB faculty are also participating in numerous multicenter trials as part of an international network of simulation experts. These include studies examining the effectiveness of CPR in a simulated setting and the relative merits of two mass-casualty triage systems.

Moss points out that simulation can be used to aid research as well. She recently completed a study that used the School of Nursing’s simulation lab to evaluate different experimental decision-support tools to help nurses in administering medications. “The participants went through a simulation where they used the systems, and we saw how the decision support influenced their medication administration practices,” Moss said.

Simulation’s future

Moss is also interested in bringing simulation to an even wider population. “Experiential learning has become a gold standard in educating clinicians,” she said. “The question now is ‘How can we transfer that knowledge to educating patients?’” Simulation could be an ideal tool to help the millions of Americans who have chronic conditions that require specialized care. “There is going to be more and more need for informal caregivers who have the skills to care for chronic conditions in the home,” Moss said. “We’ve shown that simulation is a good way to train health students; I’d like to see how it works with patients and families.”

“I believe there is a huge future for simulation” in all aspects of health care, added Ferniany, the Health System CEO. He points out that simulation offers an ideal avenue for “onboarding” new employees. “Every hospital has a way it does things: the way we deal with central line catheters, for instance, or how we do checklists in our ORs,” he said. “I think we can use simulation to bring our nurses up to speed more quickly, and ensure a consistent experience as our health system expands.”

Ferniany would eventually like to build a dedicated simulation facility. This “Blazer Hospital” would be a hub for simulation on campus and also serve as a training site for smaller hospitals in the region, he said. “These facilities can’t afford to develop the simulation expertise and equipment we have,” Ferniany explained. “We can take our simulation programs out to them, and we can bring them here to train as well.”

Simulation for innovation

Simulation can be a vehicle for testing potentially revolutionary new ideas, points out Rubin Pillay, M.D., Ph.D., assistant dean for Global Health in the UAB School of Medicine and professor of healthcare innovation and entrepreneurship at the UAB Collat School of Business. “Medicine is an evidence-based profession,” he noted. “I can’t go into the ER and start tweaking things just to see what happens. But the way health care is going, you have to be innovative just to survive. And innovation, by its very nature, is all about doing something that’s never been done before.”

That’s why Pillay is developing a “design and simulation lab” as part of the proposed UAB Center for Healthcare Innovation, “a place where anybody can feel free to come in and try out new ideas,” he explained. The approach has been pioneered by the Mayo Clinic and Kaiser Permanente, Pillay says. A nurse could use computer simulations to model a new approach to scheduling surgeries in UAB’s operating rooms, for example. Engineers and entrepreneurs could come together to test smartphone-based monitoring systems for patients. Entire medical teams could practice a new workflow in a replica patient room, without interrupting standard care.

“Not everything will work,” Pillay said. “But it’s just like the tech industry — the idea is to fail fast, cheap and forward. That’s how you learn.”