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Simulation in cardiac critical care

Simulation in cardiac critical care Abstract Medical simulation is a broad topic but at its core is defined as any effort to realistically reproduce a clinical procedure, team, or situation. Its goal is to allow risk-free practice-until-perfect, and in doing so, augment performance, efficiency, and safety. In medicine, even complex clinical situations can be dissected into reproducible parts that may be repeated and mastered, and these iterative improvements can add up to major gains. With our modern cardiac intensive care units treating a growing number of medically complex patients, the need for well-trained personnel, streamlined care pathways, and quality teamwork is imperative for improved patient outcomes. Simulation is therefore a potentially life-saving tool relevant to anyone working in cardiac intensive care. Accordingly, we believe that simulation is a priority for cardiac intensive care, not just a luxury. We offer the following primer on simulation in the cardiac intensive care environment. Simulation, Cardiac intensive care, Medical education, Process improvement, Quality improvement Introduction: what is simulation, and why does it matter Medical simulation is a broad topic but at its core is defined as any effort to realistically reproduce a clinical procedure, team, or situation.1 Its goal is to allow risk-free practice-until-perfect, and in doing so, augment performance, efficiency, and safety. In medicine, even complex clinical situations can be dissected into reproducible parts that may be repeated and mastered, and these iterative improvements can add up to major gains.2 With our modern cardiac intensive care units (CICUs) treating a growing number of medically complex patients, the need for well-trained personnel, streamlined care pathways, and quality teamwork is imperative for improved patient outcomes. Simulation is therefore a potentially life-saving tool relevant to anyone working in cardiac intensive care. Accordingly, we believe that simulation is a priority for cardiac intensive care, not just a luxury. Simulation offers unique education and training for all learners regardless of whether they are novices, unfamiliar team members, or seasoned veterans. Leaning heavily on theories of experiential learning, simulation allows for a cycle of experiencing, reflecting, thinking, and performing.3 This supplements traditional didactic instruction well by fostering an active and immersive learning environment. It promotes debriefing, which provides a broader understanding of why, how, and where errors occur. The iterative journey from novice can thus occur without risk to patient or practitioner. Simulation design ranges in fidelity from table-top planning, to task trainers, to mannequin-based, to full virtual reality. With a wide variety of clinical vignettes, simulation avoids reliance upon random patient presentation. Well-crafted simulations can address each key healthcare level: the individual, the team, and the system. Simulation can also be a strategy to attract and retain the best practitioners and to reassure patients and families. Accordingly, simulation (the science) and simulators (the devices) and simulation rooms (the location) have been described as an ‘educational revolution’, ‘an ethical imperative’, ‘a key driver of culture change’, and ‘our best patient safety laboratory’.4 With the amalgamation of increased patient complexity, the multifaceted nature of our care teams, the intricacies of health equipment and systems, and the overall less forgiveness of medical error, simulation is increasingly used worldwide as an educational and process improvement tool. We offer the following primer on simulation in the cardiac critical care environment. Why practitioners need, and patients deserve, simulation in cardiac intensive care Coronary care units (CCUs) were first formed in the 1960s in efforts to reduce premature cardiovascular death and disability in patients. This goal has remained the same over the decades. What has dramatically changed is the landscape surrounding CCUs, with greater patient, team, and system complexity, and even greater intolerance of bad outcomes. In its infancy, cardiac treatment was less invasive and centred on bed rest, passive monitoring, gentle mobilization, and gradual recovery. The introduction of thrombolysis and percutaneous angiography revolutionized cardiac care. These innovations have allowed us to have a greater emphasis on prehospital care, rapid triage, early intervention, and complex care pathways.5 Because of these advances, a greater number of patients have been saved from premature death and now present to the CCU with complex acute-on-chronic conditions. Moreover, CCUs now regularly serve as a connection point—or stabilization unit—for patients requiring a myriad of therapies including cardiac catheterization, electrophysiology intervention, organ transplantation, cardiac surgery, and extracorporeal support (see Figure 1).6 These changes necessitated that CCUs morph into CICUs that are increasingly resembling general systems intensive care units. As patient care needs evolve, so does the need for highly skilled personnel, streamlined care pathways, and a multidisciplinary framework where individuals can maximize use of their skills while working together in a larger team. Formation and implementation of such complex care units require both additional training and continuing education to maintain functional teams that often face high-acuity low-occurrence (HALO) events. Furthermore, as we embrace the best new therapies to improve patient outcomes, we also need to embrace the latest and greatest in education theory and team psychology to ensure patient safety. In short, CICUs are among the most complex and perilous environments in medicine; they ought to have education to match. Simulation is ideally suited to address these goals. The evidence behind simulation Simulation is a scientific discipline and should be subject to rigorous study and open to challenge. No controlled study has shown that simulators and simulation definitively saves lives. However, there are numerous associations with better surrogate outcomes, greater practitioner satisfaction, and greater efficiency, with no substantial disadvantage aside from cost and time. While these associations are not the same as empiric evidence, other industries have not demanded definitive proof and have mandated regular simulation at all levels—most notably the aviation industry. Similarly, for the military and police, simulation is so well accepted that it has become a part of regular training and paid work. While a comprehensive simulation review is beyond the scope of this article, we now highlight relevant, and translatable, examples. Simulation in non-medical fields: military and civil aviation Simulation is entrenched in the high-stakes environment of aviation. The first pilot trainer was developed in the 1920s and allowed pilots to simulate flying with instruments. These task trainers replicated cockpit controls and, although physically grounded, would pitch and roll in response to the pilot’s actions. By the Second World War, the attentional demands on pilots had increased. This led to more complex simulations, including disaster scenarios, so that pilots could practice their responses to both common and uncommon high-risk events.7 Flight simulation is now mandatory in modern aviation training and certification. It is used both for solo training with task trainers and for practice of teamwork between co-pilots, something that is difficult, dangerous, and costly to otherwise train. Importantly, simulation has also been associated with improved flight safety.8,9 Simulation in medical equipment design Simulation is also regularly used by medical equipment companies to test a device’s mechanical properties and response to failure. In one study, insulin pump models were recreated in Matlab Simscape, allowing for examination of the pumps’ mechanical forces, internal pressures, and fluid dynamics. Failure modes, such as infusion site occlusions, were simulated to test the model’s reliability in detecting failure, and how this affected the overall system.10 Simulation in other medical fields Simulation has been widely used for training in anaesthesiology, paediatrics, emergency medicine, trauma, and obstetrics. Anaesthesiology, in particular, has been simulation’s greatest medical proponent. This was led by Dr David Gaba, who created Simulation-Based Training in Anesthesia Crisis Resource Management (ACRM). The ACRM curriculum, used across the United States and Canada, incorporated simulated acute events, followed by detailed structured video-assisted debriefs.11 Anaesthesiology simulation has also included fibre-optic intubations, echocardiography, bronchoscopy, and front-of-neck cricothyroidotomies.12 Growing evidence suggests that anaesthesiology simulation is associated with improvement in non-technical skills, such as decision-making, efficiency, guideline adherence, leadership, followership, teamwork, and less equipment misuse.13 Regarding common critical care procedures and presentations, central venous catheter insertion simulation is associated with increased skill mastery and performance comfort, and fewer procedural complications.14 High-fidelity simulation has also been associated with greater acquisition and retention of skills needed to initiate extracorporeal cardiopulmonary resuscitation (ECPR) following out-of-hospital cardiac arrests.15 High-fidelity trauma simulations have been associated with improvement in many domains of the Trauma Team Performance Observation Tool. Improvements were noted in leadership, situation monitoring, communication, and mutual support, as well as quicker transport time to the operating room.16 Fortunately, these examples (and those below) could be repurposed to CICUs with minimal delay. With resident education moving towards competency-based education, simulation provides an opportunity to master skills in a safe environment,17 and a move away from the ‘trial-and-error’ or the ‘see one, do one, teach one’ method. Simulation in cardiology: cardiac arrest simulation One of the earliest examples of cardiac arrest simulation was the Resusci Annie doll, which was modelled after the drowning death of a young woman in Paris’ Seine River.18 This doll allowed an individual or team to talk through resuscitation steps and to crudely demonstrate compressions on a soft sternum. There are now compression simulators with mechanics closer to those of humans, such as the Ambu® Man Wireless. There are also affordable devices that can simulate different vital signs and cardiac rhythms, some of which can also be used to teach pacing and defibrillation steps.19 These devices can be controlled by a facilitator who can prompt real-time changes in cardiac rhythms or vital signs based on a trainees’ actions. Similarly, the ZOLL® X monitor contains an accelerometer, and gives real-time feedback on the rate and depth of chest compressions.20 There are also team-based courses, such as the Acute Critical Events Simulation course which includes scenarios with patients pending or in full cardiac arrest. The goal of this course is to address manual skills alongside non-technical skills and crisis resource management (CRM) principles21 including teamwork, leadership, resource use and allocation, and communication. These can then be evaluated using validated CRM rating systems and checklists.22 Simulation for new processes, policies, and devices It is common sense to perform trial runs on any new addition to a complex perilous system. Simulation is an ideal tool for this because it offers realism without risk. This was evident during the COVID-19 pandemic when performing aerosolizing generating medical procedures such as endotracheal intubations became dangerous because of the risk of infection transmission. Simulation studies helped to streamline and more quickly mobilize intubation teams, resulting in increased personnel safety.17,23 Another study highlighted how delayed intubation of COVID-19 patients, compared with early intubation, actually resulted in greater healthcare personnel contamination.24 Simulation has also shown that not every innovation is beneficial, regardless of how well intentioned. For example, COVID intubation boxes were assumed to decrease transmission risk but were rejected once simulation studies showed they were associated with time delays and inadequate visibility.25 Thus simulation use has helped to identify risks and weaknesses of new ideas while also fine-tuning procedures and policies, likely resulting in cost savings and increased patient and personnel safety. Simulation to improve research and examine disease states Simulation is more than an educational or process improvement tool; it even offers improvements in the design, enrolment, and execution of complex Phase 3 clinical research trials. After all, simulation can facilitate ‘dry runs,’ role playing, analysis of videos, and ‘what-if’ discussions. This could decrease protocol violations, which may threaten data validity. Simulated interviews with actors might help with obtaining informed consent and thereby boost study enrolment. Full-body mannequins might be used to confirm that teams can coordinate multiple complex steps. Overall, the goal of simulation in clinical trials is to maximize realism while minimizing logistics and cost, to increase the accuracy of study data, and to minimize waste.26 Another study used simulation to examine the interactions of various disease states, including left systolic failure, left diastolic failure, and mitral and aortic stenosis and regurgitation, with a variety of continuous-flow mechanical circulatory support (MCS) devices. Using MATLAB, mathematical models were created to simulate these disease states and track blood flow, pressure, and volume through the MCS devices. These simulations were validated against clinical results.27 Figure 1 Open in new tabDownload slide The modern cardiac intensive care unit as a connection hub between many cardiovascular science services. The goals of simulation in cardiac critical care Given the aforementioned examples of how simulation is currently being used, the goals of simulation in the cardiac intensive care setting are broadly described in Table 1. Table 1 Goals of simulation in cardiac critical care Goal . Comments . Individual education Mastery of procedural skills, such as central line placement, intravenous or intraosseous vascular access, airway management Safe environment for experiential learning Team education Improvement in crisis resource management skills including teamwork, leadership, resource use and allocation, communication Process improvement Trial new care algorithms or introduce new technology in a safe and cost-effective manner Identify process issues and latent hazards Quality improvement and quality assurance Examine accepted procedures and policies with a goal of continuous quality improvement Once policies are changed in response to adverse events, test the team and system regarding whether new policies have been implemented properly Research Simulate disease states when testing out new devices or therapies Goal . Comments . Individual education Mastery of procedural skills, such as central line placement, intravenous or intraosseous vascular access, airway management Safe environment for experiential learning Team education Improvement in crisis resource management skills including teamwork, leadership, resource use and allocation, communication Process improvement Trial new care algorithms or introduce new technology in a safe and cost-effective manner Identify process issues and latent hazards Quality improvement and quality assurance Examine accepted procedures and policies with a goal of continuous quality improvement Once policies are changed in response to adverse events, test the team and system regarding whether new policies have been implemented properly Research Simulate disease states when testing out new devices or therapies Open in new tab Table 1 Goals of simulation in cardiac critical care Goal . Comments . Individual education Mastery of procedural skills, such as central line placement, intravenous or intraosseous vascular access, airway management Safe environment for experiential learning Team education Improvement in crisis resource management skills including teamwork, leadership, resource use and allocation, communication Process improvement Trial new care algorithms or introduce new technology in a safe and cost-effective manner Identify process issues and latent hazards Quality improvement and quality assurance Examine accepted procedures and policies with a goal of continuous quality improvement Once policies are changed in response to adverse events, test the team and system regarding whether new policies have been implemented properly Research Simulate disease states when testing out new devices or therapies Goal . Comments . Individual education Mastery of procedural skills, such as central line placement, intravenous or intraosseous vascular access, airway management Safe environment for experiential learning Team education Improvement in crisis resource management skills including teamwork, leadership, resource use and allocation, communication Process improvement Trial new care algorithms or introduce new technology in a safe and cost-effective manner Identify process issues and latent hazards Quality improvement and quality assurance Examine accepted procedures and policies with a goal of continuous quality improvement Once policies are changed in response to adverse events, test the team and system regarding whether new policies have been implemented properly Research Simulate disease states when testing out new devices or therapies Open in new tab Table 2 Types of possible simulation in cardiac critical care Type . Equipment/personnel . Pros . Cons . Telephone Minimal—telephone, partition between facilitator and participant High fidelity, low cost No procedural skills Verbal only Minimal or none High fidelity, low cost No procedural skills Task trainer Specific task trainer for desired skill Hands-on practice for common and uncommon procedures High cost, moderate fidelity Augmented virtual reality Augmented virtual reality simulator Practice for common and uncommon procedures High cost, participant tolerance Wet lab Wet lab with biological specimens High fidelity for certain procedural simulations High procurement and maintenance costs Full team, theatre based Physical room for mock clinical setting, computerized mannequin, moulage, medical equipment, actors Crisis management skills, teamwork, high fidelity High cost Full team, in situ Real clinical room, computerized mannequin, moulage, medical equipment, actors Crisis management skills, teamwork, high fidelity High cost, can potentially impede clinical work Disaster Variable Uncommon scenarios can be simulated Moderate-to-low fidelity Type . Equipment/personnel . Pros . Cons . Telephone Minimal—telephone, partition between facilitator and participant High fidelity, low cost No procedural skills Verbal only Minimal or none High fidelity, low cost No procedural skills Task trainer Specific task trainer for desired skill Hands-on practice for common and uncommon procedures High cost, moderate fidelity Augmented virtual reality Augmented virtual reality simulator Practice for common and uncommon procedures High cost, participant tolerance Wet lab Wet lab with biological specimens High fidelity for certain procedural simulations High procurement and maintenance costs Full team, theatre based Physical room for mock clinical setting, computerized mannequin, moulage, medical equipment, actors Crisis management skills, teamwork, high fidelity High cost Full team, in situ Real clinical room, computerized mannequin, moulage, medical equipment, actors Crisis management skills, teamwork, high fidelity High cost, can potentially impede clinical work Disaster Variable Uncommon scenarios can be simulated Moderate-to-low fidelity Open in new tab Table 2 Types of possible simulation in cardiac critical care Type . Equipment/personnel . Pros . Cons . Telephone Minimal—telephone, partition between facilitator and participant High fidelity, low cost No procedural skills Verbal only Minimal or none High fidelity, low cost No procedural skills Task trainer Specific task trainer for desired skill Hands-on practice for common and uncommon procedures High cost, moderate fidelity Augmented virtual reality Augmented virtual reality simulator Practice for common and uncommon procedures High cost, participant tolerance Wet lab Wet lab with biological specimens High fidelity for certain procedural simulations High procurement and maintenance costs Full team, theatre based Physical room for mock clinical setting, computerized mannequin, moulage, medical equipment, actors Crisis management skills, teamwork, high fidelity High cost Full team, in situ Real clinical room, computerized mannequin, moulage, medical equipment, actors Crisis management skills, teamwork, high fidelity High cost, can potentially impede clinical work Disaster Variable Uncommon scenarios can be simulated Moderate-to-low fidelity Type . Equipment/personnel . Pros . Cons . Telephone Minimal—telephone, partition between facilitator and participant High fidelity, low cost No procedural skills Verbal only Minimal or none High fidelity, low cost No procedural skills Task trainer Specific task trainer for desired skill Hands-on practice for common and uncommon procedures High cost, moderate fidelity Augmented virtual reality Augmented virtual reality simulator Practice for common and uncommon procedures High cost, participant tolerance Wet lab Wet lab with biological specimens High fidelity for certain procedural simulations High procurement and maintenance costs Full team, theatre based Physical room for mock clinical setting, computerized mannequin, moulage, medical equipment, actors Crisis management skills, teamwork, high fidelity High cost Full team, in situ Real clinical room, computerized mannequin, moulage, medical equipment, actors Crisis management skills, teamwork, high fidelity High cost, can potentially impede clinical work Disaster Variable Uncommon scenarios can be simulated Moderate-to-low fidelity Open in new tab Simulation for individual education Expertise in many procedural skills is necessary for patient safety in the CICU. With the ability to repeatedly perform procedures, simulation lends itself naturally to the acquisition, improvement, and continuing competency of an individual’s technical skillset. Simulation can be used to practice many common procedures in the CICU and learn a skill they may not otherwise encounter often, such as ECPR or advanced airway management. Simulation for team education Simulation is particularly well suited to team training and highlighting ‘soft skills’ that may be overlooked in didactic or Socratic-methods of teaching. With modern CICUs treating increasingly complex patients, this focus on multidisciplinary teamwork is especially important. Team-based simulations are often able to address many crisis management principles. Most of these principles are difficult or impossible to teach in the classroom and traditionally are only learned through real-life exposure. With the modern CICU typically being at the centre of multidisciplinary code blue teams and other rapid response ‘flash teams’ (i.e. extracorporeal life-support cannulation teams), a ‘shared mental model’ is critical for getting the most optimal outcome for patients. Full-team simulation is typically the only way to train such highly variable and unanticipated events. Thus, simulation allows for the addressing of team dynamics in a safe manner. Simulation for process implementation Use of new life-saving algorithms, evolving personnel safety, and introduction of new technology are just a few of the dynamic variables that must be balanced in the modern CICU. The roll-out of any new process, policy, or device greatly benefits from ‘trial runs’ through simulation prior to real-life implementation. The modern CICU is full of new processes and equipment. It greatly benefits from the use of simulation to identify process issues and latent hazards when implementing new unit policies. Simulation for quality improvement and quality assurance As modern medicine continues to evolve and as CICU patient care needs continue to increase, so do the opportunities for medical error. Alongside this, society’s willingness to forgive these medical errors has decreased. Simulation is a tool that can be used to examine the accepted procedures and policies, dissect prior adverse events, identify latent safety threats, and test out new procedures and policies. It can be used both as a part of continuous quality improvement and as a process for ensuring that quality assurance changes are sound and well implemented. Simulation as a research tool Along with an increase in CICU patient complexity has come a rush of innovation in medical therapies, devices, and advanced life support. While its place in medical history began in education, simulation can now be adopted as an alternative to observing clinical events. It can be used to test new clinical trials, new equipment, and new processes while assessing for specific outcome measures. Simulation: the basics of how to get started Once the need for simulation is accepted, the discussion should pivot from ‘why’ to ‘how’. Simulations typically start with an orientation. This outlines the purpose, sets expectations (for both the instructor and the instructed) and hopefully decreases performance-related anxiety. Participants may agree to a ‘fiction contract’, namely that they agree to suspend disbelief, and maximize ‘buy-in’, in return for a safe learning environment.28 Orientation includes the basics of what the mannequin can and cannot do, plus an introduction to the clinical scenario and each person’s role. Participants work through the scenario in realistic teams (i.e. they play their usual clinical role) while being observed by a facilitator. Afterwards there is a facilitator-led debriefing session, where all participants and observers have a chance to reflect on both failures and successes. Simulation fidelity and realism ‘Fidelity’ refers to the degree of realism, whereas technology refers to the type of machinery used. Simulation can be high fidelity without requiring high technology or a lengthy set up. For example, simulated telephone consultations or verbal history-taking stations easily mirror the real event. They require no more than chairs, a quiet location, or a telephone and notepad. To further increase realism, however, actors can be deployed as physicians or patients and with scenarios run in the real clinical setting, with nothing more than an inexpensive partition or one-way mirror to separate participants and facilitator. Task-trainer stations can be stand-alone (low fidelity) or integrated into a real resuscitation bay (higher fidelity). Fidelity can be further increased by using anatomically accurate models or through the use of moulage. Artificial smells, sounds, and realistic backdrops can also increase realism. We can even blindfold the chief resuscitator in order to turn their focus purely onto verbal dexterity and team coordination.29 All of these techniques are designed to increase emotional buy-in, and the likelihood of longer term memory retention. High-fidelity simulation mannequins not only have changeable vital signs and cardiac rhythms, but may also have reactive pupils and the ability to have tubes inserted and collections drained. Of note, while high-fidelity simulation has obvious appeal, if simulation can be done with minimal set up, low cost, and without the need for extra personnel, then it is more likely to happen on a regular basis. This can increase simulation availability to learners who may not have dedicated time-off for travel to off-site specialized simulation centres. Simulation types in the cardiac critical care environment Types of possible simulation in cardiac critical care are described broadly in Table 2. Telephone simulation Cardiac intensive care units often offer care over vast distances and to a widely dispersed population, as well as serving as a hub for multiple hospitals. As such, much early triage and advice occurs via telephone. Simulated calls are therefore not only useful but also well suited to teaching practical skills such as collecting relevant (and not extraneous) information, synthesizing this information, and helping to stabilize and transport a patient who may be geographically far away.30 Examples could include a call from a non-specialist physician at a peripheral hospital asking for advice or transfer, or communication between an interventional cardiologist and a paramedic with a prehospital ST-elevation myocardial infarction. These simulations can help standardize both the verbal communication and written documentation of such scenarios. There has also been a push towards implementing Cardiogenic Shock Teams31 and telephone skills are integral to this role. Simulations can be designed to have participants obtain case summaries and critical information (i.e. pulmonary artery catheter haemodynamic numbers like cardiac power output and pulmonary artery pulsatility index). Just as importantly, participants learn how to achieve group consensus. As healthcare becomes more centralized and as more virtual ICUs (centres where experts offer advice but do not deliver the actual care) are built, telephone consultations will inevitably increase. This makes telephone simulation particularly attractive, especially as it is highly relevant, high fidelity, but logistically easy and inexpensive. Additional verbal-only simulation With a more complex and sicker patient population in the CICU, there is often more need for end-of-life care. Discussions around end-of-life can have a profound effect upon patients and families and therefore should not be left to the inexperienced. They can be simulated, recorded, and debriefed in order to enhance participants’ counselling skills. These could include achieving the right balance of truth and empathy, as well as how to broach limitations, palliation, and organ donation. The COVID-19 pandemic challenged our delivery of care, with many family meetings held over the phone instead of face to face. This created distress and difficulty for patients, families, and healthcare staff. Moreover, complaints received by Patient Relations departments are often due to communication breakdown, an issue perhaps rooted in insufficient training in how to conduct challenging conversations. Patient handover is another area fraught with difficulty.32 It is also one of the most common ‘procedures’ in any large teaching hospital. Poor handover has been directly shown to worsen mortality. In the current climate of work hour limitations, handovers are likely to increase. Verbal-only simulations can be designed to force participants to identify important clinical points in a rapid manner, and both effectively and efficiently communicate this to another member of the healthcare team. Task-trainer simulation, augmented virtual reality, and wet labs Many procedures are performed in the CICU and specific task trainers have been designed for most of our common procedures, including central venous catheter or arterial line placement, intravenous or intraosseous vascular access, transvenous pacemaker placement, pulmonary artery catheter placement and haemodynamics interpretation, chest tube insertion, intubation, pericardiocentesis, and ventilator and dialysis management. Moreover, with the advent of point-of-care ultrasound, these task trainers have been designed to integrate the use of ultrasound. Task trainers also allow for practicing with devices such as the LUCAS and ECLS circuits, and are useful to help with troubleshooting equipment failure. Advanced procedures such as echocardiography, interventional cardiology, electrophysiology, and cardiac surgery have all been reproduced with the use of task trainers. This includes endovascular procedures such as coronary angioplasty, pacing, electrophysiological studies, peripheral vascular and structural interventions, as well as transoesophageal echocardiograms and extracorporeal membrane oxygenation cannulation (ECMO). Augmented virtual reality simulators are also fast emerging, notably in interventional cardiology and ECMO cannulation.33,34 Augmented virtual reality means wearing goggles/glasses that superimpose an image on a workspace that can be modulated and interacted with. In the future, teams will be able to meet in a shared virtual environment. It is a burgeoning field both in- and out-side medicine, with exciting possibilities. The use of simulation in these fields is only likely to increase if reduced clinical hours or clinical volume limit the number of cases a trainee is involved with.35 Wet lab simulation (namely the use of animals or cadavers) adds a further degree of realism, both in terms of anatomy and tactile tissue feel. In both anaesthesiology and intensive care, pig tracheas are used to simulate front-of-neck emergency access with open cricothyroidotomy. Wet lab simulation can also be used for ECLS cannulation and for cardiac surgery. As wet labs do incur additional costs, they are usually limited to very specific procedures where a non-biological simulator is not realistic enough. The future may bring even more change and possibilities, with the rise in 3D printing. Theatre-based or in-situ full-team simulation High-fidelity full-team simulations are best used to address more complex clinical scenarios and assess a combination of clinical knowledge, decision-making, resource use, and teamwork and communication dynamics. These simulations include all elements of the clinical team from attending physicians, nurses, respiratory therapists, residents, pharmacists, and occupational and physical therapy. These simulations can either be theatre based, where a physical room is simulated to look like a clinical setting, or in situ, where the simulation is held in an actual clinical environment to help increase realism. Clinical vignettes can cover the acute decompensation of patients, with successful management requiring an efficient and effective multidisciplinary team who can stabilize and possibly mobilize the patient for minimally invasive or surgical interventions. Examples of high-fidelity full-team simulations include cardiopulmonary arrest requiring advanced cardiovascular life support and respiratory management, managing the logistics of physically transferring a patient to the cardiac catheterization or electrophysiology labs, managing post-transcatheter aortic valve implantation complications, and extracorporeal life-support cannulations, to name a few. Simulations can also be expanded to include transportation logistics, including sending a patient to the operating room for ECMO, organizing ground or air transport to a centre capable of a higher level of care, or assembling a rapid response team within the hospital. Disaster response Disaster simulations are a perfect example of a HALO event well suited to simulation. These can range from power outages to fires, floods, or earthquakes to mass casualties or pandemics. Although the CICU rarely sees mass casualties or natural disasters, the COVID-19 pandemic demonstrated how any additional strain might cause a system-wide collapse. Accordingly, it is each of our responsibilities to be prepared. An example of disaster simulation could include a response to a large earthquake along the San Andreas fault, which would have widespread consequences along the United States western seaboard, potentially crippling most cardiac services across North America. In closing: overcoming barriers and next steps Prioritizing simulation will be an ongoing challenge in an environment of cost restraint, clinical backlog, and practitioner burnout. A simulation programme needs stable long-term support with funds, protected time, and experts in medical content, education theory, and individual/group psychology. Regular and well-designed simulation could be a game changer, but first we need a shared understanding. Without this, money and time could be squandered, and practitioners will resent simulations that are punitive or unrealistic. This is where physician champions are needed. We will be needed to provide clinical expertise, but just as importantly, we will need to enthuse, engage, excite, and perhaps even cajole the widest range of clinicians, administrators, politicians, and funders. In order to persuade others to adopt simulation we will have to ‘sell it’ as more than just an educational tool. It must be seen as a key means for Quality Improvement and Quality Assurance, hospital reputation, and staff engagement. We do not just need more simulation, we need better simulation. This means support across organizations from multiple departments that may have previously worked in independent silos. In addition to institutional buy-in and support, we need to identify and attract experts in adult education and human performance. 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Google Scholar Crossref Search ADS PubMed WorldCat 16 Groenestege-Kreb DT , van Maarseveen O, Leenen L. Trauma team . Br J Anaesth 2014 ; 113 : 258 – 265 . Google Scholar Crossref Search ADS PubMed WorldCat 17 Wong EC , Negreanu D, Adreak N, Allan K, Thibodeau-Jarry N, Tsirigotis D, Qayumi K, Fordyce CB, Randhawa VK. Simulation tools in the research and delivery of competency-based medical education and health care: evolving considerations in the contemporary COVID-19 era . Can J Cardiol 2021 ; 37 : 351 – 354 . Google Scholar Crossref Search ADS PubMed WorldCat 18 LiveSaver Training . https://www.lifesavertraining.co.uk/facts/the-history-of-resusci-annie/. Accessed 13 September 2022. 19 Trucorp . https://trucorp.com/product/trumonitor-app/. Accessed 13 September 2022. 20 ZOLL Medical Corporation . https://www.zoll.com/medical-technology/cpr/real-cpr-help. Accessed 13 September 2022. 21 Brindley PG , Neilipovitz D, Kim J, Cardinal P. Acute critical events simulation (A.C.E.S): a novel program to improve resuscitation of the critically ill . Internet J Med Simul 2005 ; 2:1-9 . Google Scholar OpenURL Placeholder Text WorldCat 22 Kim J , Neilipovitz D, Cardinal P, Chiu M. A comparison of global rating scale and checklist scores in the validation of an evaluation tool to assess performance in the resuscitation of critically ill patients during simulated emergencies (abbreviated as “CRM simulator study IB”) . Simul Healthc 2009 ; 4 : 6 – 16 . Google Scholar Crossref Search ADS PubMed WorldCat 23 Brindley PG , Mosier JM, Hicks CM. Pandemic airway management: a cognitive aid to increase safety and team cohesion during intubation, donning, and doffing . J Intensive Care Soc 2020 ; 0 : 1 – 2 . Google Scholar OpenURL Placeholder Text WorldCat 24 Lee CP , Yip YY, Chan AK, Ko CP, Joynt GM. Early intubation versus late intubation for COVID-19 patients: an in situ simulation identifying factors affecting performance and infection control in airway management . Anaesth Intensive Care 2021 ; 49 : 284 – 291 . Google Scholar Crossref Search ADS PubMed WorldCat 25 Noor Azhar M , Bustam A, Poh K, Ahmad Zahedi AZ, Mohd Nazri M, Azizah Ariffin MA, Md Yusuf MH, Zambri A, Chong J, Kamarudin A, Ang BT, Iskandar A, Chew KS. COVID-19 aerosol box as protection from droplet and aerosol contaminations in healthcare workers performing airway intubation: a randomised cross-over simulation study . Emerg Med J 2021 ; 38 : 111 – 117 . Google Scholar Crossref Search ADS PubMed WorldCat 26 Brindley PG , Dunn WF. Simulation for clinical research trials: a theoretical outline . J Crit Care 2009 ; 24 : 164 – 167 . Google Scholar Crossref Search ADS PubMed WorldCat 27 Horvath DJ , Horvath DW, Karimov JH, Kuban BD, Miyamoto T, Fukamachi K. A simulation tool for mechanical circulatory support device interaction with diseased states . J Artif Organs 2020 ; 23 : 124 – 132 . Google Scholar Crossref Search ADS PubMed WorldCat 28 Muckler VC . Exploring suspension of disbelief during simulation-based learning . Clin Simul Nurs 2017 ; 13 : 3 – 9 . Google Scholar Crossref Search ADS WorldCat 29 Brindley PG , Hudson D, Lord JA. The blindfolded learner – a simple intervention to improve crisis resource management skills . J Crit Care 2008 ; 23 : 253 – 254 . Google Scholar Crossref Search ADS PubMed WorldCat 30 Brindley P . Novel technique for critical care training . CMAJ 2007 ; 176 : 68 . Google Scholar Crossref Search ADS PubMed WorldCat 31 Tehrani BN , Truesdell AG, Sherwood MW, Desai S, Tran HA, Epps KC, Singh R, Psotka M, Shah P, Cooper LB, Rosner C, Raja A, Barnett SD, Saulino P, deFilippi CR, Gurbel PA, Murphy CE, O'Connor CM. Standardized team based care for cardiogenic shock . J Am Coll Cardiol 2019 ; 73 : 1659 – 1669 . Google Scholar Crossref Search ADS PubMed WorldCat 32 Lee DH , Lim EJ. Effect of a simulation-based handover education program for nursing students: a quasi-experimental design . Int J Environ Res Public Health 2021 ; 18 : 5821 . Google Scholar Crossref Search ADS PubMed WorldCat 33 Pezel T , Coisne A, Bonnet G, Martins RP, Adjedj J, Bière L, Lattuca B, Turpeau S, Popovic B, Ivanes F, Lafitte S, Deharo JC, Bernard A. Simulation-based training in cardiology: state-of-the-art review from the French Commission of Simulation Teaching (Commission d'enseignement par simulation-COMSI) of the French Society of Cardiology . Arch Cardiovasc Dis 2021 ; 114 : 73 – 84 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 34 Wolff G , Bruno RR, Reiter M, Kantzow B, Kelm M, Jung C. Virtual reality device training for extracorporeal membrane oxygenation . Crit Care 2020 ; 24 : 390 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 35 Gosai J , Purva M, Gunn J. Simulation in cardiology: state of the art . Eur Heart J 2015 ; 36 : 777 – 783 . Google Scholar PubMed OpenURL Placeholder Text WorldCat Author notes The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal: Acute Cardiovascular Care or of the European Society of Cardiology. Conflict of interest: The authors have no conflict of interests to declare. © The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal. Acute Cardiovascular Care Oxford University Press

Simulation in cardiac critical care

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Oxford University Press
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Copyright © 2023 European Society of Cardiology
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2048-8726
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2048-8734
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10.1093/ehjacc/zuac132
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Abstract

Abstract Medical simulation is a broad topic but at its core is defined as any effort to realistically reproduce a clinical procedure, team, or situation. Its goal is to allow risk-free practice-until-perfect, and in doing so, augment performance, efficiency, and safety. In medicine, even complex clinical situations can be dissected into reproducible parts that may be repeated and mastered, and these iterative improvements can add up to major gains. With our modern cardiac intensive care units treating a growing number of medically complex patients, the need for well-trained personnel, streamlined care pathways, and quality teamwork is imperative for improved patient outcomes. Simulation is therefore a potentially life-saving tool relevant to anyone working in cardiac intensive care. Accordingly, we believe that simulation is a priority for cardiac intensive care, not just a luxury. We offer the following primer on simulation in the cardiac intensive care environment. Simulation, Cardiac intensive care, Medical education, Process improvement, Quality improvement Introduction: what is simulation, and why does it matter Medical simulation is a broad topic but at its core is defined as any effort to realistically reproduce a clinical procedure, team, or situation.1 Its goal is to allow risk-free practice-until-perfect, and in doing so, augment performance, efficiency, and safety. In medicine, even complex clinical situations can be dissected into reproducible parts that may be repeated and mastered, and these iterative improvements can add up to major gains.2 With our modern cardiac intensive care units (CICUs) treating a growing number of medically complex patients, the need for well-trained personnel, streamlined care pathways, and quality teamwork is imperative for improved patient outcomes. Simulation is therefore a potentially life-saving tool relevant to anyone working in cardiac intensive care. Accordingly, we believe that simulation is a priority for cardiac intensive care, not just a luxury. Simulation offers unique education and training for all learners regardless of whether they are novices, unfamiliar team members, or seasoned veterans. Leaning heavily on theories of experiential learning, simulation allows for a cycle of experiencing, reflecting, thinking, and performing.3 This supplements traditional didactic instruction well by fostering an active and immersive learning environment. It promotes debriefing, which provides a broader understanding of why, how, and where errors occur. The iterative journey from novice can thus occur without risk to patient or practitioner. Simulation design ranges in fidelity from table-top planning, to task trainers, to mannequin-based, to full virtual reality. With a wide variety of clinical vignettes, simulation avoids reliance upon random patient presentation. Well-crafted simulations can address each key healthcare level: the individual, the team, and the system. Simulation can also be a strategy to attract and retain the best practitioners and to reassure patients and families. Accordingly, simulation (the science) and simulators (the devices) and simulation rooms (the location) have been described as an ‘educational revolution’, ‘an ethical imperative’, ‘a key driver of culture change’, and ‘our best patient safety laboratory’.4 With the amalgamation of increased patient complexity, the multifaceted nature of our care teams, the intricacies of health equipment and systems, and the overall less forgiveness of medical error, simulation is increasingly used worldwide as an educational and process improvement tool. We offer the following primer on simulation in the cardiac critical care environment. Why practitioners need, and patients deserve, simulation in cardiac intensive care Coronary care units (CCUs) were first formed in the 1960s in efforts to reduce premature cardiovascular death and disability in patients. This goal has remained the same over the decades. What has dramatically changed is the landscape surrounding CCUs, with greater patient, team, and system complexity, and even greater intolerance of bad outcomes. In its infancy, cardiac treatment was less invasive and centred on bed rest, passive monitoring, gentle mobilization, and gradual recovery. The introduction of thrombolysis and percutaneous angiography revolutionized cardiac care. These innovations have allowed us to have a greater emphasis on prehospital care, rapid triage, early intervention, and complex care pathways.5 Because of these advances, a greater number of patients have been saved from premature death and now present to the CCU with complex acute-on-chronic conditions. Moreover, CCUs now regularly serve as a connection point—or stabilization unit—for patients requiring a myriad of therapies including cardiac catheterization, electrophysiology intervention, organ transplantation, cardiac surgery, and extracorporeal support (see Figure 1).6 These changes necessitated that CCUs morph into CICUs that are increasingly resembling general systems intensive care units. As patient care needs evolve, so does the need for highly skilled personnel, streamlined care pathways, and a multidisciplinary framework where individuals can maximize use of their skills while working together in a larger team. Formation and implementation of such complex care units require both additional training and continuing education to maintain functional teams that often face high-acuity low-occurrence (HALO) events. Furthermore, as we embrace the best new therapies to improve patient outcomes, we also need to embrace the latest and greatest in education theory and team psychology to ensure patient safety. In short, CICUs are among the most complex and perilous environments in medicine; they ought to have education to match. Simulation is ideally suited to address these goals. The evidence behind simulation Simulation is a scientific discipline and should be subject to rigorous study and open to challenge. No controlled study has shown that simulators and simulation definitively saves lives. However, there are numerous associations with better surrogate outcomes, greater practitioner satisfaction, and greater efficiency, with no substantial disadvantage aside from cost and time. While these associations are not the same as empiric evidence, other industries have not demanded definitive proof and have mandated regular simulation at all levels—most notably the aviation industry. Similarly, for the military and police, simulation is so well accepted that it has become a part of regular training and paid work. While a comprehensive simulation review is beyond the scope of this article, we now highlight relevant, and translatable, examples. Simulation in non-medical fields: military and civil aviation Simulation is entrenched in the high-stakes environment of aviation. The first pilot trainer was developed in the 1920s and allowed pilots to simulate flying with instruments. These task trainers replicated cockpit controls and, although physically grounded, would pitch and roll in response to the pilot’s actions. By the Second World War, the attentional demands on pilots had increased. This led to more complex simulations, including disaster scenarios, so that pilots could practice their responses to both common and uncommon high-risk events.7 Flight simulation is now mandatory in modern aviation training and certification. It is used both for solo training with task trainers and for practice of teamwork between co-pilots, something that is difficult, dangerous, and costly to otherwise train. Importantly, simulation has also been associated with improved flight safety.8,9 Simulation in medical equipment design Simulation is also regularly used by medical equipment companies to test a device’s mechanical properties and response to failure. In one study, insulin pump models were recreated in Matlab Simscape, allowing for examination of the pumps’ mechanical forces, internal pressures, and fluid dynamics. Failure modes, such as infusion site occlusions, were simulated to test the model’s reliability in detecting failure, and how this affected the overall system.10 Simulation in other medical fields Simulation has been widely used for training in anaesthesiology, paediatrics, emergency medicine, trauma, and obstetrics. Anaesthesiology, in particular, has been simulation’s greatest medical proponent. This was led by Dr David Gaba, who created Simulation-Based Training in Anesthesia Crisis Resource Management (ACRM). The ACRM curriculum, used across the United States and Canada, incorporated simulated acute events, followed by detailed structured video-assisted debriefs.11 Anaesthesiology simulation has also included fibre-optic intubations, echocardiography, bronchoscopy, and front-of-neck cricothyroidotomies.12 Growing evidence suggests that anaesthesiology simulation is associated with improvement in non-technical skills, such as decision-making, efficiency, guideline adherence, leadership, followership, teamwork, and less equipment misuse.13 Regarding common critical care procedures and presentations, central venous catheter insertion simulation is associated with increased skill mastery and performance comfort, and fewer procedural complications.14 High-fidelity simulation has also been associated with greater acquisition and retention of skills needed to initiate extracorporeal cardiopulmonary resuscitation (ECPR) following out-of-hospital cardiac arrests.15 High-fidelity trauma simulations have been associated with improvement in many domains of the Trauma Team Performance Observation Tool. Improvements were noted in leadership, situation monitoring, communication, and mutual support, as well as quicker transport time to the operating room.16 Fortunately, these examples (and those below) could be repurposed to CICUs with minimal delay. With resident education moving towards competency-based education, simulation provides an opportunity to master skills in a safe environment,17 and a move away from the ‘trial-and-error’ or the ‘see one, do one, teach one’ method. Simulation in cardiology: cardiac arrest simulation One of the earliest examples of cardiac arrest simulation was the Resusci Annie doll, which was modelled after the drowning death of a young woman in Paris’ Seine River.18 This doll allowed an individual or team to talk through resuscitation steps and to crudely demonstrate compressions on a soft sternum. There are now compression simulators with mechanics closer to those of humans, such as the Ambu® Man Wireless. There are also affordable devices that can simulate different vital signs and cardiac rhythms, some of which can also be used to teach pacing and defibrillation steps.19 These devices can be controlled by a facilitator who can prompt real-time changes in cardiac rhythms or vital signs based on a trainees’ actions. Similarly, the ZOLL® X monitor contains an accelerometer, and gives real-time feedback on the rate and depth of chest compressions.20 There are also team-based courses, such as the Acute Critical Events Simulation course which includes scenarios with patients pending or in full cardiac arrest. The goal of this course is to address manual skills alongside non-technical skills and crisis resource management (CRM) principles21 including teamwork, leadership, resource use and allocation, and communication. These can then be evaluated using validated CRM rating systems and checklists.22 Simulation for new processes, policies, and devices It is common sense to perform trial runs on any new addition to a complex perilous system. Simulation is an ideal tool for this because it offers realism without risk. This was evident during the COVID-19 pandemic when performing aerosolizing generating medical procedures such as endotracheal intubations became dangerous because of the risk of infection transmission. Simulation studies helped to streamline and more quickly mobilize intubation teams, resulting in increased personnel safety.17,23 Another study highlighted how delayed intubation of COVID-19 patients, compared with early intubation, actually resulted in greater healthcare personnel contamination.24 Simulation has also shown that not every innovation is beneficial, regardless of how well intentioned. For example, COVID intubation boxes were assumed to decrease transmission risk but were rejected once simulation studies showed they were associated with time delays and inadequate visibility.25 Thus simulation use has helped to identify risks and weaknesses of new ideas while also fine-tuning procedures and policies, likely resulting in cost savings and increased patient and personnel safety. Simulation to improve research and examine disease states Simulation is more than an educational or process improvement tool; it even offers improvements in the design, enrolment, and execution of complex Phase 3 clinical research trials. After all, simulation can facilitate ‘dry runs,’ role playing, analysis of videos, and ‘what-if’ discussions. This could decrease protocol violations, which may threaten data validity. Simulated interviews with actors might help with obtaining informed consent and thereby boost study enrolment. Full-body mannequins might be used to confirm that teams can coordinate multiple complex steps. Overall, the goal of simulation in clinical trials is to maximize realism while minimizing logistics and cost, to increase the accuracy of study data, and to minimize waste.26 Another study used simulation to examine the interactions of various disease states, including left systolic failure, left diastolic failure, and mitral and aortic stenosis and regurgitation, with a variety of continuous-flow mechanical circulatory support (MCS) devices. Using MATLAB, mathematical models were created to simulate these disease states and track blood flow, pressure, and volume through the MCS devices. These simulations were validated against clinical results.27 Figure 1 Open in new tabDownload slide The modern cardiac intensive care unit as a connection hub between many cardiovascular science services. The goals of simulation in cardiac critical care Given the aforementioned examples of how simulation is currently being used, the goals of simulation in the cardiac intensive care setting are broadly described in Table 1. Table 1 Goals of simulation in cardiac critical care Goal . Comments . Individual education Mastery of procedural skills, such as central line placement, intravenous or intraosseous vascular access, airway management Safe environment for experiential learning Team education Improvement in crisis resource management skills including teamwork, leadership, resource use and allocation, communication Process improvement Trial new care algorithms or introduce new technology in a safe and cost-effective manner Identify process issues and latent hazards Quality improvement and quality assurance Examine accepted procedures and policies with a goal of continuous quality improvement Once policies are changed in response to adverse events, test the team and system regarding whether new policies have been implemented properly Research Simulate disease states when testing out new devices or therapies Goal . Comments . Individual education Mastery of procedural skills, such as central line placement, intravenous or intraosseous vascular access, airway management Safe environment for experiential learning Team education Improvement in crisis resource management skills including teamwork, leadership, resource use and allocation, communication Process improvement Trial new care algorithms or introduce new technology in a safe and cost-effective manner Identify process issues and latent hazards Quality improvement and quality assurance Examine accepted procedures and policies with a goal of continuous quality improvement Once policies are changed in response to adverse events, test the team and system regarding whether new policies have been implemented properly Research Simulate disease states when testing out new devices or therapies Open in new tab Table 1 Goals of simulation in cardiac critical care Goal . Comments . Individual education Mastery of procedural skills, such as central line placement, intravenous or intraosseous vascular access, airway management Safe environment for experiential learning Team education Improvement in crisis resource management skills including teamwork, leadership, resource use and allocation, communication Process improvement Trial new care algorithms or introduce new technology in a safe and cost-effective manner Identify process issues and latent hazards Quality improvement and quality assurance Examine accepted procedures and policies with a goal of continuous quality improvement Once policies are changed in response to adverse events, test the team and system regarding whether new policies have been implemented properly Research Simulate disease states when testing out new devices or therapies Goal . Comments . Individual education Mastery of procedural skills, such as central line placement, intravenous or intraosseous vascular access, airway management Safe environment for experiential learning Team education Improvement in crisis resource management skills including teamwork, leadership, resource use and allocation, communication Process improvement Trial new care algorithms or introduce new technology in a safe and cost-effective manner Identify process issues and latent hazards Quality improvement and quality assurance Examine accepted procedures and policies with a goal of continuous quality improvement Once policies are changed in response to adverse events, test the team and system regarding whether new policies have been implemented properly Research Simulate disease states when testing out new devices or therapies Open in new tab Table 2 Types of possible simulation in cardiac critical care Type . Equipment/personnel . Pros . Cons . Telephone Minimal—telephone, partition between facilitator and participant High fidelity, low cost No procedural skills Verbal only Minimal or none High fidelity, low cost No procedural skills Task trainer Specific task trainer for desired skill Hands-on practice for common and uncommon procedures High cost, moderate fidelity Augmented virtual reality Augmented virtual reality simulator Practice for common and uncommon procedures High cost, participant tolerance Wet lab Wet lab with biological specimens High fidelity for certain procedural simulations High procurement and maintenance costs Full team, theatre based Physical room for mock clinical setting, computerized mannequin, moulage, medical equipment, actors Crisis management skills, teamwork, high fidelity High cost Full team, in situ Real clinical room, computerized mannequin, moulage, medical equipment, actors Crisis management skills, teamwork, high fidelity High cost, can potentially impede clinical work Disaster Variable Uncommon scenarios can be simulated Moderate-to-low fidelity Type . Equipment/personnel . Pros . Cons . Telephone Minimal—telephone, partition between facilitator and participant High fidelity, low cost No procedural skills Verbal only Minimal or none High fidelity, low cost No procedural skills Task trainer Specific task trainer for desired skill Hands-on practice for common and uncommon procedures High cost, moderate fidelity Augmented virtual reality Augmented virtual reality simulator Practice for common and uncommon procedures High cost, participant tolerance Wet lab Wet lab with biological specimens High fidelity for certain procedural simulations High procurement and maintenance costs Full team, theatre based Physical room for mock clinical setting, computerized mannequin, moulage, medical equipment, actors Crisis management skills, teamwork, high fidelity High cost Full team, in situ Real clinical room, computerized mannequin, moulage, medical equipment, actors Crisis management skills, teamwork, high fidelity High cost, can potentially impede clinical work Disaster Variable Uncommon scenarios can be simulated Moderate-to-low fidelity Open in new tab Table 2 Types of possible simulation in cardiac critical care Type . Equipment/personnel . Pros . Cons . Telephone Minimal—telephone, partition between facilitator and participant High fidelity, low cost No procedural skills Verbal only Minimal or none High fidelity, low cost No procedural skills Task trainer Specific task trainer for desired skill Hands-on practice for common and uncommon procedures High cost, moderate fidelity Augmented virtual reality Augmented virtual reality simulator Practice for common and uncommon procedures High cost, participant tolerance Wet lab Wet lab with biological specimens High fidelity for certain procedural simulations High procurement and maintenance costs Full team, theatre based Physical room for mock clinical setting, computerized mannequin, moulage, medical equipment, actors Crisis management skills, teamwork, high fidelity High cost Full team, in situ Real clinical room, computerized mannequin, moulage, medical equipment, actors Crisis management skills, teamwork, high fidelity High cost, can potentially impede clinical work Disaster Variable Uncommon scenarios can be simulated Moderate-to-low fidelity Type . Equipment/personnel . Pros . Cons . Telephone Minimal—telephone, partition between facilitator and participant High fidelity, low cost No procedural skills Verbal only Minimal or none High fidelity, low cost No procedural skills Task trainer Specific task trainer for desired skill Hands-on practice for common and uncommon procedures High cost, moderate fidelity Augmented virtual reality Augmented virtual reality simulator Practice for common and uncommon procedures High cost, participant tolerance Wet lab Wet lab with biological specimens High fidelity for certain procedural simulations High procurement and maintenance costs Full team, theatre based Physical room for mock clinical setting, computerized mannequin, moulage, medical equipment, actors Crisis management skills, teamwork, high fidelity High cost Full team, in situ Real clinical room, computerized mannequin, moulage, medical equipment, actors Crisis management skills, teamwork, high fidelity High cost, can potentially impede clinical work Disaster Variable Uncommon scenarios can be simulated Moderate-to-low fidelity Open in new tab Simulation for individual education Expertise in many procedural skills is necessary for patient safety in the CICU. With the ability to repeatedly perform procedures, simulation lends itself naturally to the acquisition, improvement, and continuing competency of an individual’s technical skillset. Simulation can be used to practice many common procedures in the CICU and learn a skill they may not otherwise encounter often, such as ECPR or advanced airway management. Simulation for team education Simulation is particularly well suited to team training and highlighting ‘soft skills’ that may be overlooked in didactic or Socratic-methods of teaching. With modern CICUs treating increasingly complex patients, this focus on multidisciplinary teamwork is especially important. Team-based simulations are often able to address many crisis management principles. Most of these principles are difficult or impossible to teach in the classroom and traditionally are only learned through real-life exposure. With the modern CICU typically being at the centre of multidisciplinary code blue teams and other rapid response ‘flash teams’ (i.e. extracorporeal life-support cannulation teams), a ‘shared mental model’ is critical for getting the most optimal outcome for patients. Full-team simulation is typically the only way to train such highly variable and unanticipated events. Thus, simulation allows for the addressing of team dynamics in a safe manner. Simulation for process implementation Use of new life-saving algorithms, evolving personnel safety, and introduction of new technology are just a few of the dynamic variables that must be balanced in the modern CICU. The roll-out of any new process, policy, or device greatly benefits from ‘trial runs’ through simulation prior to real-life implementation. The modern CICU is full of new processes and equipment. It greatly benefits from the use of simulation to identify process issues and latent hazards when implementing new unit policies. Simulation for quality improvement and quality assurance As modern medicine continues to evolve and as CICU patient care needs continue to increase, so do the opportunities for medical error. Alongside this, society’s willingness to forgive these medical errors has decreased. Simulation is a tool that can be used to examine the accepted procedures and policies, dissect prior adverse events, identify latent safety threats, and test out new procedures and policies. It can be used both as a part of continuous quality improvement and as a process for ensuring that quality assurance changes are sound and well implemented. Simulation as a research tool Along with an increase in CICU patient complexity has come a rush of innovation in medical therapies, devices, and advanced life support. While its place in medical history began in education, simulation can now be adopted as an alternative to observing clinical events. It can be used to test new clinical trials, new equipment, and new processes while assessing for specific outcome measures. Simulation: the basics of how to get started Once the need for simulation is accepted, the discussion should pivot from ‘why’ to ‘how’. Simulations typically start with an orientation. This outlines the purpose, sets expectations (for both the instructor and the instructed) and hopefully decreases performance-related anxiety. Participants may agree to a ‘fiction contract’, namely that they agree to suspend disbelief, and maximize ‘buy-in’, in return for a safe learning environment.28 Orientation includes the basics of what the mannequin can and cannot do, plus an introduction to the clinical scenario and each person’s role. Participants work through the scenario in realistic teams (i.e. they play their usual clinical role) while being observed by a facilitator. Afterwards there is a facilitator-led debriefing session, where all participants and observers have a chance to reflect on both failures and successes. Simulation fidelity and realism ‘Fidelity’ refers to the degree of realism, whereas technology refers to the type of machinery used. Simulation can be high fidelity without requiring high technology or a lengthy set up. For example, simulated telephone consultations or verbal history-taking stations easily mirror the real event. They require no more than chairs, a quiet location, or a telephone and notepad. To further increase realism, however, actors can be deployed as physicians or patients and with scenarios run in the real clinical setting, with nothing more than an inexpensive partition or one-way mirror to separate participants and facilitator. Task-trainer stations can be stand-alone (low fidelity) or integrated into a real resuscitation bay (higher fidelity). Fidelity can be further increased by using anatomically accurate models or through the use of moulage. Artificial smells, sounds, and realistic backdrops can also increase realism. We can even blindfold the chief resuscitator in order to turn their focus purely onto verbal dexterity and team coordination.29 All of these techniques are designed to increase emotional buy-in, and the likelihood of longer term memory retention. High-fidelity simulation mannequins not only have changeable vital signs and cardiac rhythms, but may also have reactive pupils and the ability to have tubes inserted and collections drained. Of note, while high-fidelity simulation has obvious appeal, if simulation can be done with minimal set up, low cost, and without the need for extra personnel, then it is more likely to happen on a regular basis. This can increase simulation availability to learners who may not have dedicated time-off for travel to off-site specialized simulation centres. Simulation types in the cardiac critical care environment Types of possible simulation in cardiac critical care are described broadly in Table 2. Telephone simulation Cardiac intensive care units often offer care over vast distances and to a widely dispersed population, as well as serving as a hub for multiple hospitals. As such, much early triage and advice occurs via telephone. Simulated calls are therefore not only useful but also well suited to teaching practical skills such as collecting relevant (and not extraneous) information, synthesizing this information, and helping to stabilize and transport a patient who may be geographically far away.30 Examples could include a call from a non-specialist physician at a peripheral hospital asking for advice or transfer, or communication between an interventional cardiologist and a paramedic with a prehospital ST-elevation myocardial infarction. These simulations can help standardize both the verbal communication and written documentation of such scenarios. There has also been a push towards implementing Cardiogenic Shock Teams31 and telephone skills are integral to this role. Simulations can be designed to have participants obtain case summaries and critical information (i.e. pulmonary artery catheter haemodynamic numbers like cardiac power output and pulmonary artery pulsatility index). Just as importantly, participants learn how to achieve group consensus. As healthcare becomes more centralized and as more virtual ICUs (centres where experts offer advice but do not deliver the actual care) are built, telephone consultations will inevitably increase. This makes telephone simulation particularly attractive, especially as it is highly relevant, high fidelity, but logistically easy and inexpensive. Additional verbal-only simulation With a more complex and sicker patient population in the CICU, there is often more need for end-of-life care. Discussions around end-of-life can have a profound effect upon patients and families and therefore should not be left to the inexperienced. They can be simulated, recorded, and debriefed in order to enhance participants’ counselling skills. These could include achieving the right balance of truth and empathy, as well as how to broach limitations, palliation, and organ donation. The COVID-19 pandemic challenged our delivery of care, with many family meetings held over the phone instead of face to face. This created distress and difficulty for patients, families, and healthcare staff. Moreover, complaints received by Patient Relations departments are often due to communication breakdown, an issue perhaps rooted in insufficient training in how to conduct challenging conversations. Patient handover is another area fraught with difficulty.32 It is also one of the most common ‘procedures’ in any large teaching hospital. Poor handover has been directly shown to worsen mortality. In the current climate of work hour limitations, handovers are likely to increase. Verbal-only simulations can be designed to force participants to identify important clinical points in a rapid manner, and both effectively and efficiently communicate this to another member of the healthcare team. Task-trainer simulation, augmented virtual reality, and wet labs Many procedures are performed in the CICU and specific task trainers have been designed for most of our common procedures, including central venous catheter or arterial line placement, intravenous or intraosseous vascular access, transvenous pacemaker placement, pulmonary artery catheter placement and haemodynamics interpretation, chest tube insertion, intubation, pericardiocentesis, and ventilator and dialysis management. Moreover, with the advent of point-of-care ultrasound, these task trainers have been designed to integrate the use of ultrasound. Task trainers also allow for practicing with devices such as the LUCAS and ECLS circuits, and are useful to help with troubleshooting equipment failure. Advanced procedures such as echocardiography, interventional cardiology, electrophysiology, and cardiac surgery have all been reproduced with the use of task trainers. This includes endovascular procedures such as coronary angioplasty, pacing, electrophysiological studies, peripheral vascular and structural interventions, as well as transoesophageal echocardiograms and extracorporeal membrane oxygenation cannulation (ECMO). Augmented virtual reality simulators are also fast emerging, notably in interventional cardiology and ECMO cannulation.33,34 Augmented virtual reality means wearing goggles/glasses that superimpose an image on a workspace that can be modulated and interacted with. In the future, teams will be able to meet in a shared virtual environment. It is a burgeoning field both in- and out-side medicine, with exciting possibilities. The use of simulation in these fields is only likely to increase if reduced clinical hours or clinical volume limit the number of cases a trainee is involved with.35 Wet lab simulation (namely the use of animals or cadavers) adds a further degree of realism, both in terms of anatomy and tactile tissue feel. In both anaesthesiology and intensive care, pig tracheas are used to simulate front-of-neck emergency access with open cricothyroidotomy. Wet lab simulation can also be used for ECLS cannulation and for cardiac surgery. As wet labs do incur additional costs, they are usually limited to very specific procedures where a non-biological simulator is not realistic enough. The future may bring even more change and possibilities, with the rise in 3D printing. Theatre-based or in-situ full-team simulation High-fidelity full-team simulations are best used to address more complex clinical scenarios and assess a combination of clinical knowledge, decision-making, resource use, and teamwork and communication dynamics. These simulations include all elements of the clinical team from attending physicians, nurses, respiratory therapists, residents, pharmacists, and occupational and physical therapy. These simulations can either be theatre based, where a physical room is simulated to look like a clinical setting, or in situ, where the simulation is held in an actual clinical environment to help increase realism. Clinical vignettes can cover the acute decompensation of patients, with successful management requiring an efficient and effective multidisciplinary team who can stabilize and possibly mobilize the patient for minimally invasive or surgical interventions. Examples of high-fidelity full-team simulations include cardiopulmonary arrest requiring advanced cardiovascular life support and respiratory management, managing the logistics of physically transferring a patient to the cardiac catheterization or electrophysiology labs, managing post-transcatheter aortic valve implantation complications, and extracorporeal life-support cannulations, to name a few. Simulations can also be expanded to include transportation logistics, including sending a patient to the operating room for ECMO, organizing ground or air transport to a centre capable of a higher level of care, or assembling a rapid response team within the hospital. Disaster response Disaster simulations are a perfect example of a HALO event well suited to simulation. These can range from power outages to fires, floods, or earthquakes to mass casualties or pandemics. Although the CICU rarely sees mass casualties or natural disasters, the COVID-19 pandemic demonstrated how any additional strain might cause a system-wide collapse. Accordingly, it is each of our responsibilities to be prepared. An example of disaster simulation could include a response to a large earthquake along the San Andreas fault, which would have widespread consequences along the United States western seaboard, potentially crippling most cardiac services across North America. In closing: overcoming barriers and next steps Prioritizing simulation will be an ongoing challenge in an environment of cost restraint, clinical backlog, and practitioner burnout. A simulation programme needs stable long-term support with funds, protected time, and experts in medical content, education theory, and individual/group psychology. Regular and well-designed simulation could be a game changer, but first we need a shared understanding. Without this, money and time could be squandered, and practitioners will resent simulations that are punitive or unrealistic. This is where physician champions are needed. We will be needed to provide clinical expertise, but just as importantly, we will need to enthuse, engage, excite, and perhaps even cajole the widest range of clinicians, administrators, politicians, and funders. In order to persuade others to adopt simulation we will have to ‘sell it’ as more than just an educational tool. It must be seen as a key means for Quality Improvement and Quality Assurance, hospital reputation, and staff engagement. We do not just need more simulation, we need better simulation. This means support across organizations from multiple departments that may have previously worked in independent silos. In addition to institutional buy-in and support, we need to identify and attract experts in adult education and human performance. 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Simulation in cardiology: state of the art . Eur Heart J 2015 ; 36 : 777 – 783 . Google Scholar PubMed OpenURL Placeholder Text WorldCat Author notes The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal: Acute Cardiovascular Care or of the European Society of Cardiology. Conflict of interest: The authors have no conflict of interests to declare. © The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Journal

European Heart Journal. Acute Cardiovascular Care – Oxford University Press

Published: Jan 9, 2023

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