New simulation centre helps prepare Emergency staff for difficult real-life cases
Abilities honed on realistic manikin that mimics life-threatening medical conditions
Healthcare professionals in the JGH Emergency Department can now plan and participate in simulation exercises with greater ease and flexibility, following the official launch on June 21 of a bright, spacious and technologically sophisticated Emergency Medicine Simulation Centre in Pavilion H.
The Rhona and Errol Stern Simulation Room and the Hart Family Teaching Room enable Emergency Medicine (EM) personnel—attending staff, nurses, medical residents and students and respiratory therapists—to hone their abilities by working on a life-like manikin whose complex, life-threatening medical conditions mimic real-world emergency situations.
Since the instructive simulations are conducted in a setting where real patients are not at risk, participants can practice their skills in a safe learning environment and gain insights that allow them to better handle a wider range of medical emergencies.
The state-of-the-art studio quality of the audio-visual system in the new Centre also allows non-participants—those who are not directly involved in the simulation—to observe by video-conferencing in an adjacent or remote conference room in the hospital or even at home. Thus, these observer-learners can also benefit from the simulation experience.
Especially important in the process of learning through experience is the post-simulation debriefing. It allows learners to share their thoughts and explain their actions,with an opportunity to explore what went well and what aspects of the scenario could be improved.
Dr. Errol Stern, Director of the JGH Emergency Medicine Simulation Centre, explains that “simulation is just an excuse to debrief. It allows participants to gain a clear understanding of their actions and thought processes to enhance future clinical performance.”
Dr. Stern, who is also Director of the Simulation Program in the Department of Emergency Medicine at McGill University’s Faculty of Medicine and Health Sciences, adds that the participants in the simulation room and the observer-learners are all involved in the debriefing process. As a result, they are equipped with increased knowledge and skills, and are better prepared to deal with unstable ER patients.
The inaugural ceremony
At the ceremony to launch the Centre, Dr. Stern thanked Nina, Jeff and Cheryl Hart who were present. He also acknowledged his mother, Shirley Stern, who attended, and his late father, Edward, whose “hard work, success and encouragement fostered him to contribute to charitable organizations and projects.”
He also expressed the hope that “with the support of the hospital administration and donors, we can sustain this incredible method of teaching and quality improvement for health care for all of our patients.”
The focus during simulation scenarios is on an adult-sized manikin that not only breathes and blinks realistically, but has a pulse and is voiced by one of the facilitators at a microphone in the control room.
Near the manikin on its examination table are monitors that display the vital signs of the artificial patient—including pulse, blood pressure and oxygen saturation of the blood—plus bedside ultrasound videos.
Separating the participants in the simulation room from the facilitators in the control room is a large one-way mirror. Seated at a large instrument panel, the facilitators create a realistically stressful atmosphere by making frequent and sudden changes to the patient’s physiological condition and emotional state.
Simulated patient, real-life benefits
Dr. Eleena Pearson, who is a senior attending member of staff in the Emergency Department and a simulation educator, emphasizes that everyone learns, including the staff.
Dr. Pearson explains that she recently participated in a simulation session involving a patient with myasthenia gravis, a chronic neuromuscular and autoimmune disorder that is not often seen in the ER.
Not long afterward, Dr. Pearson found herself with an actual ER patient who had the very same condition. She credits her participation in the simulation session with her ability to recognize the condition quickly and treat it appropriately.
Dr. Arzu Chaudhry, a new attending member of staff in Emergency, echoes Dr. Pearson’s sentiments. As a recently graduating EM resident, Dr. Chaudhry says she enjoyed learning in a safe, dynamic simulation environment.
She has made the transition from a resident-learner to teaching and facilitating simulated cases as a member of staff, which she considers a “huge opportunity” to a chance to give back to the EM residency program.
It was Dr. Marc Afilalo, Chief of the JGH Emergency Department, who envisioned advancing EM education in simulation by converting two conference rooms in Pavilion H to the Emergency Medicine Simulation Centre. Dr. Stern says his leadership and vision are appreciated by all members of the JGH multi-disciplinary team in Emergency and by EM residents.
With Dr. Afilalo’s unwavering support to promote staff expertise and the initial financial contribution of the Hart Family and by Rhona and Errol Stern, the Simulation Centre has flourished.
Dr. Afilalo praised Dr. Stern for making the Centre a reality, describing him as “the key element in this project. When Errol has a dream, he follows it, no matter what happens, and he managed to gather a whole team behind him.”
As well, Dr. Afilalo noted that the Centre owes its success to the efforts of the department’s many doctors, nurses and respiratory therapists. “At the Jewish, we love to say we’re a family. We have a wonderful team in the Emergency Department and we’re all members of a family—that’s our major strength.”
“The strength of the Centre is its multi-disciplinary approach to learning,” Dr. Stern explains. “Every scenario has a nurse participant. Nurses are involved in developing cases with objectives and learning points that are specific to nursing. Where appropriate, we also involve respiratory therapists in cases where patients require respiratory life support.”
The audio-visual advantage
Dr. Haran Balendra, a member of the EM team, is especially impressed by “the versatility of the audio-visual system, in which every participant is clearly heard by the remote observers, as well as by the facilitators in the control room.”
“In addition, the facilitators can secretly talk to a confederate nurse or respiratory therapist who is in the simulation room, but works with the facilitators. If the facilitators in the control room feel that the scenario needs a nudge in the right direction, they can provide a confederate with a fact or a suggestion through their earpiece speaker that puts all of the other participants back on track.”
“Furthermore,” Dr. Stern adds, “participants are encouraged to request help, when appropriate, by placing a phone call to a consultant,who is role-played by a facilitator in the control room.
“It is now possible for that conversation—with the simulated consultant, ICU doctor or poison control centre—to be broadcast, so that the suggested advice can also be heard by the observer-learners at the remote location.”
For the simulation to be well received, Dr. Stern says, the participants need to be properly oriented to the manikin, the simulation room and its equipment, as well as to what is expected from them.
“That’s why we hold pre-briefings, where we emphasize that the facilitators believe that the participants are intelligent and motivated, and that they care about doing their best and want to improve.
“We also point out that the facilitators need to focus on how the participants work together as team. We stress elements of crisis resource management, which includes establishing a leader, encouraging the leader to share his or her mental model with the others, and urging followers to share their opinions. Promoting thoughtful and timely communication is highlighted.”
Lessons of the COVID-19 pandemic
Dr. Stern proudly notes that the value of the EM simulation was re-confirmed during the COVID-19 pandemic, when an educational simulation program was developed to teach healthcare workers how to safely deliver care to those who had been infected with the virus.
“We produced videos, conducted Grand Rounds with over 500 Zoom participants, set up many simulated practice sessions, and even created an accredited online course with the assistance of the Teaching and Learning Services at McGill University.”
Dr. Stern calls the performance of the new Simulation Centre “exemplary. It’s been extremely engaging, and what’s especially interesting is that the residents really enjoy being facilitators and sitting at the controls.
“The system is sophisticated, yet simple enough to operate that even residents who are unfamiliar with the technology, can learn to use it quickly and easily.”
This is a result of the many hours spent in the customizing the design from the ground up, a collective effort by JGH’s IT Department, Global Unified Solution Services, CAE and Dr. Stern.
Most importantly, Dr. Stern notes that the Emergency Medicine Simulation Program is a success because of the commitment, energy and enthusiasm of the physician-educators on the Simulation team (see sidebar).
They have worked tirelessly to advance proficiency in facilitating the development of simulation scenarios and in teaching the skills needed for crisis resource management and debriefing.
“Hopefully, with the support of the Hospital administration and donors, we can sustain this incredible method of teaching and quality improvement of health care for our patients.”
Credit where it’s due
The Emergency Medicine Simulation Centre owes its success to the insights and involvement of these EM specialists:
- Dr. Kamy Apkarian
- Dr. Haran Balendra
- Dr. Arzu Chaudhry
- Dr. Eleena Pearson
- Dr. Madelaine Yona
Special thanks to Melanie Sheridan, a Clinical Nurse Educator in the Emergency Department, who has retired from the Emergency Department and the Simulation Program; and to Dr. Julia Bernard, a former team member.
Typical of the scenarios in the Centre are two that played out one morning in mid-May, when a group of residents were put through their paces. In the first case, which was set in a simulated resuscitation area, the patient—whose medical history included regular dialysis treatments—experienced dizziness and an extremely slow heartrate because his potassium level was dangerously high.
The second case involved a patient whose nausea, heavy panting and sharp abdominal pains were complicated by extreme agitation, as a result of an aspirin overdose.
The Simulation Centre earned top marks from the residents who participated in them. “One of the challenges we face in EM is that some of the most complex and difficult cases don’t happen very often in real life,” says Dr. Robert Goulden, a fifth-year resident.
“The big benefit of the Simulation Centre is getting to experience and manage those more unusual cases and diseases in a safe, controlled environment. So when the day comes when we see them in real life, we’re ready for them.”
Dr. Audrey Marcotte, a fifth-year resident, agrees, noting that the Centre “has made me a lot more confident in my day-to-day interactions with patients in the Emergency Department.
“This is especially true for what we call HALO cases—High-Acuity, Low-Occurrence—that are difficult and rapidly evolving medical conditions that don’t happen very often. Even so, we need to be prepared for them, and now we’re in a much better position to do that.”
Essential support provided by the JGH Foundation
Developing the Emergency Medicine Simulation Centre, along with its many benefits for healthcare users, would not be possible without essential support from the JGH Foundation.
Donations can be made to the Emergency Medicine Simulation Education Fund by calling the JGH Foundation at 514-340-8251.
Here is a video about the JGH Emergency Medicine Simulation Centre: