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Improving Care Outcomes Through Simulation‑Based Education | Quality Time with Dr. Schaal

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0:00 | 35:14

In this episode, Dr. Randy Steadman, chair of anesthesiology and critical care at Houston Methodist and associate director of Houston Methodist's MITIE at the Bookout Center, shares how creating realistic, immersive environments in simulation based education leads to better surgical and clinical outcomes.

Dr. Steadman has developed simulation instructor training programs for:

  • Clinical emergency response teams
  • Code blue teams
  • Obstetrical critical event teams 

Expert: Dr. Randy Steadman, chair of anesthesiology and critical care at Houston Methodist and associate director of Houston Methodist's MITIE at the Bookout Center

Notable topics covered:

  • Evolutions in simulation education
  • Benefits of using simulation education for critical incident training
  • Overview of MITIE simulation training and debriefing

Links:

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DR. SHLOMIT SCHAAL:

Welcome to Quality Time, a Houston Methodist leading medicine podcast. I'm your host, Dr. Shlomit Schaal. A Clinician Scientist and a Retina Specialist and I serve as the Chief Physician Executive of Houston Methodist, located in the world-renowned Texas Medical Center. I passionately believe that quality is the heart of health care, and a commitment to quality is essential for every health care system. Join us each month as we discuss the latest advancement in quality in health care with clinicians, researchers, physicians, industry experts, and thought leaders who are as passionate as I am. It is my pleasure to speak today with Dr. Randolph Randy Steadman. Dr. Steadman is the Carole Watler Looke Centennial Chair of the Department of Anesthesiology and Critical Care at Houston Methodist. Dr. Steadman is also Associate Director of the Methodist Institute for Technology, Innovation, and Education, also known as MITIE. He develops simulation instructor training programs for clinical emergency response teams, code blue teams, and obstetrical critical events teams. Welcome, Dr. Steadman.

DR. RANDOLPH STEADMAN:

Thank you, thank you for having me.

DR. SCHAAL:

Tell us a little bit about yourself.

DR. STEADMAN:

Well, I spent several decades in anesthesia before I came to Methodist and it was there that I got very interested in medical education and simulation, specifically. A very early mentor of mine had been exposed to simulation and he told me I needed a niche and he suggested several things that were hot topics at the time, and of them, simulation sounded interesting to me.

DR. SCHAAL:

When was that?

DR. STEADMAN:

That was in the mid 1990s.

DR. SCHAAL:

So a long time ago?

DR. STEADMAN:

Long time ago. But I had been an ACLS, an Advanced Cardiac Life Support instructor so I had a little bit of experience with -- experiential training. And I was always impressed by how engaged people were that came to ACLS courses. You could tell they were prepared, they'd studied. They didn't wanna embarrass themselves, and they performed well. And I thought, "Gee, this is something that if we can expand this to more than just a two-day or one-day ACLS course and make this a more common training modality, I think this will go over well with learners." There were certainly a number of doubters back in those early days, but being an anesthesiologist, I had the good fortune of knowing both of the two pioneering groups in simulation came from anesthesia departments that I had connections to. So I got to meet those people. And they -- They really, then, became my mentor and that's what got me started in simulation.

DR. SCHAAL:

So simulation I just, you know, remembering myself in the 1990s and obviously took ACLS and ATLS courses and, you know, all of that. That was very beginning, right? And so, tell us a little bit of how it had developed from that time until today. What are we doing differently? How has it evolved? DR. STEADMAN: Certainly. The -- You're absolutely right, it certainly has evolved a lot. When I first got involved, I proposed a business plan to my Chair and it was really a financial plan that was accepted and that's what got us our first mannequin that was automated, it had -- it breathed, and had pulses and could speak. And so, with that I started training the anesthesia residents. Because it was a departmental resource, that was my first target audience, if you will. But very soon I realized that we-- Where I was at the time was not as involved with the medical school as we could have been. And I said, "This is a great avenue for getting involved with the medical school. So I started teaching medical students there in their first year physiology course, and then we started in their -- the pharmacology course, and then we got involved with some of the third-year Sub-Is, sub-internships and clerkships, and fourth-year Sub-Is. So we got very involved with the medical school and we really then became a medical school unit that was -- that anesthesia had easy access to. And soon thereafter, the dean was very appreciative of all the efforts and he let me, then, start using it for other GME programs, other residencies. And before -- And ten years later we were teaching pediatricians, we were teaching general surgeons, working with them, with OR critical events. We even had radiologists and psychiatrists that came to the simulation center. So -- But those are very singular professions if you will, with a little bit of intermingling of surgeons and anesthesiologists. But pretty soon we realized that we need to get the whole team together. And so, we need to bring in the nurses, we need to bring in the pharmacists, we need to bring in the respiratory therapists. And when I arrived here at Methodist in 2020, they were ready. All of those groups that I just mentioned were ready for simulation. They just -- When I talked to them you could see that they knew what I was talking about, which that's very different from 20 years ago. So what is simulation? Tell our listeners.

DR. STEADMAN:

Well, simulation is really recreating events, if you will, that are not real. You're not using real patients, you might use standardized patients which would be actors, human actors that play roles, but many times we're using a plastic mannequin. The plastic mannequins, frankly, leave a little to be desired but, you know, when we do perioperative situations where the mannequin's draped and we bring in someone playing the role of the scrub tech and someone the role of the circulating nurse, it becomes pretty real as you start clanging around operative instruments. And people start acting as if they're in a real life situation. So it's --

DR. SCHAAL:

So the purpose of it is what? What is the purpose of simulation?

DR. STEADMAN:

Well, I think what we still use it a lot for are critical incident training. So these are things that, you know, when patients come in, we don't want them to have critical events. And in fact, some of the critical events that we like to train on don't happen very often. Take the quintessential critical event in anesthesia is malignant hyperthermia, and we think that happens one in 10,000 cases, maybe even less.

DR. SCHAAL:

But you train for that?

DR. STEADMAN:

We need to know how to treat that. My residents need to graduate. And they will probably not see a real case. They probably have a less than 50/50 chance of seeing an actual case. But I can guarantee that they see a simulated case that will evolve, like, some of the more challenging real cases. So, we try to make it challenging because we want them to sort things out and think about the differential diagnosis and think about the treatment. We also, very much, encourage them to use cognitive aids to call for help, to communicate clearly. So these are universal things that help not only that event that you're training them in but every other event that they might encounter.

DR. SCHAAL:

And has this become the standard now in medical student teaching all over the country? Every medical school is using simulation?

DR. STEADMAN:

I have seen data from the AAMC, the American Association of Medical Colleges, that I think 90% or more, if not approaching 100%, are using some form of simulation. Now, not everybody has MITIE that we have here.

DR. SCHAAL:

So tell us, what is MITIE?

DR. STEADMAN:

Well, MITIE is a 30,000 square foot area in the research institute that has a number of rooms that are connected audio visually that we can do these simulations with mannequins. I can be in a control booth and behind a one-way glass and then the learners are on the other side of the glass with the mannequin and the other, what we call actors, that are playing the roles of -- like I said, the circulator and scrub tech. And so we -- typically these scenarios take about 15-20 minutes to play out. I'm sure to the learners it seems like a lot longer than that, but then the most important part is sitting down afterward and reflecting on the objectives. So every scenario that we use has pre-scripted objectives and then they have objectives that you might run into based on the performance of the learner. In other words, they may start going to left field and,"Oh I didn't think they would even think of that. We need to talk about that during the debriefing." So, the debriefing is a way to unravel, just like they do in the military after a training operation or real interaction with an enemy. They debrief and they talk about what happened, what went well, what could be improved, what's generalizable for future other events that might be somewhat different. So, it's very customized to the learner, and they realize that and they very much appreciate that.

DR. SCHAAL:

So in medical school it's common, it's also very common in the medical licensing examinations, you know. Step three is, you know, you have actors and you have scenarios. What happens in residency? How prevalent is that?

DR. STEADMAN:

Well, most of the ACGME, the Accreditation Council for Graduate Medical Education program requirements do specify that simulation should be used because they realize we can't expose our learners to every type of event that we want them to become familiar with. They don't typically specify how much or what the nature of it needs to be. So we're very fortunate to have something like MITIE, a facility like MITIE.

DR. SCHAAL:

So, which residents do we train here? What department?

DR. STEADMAN:

The -- internal medicine has been very active. That's -- They help us with the codes and the CERT, the Clinical Emergency Response Team responses. So they're involved with that. We've also gotten RT, respiratory therapy as well as pharmacy are involved in those response teams. So they also participate with us. Critical care has been involved, anesthesia, of course, my department is involved. We have a new residency, so my residents are just now getting into monthly simulation exercises. We've done some with surgery, and that -- I think that's -- The other thing is nursing, nursing is way ahead of us here at Methodist in simulation. So the -- DR. SCHAAL: How so? SimPrep program has been involved with simulation for a long time. You know, as we know that we're understaffed with nurses and we need to train more nurses, the nursing requirements for training really allow a significant portion of their skills to be practiced in simulated areas. DR. SCHAAL: And they do it here? And they do it here. So, they have their own training but we also do training with them. So, I think the biggest -- You asked me earlier about what's changed over the years, I think getting these interprofessional teams together is what's really happened in the last three to five years.

DR. SCHAAL:

That's fascinating. And one question that I have for you is, you know, Houston Methodist Hospital is here, it's an academic medical center but we do have regional hospitals all over Houston. Is there simulation provided there to their physician nurses and the other staff members?

DR. STEADMAN:

Great question, and the answer is a resounding yes. DR. SCHAAL: Okay. Now, it's in a little bit different states at different community hospitals but some have dedicated space. Others use conference rooms. But I was just last week at the Woodlands and we did an obstetrical scenario, a postpartum hemorrhage and a prolapsed cord scenario. So, we got together teams of nurses, we had pharmacy there and we spent probably, like I said, about 20 minutes on the scenario and then about 40 minutes debriefing the scenario.

DR. SCHAAL:

So, is there any research to show that, you know, if you train by simulation, if you do this, if you spend time and resources on this you become a better physician, better nurse, better pharmacist? Is there any research about that?

DR. STEADMAN:

Yes, there is. Probably the classic paper is looking at central line insertion. So, inserting a subclavian, or internal jugular catheter. So, there were studies done at University of Chicago that show if you practice in a simulated environment you will not only do better, you'll have less errors, less pneumothoraxes, less infections, but it's also cost efficient. Which, that's one of the raps against simulation is, "We got plenty of patients to treat, why do we need to go off in MITIE and play with, you know, plastic mannequins?" Well, they actually looked at that and they saw the cost of sending people to a half-day training and then they looked at the pneumothoraxes that were avoided, infections that were avoided, and it actually came out to have a very good financial return on investment.

DR. SCHAAL:

So, that's fascinating. We've been interviewing, here, people form the aviation industry and their simulation is kind of, it's a no-brainer. They use simulators all the time. And I'm wondering if the culture, at least here at Houston Methodist is embracing the simulation because I do hear, yes,"We have so many patients why do we need to go into the lab?" If you will.

DR. STEADMAN:

Right, right. The -- I think the -- For the health care provider, you're not gonna see a prolapsed cord that often during a delivery and you're concerned whether you're gonna treat that correctly. So, by having -- simulating it and going through the steps and debriefing that and understanding the resources, who do I need to call? what do we need to do? In this simulation that we did last week at the Woodlands, the provider actually, when they were doing their exam and they felt the prolapsed cord, the correct thing is to not move your hand and keep the baby's head, the fetus' head from occluding the cord. So, once you're involved in this exam, you're stuck until you get the patient in the operating room and do a caesarian section and get the baby out safely.

DR. SCHAAL:

So it's better to practice it?

DR. STEADMAN:

So, we actually-- We're wheeling the mannequin down the hall with the health care provider holding the baby up while we got into the operating room.

DR. SCHAAL:

That's fascinating. And tell me a little bit about the technology. You know, the mannequins the 90s they could do very basic stuff, and I bet now with all the technology that we have, you have way more ways to mimic reality. How's that transpiring?

DR. STEADMAN:

There's certainly a huge industry now in medical simulation. So, there is a meeting every January, the International Meeting on Simulation in Healthcare. And there will be three football fields full of simulation technology there. The things that I'm excited about involve wearables. So, there's now wearables that you can then deliver a mannequin baby but you'll have an actual person wearing this prepartum belly. DR. SCHAAL: Wow. And it really let's you interact with a person who -- And it makes it so much more lifelike. And again, those communication skills, the teamwork, it's just richer if we have an actual patient. So, I actually am excited about these wearable technologies. The other thing that's also happened in the last, probably, decade has been more and more computer-based virtual reality type things and augmented reality. I still am not super excited about everything I've seen, but for things like surgeons who need to learn laparoscopic skills that did not learn that during their residency, virtual reality trainers are really the way to go to at least get them started before they're then proctored in the operating room.

DR. SCHAAL:

And so many of our processes and procedures today involve technology, so it's better, maybe, to learn this in a protected environment where you cannot harm anybody. DR. STEADMAN: That's true. That's true. So specifically for surgical simulators, I have experience with the, you know, when I started retina surgery, there was no simulator for that and now there is simulator that you can train in a safe environment. And you're inside an eye of a mannequin, but it really looks like reality and you're under a microscope. I used to operate on tomatoes and apples.[Laughing] In order to improve my surgical skills. So, I think that, you know, this is really a leap forward in how we train the younger generation. You talked a little bit about communications, tell me a little bit more of what these communications involve and why it's important.

DR. STEADMAN:

Well, you know, we think simulation is underutilized for patient safety and quality. So, we've just prepared a manuscript that's been accepted to a journal talking about how quality departments and simulationists need to spend more time together.

DR. SCHAAL:

Tell me more.

DR. STEADMAN:

So, we think that simulation is used to train students but instead we need to look at the kind of things that you and I look at in our hospital dashboards. So, if we're looking at something like this maternal hemorrhage, if we're looking at something like an infection or a deep vein thrombosis, these are things that we don't like to see. We like to keep patients safe, and by getting the whole team aware of, "What do we need to look for?""Oh, this patient doesn't have their SCD stockings on. This patient didn't get their dose of anticoagulant and they're bedbound, so they need something." So to get everybody on the team thinking about these type of critical events, patient safety events, is really important. In simulation, when you do simulation with the entire team, you can get everybody aware of what everybody else is focused on.

DR. SCHAAL:

And is there standardized communication?

DR. STEADMAN:

The communication -- Yes, there are. So, we talk about things like call outs, we talk about things like check backs. So, if something's happening quickly, a call out would be appropriate.

DR. SCHAAL:

What's a call out?

DR. STEADMAN:

A call out would be, "Over here, pulseless!" And so, you would want people to come and help immediately."Prolapsed cord" was what I heard last week. So that would be the call out. There, you're not necessarily expecting a response, but you're screaming it out and you see people around that you are expecting to come help. A check back would be if I suggested a dose of medicine, I would want the person that I told to give that dose to check back with me."Did you stay epinephrine 100 micrograms? Or was that milligrams?" Oh, that's an important distinction. So, the check back is to make sure that you have the facts correct.

DR. SCHAAL:

So call out, check back, anything else?

DR. STEADMAN:

There are, you know, there are leadership skills that we talk about, about delegating information. We talk about briefing, that's a role of the lead to brief the team at the beginning of either the day or the event or the clinic, or the --

DR. SCHAAL:

And who would that be? Would it always be the physician or anybody else?

DR. STEADMAN:

It can be anyone, but typically we want the lead to make sure it gets done. Whether they do it or delegate it to someone else is -- that's -- we could debate that. But in the operating room, there is time-out before induction that the anesthesiologist or the nurse anesthetist typically leads and then there's the second time-out before incision that the surgeon typically leads. So, there will be -- So, time-outs are one example of a brief and then intra --

DR. SCHAAL:

Do we practice that? Do we simulate time-outs?

DR. STEADMAN:

Oh, we do that. We audit it in the OR, we also simulate it. We also talk about huddles. A huddle would be communication that would occur if something unexpected happens or you get new information. You're in the emergency room, you see the EKG is showing an MI. Let's huddle up, we need to talk about -- We may need to get this patient to the cath lab.

DR. SCHAAL:

Mm-hmm.

DR. STEADMAN:

So that would be a huddle. And then a post-event, and we don't do this quite as uniformly and universally as we might, is the post-event debrief. And you can imagine how that might be a little hard in the operating room in that different people leave the case at different times. And everybody has different focuses of counting the laps or dictating their note or getting the patient to the ICU, but still, we need to be better at doing debriefings to talk about, you know, "This case was a little bit delayed because we didn't have the imaging.""We need to make sure that we have the imaging next time." We had the surgeon's preference card but we didn't have everything on it. We, you know, the -- So forth and so on.

DR. SCHAAL:

So debriefings should happen, actually, as a regular thing, you know, even if nothing unusual happened?

DR. STEADMAN:

I think it gets people used to improving.

DR. SCHAAL:

Mm-hmm.

DR. STEADMAN:

The debrief is designed to improve the next time, and if you don't do it regularly, it sounds punitive. If you only do it when something bad happens, it has a totally different sense to it and it doesn't improve the culture that we're trying to improve, and that is better, effective communication that improves care rather than blaming.

DR. SCHAAL:

So, tell me a little bit about TeamSTEPPS. You know, this is something that we're very proud of here at Houston Methodist. And, you know, some people know about it but I bet you the majority of our listeners don't. So, tell them a little bit about what it is.

DR. STEADMAN:

TeamSTEPPS was originally developed through work at the Department of the Defense and the Agency for Healthcare Research and Quality, and that was probably about 20 years ago. And I've been involved with it for a little over ten years now and it is, again, to teach these kind of communication tools that I talked about, check backs, call outs. It's to talk about how to deescalate situations, it's to talk about leadership, the briefing/debriefing that we just reviewed. And so we do this in a setting of exercises. So we will do some exercises that maybe -- tabletop exercises that are not medical but will get people thinking about,"Okay, were you using these tools that we've covered?" There's an app that you can get for your phone.

DR. SCHAAL:

Oh, there is?

DR. STEADMAN:

So, TeamSTEPPS is something that I strongly encourage people to look into, learn about. We've been doing two-day master training courses throughout the Methodist system and we've done, I think, three of those now for Methodist attendees and we've done probably about 30 people per course, so. And we try to follow up with them 2-3 months later and see are they incorporating the tools that we've given them in their workplace?

DR. SCHAAL:

And what do they say?

DR. STEADMAN:

We always get some good -- We get some great responses."Yes, we've started doing this and we've even gotten people that we didn't think we would get to do these things to do them." And then we also sometimes hear,"No, we haven't had time." So you hear a little bit of both, but I think I have seen, over this 10 years that I've been involved, more and more people being receptive. Because, there are certain words like "concern." That's a red flag word. So if I say to you "concern" and I might use that term in front of a patient, that means I want your attention and you need to respond to me. And you might say,"Oh, you shouldn't be concerned because of this," or you might say,"That's a good point, let's review that again." So, there -- Those kind of communication tools, I think, are very important to flatten the normal hierarchies that exist in health care so that the subordinate people on the team feel that they're not subordinate, that they can bring up anything they want. And -- Because, we frequently see -- When critical events happen, we see team members that fail to speak up.

DR. SCHAAL:

Yes, and this is something that we also discussed here with different people in our podcast, this culture of really -- People are afraid to speak up even though they think or know that something goes wrong. And this is, I think, a remnant of the culture of medicine that developed, you know, years ago, specifically in surgery where people, you know, the surgeon was almost, like, godlike figure and you were not allowed or you didn't feel comfortable doubting anything. But we're really working hard to change that because the patient is our biggest priority and we wanna keep patients safe. And so we want to allow people to speak up. And so, can you tell us a little bit, you know, in your department, you're the Chair of Anesthesia, how have you seen that played out either in your faculty or staff? Have you seen the change in culture where people are -- feel more comfortable speaking up and is it thanks to the training and -- Tell us a little bit more.

DR. STEADMAN:

Yeah. I certainly appreciate what you're saying that 10, 20 years ago, things were very different. There was the captain of the ship and everybody else just followed orders. And that concept is now dispelled, no one believes, that is in medical education, that that is the way things should be done. So, most medical schools are teaching some form of communication, be it TeamSTEPPS or some other methodology. So, the medical students that are arriving to our campus, you know, have generally been indoctrinated. What we have to do is not then undo that training that they got, so we need to model that kind of ideal communication. I think one of the things that when we see any kind of incivility or bullying, I think we need to call it out. And so, Dr. Montero and I in the department of anesthesiology have been very active in promoting that to our faculty, that we expect reports. And the reports may be about you if you're not -- if you're bullying. So we need to call it out and show people that we don't -- we need a respectful environment.

DR. SCHAAL:

So the -- Let me tell you -- ask you a little bit about anesthesia as a profession. Because, I think the, you know, so many procedures are done everywhere in our systems, including our outpatients clinics. How do you ensure that our patients are safe in all these areas, in all these operating room and procedure rooms? How do you maintain that level of quality.

DR. STEADMAN:

Great question. It is constant vigilance. Vigilance is kind of one of the bylines of an anesthesiologist. That's what we like to be in the operating room, but we also need to be vigilant during preparation. And I'm a big believer in standardized protocols, so we need these time-outs that we have, we need them written down and agreed upon and posted, and we need to use the same format every time. And not everyone agrees with that, but not everybody uses the cognitive aids that we provide. So, I think that's one of the ways to stay safe. You mentioned aviation, we know they have a pre-flight checklist. DR. SCHAAL: Right. And they actually look at the checklist, they don't try to memorize it, and they check it off with each other, the captain -- the pilot, and the copilot. And so, that's the concept that we're trying to get into in the OR and in procedural areas. And I think -- I think we're moving in that direction more and more.

DR. SCHAAL:

And did it play any role that, you know, more and more women are in that profession? Because, in the past it was all, you know, male anesthesiologists. And then you developed and there are more women anesthesiologists but also CRNAs and other medical professions that are involved in the anesthesia process. Did it help and make it better?

DR. STEADMAN:

That's a great question. You know, I don't know that I've ever seen a study that tells us that, but you're absolutely right in your observation that anesthesia is an area that in many places it's 50/50 or even more heavily weighted toward female anesthesiologists. And certainly CRNAs are significantly weighted toward female. So, it does. I think it does maybe make it a little more collegial.

DR. SCHAAL:

What are the biggest threats to patient safety and quality?

DR. STEADMAN:

Yeah, I think -- These were, certainly some of these things were highlighted by the pandemic, but even now as we're emerging from the pandemic, we still see that we're struggling with staffing shortages. We also, in medicine, as in a lot of professions, have production pressure and we also have burnout. We know that health care workers are some of the most burned out workers in any profession. We know that nursing and even my field, anesthesiology, high rates of risk of burnout. So, we need to make the workplace respectful and a destination for people to work so that we don't put undue production pressure on and cause burnout. And we need to try to be, you know, decide what staffing, appropriate staffing is and try to achieve that. And I certainly appreciate being here at Methodist where we do all of those things and prioritize them.

DR. SCHAAL:

That's wonderful. So, Dr. Steadman, we always ask our guests here, what does quality mean to you?

DR. STEADMAN:

Well, I think -- I was fascinated to hear a couple months ago at a Methodist event that eight out ten patients would change providers for convenience. So, that made me realize that if we're gonna take a patient-centric approach to quality care, it has to be accessible. DR. SCHAAL: Mm-hmm. So, that is something that I know you and I have talked about in meetings. We don't want long waits for our patients to get into our offices. So, that's kind of the first step. The other is safety. We know patients expect not to be harmed, so that's another core element of quality. And then the other typical things that we talk about are effective, efficient, patient-centered, so those are other aspects of quality.

DR. SCHAAL:

Yeah. I love that you put the access first. I always say access is quality. If patients cannot reach us, if it's not convenient to reach us then we don't provide high quality of care. Dr. Steadman, thank you so much for being my guest today. I really enjoyed listening to you and learning from you.

DR. STEADMAN:

It's my pleasure. Thanks for having me.

DR. SCHAAL:

And thank you for listening. Quality Time is part of Houston Methodist's leading medicine series of physician-led podcasts. So that you never miss an episode, subscribe to Quality Time. New episodes will download to your podcast device. If you enjoyed our conversation today, please consider rating this episode and sharing it with your colleagues. I appreciate your support, thank you. And until next time, I am always listening.♪ ♪