A patient has gone into cardiacarrest in the middle of a com-plex surgery. And just as thecrash cart is brought into the

room, the power goes out. Panicked?Maybe a little. But is the patient safe?Absolutely! Because the patient cannotbe killed — it is a mannequin.

PHOTO COURTESY OF BEAUMONT HEALTH SYSTEM

This simulatedoperating

room is hardlydistinguish-able from thereal thing.

PRACTICEMAKES PERFECT

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Planning considerations for medical simulation centers

| BY KENNETH ROSS

And this is strictly an exercise to helpclinical staff remain calm and focusedduring a moment of crisis. Welcome tothe world of patient simulation.The use of patient simulation has been

growing as more health care facilities real-ize the value of training clinical staff incontrolled environments. New and experi-enced doctors and clinicians can practice

skills and learn new procedures onadvanced mannequins or other trainingdevices. And where better to train newnurses on procedures than in a simulationarea away from patients and operatingrooms (ORs) that are heavily scheduled?This inevitably means new projects for

health facilities professionals. Over thepast 10 years, health care has experi-

enced a five- to tenfold increase inthe number of simulation centers,or “sim centers.” There are about1,000 sim centers in the UnitedStates and the number is expectedto grow. Patient simulation trainers— full-size mannequins (alsoknown as training mannequins orpatient simulators) and anatomicalmodels (partial bodies like torsos,abdo mens, and arms) — are usedto simulate a range of scenarios,from infant delivery to multivictimdisasters.Medical schools were early

adopters of medical simulationbut, more and more, nonacademichealth care facilities are seeing thevalue of staging and recordingevents. But why are medical cen-

ters spending millions of dollars on thesecenters? What kind of technologies areinvolved? And what are the infrastructureand space requirements?

Why build sim centers?Simulation centers provide a customizedlearning experience where it’s OK tomake mistakes. Training can take many

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» PRACTICE MAKES PERFECTPHOTO

S COURTESY OF BEAUMONT HEALTH SYSTEM

TOP This surgical skillsand tissue lab allowsup to 40 surgeons-in-training to practiceindividual and groupsurgical skills.

BOTTOM A full-scalemock operating roomwith a da Vinci Sur -gical System is usedto practice minimallyinvasive procedures.

forms. It can utilize simulated patients oractors in simulated situations. These arecompletely different situations but bothhave a common goal — to create a betterprepared medical professional.Simulation centers are all about prac-

tice. Whether training on a simulator orwith an actor, there is no better way tolearn the skills of working in an OR thanpracticing in a simulated OR. Likewise forsimulated intensive care units (ICUs),emergency departments or other units. Sometimes, the skills are as simple as

opening a sterile pack or learning how todeliver bad news to a patient or family.They’re necessary skills, but just not easyto learn from reading a textbook. Simulat-ed environments also allow for coordinat-ed team training and video debriefing,including assessment, immediate feed-back and evaluation at the conclusion ofthe training session. This can be a valu-able tool for assessing progress and levelof competency.Simulator use varies substantially.

Basic models can help health careproviders remain competent in perform-ing intubation skills, basic life support,and advanced cardiovascular life support.Also, hospitals increasingly are turning tosimulated operating and labor and deliv-ery rooms with mannequins that help todevelop and assess skills for training pur-poses. With training focused on the simu-lated patient, sim centers can mimicmany circumstances, including realisticchallenges like heart rate changes, poweroutages and specific device failures, suchas the shutdown of an anesthesiamachine.Another trend is for simulation spaces

to be used for conferences and equip-ment trials. In some cases, flexible spaceis being used to build entire operatingsuites to evaluate the type and position ofnew equipment.

Complex design taskEstablishing and running a state-of-the-artsimulation center often requires numer-ous staff members and millions of dollars.What once was a simple training roomhas been transformed into a showcase forthe hospital and potential revenue sourcefrom outside clinicians willing to pay forpractice and training sessions.The typical simulation center includes

the technology to record, review, scoreand store the simulation scenarios. This

requires not only a staffed control roomand robust data storage capability, but asophisticated network of video cameras,monitors and conference rooms for view-ing — similar to audiovisual (AV) control

of an OR integration system.Space and design. As centers have

grown, so has the necessity to planahead. Simulation centers come in allsizes, from 5,000 to more than 90,000

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MEDICAL TRAINING EQUIPMENT commonly found in sim centers

Simulation centers, or “sim centers,” house a wide variety of trainingtools ranging from simple anatomical models to realistic simulators.The most common ones include the following:

• High-fidelity simulators. Some of the most expensive items found in asimulation center are the high-fidelity mannequins. High-end models can runfrom $20,000 to $100,000. They continue to be designed more lifelike andare capable of simulating physiologic changes such as a loss of pulse, dila-tion of the pupils or a sudden drop in blood pressure. Mannequins can bewirelessly controlled by an operator through a computer or a personal digitalassistant and may be able to speak in prerecorded sounds or those of theinstructor. Custom scenarios can be loaded to provide unique experiencesto each training team, such as creating stress that might lead to errors, anddata can be collected for performance analysis. • Medical equipment simulators. While simulation centers are full of

actual medical equipment, such as that used in an operating room or inten-sive care unit, users also will find equipment designed specifically for thesimulation environment. Since it isn’t practical to purchase a $1-million to$2-million da Vinci Surgical System from Intuitive Surgical Inc., Sunnyvale,Calif., on which to practice, hospitals are turning to Intuitive Surgical’s$85,000 skills simulator instead. Likewise, ultrasound simulators are con-venient because they combine the learning of an ultrasound system withspecialized mannequins, providing another type of hands-on experience with-out the need for live patients. • Models. Simple models are essential in classroom environments. Avail-

able as either a full body or specific body parts, such as the heart or theeye, these aids are used to demonstrate anatomy or teach basic skills.• Simulation center software. Software to run a simulation center is

equally important. Software can range from basic scheduling programs tomore advanced programs to record and score scenario-based interactions.• Task trainers. Typically, the bulk of the items in a simulation center are

the task trainers and other basic mannequins for a wide variety of students.Basic mannequins are used for teaching the general public basic skills andcardiopulmonary resuscitation (CPR). Advanced mannequins for CPR,advanced cardiovascular life support and pediatric advanced life supporttraining that provide feedback for improving skills also are common. Besidesthe full- and partial-body mannequins, users will find specific trainers forsuch tasks as tying sutures or for inserting an intravenous therapy line.• Virtual reality procedural trainers. Virtual reality trainers also are an

important component of the simulation center. These trainers typically arefocused on minimally invasive procedures such as endoscopic, laparoscop-ic, endovascular and urologic procedures. Using realistic hand controls withhaptic feedback, students can practice skills like deploying a stent whilemonitoring patient vital signs and watching a screen, similar to watching afluoroscopy screen in the operating room. �

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square feet, and space must be allocatedfor many different activities. But, decid-ing how much space to allot for differenttasks is challenging. Adding more stan-dardized patient rooms could reduce thenumber and size of classrooms. Likewise,adding more simulated surgical suitescould reduce storage significantly anddrive up costs, because each OR typicallyis filled with actual medical equipment.

In the end, knowing the student volumeis key to accurate planning.The four primary physical areas of a

health care simulation center include thefollowing:

• Reception and waiting areas. Firstimpressions are important and a hospitalmust decide whether its simulation centerwill focus on function or show. For exam-ple, if the simulation center is intended to

be used for a fee by outside clinicians,the hospital may want a larger, moreimpressive reception area. In general,reception and waiting areas are used togreet trainees and visitors and often haveelectronic monitors with schedules anddirections. Additional gathering areas willbe necessary near skill areas, especially ifthe center spans several floors. The hospital may even want to consid-

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» PRACTICE MAKES PERFECTPHOTO

S COURTESY OF HARTFORD HOSPITAL

TOP A control roomview of a simulatedoperating room.

BOTTOM LEFT Thisrobotics lab includestwo different da Vincitraining simulators.

BOTTOM RIGHT Anadvanced trainingmannequin ready forthe next educationalsession.

er adding kiosks or interactive maps ifapplicable. The size of these areas shouldassume full operation of the center.

• Skill areas. This is the heart of anysimulation center. Whether a full-sizedOR, a skills lab or a standardized patientroom, these areas define a simulationcenter. They require control rooms — typ-ically one for each one to two simulationrooms — that are located adjacent to thesimulation. They’re often behind one-waymirrors with space for monitors, key-boards and microphones. Standardized patient rooms often can

be monitored by one central controlroom. Depending on the size of the cen-ter, users may find one to three ORs, fiveto more than 40 standardized patientrooms, a fully simulated ICU, imagingrooms and multiple skills labs with fourto 20 stations. If a technology is being used in hospi-

tals — including Sunnyvale, Calif.-basedIntuitive Surgical Inc.’s da Vinci SurgicalSystem and various computed tomogra-phy scanners — there’s a high chance thatit can be found in a simulation centersomewhere in the United States.

• Teaching areas. No simulation centeris complete without classrooms anddebriefing rooms. Classrooms are used toteach groups and often incorporate flexi-bility, such as partitions that can beremoved to combine spaces.Teaching areas need to be near skill

areas because they often are used to prepor review with large groups. Some largercenters add auditoriums for large gather-ings or boardrooms for more intimate settings in addition to the standard class-rooms. Debriefing rooms typically are smaller

and intended to be used by two to fourpersons to review the exercise personallywith a trainee. Often video is played backso trainees can learn from their mistakes.

• Support areas. Hospitals must becareful not to forget the behind-the-scenes spaces that are critical to the sup-port of the educational operations. Simu-lation centers also include offices, breakareas, locker rooms, storage rooms anddata centers. The larger the center, the larger these

areas need to be. Some centers havebecome creative with storage, fillingentire walls with large storage units thatcan house numerous mannequins and

other training aids.Location. The size of a medical simu-

lation center often dictates its location.Small centers can be accommodated in ornear the main hospital, but larger centersoften dictate alternate sites. The closerthe simulation center is to the main hos-pital, the easier it will be for staff to uti-lize. If services for visitors are being con-templated, accessibility to parking shouldbe considered.Other major considerations. Addi-

tional key issues that require proactiveplanning to prevent big problems down-stream include the following factors:

• Logistics. Unless a hospital plans tohave numerous staff members standingaround to direct students, it will need toinstall a system that directs them to theproper training room. This means moni-tors in reception areas, waiting rooms,hallways and possibly outside each simu-lation and standardized patient room. Medical simulation centers go to

extreme measures to ensure that theproper student enters the standardizedpatient areas and that documentation isaccurate, including the use of radio fre-quency identification tags.

• HVAC load. Facilities professionalsshouldn’t underestimate the heat generat-ed by the computers, servers, monitors,lights and other equipment within thesimulation center space. This load mustbe accounted for in the overall HVAC sys-tem design. Special attention should bepaid to control rooms and server rooms,because these areas often are crampedand filled with heat-producing items thatare sensitive to fluctuations.

• IT and AV needs. Simulation centersare challenging for information technolo-gy (IT) and clinical engineering depart-ments. Computers are needed to run thecenter, schedule students, schedule stan-dardized patients and reserve man-nequins as well as to score the simula-tions and to debrief the students. Plus, allthe systems that run the simulators andother support systems are needed. Adding to the data overload are the

cameras and microphones required torecord all of the simulation and standardactivities in the center. In most cases,there will be more than one camera perroom because of the importance of cap-turing facial expressions. This means sig-nificant amounts of data will be generat-

ed each day, regardless of whether high-definition quality is utilized in all areas. All of the data need to be backed up.

Backing up on-site or remotely is critical.The bottom line is that the IT and, likely,clinical engineering departments need tobe involved early.

• Future proofing. Like all electronics,the useful life of simulation equipment islimited. Items installed today likely willbe obsolete in three to five years. Moni-tors will break. Computers will need tobe replaced. Cameras may need to beupdated due to resolution improvements. The good news is that while there like-

ly will be more pieces of equipment, theytend to be more compact with each suc-cessive generation. The trick is to preparefor these changes in technology. This is nowhere more important than

with the cabling. Category 6 cabling willbe outdated. Digital visual interface sig-nals will be run over fiber rather thancopper. Running conduit in walls — thelarger the better, especially if there are90-degree angles — and providing ceilingswith accessible pathways is critical toensuring that a simulation center remainsstate of the art. A path for a large, high-speed backbone for remote off-site databackup also should be considered.

Coming into their ownSimulation centers are coming into theirown and hospitals are investing largeamounts of money to make their centersstate of the art. What once was a 5,000- to 10,000-

square-foot skills center began to morphinto a 20,000-square-foot simulation cen-ter. Then health facilities professionalsbegan to see larger and larger trainingcenter projects reach the 50,000- to60,000-square-foot range. Centers addedmore and more classrooms and increasedthe simulated patient rooms past 100. The sky now appears to be the limit for

teaching medical professionals, as a $38-million, 90,000-square-foot facilityopened earlier this year in Florida thathopes to train 30,000 to 60,000 medicalprofessionals per year. HFM

Kenneth Ross is senior program

manager in the applied solutions

group at ECRI Institute, Plymouth

Meeting, Pa. He can be reached at

kross@ecri.org.

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