Three years of “CASMS”: the world’s busiest medical simulation centre

Medical education is undergoing significant change, with curriculum redevelopment and the introduction of new teaching methods, including enhancement with computer-based programs and increasingly sophisticated task trainers and simulators. Leading the change in new teaching techniques is simulation technology.1-3 Simulators themselves are costly, as is maintaining appropriately trained staff in a realistic clinical environment, with appropriate audiovisual support. Governments, universities and professional medical, nursing and paramedical colleges and societies are likely to acquire such sophisticated training capabilities only through a collaborative approach. In this article we describe the development and operation of a purpose-built medical simulation and skills centre known as “CASMS”, the Centre for Anaesthesia Skills and Medical Simulation, at the Clinical Training and Education Centre (CTEC), University of Western Australia.

CASMS contains three complete and independent simulation suites, a skills area, a conference room and an administration area (Box 1). Each suite comprises a simulation room, which can be presented and equipped as an operating theatre, emergency department resuscitation area, recovery room, endoscopy suite, medical practitioner’s office, or any other area as the training need requires. An adjoining control room allows course leaders to observe participants, control events, manipulate mannequins remotely, and communicate to role-playing training staff in the simulation room via wireless headsets. An adjacent “debriefing” room is used for tutorials, discussions and formal debriefing sessions after each scenario.

The scenario-based training was pioneered by Gaba and colleagues at Stanford University.4 This novel style of medical training was well known in aviation and other high-risk industries that involved complex work environments requiring active decision-making. After a period of familiarisation with the simulator and discussion of strategies for managing medical crises, participants take turns at experiencing a medical crisis in an environment that matches their workplace. The scenarios are usually audiotaped and videotaped in real time. Segments of the crisis are replayed where appropriate during facilitator-managed debriefing sessions. An example of a medical crisis during a routine dental procedure (from a “Medical emergencies during dental practice” course) is shown in Box 3.

There is increasing awareness of the need for improved patient safety among the general public and medical defence organisations. Simulation centres play a valuable role in providing a safe environment for training without risk to the patient.5 The ability of simulation centres to repeatedly present rare and unusual cases to participants is also valuable, at a time when inpatient numbers are declining and fewer real “cases” are available for students and junior staff to experience.

However, for simulation centres to maintain high standards and to continue improving the quality of training available, access to a simulation centre must be increased for the wider medical and nursing community. Scenario-based training requires a dedicated area that appears no different from the clinical domain that it represents. Medical and audiovisual equipment demands are such that it makes sense to build a dedicated clinical area that is flexible enough to be modified according to the setting, and is well-equipped for inconspicuous videotaping of clinical events. At least one separate area for small-group teaching and post-event discussion is also required. Debriefing sessions are essential in scenario-based training, and are regarded as the most difficult role for instructors. Training in debriefing techniques should be acquired before undertaking scenario-based training.

Sufficient funds to construct several simulation suites in a centre allows for more efficient use of resources. Ideally, surgical skills centres would be collocated with medical simulation centres to foster interdisciplinary courses, and to share support services and lecture rooms. The use of web-based learning materials to be completed before attending the centre also leads to more efficient use of the simulator centre.

Worldwide, there are over 150 centres with high-fidelity simulators and more than a third of medical schools in the United States have at least one simulator. In Mainz, Germany, a shared medical and aviation simulation centre has been established. In Australasia, simulation and/or medical skills centres operate cooperatively and share expertise and even instructors. Currently, the centres are: Southern Health Simulation and Skills Training Centre (Monash Medical Centre, Melbourne); St Vincent’s Simulation Centre (St Vincent’s Hospital, Melbourne); Sydney Medical Simulation Centre (Royal North Shore Hospital, Sydney); National Patient Simulation Training Centre (Capital Coast Health, Wellington, New Zealand); and Flinders Clinical Skills and Simulation Unit (Flinders University, Adelaide). New simulation centres are planned for Brisbane (Queensland) and Auckland (New Zealand).

Flexibility of educational style is important, and the input of a dedicated medical educationalist is of great benefit. Gaba’s scenario-based training methods are only suitable for some courses, and assessment of individual and group performance during simulator-based medical emergencies is complex.6,7 Other methods, such as problem-based learning, may be particularly appropriate for medical students,8,9 and outcomes-based learning should be considered as a method of guiding the content of courses and assessment of participants. Continuing development of simulation-specific assessment tools and evaluation of courses are vital.

Remediation for professionals with specific needs is also an area that should be further considered by simulation centres. Simulation centres are ideal for fully assessing individual need in a safe environment and for providing learning opportunities to remedy specific problems.10,11

In conclusion, medical simulation centres have a significant contribution to make at all levels of training for healthcare professionals. Despite large start-up and maintenance costs, the increasing need for such collaborative skills centres will ensure their continued success in the Australian healthcare system.

1: Floor plan and images of the Centre for Anaesthesia Skills and Medical Simulation (CASMS), University of Western Australia

(Architectural drawing copyright, John Flower Architect Pty Ltd)

3: Dental scenario: a cardiac event during a routine dental procedure

Setting: A 55-year-old man with known heart disease undergoes a prolonged dental procedure. The patient complains of chest discomfort and the dental nurse notices that the patient has been sweating and now appears grey. He is then unresponsive, pulseless and apnoeic. The dentist and nurse start cardiopulmonary resuscitation (CPR) after a pocket mask is found in a drawer. They call for help from the receptionist. An ambulance is not called. The scenario is stopped when the instructor detects effective ventilation and cardiac compressions. Debriefing: The facilitator (F) asks the dentist (D) to describe to the group (observing via videolink from a nearby room) what happened and what he was thinking. Laerdal SimMan adult simulator in a dental chair →
F: “Let’s go over what just happened.”	D: “The patient crashed on me.”
F: “When did you first realise you had a crisis?”	D: “When he didn’t answer the nurse’s question.”
F: “What type of emergency was it?”	D: “A cardiac emergency.”
F: “What clues were you given that something like this might happen?”	D: “He had a history of heart disease and the procedure was long and stressful. Apparently he was sweating a lot, but I didn’t realise that”.
F: “Were you prepared for this?”	D: “I am a bit shaky on my CPR skills and you never hear of patients having an arrest in the chair, do you? We are not really prepared for this sort of thing anyway. I don’t even know if our receptionist could do much to help out if something like this happens.”
A segment of the scenario (patient stops breathing) is replayed.
F: “What do we learn from this?”	D: “There was a long delay before we did anything. I was distracted with the job and then I couldn’t believe this was really happening. I guess we didn’t know where our emergency gear is kept. We don’t have much gear anyway. We should have called for an ambulance.”
F: “How could we improve our ability to handle medical emergencies?”	D: “Have a ‘resus’ kit in clear view, make sure our staff get some training, and organise a system in our practice to follow when this happens”.
A discussion follows on emergency equipment needed for dental practices and staff training.