Mastering healthcare on mannequins

Simulation in healthcare, in the broadest sense, covers a wide range of techniques and technologies, from computer-based simulation, to part-task trainers (such as cannulation arms), to simulated actor patients, to mannequin-based simulation.
This article will focus on mannequin‑based simulation, primarily because this is the simulation modality most frequently employed at the Scottish Clinical Simulation Centre (SCSC).
The earliest simulators included Chinese bronze statues which showed the surface anatomy for acupuncture and, in the 18th century, Giovanni Antonio Galli built an obstetric simulator with a glass uterus and flexible foetus which students had to deliver blindfolded. The first mannequin which attempted to replicate cardio-respiratory physiology and allowed for changes in response to medical intervention was Sim One.
Developed and manufactured at the University of Southern California in the mid‑1960s, Sim One could blink, breathe, had a heartbeat and palpable pulses. Unfortunately only one Sim One was ever built due to the expense of the mannequin and the lack of sufficient demand. It was not until 1987, when Dr David Gaba and colleagues constructed CASE 1.2, that a full‑bodied mannequin was used in the training of medical personnel. The sophistication and complexity of the mannequins has increased over the past 25 years and today’s mannequins are able to realistically replicate an increasing number of pathologies.

The state of the art
In the United Kingdom there are currently three main suppliers of high-fidelity mannequins: CAE Healthcare, Gaumard, and Laerdal. Each manufacturer provides a range of mannequins, both in terms of price and figure being replicated (e.g. pregnant woman, baby, adult man, etc.) The top of the range mannequins can replicate signs such as convulsions, bleeding and “falling asleep” in response to anaesthetic gases. A number of mannequins now also provide feedback to the controller regarding the actions that are being performed on the mannequin such as chest compressions, de-fibrillation and movement of the head. Many mannequins will allow the controller to note when certain events have occurred, such as the provision of oxygen, calling for help, and so on. This means there is synchronous development in physical replication, software physiological modelling and software integration with educational objectives. The concept that accurate replication of anatomy and physiology is not the end-product, but rather a means to an end is discussed in the next paragraph.

Simulation training and Team Resource Management (TRM)
Although he has now fallen from grace, Lance Armstrong’s book title “It’s not about the bike” could be slightly modified to create a truism in simulation: “It’s not about the mannequin.” Mannequins are only useful if the training which is carried out on them is of value.

Dr David Gaba realised this from the outset and used the CASE 1.2 mannequin to evaluate and improve team performance during simulated critical illness. Gaba modelled his programme on the aviation industry’s “Team Resource Management” (TRM) training, which aims to maximise team-working, effective communication and leadership while reducing errors. Although there are significant differences between aviation and healthcare, similarities include the risk of death or disability and the position of fallible human beings at a number of crucial decision-making points. There has been significant progress in the development of healthcare-specific programmes and methods for assessing healthcare personnel such as the Anaesthesia Non-Technical Skills (ANTS) and the Non-Technical Skills for Surgeons (NOTSS) behavioural rating scales.
The mannequins are therefore most educationally effective when they are used as part of a programme or course which has defined learning objectives (LOs). LOs should be derived from the needs of the healthcare personnel. These requirements in turn may be obtained from a needs analysis which uses data from a variety of sources such as adverse incidents, complaints and personnel feedback.

LOs must be specific to the specialty (e.g. nurses, dentists, healthcare assistants) and their level of experience (e.g. student, post-graduate, returning to work). A course which is designed around specific LOs can be organised to ensure that the mannequin’s capabilities are used to maximise the chances of addressing the LOs.
The LOs are addressed during the simulation course by carrying out debriefs after every scenario. The debrief varies between simulation centres but generally it involves a facilitated discussion between the participants regarding their actions, thoughts and behaviours in the scenario. The well-run scenario guides the participants to reflect on the LOs and to take away concrete steps for improving their future performance. It is hoped that this improved performance by healthcare personnel will lead to improved patient safety.

Simulation and patient safety
In 1999, the United States’ Institute of Medicine (IOM) published “To Err is Human: Building a Safer Health System.” This landmark report revealed that the healthcare sector is responsible for a large number of preventable deaths and injuries. Subsequent reports from around the globe have confirmed the IOM’s findings. The IOM report also claimed that the vast majority of preventable errors are due to human error. In effect, healthcare personnel, due to poor communication, leadership, team-working, planning, and so on, are responsible for thousands of deaths per year.
Because Simulation-based medical education (SBME) focuses on these specific behaviours, one would expect that SBME would result in improvements in patient safety. According to a 2011 review of the literature by McGaghie et al, SBME has shown this level of results in specific areas such as catheter-related bloodstream infections, obstetric complications and cataract surgery.

Confounding factors and the number of participants required to show effect will continue to make studies showing patient safety improvements difficult.

Lastly, although SBME can be effective in improving patient safety, it is not the solution but only part of the solution. SBME needs to be integrated within a wider programme of patient safety which includes governance, safety culture and an ethos of making patient safety the number one priority.

Further information