Simulating your way to success

From CPR dummies to a Sims game

If lucky, the typical obstetrician sees a postpartum hemorrhage just a handful of times in his or her career. The problem is that the rarity makes it hard to prepare for the emergency. And even if the doctor is ready, will the team around the doctor know what to do without experience? You can read about what to do all you want, but just as your piano teacher told you, practice makes perfect. For a small obstetric and med/surg hospital, such as the 30-bed Sutter Maternity and Surgery Center in Santa Cruz, CA, drills using actors as patients seemed the best way to prepare. But they are imperfect, says Betsy Stone, MPH, DrPH, director of quality and patient safety for the Palo Alto Medical Foundation, which runs the facility.

The hospital is half perinatal, and half med/surg. There is no emergency department, and no ICU. If there is a bad outcome, the patients are transferred to Dominican Hospital, about a mile down the road. "Having people to pretend to be patients is just not the same as seeing the events unfold and cascade downhill," she says.

Lucky for Sutter, Cabrillo College, the local community college in nearby Aptos, has a nursing program that includes a simulation lab. One of the instructors is a nurse at Sutter, and she helped put together a program to do patient safety training drills with the Sutter staff at the college. The first drills, on issues such as coding patients and perinatal hemorrhaging, were in August. The hospital provided its own equipment so that staff would be working in a situation as close to that which might occur in their facility as possible. The sessions were taped, and the dummies were programmed for a progressive drill where a series of events showed the patient decompensating. The goal, Stone says, was to improve teamwork, collaboration, and communication.

In each drill, primary nurses started, with additional nurses coming in as the situation mandated and as they were called. For instance, a single nurse would do a hand-off to her successor for a patient. The new nurse would listen to the dummy's chest and perhaps hear some crackles in its "lungs." The "patient," however, would report feeling fine. What happens next?

Two obstetricians were also present for the perinatal drills, and other scenarios that include physicians are being considered. "These were learning situations, not punitive, and people were really excited to participate." Eventually, all the nurses at the facility will probably go through the drills.

What to start with was based on things that had either happened at the hospital or that keep staff up at night worrying they might happen, Stone says. "Sim labs help students learn to nurse, and it's the next best thing to using real patients. If you see something every five years, will you catch it after two minutes, when you might make a difference, or after 15, when you can't?"

If the hospital expands to include an ED or ICU, the ability to pair with a local simulation lab to work on issues like triaging will prove helpful. And she thinks it's a "gift" to give to staff to show them that in a fast-paced situation, they have the skills they need to make a difference. Reacting to an actor is different from reacting to real-looking data from a computer. An actor can't change his blood pressure; you can't pound on an actor's chest.

Sutter shared some costs with the lab, used its own supplies, and had to pay for the staff to attend the training. There was also a fee to use the lab. "But it was totally worth it," says Stone.

Expanding reach

While more facilities understand the value of simulation in improving patient safety, it's still not used everywhere it could be, or everywhere it will be, says Jeffrey Cooper, Ph.D., executive director of the Center for Medical Simulation at Harvard Medical School. Part of that is the worry about associated costs. But there are ways around that argument.

For instance, at Massachusetts General Hospital, anesthesiologists and some surgeons who go through a simulation training program get a break on their malpractice fees, he says.

And you don't have to build a whole simulation lab to use simulation dummies, says Cooper. You can use empty rooms. As for up-front costs, he notes that donors often like the idea of springing for such novel and potentially useful equipment. Training costs money, but there are grants.

"You don't know when you will have a fire or a disaster, but you train for that," Cooper says. "You are required to. But there is no requirement to train for clinical disaster." The costs associated with such dramatic adverse events can be astronomical. "But simulation as a training technique helps you learn to work together to prevent such catastrophic errors and harm to healthy people." Those are the cases that make headlines, Cooper says. It seems like an easy calculation for even the most cost-averse organization to make that working simulation into patient safety training is a good idea.

But it isn't just those exciting, sexy applications of simulation that matter. How to do basic infection control — things you have to practice until they become rote and that you don't necessarily want to practice on real patients — is a good use for mannequins, says Cooper. Another good one is to practice emergency procedures. "Not codes, but other kinds of emergency protocols. Pilots don't memorize what to do if an engine fails. They work in simulation, practice, train, and then do. Healthcare can do that, too, for all sorts of emergencies."

Usually, it takes one of those news-making bad events to get people on board with simulation. "Don't wait for that," Cooper says.

Coming down the pipeline is a new form of simulation that probably has more in common with your children's Sims computer game than a CPR dummy. It could be one of the most useful tools yet, says Jeff Terry, FACHE, managing principal of clinical operations for GE Performance Solutions.

Computer program models of a facility are created with a great level of detail. How many beds are filled and the number of transfers you expect; the times of your expected supply deliveries and how that might change if it snows; how many patients you have on the third Sunday in October — all of that is included. Using these models, you can change variables to see how your facility overall will perform. So if you have a busy winter Monday morning — because Mondays are always busier than Tuesdays — but three of your nurses come down with a cold, what will happen? How will your facility react if there is an outbreak of swine flu? What happens if your expected delivery of surgical supplies is a day late?

Terry says that knowing how many transfers you usually get on a Monday, with what acuity, and considering your existing patient census will allow you to staff appropriately.

Instead of practicing a procedure on a mannequin, you are simulating processes of care on a computer, Terry says.

The primary users of these newfangled simulation programs are primarily the bed desks, but the data they provide are helping QI staff, too. "There is a lot of capacity strategy in this at the start," he says. "But then you develop the QI and safety strategies to deal with your capacity. If three cardiologists leave, what do you do? If a hurricane hits, what happens?"

"Let's pretend" used to be a game for children. But dolls and computer game substitutes can be considered tools in the healthcare workplace of the future, too.

For more information on this topic, contact:

  • Betsy Stone, MPH, DrPH, Director of Quality and Patient Safety, Palo Alto Medical Foundation, Santa Cruz, CA. Telephone: (831) 212-5659. Email:
  • Jeffrey Cooper, Ph.D., Executive Director, Center for Medical Simulation. Boston, MA. Telephone: (617) 768-8906. Email:
  • Jeff Terry, FACHE, Managing Principal of Clinical Operations, GE Performance Solutions. Email:

Additional Resources