Harbor-UCLA Pediatrics

In a long forgotten space of the Harbor-UCLA campus, a corridor where discarded equipment used to collect dust, Tom Kallay, M.D., found a home for his passion: The Simulation and Skills Center at Harbor-UCLA. The Simulation and Skills Center at Harbor-UCLA is a place where health care practitioners from any field can participate in educational sessions utilizing a technique called simulation.

Simulation in medical education is a cutting-edge field where medicine, science, bioengineering, technology, and even theatre converge to create a training ground not unlike a Hollywood science fiction movie. Simply put, it involves training physicians with simulated human patients (computerized manikins) or body parts (task trainers), virtual reality, and standardized patient encounters performed by actors. Medical scenarios can be delivered which mimic reality in the hospital, and trainees have the opportunity to manage clinical problems in a safe environment. They can order tests, make management decisions, perform procedures, and practice their communication skills with real people portraying hospital staff or family members. It provides a safe arena to practice critical decision making and psychomotor skills, and even train on new systems implemented in the hospital. These attributes have led some medical resident education programs to include simulation as a required resource for education. Simulation has now been incorporated into the board certification process for Anesthesiology. For many years simulation has been embraced by the military, aviation, and the space travel industry, and today it is gaining momentum in the field of medicine.

Dr. Kallay is an assistant clinical professor of pediatrics in the division of pediatric critical care medicine and serves as the director of both the Simulation and Skills Center and the Pediatric Intern Airway Course at Harbor-UCLA. When Kallay first joined the faculty in 2006, he knew he had much to offer in the way of teaching – just not in the traditional way. Since then, he has received two Outstanding Faculty Teaching Awards from the Department of Pediatrics residency program. With support from Harbor-UCLA administration, LA BioMed, and the Department of Pediatrics, Kallay secured a space for a project he had been planning for years – the Simulation and Skills Center. The Center is located in building B-4 North, a complex adjacent to the hospital which had been occupied by neurology and neurosurgery for many years. The mission of the Center is to promote patient safety and clinical outcomes by integrating simulation technology into the current educational curriculum for all healthcare practitioners and students at Harbor-UCLA.

While the lab is still in the process of becoming fully operational, it will be a multidisciplinary innovative learning center that incorporates medical scenarios, task training for procedures, and patient encounters such as office visits. All training can be video recorded, played back, and analyzed for competency and improvement. In addition, a state of the art observation “theatre” outfitted with large high-definition LCD monitors is in the works so observers can watch live simulation training in progress. The lab will also conduct medical education research for future grant applications to help advance the field of simulation-based medical education.

The Simulation Center houses high-fidelity three-dimensional models of adults, children, and babies, all of which look and feel like real human beings. The sim models are anatomically correct and emulate human physiology as closely as possible. Their hard, artificial spines even contain tubing filled with water to mimic the spinal canal. The models are networked wirelessly and are controlled remotely via computer. Depending on the scenario, features such as blood pressure, pulse, or heart sounds can be modified from a one-way mirrored control room. Some of the manikins can produce arterial or venous bleeding and have pupils which react to light, providing opportunities for many types of procedures. Students can practice spinal taps, intubations, central lines, chest tube insertions, bronchoscopy, suturing -- virtually any procedure which is performed in the hospital. With the incorporation of virtual reality, skills such as laparoscopy or endovascular stent placement can also be practiced. See below for a slideshow of various models:

The instructor explains each aspect of a procedure to students and then students carry out the task on the models. In the case of a spinal tap, this involves detailing the task from start to finish – setting up the kit, sterilizing the skin, draping the patient, and inserting the needle. When a student successfully performs a spinal tap on a model, water is expelled from the tubing. If a student does not hit the tubing correctly, he or she can repeat the procedure with hands-on help from the instructor.

For Kallay, the impetus for this avant-garde project originated during his training. At times during medical school and later in his residency, he observed that procedures taught in “real-time” were not as effective as they could be. Sometimes communication skills were lacking or an actual medical crisis took priority over training. Frequently, doing a difficult procedure for the first time while family members looked on was just plain nerve-wracking.

As Kallay saw himself as an educator, he joined the Harbor faculty with the intention of developing innovations in medical training and education. During his medical education fellowship at UCLA, he was formally introduced to simulation based medical education. As part of his fellowship Kallay designed a simulation education and research center -- thus laying the groundwork for his future plans. In the process of completing his assignment, Kallay decided he would eventually build the simulation center and the assignment evolved into a full-fledged business plan. What Kallay loves about the process of building the lab is that he has learned skills that extend beyond medicine. “I’m learning about construction and producing -- creating things, which I’ve never done before and that’s really satisfying.”

Kallay’s passion came from the notion that simulation medical education wasn’t just novel, it offered the freedom to experiment, to learn and to build confidence in a safe environment. If mistakes happened, no patient would be harmed. There was a clear opportunity for both the educator and the physician-in-training to execute and repeat procedures without any risk whatsoever.

To understand the benefits of simulation training, one needs to examine the beginning of the learning curve. For example, in a clinical setting a resident will typically instruct a medical student on how to perform their first spinal tap on a real patient. Kallay says that in this scenario, most students have never seen or handled the tray of instruments before, much less inserted a needle into a child’s back. “Why should this child serve as a training ground for a person performing their first spinal tap, when there are models to practice on beforehand? Being familiar with the tools and the process will increase their chances of success on a real patient, and hopefully will decrease the risk of complications.” Having been instructed this way and teaching others in this fashion, Kallay wanted to provide students another avenue to gain experience with such complex procedures, which he feels is better for patients overall.

In addition to the safety factor, Kallay says this type of training fosters one of the most important skills a physician can have – confidence. One of his students had a particularly tough time performing spinal taps. Kallay said they practiced on a baby model and “worked through her nerves.” When she hit the spinal canal tubing, she was elated. According to Kallay, assuaging the fear of failure is a huge triumph. “Students can practice in a safe environment, they’re not hurting any patients, they’re becoming familiar with difficult procedures, and they’re building up their confidence. Then when they go out into the real world and do it, they’re more likely to be successful.”

While Kallay believes compassion is innate and not learned, he asserts that training doctors for tough moments makes a difference. After a lecture on the proper protocol for handling bad news, such as a patient death, Kallay employs fictional scenarios. Kallay presents a case “story” to the student and the student must then deliver the news to the patient’s family. Real people play the parts of the patient and family members and the scenario is recorded and played back for review. Sometimes physicians do not realize that their own perceptions may differ from reality. Kallay remarks that in nearly all the breaking bad news scenarios, students gain insight as they watch themselves. They realize that they could have delivered some of the information in a different way, or that their body language was not what they had imagined. In this way, simulation training offers more opportunities outside the clinical setting for physicians-in-training to learn better communication skills.

Even though the benefits of simulation medical education make sense intuitively, many health practitioners are skeptical. They believe medicine is far too complex to simulate properly. Critics conceive that simulation cannot replicate a bona fide human encounter, or that it takes time away from true clinical experience. While there is some validity to these concerns, there is a chance a resident may not come across certain clinical situations during their entire training. Simulation offers an opportunity to practice the low frequency, “high stakes” cases. If residents were not exposed to particular cases during their real-life training, simulation ensures they can practice the fundamental aspects of scenarios in a real-time, three-dimensional way that a book cannot provide. Simulation-based education is a supplement, not a substitute, for true-life clinical experience. As an experienced clinician, Kallay says “It’s really important that simulation education is only a small part of medical training. It must be laser-focused, intense and high-yield.”

Although training sessions are now in progress, Kallay plans to formalize programs in the coming months once the Center is fully "online." One program planned for the near future is a “boot-camp” at the start of the academic year. Interns will learn basic skills such as resuscitation, defibrillation and intraosseous line placement in focused sessions. In addition, the Department of Emergency Medicine will be holding part of their intern orientation at the Center in July of this year. For the 2011-2012 academic year, training will be available to all Harbor-UCLA staff, with different blocks during the week carved out for each participating department. An online scheduling system will allow learners to access the calendar of events, as well as course materials and tests. Kallay has just completed the first stage of remodeling and has hired a full-time Simulation Coordinator, Johnny DiBonaventura. DiBonaventura has experience in developing medical simulation centers and is an expert at producing learning modules. The space has a large elegantly designed suite for scenario delivery and an area for skill labs. There are also two offices which will serve as outpatient encounter rooms in the future.

For more information on the Simulation and Skills Center contact Dr. Tom Kallay at tkallay@labiomed.org or Johnny DiBonaventura at jdibonaventura@labiomed.org.