So Precisely What Is Simulation? 
David Gaba, MD, associate dean for Immersive Simulation-Based Learning and director of the Consortium for Immersive Based Learning at the Stanford School of Medicine, describes it as “a technique—not a technology—to replace and amplify real experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner.”¹ Applying this definition to medicine, simulation provides the opportunity for individuals and clinical teams to practice technical, cognitive, and teamwork skills without subjecting actual patients to the possibility of being harmed.

Simulation in the Real World of Medicine
While simulation takes many forms, it is proving to be most efficacious for training and practicing events that are regarded as emergent or high acuity. Because these types of events are encountered infrequently, it is difficult to perform the appropriate interventions with a high degree of reliability. Obstetrical emergencies, such as shoulder dystocia and post partum hemorrhage (PPH), are classic examples of the types of events that benefit from simulation.

The following PPH case outlines how simulation might have been useful in avoiding, or at least mitigating, an adverse outcome:

A 32-year-old gravida 3 para 2 presented to the hospital at 39 weeks’ gestation in active labor with complaints of contractions two to three minutes apart and some vaginal bleeding. Due to continued vaginal bleeding, an ultrasound was performed six hours after admission. It revealed a right posterior, low-lying placenta with no sign of previa. Pitocin augmentation of labor was begun. Twelve hours after admission, the patient’s vitals remained stable, and a spontaneous rupture of membranes occurred. About 30 minutes later, the patient had the urge to push. The Pitocin infusion was increased, and the patient was soon completely dilated and pushing. A vacuum extractor was applied, and delivery occurred shortly afterward. Apgars were 9 and 9.

The placenta delivered spontaneously at 1755. At 1800, the patient’s blood pressure fell to 90/60, and she was bleeding profusely. Despite uterine massage, 20 units of Pitocin IM, and Methergine IM, the bleeding continued. At 1900, Cytotec was administered rectally and repeated 20 minutes later. Both times Cytotec was administered, bleeding stopped temporarily then resumed. Hemabate was not available. At 1940, the patient, pale and lethargic, was transported to the operating room. She coded on the table. She received CPR and multiple blood products, but platelets were not available at the hospital. She was transferred to another hospital where she eventually recovered but with severe anoxic brain injury.

An in-depth review of the case revealed many opportunities to improve the management of catastrophic PPH. Here are some examples of the improvement opportunities that simulation may have addressed in this case:

• Technical skills

- Operative vaginal delivery technique (OVD)
- Correct estimation of blood loss
- Rapid and correct diagnosis
- Rapid treatment and resuscitation

• Teamwork skills

- Adequate and appropriate referral, consultation, and transfer of care
- Communication of the big picture
- Proper performance of the team in event management

• Clinical systems

- Ensure adequate preparation for PPH, including the availability of proper medications (hemorrhage kit) and platelets
- Address policy/protocol/guideline issues regarding OVD, Pitocin administration, PPH, and massive transfusion

Simulating PPH in-situ helps clinical and support staff examine their rapid response systems, identify where they may be vulnerable to error, and facilitate practice of technical and teamwork skills needed for optimally managing such events.

The Doctors Company’s Role 
Realizing that simulation has become a significant driver in the patient safety movement, The Doctors Company embraced it as a key initiative nearly five years ago. After introducing simulation to our members in the field of obstetrics, we are now expanding our activities to include anesthesia, emergency medicine, and hospitalist programs. Other specialties will follow.

Because we also recognize that simulation is fast becoming a valuable experience and a requirement for board certification/recertification for some of our members, we have adopted a plan to support those who choose to participate in simulation activities. The plan entails the following actions:

• Provide orientation demonstrations to create awareness about simulation and its advantages as a key risk mitigation strategy.
• Review closed claims data in our Executive Information System (EIS) to help us identify and create new standardized simulation scenarios.
• Identify accredited simulation centers willing to simulate scenarios that The Doctors Company sees as potentially beneficial, and introduce our members to them.
• Collaborate with specialty organizations that incorporate simulation into their medical education requirements, and help our members achieve required skill maintenance.

Conclusion
The Doctors Company is fiercely committed to advancing the practice of good medicine. Our simulation program is just one example of the steps we are taking to meet that goal. If you would like to learn more about our program, contact the Patient Safety Department at (800) 421-2368, extension 1243.

What Members Are Saying After Attending
Our Simulation Demonstrations

“My involvement with the simulation ofOBemergencies and urgencies ‘in-situ’ (in our Labor and Delivery Department) has been one of the most rewarding experiences in my career. It has done more to change the hierarchal barriers to communication and team building on our unit than any other single thing. It is very satisfying to see our staff express how happy they are to be part of our ‘Family Birthplace Team.’”

“This program demonstrated how simulation can improve our communication and confidence in managing emergencyOBevents. I very much enjoyed it and learned a ton! Thank you!”

“Thanks—this was a great experience! The knowledge and skills presented will help to make me more comfortable in dealing with potentialOBemergencies.”

“This experience gave us a safe, non-threatening environment in which to learn—greatly appreciated.”

“Wow…what an effective way to make sure we’ve got it all together! Fabulous!”

References

1. Gaba DM. The future vision of simulation in health care. Qual Saf Health Care. 2004;13(Suppl 1):i2-i10.

By Dieter Zimmer, MHA, FAAMA, Regional Vice President, The Doctors Company; Marion Y. Constable, MSN, CNM, Director of Simulation and the Obstetrical Collaborative, The Doctors Company; and Roxane Gardner, MD, MPH, DSc, Assistant Professor, Obstetrics and Gynecology, Brigham and Women’s Hospital, and Simulation Specialist, Center for Medical Simulation.

This article originally appeared in The Doctor’s Advocate, second quarter 2011 (www.thedoctors.com/advocate).

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We appreciate your continued support of The Doctors Company. If you have any questions or concerns, please contact:

Matthew McDowell, Manager, Business Development
(517) 324-6773
mmcdowell@thedoctors.com

Cheri Schultz, Manager, Business Development
800-748-0465, ext. 4008
cschultz@thedoctors.com

The CyberGuard eRisk Management Web Site features a wealth of state-specific risk prevention for members, as well as necessary forms and checklists. It also includes thought-provoking articles that cover issues pertinent to the more than 60 percent of physician offices currently without electronic health records (EHRs). For physicians and office managers with EHRs, the site serves as a critical storehouse of must-have knowledge to get or remain HIPAA compliant, reduce risk, create staff data-management policies, or handle a breach.

“Providing the very latest in protection for the fastest-growing threats to physicians drives our development of this key resource for members,” says Bill Fleming, regional vice president, The Doctors Company. “The eRisk Site is another way we fulfill our mission to defend, protect, and reward physicians who advance the practice of good medicine.”

Members may access the CyberGuard eRisk Management Web Site through www.thedoctors.com/members.

About The Doctors Company

Founded by doctors for doctors in 1976, The Doctors Company (www.thedoctors.com) is relentlessly committed to advancing, protecting, and rewarding the practice of good medicine. The Doctors Company is the nation’s largest insurer of physician and surgeon medical liability with nearly 55,000 member physicians, $4 billion in assets, and an A rating from both A.M. Best Company and Fitch Ratings.

Medical Liability Expertise

• 27 years in the insurance business
• 23 years of medical malpractice claims experience
• CPCU - Advanced insurance designation
• Expert knowledge of the litigation process
• Long-standing relationship with the best medical malpractice defense attorneys in the state.
• Personally handled or supervised thousands of medical malpractice claims
• Extensive experience with the National Practitioner Data Bank
• Understands the difficulties physicians face when confronted with a claim and can assist in answering your questions regarding the litigation process

Coverage will primarily be placed through American Physicians Assurance Corporation, one of the leading physician insurers in the state of Michigan. However, if for some reason, insurance is not available to you in the standard market, due to loss history or licensing issues, we can assist you in finding coverage in the non-standard market. Together, Tungate Professional Insurance Services and American Physicians offer Michigan’s best coverage for physicians and claims service excellence. Contact TPIS if you have questions on medical malpractice issues, your insurance policy, the litigation process, Michigan licensing investigation triggers, and more. You may also request a quote for your professional liability insurance needs.

Physicians often seek insight about a patient from another doctor who has not seen the patient or reviewed the medical record. When you are the doctor being asked for one of these ‘curbside consultations’ you need to be careful not to cross into territory that could imply you have a physician-patient relationship with the patient in question. Following are steps you can take to help prevent this from happening:

• Never give specific treatment advice.
• Keep curbside consults brief and simple. For complex cases, a formal consultation should be obtained.
• Recommend a formal consultation when a curbside consultation is repeated on the same patient.
• Ask your colleague not to document the conversation or include your name in the medical record. If the discussion needs to be recorded, there may be a need for a formal consultation.
• Do not provide curbside consultations by e-mail. Doing so could imply that you had greater involvement in the patient’s care than intended and distribution of the information cannot be restricted.

Information obtained from: Journal of Healthcare Risk Management, Vol. 28, No. 1 pp. 27-29

Tungate Professional Insurance Services is proud to represent American Physicians Assurance Corporation. This tip is used with permission from American Physicians.