Enhancing Clinical Education and Training, Improving Care

March/April 2013

Enhancing Clinical Education and Training, Improving Care

More than a decade ago the Institute of Medicine published its landmark study, To Err is Human (2000), documenting an unacceptably high rate of medical errors, many of them resulting from poor clinical decision-making. In fact, surgeons in the United States make medical errors more than 4,000 times a year, which can result in permanent injury or death. These types of preventable errors include wrong-site surgery, retained surgical items, wrong-patient surgery, and wrong-procedure surgery, causing nearly half of the affected patients to suffer temporary injury (Landro, 2012). In primary care, diagnostic errors account for 34% of negligent adverse events in the United States (Phillips et al., 2004) and 63% of claims against practitioners in the United Kingdom (Silk, 2000). Several factors have been found to be associated with errors in primary care, among them are co-morbidities, low prevalence, and atypical presentations (Kostopoulou, Delaney, & Munro, 2008). Despite diligent efforts on the part of both healthcare institutions and accrediting bodies to reduce errors, there is little evidence that the situation has significantly improved (Landrigan et al., 2010; Levinson, 2010; Liang & Mackey 2011; Schreve et al., 2010).

To help improve patient care, safety, and satisfaction, healthcare organizations should enhance the ways they train their healthcare providers (HCPs) to make decisions. HCPs have many ways to gain knowledge and skills, yet the ability to practice the application of these is often limited to direct interaction with patients (Tworek et al., 2010). With the increasing use of new care models and evidence-based decision-making, HCPs need new approaches to practice and accelerate the application of new skills that optimize both patient and financial outcomes.

One effective way to enable clinicians to practice and enhance their decision-making skills is via simulation—a proven educational technique involving scenarios that mirror clinical situations (Radomski & Russell, 2010; Kneebone & Nestel, 2005). One particular type of simulation, web-based clinical simulation, leverages adult learning concepts, particularly experiential learning (Kolb & Fry, 1975). This approach allows HCPs to see the consequences of their decisions and receive immediate feedback—positive and negative—in a safe, teaching environment. Additionally, web-based clinical simulation can help assess competency levels and identify education gaps.

Interactive Clinical Scenarios
Web-based simulation involves interactive clinical scenarios that allow HCPs to progress through the case by making a series of diagnostic, therapeutic, and patient safety decisions.
Educators can address specific gaps such as the identification of at-risk patients, the management of medical conditions, and the appropriate application of evidence-based protocols. Unlike real-world interactions, learners are able to explore the consequences of their mistakes and receive immediate feedback without causing harm to patients.

Pre- and post-simulation assessments allow educators to gain an appreciation of learners’ competency regarding protocols and interventions, as well as how their decision-making skills are progressing. This information helps educators identify opportunities for further education and allows learners to track their progress against peer groups and experts. By reinforcing correct decisions and providing evidence-based feedback on poor decisions, simulated patient cases can help learners improve their decision-making and ultimately improve patient outcomes.

Web-based Simulation for Management of Pressure Ulcers
One organization that is testing the potential benefits of web-based simulation training is the MedStar National Rehabilitation Hospital in Washington, DC. With many of its patients at risk for hospital-acquired conditions such as pressure ulcers, the organization wanted to explore the benefits of using a tool to train HCPs on how to recognize at-risk patients and apply appropriate therapeutic protocols.

MedStar is not alone in dealing with the challenge of improving the identification and management of pressure ulcers, a highly significant “never event.” Every year, more than 2.5 million hospital patients suffer from a pressure ulcer (Tschannen et al., 2012) and 60,000 patients die from pressure ulcer complications (The Joint Commission, 2008). The cost of treating a hospital-acquired pressure ulcer can be as high as $70,000 per patient, and U.S. healthcare organizations collectively spend $11 billion a year treating this condition (Redelings et al., 2005). With hospital-acquired Stage III and Stage IV pressure ulcers no longer reimbursed, there is a further incentive for healthcare organizations to address the issues.

The MedStar National Rehabilitation Hospital, which conducts a physical medicine and rehabilitation (PM&R) residency training program jointly with Georgetown University Hospital, is currently engaged in a pilot study to assess the impact of web-based simulation as an educational approach for instruction and assessment in the preventive medical management of persons who are at high risk for developing pressure ulcers (Pineda & Schladen)*. Preliminary results are expected in the fall of 2013.

Since evidence-based information offered through web-based simulations can be more salient and engaging than other training methods, the investigators hope to show that information is easier to remember and generalize to clinical settings. The investigators have selected DecisionSim™, a web-based simulation platform from Decision Simulation, for their project due to its ability to allow the investigators to easily author and customize the simulations.

In this study, Georgetown University School of Medicine students will interact with the simulations, based on an actual, complex patient case, during their physical medicine and rehabilitation selective/elective rotation.

In the simulation, they will assume the role of a resident providing care to a patient with spinal cord injury, a condition that carries with it a high risk for developing pressure ulcers. In the course of care, students will take an appropriate patient history; identify the body locations that are particularly vulnerable to pressure ulcers in patients with impaired sensation and mobility; recognize pressure ulcer prevention techniques; describe staging and grading using the NPUAP (National Pressure Ulcer Advisory Panel) guidelines; recognize the need for further evaluation and management; and communicate the problem to another HCP and to the patient using the Situation, Background, Assessment, Recommendation (SBAR) technique (Vardaman et al., 2010). Assessments during the simulation provide immediate feedback for learners and allow them to correct their decisions to achieve better outcomes.

For comparison, these students will also interact with traditional static, didactic education materials online. A series of pre- and post-structured assessments, along with focus groups, will be used to analyze the degree of learning and retention achieved from each form of education. Ultimately, investigators believe that the pilot will lay the foundation for the optimal use of web-based clinical simulation in medical education to promote learning and retention.

Because of the flexibility and adaptability of the web-based simulation platform selected, MedStar PM&R faculty and clinical education researchers will be able to leverage their investment in the development of these simulations. Educators will be able to reuse and repurpose the simulations created for this project and adapt them to address the needs of other healthcare providers in pressure ulcer management as well as in other critical areas. These simulations can be easily modified and updated to reflect new evidence and address new education gaps.

The value of this educational approach is also appreciated by other leading healthcare systems. The Veterans Health Administration (VHA) is also using DecisionSim for its Simulation, Learning, Education and Research Network (SimLEARN). Clinical simulation has been identified as “one of the most important and significant advancements the VHA has seen in education and training in years. The direct benefits to the quality and safety of health care provided to Veterans will be real and sustained” (U.S. Dept. of Veterans Affairs, 2012).

Better Decision-Making and Outcomes
Clinical decision-making skills are some of the hardest aspects of medicine to assess and refine (Norman, 2005; Norman & Eva, 2010). By leveraging web-based clinical simulation as part of an education strategy, healthcare organizations can offer interactive, relevant and engaging educational opportunities that enhance decision-making. In the case of pressure ulcers, web-based simulation training could help healthcare providers improve their ability to recognize at-risk patients, adhere to protocols that reduce the possibility of ulcer development, and make appropriate diagnostic and therapeutic decisions.
Strengthening education and training is one way to help clinicians improve clinical decision-making behavior with the goal of reducing the occurrence of serious conditions such as pressure ulcers. Web-based simulation provides a cost-effective way for healthcare organizations to increase both the consistency and accuracy of clinical decisions—and share best practices—ultimately resulting in improved patient and financial outcomes.

Manon Maitland Schladen is a senior research associate at MedStar National Rehabilitation Hospital and a member of the research faculty at MedStar Health’s Simulation Training and Education Laboratory (SiTEL). Her current research is focused on the extension of experiential learning theory to help inform virtual patient design. Schladen may be contacted at manon.schladen@medstar.net.

Cynthia G. Pineda is an associate director of the MedStar Georgetown University Hospital –National Rehabilitation Hospital Physical Medicine and Rehabilitation Residency Training Program and director of continuing medical education programs. She is an assistant professor of clinical rehabilitation medicine at the Georgetown University School of Medicine. Pineda may be contacted at cynthia.g.pineda@medstar.net.

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* Evidence-based content for the simulation was developed by the authors under the auspices of The Rehabilitation Research and Training Center on Secondary Conditions in the Rehabilitation of Personswith Spinal Cord Injury, Grant # H133B090002 from the National Institute on Disability and Rehabilitation Research, Suzanne L. Groah, MD MSPH, principal investigator.