Transcript Simulation-Based Curriculum to Teach Procedural Skills to

Simulation-Based Curriculum
to Teach Procedural Skills to
Hematology Fellows
Program Directors Meeting
52nd ASH Annual Meeting
Orlando, Florida 2010
Alexandra P. Wolanskyj MD, FRCP,
Program Director, Hematology
Education Chair Division of Hematology
Mayo Clinic Rochester, MN
Disclosures for Alexandra
Wolanskyj
Consultancy
none
Equity Ownership
none
Research Funding
none
Honoraria
none
Patents & Royalties
none
Speakers Bureau
none
Membership on Board of
Directors/Advisory Committee
Other
Presentation includes a description
of the following off-label use of a
drug or medical device
none
none
None
52nd ASH Annual Meeting ♦ Orlando, FL
In compliance with ACCME policy, ASH requires the following disclosures to the session
audience:
Mayo Clinic, Rochester MN
Employment
BACKGROUND AND RATIONAL
• ACGME Procedural Requirements for
Hematology Fellows
• ACGME Current and Forthcoming
Requirements
• ACGME Requires documented
Outcomes Measures when teaching
competencies
GOALS AND OBJECTIVES
• Review ACGME current and forthcoming
required procedures and related
competencies
• Present Simulation based curriculum to
teach procedures
• Intrathecal chemotherapy via LP and
Ommaya reservoir
• Anterior and Posterior Iliac crest
Bone marrow biopsies and aspiration
• Present Resources & Evaluation tools
ACGME PROCEDURAL
REQUIREMENTS
• Current: Must Demonstrate
competence in
• “Performance of and/or
interpretation of bone marrow
aspiration and biopsy”
• “Use of chemotherapeutic agents..
through all therapeutic routes”
• Forthcoming 7/2011:
• “Performance of Lumbar puncture
and interpretation of CSF fluid
evaluation”
ACGME PROCEDURAL
REQUIREMENTS
• “Must develop a comprehensive
understanding of indications,
contraindications, limitations,
complications, techniques and
interpretation of results of those
diagnostic and therapeutic
procedures integral to the discipline”
• “Fellows must have access to
training using simulation”
ACGME website summary and impact of major
revisions to Prog Requirements for GME in
Hematology and medical Oncology 2009-2010
ACGME PROCEDURAL
REQUIREMENTS FORTHCOMING
• “Assessment of procedural
competence should not be based
solely on a minimum number of
procedures performed but should
include a formal evaluation process
…include objective performance
criteria.”
ACGME website summary and impact of
major revisions to Prog Requirements for
GME in Hematology and medical Oncology
2009-2010
HEMATOLOGICAL PROCEDURES
• WORKSHOPS IN YEAR 1 (BOOT CAMP)
• INTRATHECAL CHEMOTHERAPY
ADMINISTRATION
• Via Lumbar Puncture and Ommaya
Reservoir
• Simulation center
• BONE MARROW BIOSPY AND
ASPIRATION:
• Anterior and Posterior Iliac Crest
• Anatomy procedural Laboratory
WORKSHOP COMPONENTS
• Resources sent to learners ahead of
time
• Didactic session with review of
materials
• Procedural workshop with every
learner participating
• Evaluation of competency by direct
observation
• Documentation with checklist
INTRATHECAL
CHEMOTHERAPY
PROCEDURES
INTRATHECAL ADMINISTRATION OF
CHEMOTHERAPY VIA LUMBAR PUNCTURE AND
OMMAYA RESERVOIR WORKSHOPS
INTRATHECAL CHEMOTHERAPY
VIA LUMBAR PUNCTURE
• WORKSHOP LED BY PD AND ASS PD
• Simulation Center
• Task Trainer
• Multi Learners (include Pharm)
• Experiential Learning
• Didactic Session precedes
• Performance assessment
including deliberate error
insertion
• Fluoroscopic Guidance
Simulated
DIDACTIC TEACHING
• Materials forwarded to fellows in
advance including
• Relevant Articles
• Relevant Videos
• Relevant Documents reviewing
Indications/Contraindications/ etc.
• Protocol and checklist for
assessment
• Review of documents with teaching
points emphasized
INTRATHECAL CHEMOTHERAPY
VIA LUMBAR PUNCTURE
MULTI LEARNER –EXPERIENTAL LEARNING
EXPERIENTIAL LEARNING AND
EDUCATION
• Experiential learning is the process of
making meaning from direct
experience
• Experiential Education as a
philosophy and methodology in
which educators purposefully engage
with learners in direct experience and
focused reflection in order to
increase knowledge, develop skills
and clarify values
EXAMPLES OF EXPERIENTIAL
EDUCATION
• Active Based Learning--All
participants in the group must
engage actively in working together
toward the stated objectives.
• Problem Based Learning--Provides a
structure for discovery that helps
students internalize learning and
leads to greater comprehension
MULTI LEARNER SCENARIOS WITH
DELIBERATE ERROR INSERTION
• MEDICAL RECORD REVIEW:
• Severe Thrombocytopenia
• Wrong Chemotherapy drug
• Wrong Dose of Chemotherapy
• Wrong date
• No signature on chemotherapy
record
MULTI LEARNER SCENARIOS WITH
DELIBERATE ERROR INSERTION
• ACQUISITION & INSTILLATION OF
CHEMOTHERAPY
• Wrong Chemotherapy drug
• Wrong Dose of Chemotherapy
• Wrong Label on chemotherapy vial
• Wrong Patient record number
• Wrong Patient at bedside
• MUST BE RECOGNIZED BY LEARNER
OR PATIENT IS GIVEN BAD OUTCOME
PROTOCOL CHECKLIST STEPS
FOR IT VIA LUMBAR PUNCTURE
1) LIST INDICATIONS/CI/COMPLICATIONS/RISKS/BENEFITS
OF PROCEDURE
2) VERIFICATION OF PATIENT & CHEMOTHERAPY AND
CONSENT
3) ACQUISITION OF CHEMOTHERAPY AND SUPPLIES
4) VERIFICATION PRIOR TO CHEMOTHERAPY
ADMINISTRATION
5) PERFORMING LP UNDER FLUORO BY RADIOLOGY
6) CSF CONFIRMATION & MEDICATION INSTILLATION
7) POST-PROCEDURAL STEPS
8) CSF ANALYSIS FOR STUDIES/TESTS
9) DOCUMENTATION IN MEDICAL RECORD
INTRATHECAL
CHEMOTHERAPY VIA
OMMAYA RESERVOIR
PROTOCOLISED CHECKLIST
STEPS FOR IT VIA OMMAYA
1) LIST INDICATIONS/CI/COMPLICATIONS/RISKS/BENEFITS OF
PROCEDURE
2) VERIFICATION OF OMMAYA & CHEMOTHERAPY; OBTAIN CONSENT
2) ACQUISITION OF CHEMOTHERAPY AND SUPPLIES
3) VERIFICATION PRIOR TO CHEMOTHERAPY ADMINISTRATION
4) PREPARATION OF SITE AND ANESTHESIA
5) ACCESSING OMMAYA RESERVOIR
6) FLUID WITHDRAWAL & MEDICATION INSTILLATION
7) POST-PROCEDURAL STEPS
8) CSF ANALYSIS FOR STUDIES/TESTS
9) DOCUMENTATION IN RECORD
EVALUATION OF PROCEDURES
• To be Successful the learner must:
• Perform every step of checklist
• Recognized inserted errors and their
consequences
• Remediation is immediate if error
was not picked up by repeating
procedure with a different patient
scenario
• Documentation of competence via
checklist
DOCUMENTATION STATEMENT
FOR EACH WORKSHOP
• “I CERTIFY THAT------- HAS SUCCESFULLY
COMPLETED THE
• -ANATOMY LAB TRAINING FOR BONE
MARROW BIOPSY AND ASPIRATION or
• -SIMULATION CENTER TRAINING FOR
INTRATHECAL CHEMOTHERAPY VIA LP or
OMMAYA RESERVOIR”
• “AND DEMONSTRATES A COMPREHENSIVE
UNDERSTANDING OF THE INDICATIONS,
CONTRAINDICATIONS, AND
COMPLICATIONSTECHNIQUES OF THE
PROCEDURE:
• SUPERVISOR NAME
DATE:
BONE MARROW BIOPSY AND
ASPIRATION PROCEDURES
BONE MARROW BIOPSY AND
ASPIRATION WORKSHOP
DIDACTIC TEACHING
• Materials forwarded to fellows in
advance including
• Relevant Articles
• Relevant Videos
• Relevant Documents reviewing
Indications/Contraindications/ etc.
• Protocol and checklist for
assessment
• Review of documents with teaching
points and anatomy emphasized
BONE MARROW BIOPSY
PROCEDURAL WORKSHOP
• In Anatomy Lab
• Led by PD and head Bone Marrow
Biopsy instructor (RN)
BONE MARROW BX DEMONSTRATION:
ANT & POST ILIAC CRESTS
BONE MARROW ASPIRATION
BONE MARROW BIOPSY
CONFIRMATION OF BONE
MARROW BIOPSY SAMPLE
PROTOCOL CHECKLIST STEPS FOR
BM BIOPSY AND ASPIRATION
1) LIST INDICATIONS/CI/COMPLICATIONS/RISKS/BENEFITS
OF PROCEDURE
2) VERIFICATION OF PATIENT , TESTS, TYPE OF
ANESTHESIA & OBTAIN CONSENT
3) ASSEMBLY OF SUPPLIES & IDENTIFICATION OF SITE
4) PREPARATION OF SITE
5) ANESTHESIA OF SITE AND VERIFICATION OF ADEQUACY
6) BONE MARROW ASPIRATION PORTION WITH
VERIFICATION OF ADEQUACY
7) BONE MARROW BIOPSY PORTION WITH VERIFICATION OF
ADEQUACY
7) POST-PROCEDURAL STEPS
8) DOCUMENTATION OF PROCEDURE IN MEDICAL RECORD
ANATOMICAL CORRELATION
• Dissection by
anatomist
following both
successful
procedures
• Landmarks
indentified
• Potential
complications
reinforced
ANATOMICAL CORRELATION OF
BONE MARROW BIOPSY AND
ASPIRATION
iliac
crest
Puncture
hole along
iliac crest
RESOURCES FOR PROCEDURAL
SKILLS
VIDEO AND ARTICLES FROM NEJM
• Lumbar Puncture:
http://www.nejm.org/doi/full/10.1056/N
EJMvcm054952
• Bone Marrow Biopsy and Aspiration
http://content.nejm.org/cgi/content/sho
rt/361/15/e28
FEASABILITY AND REQUIRED
RESOURCES
• Simulation LP and Ommaya easy and
relatively affordable (task trainers)
• Scenarios created on PPT are optional
• Anatomy lab with fresh frozen cadavers
• Requires limited personnel
• Didactic portion straightforward
• Checklist done using main points
• Documentation done with checklist