Simulation Specialist Receives Patient Safety Grant

Jeffrey M. Taekman, MDDurham Casualty has awarded Duke Anesthesiology’s Dr. Jeffrey Taekman $108,668 in funding for a patient safety project titled, “Simulation-Based Crisis Resource Management as a Risk Reduction Strategy for the Health System.”

Throughout medicine, safe and effective delivery of health care has relied on proper team coordination and communication. The Joint Commission cites failures of teamwork and communication as a root cause of more than 50 percent of sentinel events. These events can have both economic and patient safety implications. In perioperative medicine, communication breakdowns represent the second leading cause of preventable intraoperative error, resulting in patient harm, second only to technical error. Analysis of closed claims by the American Society of Anesthesiologists (ASA) and the American College of Surgeons (ACS) implicate poor communication as a major preventable cause of adverse events.

In order to combat communication errors, Dr. Taekman proposes to implement an interprofessional simulation-centric crisis resource management (CRM) learning experience within Duke University Hospital. The expected outcome of this project includes decreased malpractice liability exposure and improved patient outcomes.

The proposed program, with interprofessional simulation at its core, will be carried out in collaboration with the Department of OB/Gyn and the faculty and staff of the Duke Birthing Center. Dr. Taekman’s collaborators include Ankeet Udani, Zaneta Strouch, Chad Grotegut, Andrea Fiumefreddo, Joe Chapman, Trish Fletcher, and Jennifer Justice.  Dr. Taekman’s vision is to build a similar program for each of the high risk surgical/perioperative services.

Dr. Taekman is the assistant dean for educational technology and the director of the Duke Human Simulation and Patient Safety Center, a joint project of Duke Anesthesiology, the School of Medicine and the School of Nursing.

Chris KeithSimulation Specialist Receives Patient Safety Grant
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Dr. Taekman Awarded Funding for Microbiome Clinical Trial

Jeffrey M. Taekman, MDClasado/Host Therabiomics has awarded Duke Anesthesiology’s Dr. Jeffrey Taekman $69,885 in funding for a clinical trial titled, “Exploring the Impact of Perioperative Galacto-Oligosaccharides (GOS) on Stress, Anxiety and Cognition.”

Studies link the gut microbiota to the function of the central nervous system, both in behavior and cognition. Prebiotics stimulate growth of beneficial bacteria in the gut. The overall objective of this proposal is to explore, in the perioperative period, the association between the administration of the prebiotic GOS and pain, anxiety and cognitive function. His central hypothesis is subjects who consume GOS in the perioperative period will demonstrate lower levels of salivary cortisol before, during, and after their operative procedures. In addition, he expects subjects who consume GOS to have lower perceived levels of anxiety during the perioperative period. Finally, he hypothesizes that subjects who consume perioperative GOS will perform better on tests of cognition in the postoperative period.

Dr. Taekman is a professor of anesthesiology, the assistant dean for educational technology, and the director of the Duke Human Simulation and Patient Safety Center. He is currently a fellow in the University of Arizona’s Center for Integrative Medicine where he is pursuing his interests in the medicinal use of food as well as mind-body medicine.

Chris KeithDr. Taekman Awarded Funding for Microbiome Clinical Trial
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Duke AHEAD Grant Awarded

Drs Udani and De GagneThe Duke Academy for Health Professions Education and Academic Development (Duke AHEAD)  has awarded Dr. Jennie De Gagne (Duke School of Nursing) and her team of five co-investigators, including Duke Anesthesiology’s Dr. Ankeet Udani, a $5,025 grant for their project titled, “Needs Assessment of Cybercivility Learning in an Interprofessional Education.”

The goal of this study is to conduct a needs assessment to facilitate the development of interprofessional cybercivility learning modules and curriculum resources for health professions students.

Dr. Udani, assistant professor of anesthesiology and assistant director of the Duke Anesthesiology Residency Program, was awarded membership to Duke AHEAD in July of 2014. Its mission is to promote excellence in the education of health professionals by creating a community of education scholars, fostering innovation in health professions education, supporting outstanding teachers, providing faculty development programs, and facilitating quality education research.

Chris KeithDuke AHEAD Grant Awarded
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Ankeet Udani, MD, Wins New Scientist Award

Ankeet D. Udani, MD, MSEdDr. Udani recently received a notice of award in the amount of $150,000 by the Anesthesia Patient Safety Foundation for a two-year APSF Safety Scientist Career Development Award for his research project titled, “A Comparison of two learning theories on emergency manual use: Classroom-based experiential learning versus electronic-based self-directed learning.”

Ankeet Udani, MD, MSEd, is an assistant professor in the Department of Anesthesiology, the assistant director of the Human Simulation and Patient Safety Center (HSPSC), and an assistant director of the Anesthesiology Residency Program at Duke University. His primary mentor, Jeffrey Taekman, MD, is a professor of Anesthesiology, the director of the HSPSC, and the assistant dean for Educational Technology at Duke University. Dr. Udani completed a fellowship in Patient Safety and Simulation-based Medical Education at Stanford University and a Master’s in Education at Johns Hopkins University. He has previously designed and studied the impact of educational strategies in anesthesiology. With this career development award of $150,000 over two years, Dr. Udani will develop skills in implementation science to complement his knowledge in anesthesia education, simulation and patient safety. The proposed project, “A comparison of two learning theories on emergency manual use: Classroom-based experiential learning versus electronic-based self-directed learning,” will study the effectiveness of two exclusive educational strategies.

Using emergency manuals during intraoperative crises enhances patient safety by ensuring critical steps are considered and completed. Dr. Udani and his team of mentors and consultants will use quantitative and qualitative methodology to assess the impact of each educational strategy both in simulation and the clinical environment. Dr. Udani’s development through this award will give him the skills necessary to gain experience in implementation science and translational research design in medical education. Dr. Udani aims to be a leader in thematic and systematic design of educational interventions to best impact perioperative patient safety at the level of clinical care and population outcomes.

View Dr. Udani’s feature article about this award in the Newsletter, the official journal of the APSF.

Chris KeithAnkeet Udani, MD, Wins New Scientist Award
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Interactive Learning Initiative Joins SoM Curriculum

ILEDuke Image 2016

For years, medical education has traditionally been passive, mainly using a lecture format. Over time, the trend of interactive learning, also known as ‘flipping the classroom,’ started to evolve as a more effective way to learn. Although engaging, one downside to in-person interactive learning is that it’s not as scalable as a lecture. That’s why Duke Anesthesiology and its collaborators believe the answer lies somewhere in the middle and that immersive learning will be a game changer.

In 2009, Dr. Jeffrey Taekman and former project manager, Michael Steele, spearheaded an initiative called Immersive Learning Environments at Duke (ILE@D). Their grand vision was to build an educational framework (using immersive learning in virtual training) to support a variety of inter-professional health care training scenarios. The ultimate goal of the initiative was to become a hub of virtual health care education.

Seven years after its launch, we look back at the creation of ILE@D as the department advances it to the next level by officially implementing it into the Duke School of Medicine’s curriculum and in a Massive Open Online Course on Coursera.

Q: How did the concept for ILE@D come about?

A: (Dr. Taekman) I became interested in the addictive nature of video games, and wondered if some of the psychology and technology behind commercial games might be applied to health care learning. In 2004, we developed our first simulation, 3DiTeams, which allowed health care teams to practice teamwork and communication in a virtual space. The popularity of this type of learning snowballed into many unique projects. Accessible from any internet-connected computer, ILE@D provides an innovative, interactive, “front-end” to distance education for health care professionals. 

Q: What is ILE@D ?

A: (Dr. Taekman) ILE@D leverages commercial video game platforms to build educational modules for health care. It has a lot of interactivity, can be scaled to a larger size, and engrosses the student in the learning process. We believe ILE@D has the potential to improve the efficiency of the learning process. We don’t expect screen-based simulation to replace mannequins, but instead they will be complimentary. We expect ILE@D, when used early in the learning process, to improve face-to-face interactions between teachers and students. ILE@D will improve the face time through early self-directed, team-based, and facilitator-led preparatory activities in a virtual environment. The lessons students learn in virtual environments can be applied to real-world scenarios (this process is called abstraction). An added benefit of  computers is their ability to collect data. This data can then be collated and analyzed. For this reason, we believe virtual environments and screen-based simulation will have a huge impact on the certification and recertification processes.

(Michael Steele) It’s a three-dimensional, collaborative world, essentially acting as an umbrella that encompasses five virtual learning experiences:

1.) Stroke a neurological exam that trains users how to identify the signs and symptoms of a stroke
2.) Handover aims to improve communication and decrease preventable adverse events related to operating room to Neuro-ICU handovers
3.) Medic trains Army medics and other medical personnel to manage the top causes of death in the modern battlefield, including hemorrhage, airway obstruction and tension pneumothorax. These cases are also applicable for civilian medical personnel practicing treatment of trauma cases.
4.) Hemorrhage trains clinicians on effective teamwork and communication behaviors in the context of a postpartum hemorrhage case
5.) Sedation teaches and refreshes the cognitive skills of rapid sequence intubation and moderate/deep sedation to non-anesthesia providers

Q: How did you determine the need for these five virtual environments?

A: (Dr. Taekman) When we first started exploring what we could do with the technology, team training was in its infancy in health care and simulation wasn’t as far along as it is now. We were looking for a scalable, distributable way to conduct team training, which is how the idea for Hemorrhage came about.

For the other projects, we tried to intertwine national needs, aligning these needs with funding opportunities. For example, Sedation was developed at at a time when both military and civilian medicine had a need to train non-anesthesiologists about moderate sedation.

Treatment of stroke is also a huge national issue. Although our Stroke software was developed to train nursing and medical students to perform a neuro exam, I really believe there is potential for Stroke in telehealth, where health related services and information are delivered remotely via telecommunications technologies. Health care providers in outlying hospitals may not care for stroke patients very often. This type of software will allow those clinicians to practice diagnosing and treating a virtual stroke patient to better prepare them to collaborate with central hospital staff during a real emergency.

Q: Who are you specifically targeting to engage with this program?

A: (Dr. Taekman) ILE@D is targeted primarily at medical and nursing students, but I think the greatest unmet need is in the health system, training physicians and nurses. Currently, physicians receive much of their training as lectures, but hundreds of studies dating back to the 1990s prove that lectures are ineffective in changing behaviors.

The way you change behavior is by having individuals learn information in the context of how they will use the information in the future, then letting them apply what they learn and learn from mistakes. Obviously, we wouldn’t willingly allow mistakes to happen with live patients, but in virtual environments we can. Ultimately, that’s where immersive learning will be used more frequently in the health system—as a scalable distributable form of simulation.

Q: How does it work? 

A: (Michael Steele) There are different learning experiences for each of the tools we’ve developed. For example, Stroke is a single-player environment which allows the learner to experience a neurological exam with a virtual patient named Carl. There’s an electronic health record where a learner records all of their findings and will receive immediate feedback on their performance and diagnosis. Then, there’s a phase where they map patient deficits to parts of the brain and arteries. It’s an opportunity for the learner to apply and synthesize what they’ve learned in lectures.

Hemorrhage is the second generation of our teamwork and communication trainers. It is a multi-player simulation we have used to train learners in Africa and Australia. It’s focused on teamwork training in the context of obstetric hemorrhage. It is meant to promote interaction between players and practice communication skills. We’ve added additional scalability by adding a tagging system based on the TeamSTEPPS materials, where observers can watch the simulation in real time and tag TeamSTEPPS behaviors.

Q: Have you seen a direct impact with ILE@D?

A: (Dr. Taekman) We just submitted a paper to Anesthesia and Analgesia on our experience using the Hemorrhage software in Uganda with an inter-professional education. We looked at users’ confidence and their ability to manage post-partum hemorrhage. With the software as the center piece of their experience, we found that Hemorrhage increased learner confidence across all the three domains of Bloom’s Taxonomy: (1) affective; (2) cognitive, and (3) psychomotor. The increased psychomotor confidence was an unexpected finding given that the users did not practice any psychomotor tasks. There is precedent in sports and other psychomotor tasks showing mental rehearsal has real-world impact in performance. This finding needs more exploration, but if it holds up, it will unveil a range of new and exciting possibilities.

Q: How is ILE@D being funded?

A: (Dr. Taekman) Over the past five or so years, the Duke Endowment has provided nearly $3 million in funding to initiate this effort with the goal of making the platform broadly available to the health care community. We received other funding from the military, primarily the U.S. Army’s Telemedicine and Advanced Technology Research Center (TATRC) and Research, Development and Engineering Command (RDECOM). Other sources of support  have included Agency for Healthcare Research and Quality (AHRQ), the U.S. Department of Health and Human Services (HHS), and global pharmaceutical and health care companies. At the end of this month (March 2016), our Duke Endowment grant comes to an end. While the program is currently free for users, we welcome other funding opportunities and hope that organizations will be interested in licensing ILE@D because we are finding that it truly fulfills a need in the health care community.

Q: What projects are coming up the pipeline?

A: (Dr. Taekman) It’s an exciting time for us as ILE@D is now being incorporated into the School of Medicine’s curriculum. We just launched Stroke, which medical students started using last month (February 2016). It’s plugged into Coursera, an education platform that partners with top universities and organizations to offer online courses for anyone to take. We’re hoping to generate some data from this partnership. In the future, we’re looking to develop relationships with companies on projects such as central line training.

Q: What are your long-term goals for ILE@D?

A: (Dr. Taekman) We’d like to expand the amount of content we have. We’re still in the beginning phases of screen-based simulation/games-based learning in health care but ultimately, I see immersive learning playing a key role in education because of the accessibility of computers and all of the data that it generates. In the future, we may hand our students and staff a Playstation.

A huge opportunity is using health system data to develop interactive cases. Through electronic health record data, we can identify the gaps in patient care and develop interactive, immersive technology to address those issues. We could then use pooled data from the electronic health record to see whether we’ve made a difference. This screen-based simulation can be pooled locally, nationally and internationally, and then analyzed. This data and the accompanying analytics will open up all sorts of new opportunities in education and patient safety/quality improvement.

As for national organizations using screen-based simulation, the American Society of Anesthesiologists (ASA) Ad-Hoc Screen-based Simulation Committee has taken the first step towards a national initiative. They recently named an ad hoc committee on screen-based simulation, which I am fortunate to be involved with, to develop screen-based simulation for anesthesiologists nationwide. It’s been nice to see the momentum for screen-based simulation building after such an investment in time. It validates that we’re on the right track. We don’t have all of the answers, but it’s nice to see that taking place outside of here. I’m really interested to see what happens with all of the new technology coming out.

(Michael Steele) In terms of new technology, virtual reality will offer new opportunities as well, increasing the immersion experience. For example, instead of sitting in front of a flat screen, you may don goggles and walk around a virtual operating room. There are also new devices, like Kinect, which sense your body and can actually place you into a true virtual environment, such as a mock operating room. Even though you’d be walking around in regular space, the things that you would be seeing and doing would be reflected in a virtual world.

Microsoft HoloLens, which I’m most excited about, will project virtual patients into the actual environment. Though you won’t be able to feel or touch, the technology will know where you are and allow you to interact with a holographic patient.

(Dr. Taekman) The sense of touch is the slowest one to develop in virtual worlds. It makes it more challenging to do procedural-based things. There are companies working on producing realistic feeling computerized tissues. Devices like the Hololens “mix reality,” but eventually, we imagine simulations like the holodeck in Star Trek. That won’t happen for quite a while – but probably sooner than you think.

Q: How can people access these programs or participate? 

A: (Michael Steele) All five virtual environments can be found at ILE@D’s website: simcenter.duke.edu. Stroke will be available for a limited time for Duke’s Medical Neuroscience Coursera users, which we hope will prompt some additional interest in the other programs.

If you’re interested in learning more about ILE@D, gaining access to its five simulations, or would like to explore a potential funding opportunity, please email ILEAD@duke.edu or visit simcenter.duke.edu.

Chris KeithInteractive Learning Initiative Joins SoM Curriculum
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