Innovations in STEMI Interventions – Improvements in D2B Times through Medical Simulation

Innovations in STEMI Interventions – Improvements in D2B Times through Medical Simulation
Innovations in STEMI Interventions – Improvements in D2B Times through Medical Simulation
Innovations in STEMI Interventions – Improvements in D2B Times through Medical Simulation

Cath Lab Digest talks with William R. Hamman, Western Michigan University, Kalamazoo, Michigan, and Sameer Mehta, MD, FACC, MBA, Course Director, LUMEN 2009: The Symposium on Optimal Treatments for Acute MI and author, Textbook of STEMI Interventions.

2010 Update: William Hamman claimed to be a physician, a claim that has since been proven false.

A report from the upcoming February 2009 LUMEN meeting

The STEMI process is comprised of three distinct processes — the pre-hospital EMS phase, the emergency department phase and the cardiac cath lab phase. Each phase has its own skilled people conducting their own specialized work. To increase STEMI procedure success and meet mandated door-to-balloon time guidelines, these processes must be streamlined and made more efficient through the creation of a standardized process and the following of approved protocols. Most STEMI procedures become chaotic as a lack of cohesive teamwork.

Dr. Sameer Mehta is a STEMI world expert who has been studying the STEMI process and procedures, as recorded in his SINCERE database, and discussed in the Textbook of STEMI Interventions.

Dr. William Hamman is a systems expert, a commercial pilot and a cardiologist who has been using simulation processes to increase system efficiencies, reduce costs and promote patient safety.

Together, Dr. Mehta and Dr. Hamman are conducting an “In-situ® Simulation” workshop at the LUMEN STEMI symposium, February 26-28, 2009 at the Loews Miami Beach Hotel, in Miami Beach, Florida.

Dr. William R. Hamman

You have been a pilot for thirty years and a clinician for fifteen years.

I flew first, and then I returned to school to finish my pre-med requirements and went on to medical school. I started flying after my first year in medical school, and have been doing both ever since. Over time, I have fallen more on the flight time side. I couldn’t handle a cardiology practice full-time. What I have been able to weave together, which I very much enjoy, is specialty projects or research in healthcare along with my flight schedule. An average flying time per month is about 90 hours, and I am usually right around 55-60 hours, so with that reduction, it frees up my availability to do work in healthcare.

It sounds like you’ve found a way to balance a love of flying with your interest in healthcare.

When you get into the culture of aviation, it’s almost like an addiction, but a nice one to have. It’s an environment that you just don’t find anywhere else. I am able to be in that environment as well as focus on patient safety and patient care. I truly have been blessed with the best of both worlds.

How did you become interested in patient safety and process management?

My interest developed while I was working in the airline industry. I was never an active physician for United Airlines; however, because I was a physician, I think it opened up some doors at United, and I ended up as manager of quality and risk assessment.

Risk has somewhat of a different meaning in the airline industry than it does in healthcare. In healthcare, looking at risk usually means minimizing loss. In the airline industry, risk means the never-ending search for system weaknesses as well as broken-down processes that could lead to an accident. Early on in my career, I was involved in accident investigations and saw how the frailty of human beings could have a huge impact on the outcome of an airliner. Of course, when there is an airplane crash, hundreds of lives are usually lost versus one life at a time in a healthcare situation, but basically the same dynamics are involved on the healthcare side.

My work first began on the aviation side, in the world of airline evaluation training and assessment. In aviation, we developed processes allowing us to train and assess team dynamics at the same level that technical competency was assessed. Both elements are extremely critical.

Seventy percent of accidents in the airline industry are not the result of technical competencies or mechanical issues, but are caused by a breakdown in the “softer” skills of communication in situation management. Yet at that time (the late 1980’s and early 1990’s), in aviation, all the work that was being done — the processes and focus at the training centers, the entire time spent in twenty-three million dollar virtual reality simulators — was focused on the technical competency of the pilot. Finally, in the late 1980’s, the Federal Aviation Administration and the National Transportation Safety Board said, you have to address these issues. These “softer” skills are crucial to avoiding accidents, yet the aviation industry’s evaluations were totally technically based, to the detriment of teams and to the detriment of understanding the processes that got in the way.

But the real question was, how do you assess these team factors, these “softer” skills as everyone calls them, in the context of more focused, technical skills (can you fly an engine failure during takeoff, or in healthcare, can you do an intubation into a difficult airway management)? I found it a fascinating dilemma. I developed a process of simulation that allowed us to assess team interactions in a very factual and meaningful way for flight crews. It was also trainable, which was one of the key issues. Obviously, in the airline business, you have to provide training if you are going to invest in this type of assessment; plus, it’s the right thing to do. I worked on team assessments extensively for about ten years in the airline industry, and then I worked for another physician, Dr. Bill Rutherford, who was vice president of flight ops at United Airlines, and has since retired. He was always very interested in my work and very supportive. When he retired in early 2000, he went down to the University of Miami. They were developing a patient safety center. He began working to try to bring some of the processes, not the content, of airline methodology to help develop the center. Eventually, he asked me to come along, and that was my jumping-off point.

This was a few years after the Institute of Medicine Report (IOM) report in 1999, which said that healthcare needed to look to other high-risk industries, such as the aviation or chemical industry, for ideas to improve patient safety. The airline industry offered up their models of crew resource management. Unfortunately, a cottage industry then arose, with pilots selling resource management programs to healthcare organizations in order to help them with the dilemma identified by the Institute of Medicine (IOM). This dilemma was the significant amount of patient safety issues and mortality that, again, was not caused by the technical competency of clinicians and healthcare professionals, but by the softer skills of communication, situational awareness and workload management.

I knew what it took to understand the team dynamics and the needs of a flight crew. What I saw in healthcare is that this type of work has not been done. I have an understanding of both the culture of healthcare and the culture of a flight deck. As a result, I was adamantly opposed to simply taking a model developed in the aviation industry (or any other industry), superimposing it upon healthcare and thinking it was going to work. The premise of my work and of our research grant, which we have been working on for the last few years, is that you can’t take a model developed in an airliner at 35,000 feet and expect it to work in a cath lab or an ED or in a SICU, for example. My theory was that the processes developed in the airline industry to understand the flight team and create a template for the assessment and training of team skills could be brought to healthcare to do the same work. We could use these processes to understand what critical team skills healthcare professionals need to acquire.

This was how I became involved in patient safety. It was born in aviation, and my initial work with Dr. Rutherford sparked a research grant to bring our design concepts of simulation to healthcare. Looking at the team dynamics in healthcare, we find the same type of interactions, whether between the team, the clinician and the patient, or the clinician with other clinicians, in the sense that these interactions are very fragile, and a whole series of elements exist that tend to break down. What is different about healthcare, is that there hasn’t been a lot of work done to gain understanding of the challenges and dynamics involved. Nor have there been a lot of processes developed to help support healthcare professionals so that when there is an error or a miscommunication, something gets dropped or an incomplete handoff occurs, a backup system traps that error and mitigates its outcome. What we worked so hard on in the airline industry is the creation of a system to trap problems, because it’s not if we are going to make errors, it’s when we make errors, and there are backups in the processes that allow for mitigating a potentially catastrophic error.

You mentioned a 70% soft error rate in the airline industry. Would that same figure apply in healthcare?

Across different types of events such as medication-managed error or infections on central lines, the number on The Joint Commission error charts is right at about 70%. These are errors caused by the softer skills of communication or a workload management situation, not by technical competency issues in healthcare professionals. The dynamics and the numbers are basically the same between the two industries, but the challenges are significantly different, and this is where our work is important, because it’s the first time we have taken simulation and moved it to focus on the softer skills. In aviation, we spend millions and millions of dollars on high-fidelity simulators to re-represent the airplane, and the same is being done in healthcare to re-represent the physiology and presentations of physiology in a simulator. This is important. But these types of simulations don’t address the crucial dynamics of the healthcare team and its softer skills. To look at a technical competency, at a pilot flying an engine failure on takeoff or a physician managing difficult airway management or inserting a cardiac catheter, you create a simulator and put varying challenges into it, such as difficult insertion, anatomy anomalies and so on. In healthcare, data is starting to come out in simulation that, yes, if you intubate, intubate, intubate, and practice over and over again, most probably you are going to be a better intubator with fidelity simulation to the cases. But when it comes to the team skills, how do you create training and simulation in order to facilitate healthcare professionals in workload management or trigger effective communication? That is the process that we have developed, which is more of a scenario design process than an actual simulator.

In our research, we were originally going to use a simulation laboratory to understand the healthcare team. However, very early on in our work, the University of Minnesota asked us to come and run scenarios in the actual patient care units as a process to elicit team responses. When we utilized this type of simulation in the real world, it became clear there was no way this work could be accurately performed in a simulation healthcare laboratory. It was essential to do the work in actual patient care units. What we saw was the full impact of the environment, the systems, the processes and the communication complexity healthcare professionals have to deal with as they move a patient from the ED to the cardiac cath lab, for example.

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