“Simantha” is part of the simulation training offered by Medical Simulation Corporation.

Simulation training has finalized its move into the mainstream. The technique received the stamp of approval earlier this year when the American Board of Internal Medicine (ABIM) adopted its use into its Maintenance of Certification program for interventional cardiologists.

In 2002, the ABIM realized that the method of testing in the future would involve some type of simulation, according to Amy Ketron, manager of clinical development for Medical Simulation Corporation (MSC) of Denver. The ABIM evaluated several simulation companies and chose MSC, which then conducted a feasibility study with 120 interventional cardiologists to determine if simulation training would provide a valid method of measuring the differences in skill levels among cardiologists. “We showed it could,” Ketron says.

A study by David L. Dawson, MD, and colleagues from the division of vascular and endovascular surgery at the University of California, Davis, found significant benefits to simulation training (J Vasc Surg 2007;45:149-54). Researchers trained nine vascular surgery residents over three days using simulation technology from MSC. Trainees also underwent conventional training. Compared with performance early on day one, residents improved significantly in three categories:

• Total procedure time decreased 54 percent
• Volume of contrast decreased 44 percent, and
• Fluoroscopy time decreased 48 percent.

Another study by Berry et al found that simulation training was up to 16 times less expensive than endovascular training with animals (J Vasc Interv Radiol 2008;19:233-238). The analysis compared the purchase or rental of the simulator Procedicus VIST (Mentice) to the rental of an animal laboratory. The authors concluded that the biggest cost factor in the animal laboratory is the “consumption of stents for each procedure because the stent cannot be retrieved from the animal. In the simulation laboratory, the stents are only virtually placed.”

In conjunction with MSC, the ABIM has developed five case scenarios that include common problems faced by interventional cardiologists. Physicians complete the simulations on-site at one of MSC’s six SimSuite education centers across the country or at conferences throughout the year, such as the upcoming Transcatheter Cardiovascular Therapeutics (TCT) conference in Washington, D.C.

Upon successful completion of a simulation session, interventional cardiologists receive 20 points toward Maintenance of Certification. “Typically, this takes three hours of training and self-testing at the simulator,” write George D. Dangas, MD, and Jeffrey J. Popma, MD, in an article on certification in the Journal of the American College of Cardiology – Cardiovascular Intervention (2008;1;332-334). According to the researchers, the ABIM has said it will expand the simulation program, eventually making it a mandatory step in the certification process.

The Society for Simulation in Healthcare, a multi-disciplinary, multi-specialty, international society established in 2004, is currently developing a process by which simulation programs can become accredited. Programs must first meet standards in one or more of three areas: assessment, research or education, which then allows them to seek additional accreditation in the areas of system integration and patient safety.


Simulation is for real

Much of the momentum for the acceptance of medical simulation training began in 2004. In that year, representatives from the Society for Cardiovascular Angiography and Interventions (SCAI), the Society for Vascular Medicine and Biology (SVMB) and the Society for Vascular Surgery (SVS) met with the FDA behind closed doors and in public to promote the technique. An FDA panel voted that year to accept a proposal that “virtual reality simulation would be an important component of a training package for carotid stenting” (JAMA 2004;292:3024-3026). The FDA then approved the Cordis carotid stent system, with the proviso that the manufacturer would work with physician trainers to “learn catheter and wire handling skills on a high-fidelity virtual reality simulator.” Also in 2004, SCAI, SVMB and SVS included medical simulation in a joint competency statement and the Centers for Medicare & Medicaid Services elected to reimburse for carotid stenting.

Giora Weisz, MD, and colleagues at the Cardiovascular Research Foundation and Columbia University in New York confirmed that simulation could reliably discriminate between different levels of experience. Their stated aim in the study was to provide a mechanism that could assess competency in performing percutaneous endovascular carotid stenting. They tested 34 operators—10 expert, 12 intermediate, and 12 novice— on Simbionix equipment and concluded that simulation training has the potential to be an objective examination tool. They further stated that their results “justify the use of interventional cardiovascular simulation for certification and credentialing” (J Soc Sim Healthcare 2007;2[1]:81).

Weisz’s findings, at least on the expert level, were confirmed by Simon Neequaye, MD, and colleagues at Imperial College London. Researchers evaluated 11 experienced endovascular physicians from several medical disciplines with minimal experience in carotid artery stenting, using Simbionix simulation equipment. They observed a total procedure time decline from a median of 36 to 20 minutes; a drop in fluoroscopy time from 20 to 11 minutes; and a decrease in delivery-retrieval time of the embolic protection device from 12 to nine minutes. The study was presented at the 2007 European Society for Vascular Surgery meeting in Madrid, Spain.

At the 2008 American College of Cardiology conference, MSC presented a simulated scenario that followed a patient suffering from an acute myocardial infarction from the onset of symptoms, through the EMS and ER process of care, and then to the cath lab for a cardiovascular intervention.

“A primary initiative in improving care of AMI patients is finding ways to speed the door-to-cath lab time with the overall goal of saving more heart muscle. Simulation training provides the ideal platform to address these challenges in a realistic environment,” said moderator Mark A. Turco, MD, director of the Center for Cardiac and Vascular Research at Washington Adventist Hospital in Takoma Park, Md.