Simulation - Perfusion.com

Using Simulation to 

Reduce Risk in 

Perfusion 

Jeffrey B. Riley MHPE CCT CCP 

Mayo Clinic 

Rochester MN, USA 55902 

Reducing perfusion risk with simulation

Disclosure 

Mayo Clinic Division of Cardiovascular Surgery 

Research funding within the past year: 

Atricure 

Jarvik Heart 

Boehringer Ingelheim 

St. Jude Medical 

Bolton Medical 

Thoratec Corporation 

Carbomedics/Sorin Group 

Ventracor 

Edwards Lifesciences 

W.L. Gore and Associates 

Medtronic 

Current Technology Licensing Agreements: 

St. Jude Medical 

Sorin Group 

No personal equity, patents, licensing, or consulting agreements 

with the medical device or pharmaceutical industry to disclose 


Rochester MN 


Perfusion 

Simulation 

at the 

Mayo Clinic 

Multidisciplinary 

Simulation Center 


The Mayo Clinic 

Cardiac surgery facts of interest 

t 

• 2 nd US News & World Report 

• 2,400+ annual cardiac surgeries 

• 10 surgeons, 16 anesthesiologists, 16 

perfusionists, i and multiple l ATs, MTs, CRNAs 

and CSTs 

• 8-9 cardiac ORs, 8-16 procedures per day 

• Annually: 200 pediatric, 325 adult congenital, 

35 VADs, 34 ECMOs, DHCAs, multiple re- 

operation procedures 


Perfusionists 

Self-Select 

ICEBP / AmSECT 

Simulation Pilot Project 

New Orleans, June 2009 

Assign to 

Sim Room 

Brief 

Delegate 

Run the 


Rate at 

Four Levels 

Goals: 

• Can we measure perfusionist safety with 

simulation models in a large group? 

• Can we identify opportunities for community 

practice improvement? 

• Is current perfusionist practice consistent 

with best evidence-based guidelines? 

Analyze the 

Results 

Report 

Results 


Objectives: Reducing Perfusion Risk 

with Simulation 

• Define the concept of risk 

• What is risk in perfusion? 

• What makes perfusion safe? 

• Quantifying risk in perfusion 

• Perfusion team risk reduction 

model 


What is Risk? 

• “Risk is a concept that denotes the 

precise probability of specific 

eventualities.” 

• Risk is not necessarily associated with 

positive or negative outcomes 

• One may refer to the risk or probability of 

a beneficial result 

Wikipedia 


Premise for Perfusion Team 

Risk Reduction Model 

6σ 

DMAIC 

Incident 

Reporting 

Reduce 

Incidence 

SPC Run 

Charts 

Remediate 



Human Factors and the 

Cardiac Surgical Team 

• HF contribution to cardiac surgery is becoming 

obvious 

• Given the scientific gains in cardiac surgery – the 

greatest t opportunity for future improvement lies in 

improving human performance 

• Implies the evaluation of clinicians and of 

equipment and the interaction between the two 

• A large part of the HF science involves improving 

aspects of teamwork to reduce errors 


Safety Drills for Common 

Cardiopulmonary Bypass Incidents 

• Annual competency 

check-offs 

• Safety drills and crew 

resource 

management for 

critical incidents 

• Incorporate learning 

from procedure 

incident-reporting 

system and FMEA 

• Multi-disciplinary 

communication 


Simulator Use in the UK 

British Airways: 

3,200 pilots 

14 high-fidelity simulators 

Adherence to standards 

NHS in England: 

34,00 consultants 

47,000 doctors in training 

Fewer than 20 high-fidelity simulators 

Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting paradigms: From Flexner to 

competencies. Acad Med 2002;77:361-7 


Cardiothoracic Surgical Simulation 

• Traditional apprenticeship model 

• Visioning Simulation Conference e was held in April 2007 

• Simulation will also bring any conflict between service 

and education to the forefront 

• Meeting patient care demands, already stressed by 

restricted work hours, will be further stressed by having 

residents partially educated with simulators. 

• Who will be the teachers in a simulation curriculum 

• Stimulate development of more simulators specific to 

cardiothoracic surgery 

• The use of simulators will revolutionize education in 

cardiothoracic surgery in the near future, but it will 

require creativity, hard work, leadership, and money. 

Feins RH. Expert commentary: Cardiothoracic surgical simulation. JTCVS 2008;135:485-6. 


Is Perfusion Ready for the “Flock of 

Geese?” [ICEBP 2009] 

• US Airway flight 1549 landed in in the Hudson River – all 

155 passengers and crew were safely extracted t with in 

minutes 

• Safety yp principles p are engrained early in perfusion 

education 

• Standardization of CPB is a key ingredient to safety – just 

like in the airline industry 

• Our colleagues have developed EB guidelines focused 

on CPB principles 

• Collect data is a starting point of benchmarking 

• Cannot always anticipate crisis events during CPB 

• This meeting is synergistic and unique opportunity 

ICEBP Committee. AmSECT Today: May/June:14 


Are You a Safe Perfusionist? 

• What is the risk of an undesired outcome while 

you are operating the heart lung machine ? 

• Safe perfusionists do more than conduct bypass 

safely 

• Safe perfusionists study their practice and 

evaluate the risk of adverse events (being free of 

adverse events) 

• What are your most frequent adverse perfusion 

events? 

• How many CPB procedures do you perform 

between adverse perfusion events? 


Perfusion Event-Reporting 

• Event or variance-reporting reporting is important for 

sustaining i a safe perfusion practice. 

• Variance reporting identifies and logs our 

experiential learning. 

• Reviewing the perfusion case report literature 

identifies the evidence side of safe perfusion 

practice. 

• Clinician process improvement ideas should be 

captured daily as an integral element of safe 

perfusion practice. 


Preparing to Use 


• Task (or job) analysis is a science 

to itself 

• There are standards for designing 

and conducting simulations 

• Interviewing, flow-charting and 

root cause analyses are used to 

design effective simulations 

• Simulation briefing, and debriefing 

are employed to give clinicians 

opportunities to demonstrate their 

skills and knowledge in high 

fidelity situations 

Dunn W, Murphy JG. Simulation: About safety, 

not fantasy. Chest 2008;133:1719-20. 

C:\Documents and Settings\m051242\Desktop\simulation.abc 

Tuesday, March 24, 2009 

7:52 AM 

Begin 


No 

AMOD-01:___ 

Read Patient 

Medical 

Record 

Set-Up HLM 

and DMS 

Surgeon: "Aortic 

cannula is in" 

Perf Test 

Art Line? 

Perfusionist Tests 

Art LIne, Discovers 

Clamp 

Perfusionist Communicates 

Appropriately 

Surgeon: "Go on 

bypass' 

Anesthesiologist: "Let me know 

when you are up to full flow" 

Initiate 

CPB per 

MD VO 

No 

Orpheus: Clamp arterial line 

Orpheus: Unclamp arterial line 

AMOD-02:___ 

On CPB: P2 

Orpheus: Set SVR = 7 


Simulation Scenarios 

• Briefing 

• Scenario one 

• Debrief one 

• Scenario two 

• Debrief two 

• Evaluation 

• Meta-Evaluation 


CRM – Seven Skills 

• Mission / Flight Analysis 

• Assertiveness 

• Decision Making 

• Communication 

• Leadership 

• Adaptability and Flexibility 

• Situational Awareness 


Orpheus Perfusion Simulator 


ECMO Specialist Case Study 

• ECMO case study 

• ECC arterial line 

hypertension during 

ECMO 

• Reduce negative 

patient risks 

associated with 

ECLS 

• Role of debriefing in 

simulation 

Simulation in Healthcare. 2006;1:220-7 


Future Simulation Scenarios 

to Drive Out Risk 

• The most frequently identified reasons for 

incidents of patient harm resulting from technical 

errors with equipment are user error and 

inadequate device education 

• If surgical (multidisciplinary) teams use incident 

reporting and process improvement ideas, there 

are numerous future simulation scenarios 

• Simulation has been demonstrated to reduce the 

negative risks associated with ECC and ECLS 

• Simulation center activities must be a 

professional extension of the clinical perfusion 


Thank you! 

Riley.Jeffrey@Mayo.edu 




Comparison of Learning Constructs 

Tradition-based Programs 

Constructivist-Based Programs 

Teaching 

Teacher-centered centered instruction 

Authority driven 

Learning as product 

Knowledge is fixed 

Isolated work 

Information deliver 

Skill acquisition and rote learning 

Practice makes “correct” 

Learning 

Student-centered instruction 

Empowerment 

Learner autonomy and initiative 

Knowledge is provisional 

Collaborative work 

Knowledge creation and exchange 

Exploratory, inquiry-based learning 

Practice as “shifting 

Campbell MR, Brummett VM. Mentoring preservice teachers for development and growth of 

professional knowledge. Music Educators Journal, 2007;93(3):50-55.

Simulation - Perfusion.com

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