How Hospitals Benefit from Surgical Simulation Systems

In no area is the dramatic pace of medical innovation more apparent than for cardiovascular treatments. It’s been said, in fact, that “technology is health care,”(1) which rings true when you consider the advancements in minimally invasive endovascular therapies of the past few years. Because medical simulation offers an intermediate stage in medical education between the classroom and the clinical setting, it’s a particularly valuable tool for cardiovascular interventionalists interested in the very latest devices and procedures. But besides the purely educational advantage to surgeons, medical simulation systems can also offer hospitals a path to new revenue streams, the possibility for reduced insurance and other costs, and support for enhanced patient safety. First, an update on surgical simulation systems today.

The CathLabVR™ by Immersion Medical
As an example of today’s surgical simulation technology, the virtual reality interventional catheterization CathLabVR™ Surgical Simulator from Immersion Medical, Inc. (Gaithersburg, Maryland, USA) allows clinicians to practice endovascular procedures such as coronary and peripheral vascular interventions, cardiac pacing, and cardiac valve replacements.
The virtual reality system mimics the functionality of a real cath lab and provides the responses of the virtual patient. It supports careful attention to interpretation of the fluoroscopic image and reproduces the subtle feel transmitted through guide wires, catheters, and other interventional devices. The system includes a manifold for contrast instillation, balloons, balloon stents, guidewire, and catheter. A platform fills roughly the same space as would a real patient, and a foot pedal, keyboard, mouse, and two monitors are included. The foot pedal is used to virtually capture cines and control fluoroscopy. Other system functions are controlled using a joystick to manoeuvre the simulated C-arm and a keyboard and mouse to make onscreen selections.

The primary (right) monitor displays fluoroscopic views, Virtual Assistant (advice) functions, navigation control, and simulated patient information, including aortic pressure, heart rate, respiratory rate, oxygen saturation, ECG strips, and catheter tip pressure wave.

The secondary (left) monitor displays physio, cine, and still images and controls for the C-arm/Table glyph. The Physio View displays the 3D model of the aorta (descending, arch, and ascending), native coronary arteries, and in some instances saphenous vein grafts. The anatomy beats in rhythm with the virtual patient’s pulse, and rises and falls according to the patient’s breathing. The secondary monitor also displays total procedure running time, fluoroscopy and cine radiation time, and contrast instilled.

“We believe we are uniquely qualified to support the industry with a virtual reality surgical simulation training platform for deployment of endovascular therapies from head to lower limb,” says Mark Meents, vice president of sales and marketing for the company. “For example, our cardiac resynchronization therapy (CRT) procedure requires the use of cannulation and subselection catheters, guide wires, balloon inflation, contrast injections, and pacing lead placement. I don’t believe there is another surgical simulator manufactured today that has this advanced capability.”

New revenue streams
In 2002, Immersion Medical sponsored a Frost & Sullivan study with the American Hospital Association to determine the payback period for several of the company’s medical and surgical simulators. The study included detailed interviews with 237 attending staff physicians, risk managers, CFOs or controllers, and other personnel. The results were dramatic, showing that payback periods ranged from just 57 to just 169 days, even for the company’s sophisticated computer-based simulators.

The aim of the study was to identify factors that contribute to return on investment. Among the non-financial factors, it was found that hospitals offering courses or workshops based on simulator training were generating revenue. While the average for this opportunity was US$23,250, some institutions were realizing revenue streams of up to US$150,000 per year.(2)

The merits of training on a simulator were well described by Dr. Campbell Rogers in an Immersion Medical case study(3). Rogers, who is director of the Cardiac Catheterization Lab at Brigham & Women’s Hospital in Boston, described his participation in Medtronic-sponsored training sessions for over 150 interventionalists in China.

“The simulator allows you to dial in those sorts of complexities or complications, so you can give experience to people in a much more focused way,” Rogers explained.

This point also suggests how hospitals could use simulators to help their surgeons adopt and successfully use new technologies that bring in revenue and help establish a reputation for leading-edge care. But of course, training and education of new technologies and treatments is essential. With physics-based simulators, such as Immersion Medical systems, realistic training software can be developed and loaded on the system, letting doctors quickly and conveniently become familiar with the look, sound, and feel of the latest techniques and procedures. Although physics-based systems are much harder to create than those that use mathematics-based models, they can much more easily be tuned to achieve a more authentic response for surgical devices and tools, making the training experience highly realistic.
In addition to revenue streams from training and deployment of new high-value services, Frost & Sullivan found that, with the skill improvements resulting from practicing on Immersion Medical simulators, operating room or procedural time savings resulted. Faster procedures with fewer errors supplies the opportunity to perform more procedures, which increases revenue.

Reduced insurance costs and other savings
In response to rising medical insurance costs in the U.S., several organizations have forged alternative strategies. Many doctor-owned insurers provide discounts on premiums if doctors and hospitals participate in approved patient safety workshops or programs, which are often strongly based in medical simulation.(4)

Dr. John Schaefer a pre-eminent authority on medical simulation, served as director of the Peter M. Winter Institute for Simulation, Education and Research at the University of Pennsylvania. “At Pittsburgh, the health care system was self-insured, so they required the simulation training,” Schaefer explains. “They didn’t wait, and they were the ones paying for it. The malpractice industry is looking for solutions. This training makes doctors more insurable and cheaper to insure.”(5)

Patient safety and better quality of care
Related to reducing insurance costs, medical and surgical simulation can provide an objective measure of competency for granting hospital privileges. Further, practicing on a simulator can expose a surgeon to a very broad range of cases whenever convenient. Even rare complications can be practiced repeatedly, helping to keep skills fresh and increase the probability of successful outcomes. These training effects may result in fewer complications and cancellations, which helps reduce costs - even costs as large as a multimillion dollar malpractice suit.

Dr. Rogers of Brigham & Women’s agrees. “The endovascular simulator has incredible potential. Financial and clinical cost savings will be realized through prevention of complications or more rapid recognition and treatment. From a physician’s point of view, by training to prevent complications in the first place, you’re greatly enhancing the safety of procedures.”

There’s one more way in which medical and surgical simulators may help patient safety. Writing in Health Management Technology, Dr. Carl A. Patow states, “Learning procedures using advanced medical simulators is a step forward, but medical errors often result from ineffective processes and poor communication. After training in simulation centers, teams can stop to reflect on their performance in detailed debriefing sessions. Reviewing video to discuss and learn from what transpired during a training exercise is an essential element of the learning process. That kind of in-depth review often is not possible in real, fast-paced clinical settings. Developing the capacity to work closely with others in proficiently functioning care teams could be the most important contribution of simulation to medical education and patient safety.”(6)

References

(1) Durenberger, D. and S. B. Foote. Medical Technology Meets Managed Competition. Journal of American Health Policy. May/June 1993: 23.
(2) Frost & Sullivan. 2004. Return on Investment Study for Medical Simulation Training. Performed in conjunction with the American Hospital Association HRET.
(3) Immersion Medical. 2004. Endovascular Simulator Enhances Patient Safety and Physician Training.
(4) Physician Insurers Association of America.2007. Provider-Directed Insurers Ahead of the Curve. www.piaa.us
(5) South Carolina Business. 2007. Stunt Doubles: MUSC/Dr. John Schaefer, MD, June 2007.
(6) Patow, Carl A. 2005. Medical Simulation Makes Medical Education Better and Safer. Health Management Technology. Nelson Publishing, Nokomis, Florida: December 2005.