2019 STRATUS Annual Report

ANNUAL REPORT SIMULATION TRANSCENDING HORIZONS 2019

OUR MISSION THE NEIL AND ELISE WALLACE STRATUS CENTER FOR MEDICAL SIMULATION IS COMMITTED TO ADVANCING MEDICAL EDUCATION, PATIENT SAFETY, AND HEALTHCARE OUTCOMES THROUGH CUTTING-EDGE APPLICATION OF MEDICAL SIMULATION TECHNOLOGIES SUPPORTED BY INNOVATIVE CURRICULA, CONTEMPORARY EDUCATIONAL METHODOLOGIES, CONTINUOUS IMPROVEMENT, AND RIGOROUS, MULTIDISCIPLINARY RESEARCH.

EXECUTIVE DIRECTOR'S NOTE This past year the STRATUS team has continued to contribute to the clinical and educational mission of Brigham Health. In addition, our reputation of conducting excellent, cutting-edge research has led to STRATUS securing record levels of grant funding that will ensure a strong future for our world- class research program. STRATUS has enhanced its contributions to the establishment of robust simulation globally through our consultations with international healthcare and educational institutions and the training of an increasing number of future simulationists from around the world. STRATUS’s entrepreneurial success has enabled us to support the growth of future internal and external programs, the resources that promote expansion of our exceptional simulation offerings, and the ability to navigate STRATUS on a course of continued growth. I hope that you will read our annual report highlighting these and other important contributions and milestones. Charles Pozner, MD Executive Director

15 YEARS OF STRATUS ACS Accreditation Mock Expansion Medicine Codes Proposal Adopted OB/GYN Anesthesiology Surgery Code Team Expansion Radiology Training Team Formed Neurology EM BWH DFCI 1st Director of Curriculum Considers Initiate Education & Expansion Curricula Research Begins 1st Intern Orientation STRATUS Trauma Team Expanded 1st Simulation Opens Training STRATUS Opens Fellow 2004 2005 2006 2007 2008 2009 2010

STRATUS Reaccredited 2nd International Deep Space STRATUS Affiliate Opens in Research Funded Develops Astana, Kazakhstan Entrepreneurial by NASA Strategy SRM/STRATUS 1st Opens in International Chennai, India Scholar of STRATUS STRATUS Non-Technical STRATUS Publishes 1st Skills Research Undergoes 2nd Simulation Study in New England Lab Opens at Expansion STRATUS Journal of Medicine 2019 2011 2012 2013 2014 2015 2016 2017 2018

TRAINING WITH SIMULATION The use of simulation as a tool supporting delivery of high-quality healthcare continues to expand. This has been evident in the growth of simulation’s application in competency assessment, research, and process improvement. However, the provision of skills-based and scenario-based education for the entire spectrum of healthcare providers at all levels, continues to drive the utilization of simulation. This is supported by our knowledge that active learning enhances knowledge acquisition in adult learners, avoids the unpredictability of the clinical environment, and enables clinical educators to use the precious and ever-shrinking learning time available in the most efficient manner. This is illustrated by the growing number of BWH user groups utilizing STRATUS’s resources.

2,433 LEARNERS 364 EDUCATORS 17,029 LEARNER HOURS 1,218 SESSIONS 3,807 HOURS DEDICATED TO INTERDISCIPLINARY TEAM TRAINING

PROGRAM TYPES Interprofessional Undergraduate Team Training Medical Education 19.5% 13% 10.3% Continuing Medical Education 47.4% 6.4% Nursing Graduate 3.4% Medical Education Other *This data is derived from 1,218 sessions at STRATUS in 2019

LEARNER TYPES Medical Students Attending Physicians 13.5% Physician Assistants Nurses 8.7% 3.8% 13.7% 8.4% Other 51.9% Residents & Clinical Fellows *This data is derived from 2,433 unique learners at STRATUS in 2019

INTERNAL PROGRAMS SPOTLIGHT ADVANCED The Advanced Leadership Skills in Trauma course is LEADERSHIP designed to give senior surgical residents the skills SKILLS IN TRAUMA needed to manage a mass casualty incident. We focus on non-technical skills including; teamwork and communication, decision making, situational awareness and leadership. We are able to make use of STRATUS to simulate multiple environments including the incident site, a trauma resuscitation room and an operating room simultaneously. The residents are challenged to work together to solve complex real world problems. ORTHO LOWER The HAEMR Residency program conducted a high EXTREMITY yield, practical, hands on course designed to review COURSE and practice various techniques to address common lower extremity orthopedic injuries seen in the emergency department. The session had 4 stations including reviewing and practicing common lower extremity splinting techniques, performing a comprehensive knee examination for ligamentous stability and the proper application of knee immobilizers, ankle splints, and cast shoe, as well as practicing reductions of hip, knee, patellar, and ankle dislocations. SURGICAL STRATUS provides surgical cricothyroidotomy CRICOTHYROTOMY training for several groups across the hospital. This vital technique must be in the airway algorithm for COURSE physicians from a broad range of specialties. Simulated tracheas are provided, as well as instruction, for anesthesiologists, general surgeons, pulmonary intensivists, neurologic intensivists and cardiothoracic surgeons. The training is combined with robust discussion of intubation medications, devices, and scenarios.

SIMULATION EDUCATOR OF THE YEAR 2018-2019 AWARDS David Meguerdichian, MD of the Department of Emergency Medicine; Robert Boxer, MD, PhD, of the Department of Medicine; and Stella Lee, MD of the Department of Orthopaedic Surgery, received 2018-2019 Simulation Educator of the Year awards from STRATUS. This award recognizes outstanding commitment to creating high-quality, simulation-based courses for trainees, staff, and faculty at BWH. Stella Lee, MD, Robert Boxer, MD, PhD, and David Meguerdichian, MD

THE WAY Brigham and Women's Hospital has embraced “the Brigham Way”, a concept that identifies and promotes the many ways that staff go above and beyond to make our hospital an even better place to work, visit, and receive care. STRATUS is proud to both exemplify the virtues of the Brigham Way and to provide others at the hospital an opportunity to develop and implement strategies allowing them to provide the safest and most effective collaborative care. An increasing number of hospital employees and staff are attending interprofessional team training programs provided by STRATUS. This training teaches the principles of communication, leadership, followership, decision-making, and situation awareness.

PROCESS IMPROVEMENT In 2019, STRATUS teamed up with the Quality and Safety Department to enhance the provision of the safest care throughout our hospital. In addition to providing mock drills for over 15 years that prospectively identify latent safety threats that exist in all healthcare institutions, STRATUS is now a member of BH’s quality improvement team that retrospectively investigates opportunities for care improvement.  From using simulation to re-enact safety events to providing a safe place to develop and test solutions, STRATUS continues to enhance processes that promote the best care at our hospital. DISCOVER BRIGHAM HOW TO HANDLE A MEDICAL EMERGENCY ON A DEEP SPACE MISSION STRATUS and NASA’s National Biomedical Research Institute have partnered to develop non-technical skills measurement tools and a medical simulation platform to prepare astronauts to deal with medical events on long duration space missions and enhance crew management of in-flight medical emergencies. The multidisciplinary team at STRATUS built a simulated medical bay to the exact specifications of the medical module on the International Space Station. During the demo, participants had the opportunity to talk with our researchers and observe the application of cutting- edge technologies, such as wearable physiological sensors and artificial intelligence (computer vision) for research, training and assessment.

RESEARCH & INNOVATION Steven Yule, PhD MISSION Director of Research & To save lives by understanding the non-technical Innovation practices of healthcare teams in real and simulated medical contexts. OBJECTIVES 1. Develop reliable assessment tools 2. Link team behaviors to clinical outcomes 3. Intervene to improve performance RESEARCH LABORATORY TEAM Charles Egide Abahuje, Baraa Tayeb, Pozner, MD MBBS MBBS Roger Dias, Abdulrahman Benjamin MD, PhD, MBA Al-Ballaa, MD Mormann, MD Valerie Dobiesz, Ahmed Robert Riviello, MD, MPH Aljaberi, MD MD, MPH David Wed AlMutairi, Jamie Robertson, Meguerdichian, MBBS PhD, MPH, CHSE MD Mohammed Douglas Smink, Basurrah, MBBS, MD, MPH Andrew Eyre, MD, MHPEd SORL-HNS

DISSEMINATION Dias RD, Avni G, Yule S. Using Machine Learning to Assess Physician Competence: A Systematic Review. Acad Med. 2019 Mar;94(3):427-439.   Dias RD, Barros JV. Burden of hospitalisation among older people in the Brazilian public health system: a big data analysis from 2009 to 2015. J Epidemiol Community Health. 2019 Jun; 73(6):537-543.   Dias RD, Zenati MA, Stevens R, Gabany JM, Yule SJ. Physiological Synchronization and Entropy as Measures of Team Cognitive Load. J Biomed Inform. 2019 Jul 8:103250. [ahead of print]   D i s s e c t i n gD i a s R D , Z e n a t i M A , C o n b o y H M , C l a r k e L A , O s t e r w e i l L J , A v r u n i n G S , Y u l e S J . Cardiac Surgery: A Video-Based Recall Protocol to Elucidate Team Cognitive Processes in the Operating Room. Ann Surg. 2019 Jul 24 [ahead of print]   Jung JJ, Yule S, Boet S, Szasz P, Schulthess P, Grantcharov T. Nontechnical Skill Assessment of the Collective Surgical Team Using the Non-Technical Skills for Surgeons (NOTSS) System. Ann Surg. 2019 Feb 21 [ahead of print]   V a r i a b i l i t y i n t h eM a t a l o n S A , C h i k a r m a n e S A , Y e h E D , S m i t h S E , M a y o - S m i t h W W , G i e s s C S . Use of Simulation for Procedural Training in Radiology Residency: Opportunities for Improvement. Curr Probl Diagn Radiol. 2019 May - Jun;48(3):241-246.   Pradarelli JC, Delisle M, Briggs A, Smink DS, Yule S. Identifying Naturalistic Coaching Behavior Among Practicing Surgeons in the Operating Room. Ann Surg. 2019 Aug 16 [ahead of print]   AR a m o s J G R , R a n z a n i O T , P e r o n d i B , D i a s R D , J o n e s D , C a r v a l h o C R R , V e l a s c o I T , F o r t e D N . decision-aid tool for ICU admission triage is associated with a reduction in potentially inappropriate intensive care unit admissions. J Crit Care. 2019 Feb 4; 51:77-83   Robertson JM, Dias RD, Gupta A, Marshburn T, Lipsitz SR, Pozner CN, Doyle TE, Smink DS, Musson DM, Yule S. Medical Event Management for Future Deep Space Exploration Missions to Mars. J Surg Educ. 2019 Nov 12;246:305-314   Scott JW, Lin Y, Ntakiyiruta G, Mutabazi Z, Davis WA, Morris MA, Smink DS, Riviello R, Yule S. Identification of the Critical Nontechnical Skills for Surgeons Needed for High Performance in a Variable-resource Context (NOTSS-VRC). Ann Surg. 2019 Dec;270(6):1070- 1078.   Zenati MA, Kennedy-Metz L, Dias RD. Cognitive Engineering to Improve Patient Safety and Outcomes in Cardiothoracic Surgery. Semin Thorac Cardiovasc Surg. 2019 Oct 17 [ahead of print]   A n o t h e r D u t c h t r e a tZ e n a t i M A , Y u l e S J . . J Thorac Cardiovasc Surg. 2019 Sep 23.

NASA In collaboration with an international multidisciplinary team, STRATUS scientists carried out a project funded by NASA to develop simulation-based countermeasures to mitigate team and system vulnerabilities during medical event management on long duration space missions. This project used STRATUS' simulated spacecraft to develop a high- fidelity simulation environment in multiple settings to investigate crew behaviors in different autonomous conditions.

DIGITAL BIOMARKERS STRATUS scientists have been pioneers in the use of physiological signals to assess individual and team performance in a variety of fields, including emergency medicine, surgery and space medicine. We have been using unobtrusive, wearable devices to collect EKG and EEG signals from participants, and machine learning techniques (computer vision) to automatically track body position and face recognition. This has enabled us to create novel methods to measure team dynamics and behaviors in an automated manner. The findings generated by our research have added valuable knowledge to medical education and clinical medicine.

EDUCATION STRATUS’s impact on healthcare extends far beyond the walls of Brigham and TRAINING FUTURE Women’s Hospital. Our international LEADERS IN fellowship in clinical simulation now SIMULATION AROUND matriculates up to 8 fellows per year who THE WORLD spend one-year at STRATUS honing the skills needed to develop robust simulation programs in their home institutions. Our graduates have gone on to be leaders in education at medical schools, hospitals, and in senior governmental posts. This year, we have accepted our first nurse educator who we expect will expand the impact STRATUS will have on global health.

CURRENT FELLOWS Wed AlMutairi, MBBS International Fellow | Emergency Medicine Egide Abahuje, MBBS Research Fellow | General Surgery Mohammed Basurrah, MBBS, SORL-HNS International Fellow | Otolaryngology Abdulrahman Al-Ballaa, MD, International Fellow | Trauma Surgery Ahmed Aljaberi, MD Pre-Residency Bridge Fellow | Internal Medicine

2019 GRADUATES INTERNATIONAL FELLOWSHIP IN CLINICAL SIMULATION Baraa Tayeb, MBBS International Fellow | Anesthesia / Palliative Care SHORT-TERM SCHOLARS Sui An Lie, MD Britlyn Orgill, MD Anesthesia Anesthesia Killiam Argote, MD Fahad Al Hajjaj, MBBS Disaster Medicine Disaster Medicine

COMMUNITY & INDUSTRY PARTNERS At STRATUS, simulation extends outside of Brigham and Women’s Hospital to empower the youth through the center’s offerings customized for STEM students. In addition, the center offers the ideal setting for industry to conduct prototype testing, usability studies, and facilitate training for clinicians and staff.  STRATUS’s numerous clinical environments provides realistic backdrops for photography and/or filming supporting the marketing and promotional efforts of our clients.

SIMULATION FOR YOUNG LEARNERS STRATUS offers unique hands-on experiences to secondary schools and summer programs, stimulating participants' interests in healthcare and other STEM fields. In 2019, STRATUS hosted students from Boston Leadership Institute, Colby College, EXPLO, The Perse School (UK), Roxbury Latin High School, and Weston High School. CONTINUING EDUCATION STRATUS offers its services and technologies to a variety of continuing medical education programs for practicing clinicians.  POP-UP STRATUS In efforts to spread simulation awareness, we brought STRATUS to the BWH mezzanine for the third year in a row where 100's of passerby received a hands- on introduction to simulation.

FILMING & PHOTOGRAPHY STRATUS maximizes the value of its unique clinical backdrop by offering it to a variety of clients for photo- and video-shoots; helping to support its programs and initiatives. TOURS & EXPERIENCES Our realistic clinical environment and the resources we have to bring it to life are another winning combination that is appealing to innovators. Virtual reality and augmented reality will be significant contributors to the future of simulation. USABILITY & PROTOTYPE TESTING STRATUS worked with several product development companies to support usability studies. Device users provide feedback to product engineers and user-interface specialists who are testing devices in our simulated clinical environment.

GLOBAL INTERACTIONS In 2019, STRATUS has continued to grow its international footprint. We have hosted future leaders in medical stimulation from around the world who participate in our clinical fellowship in medical stimulation. STRATUS has secured a contract with a large academic medical center in China to help them design and operationalize an expansion of their simulation center. STRATUS faculty and staff continue to provide lectures throughout the world.

AFRICA Malawi Egide Abahuje, MD, MMED, led a non-technical skills (NOTSS) workshop for 25 junior surgeons from Malawi, Nigeria, and Zambia Rwanda Egide Abahuje, MD, MMED, supported NOTSS instructors to train multidisciplinary OR teams working in Rwandan district hospitals integrating surgical skills and non- technicall skills for surgery ASIA China Bo'ao delegation visit to STRATUS STRATUS visits Chengdu People's First Hospital to kick-off its 5-year project Guangzhou delegation visit to STRATUS Charles Pozner, MD was a guest speaker at the 2019 Belt and Road International Cooperation Promotion Conference in Haikou Singapore Deborah Navedo, PhD, CPNP, FNAP, was invited as an education expert to the National Health Group (HNG) Ten Tock Sang Hospital and Khoo Teck Puat Hospital. She presented, workshops, and consulted with education and research teams on topics related to simulation-based learning 

CHENGDU PEOPLE'S FIRST HOSPITAL In 2019, STRATUS signed a 5-year contract with the Chengdu First People's Hospital (CFPH) located in Sichuan Province in the People’s Republic of China to assist them in the expansion and re-design of their medical simulation center. The first component of the project was a needs assessment to ascertain the project's scope. The STRATUS team spent four days in Chengdu interviewing potential stakeholders and collecting the data necessary to provide a five-year plan. During the trip, over 25 individual interviews were completed culminating in a 60-page report delineating the actions necessary and milestones to successfully complete the project.   The current phase of the project includes leadership recruitment for the center. These leaders will travel to STRATUS to acquire knowledge and experience to successfully operationalize the center and gain the skills necessary to design and implement simulation-based curriculum. In parallel, STRATUS will work with CFPH staff to design and outfit the simulation center for its grand opening.   Once opened, next steps will focus on increasing usage, expanding the scope of educational offerings, and providing external programs locally, regionally, and nationally. Assessment, research, process improvement, and other simulation- based activities will be added on an incremental basis, synchronous with faculty and staff growth. STRATUS will work side-by-side with CFPH to ensure a successful project.

EUROPE Austria Deborah Navedo, PhD, CPNP, FNAP, attended AMEE's 2019 annual conference in Vienna France Roger Dias, MD, PhD, MBA, presented Psychophysiological Data & Computer Vision to  A s s e s s C o g n i t i v e L o a d a n d T e a m D y n a m i c s i n C a r d i a c S u r g e r y a t t h e 1 0 t h I n t e r n a t i o n a l Conference on Information Processing in Computer-Assisted Interventions in Rennes Portugal STRATUS was contracted by the U.S. Department of State (DOS) to create a blended educational program for their entire medical staff from U.S. embassies and consulates around the world Scotland Steven Yule, PhD, FRCSEd, gave the keynote speech on simulation and non-technical skills at the 25th SESAM Annual Meeting in Glasgow NORTH AMERICA Mexico Roger Dias, MD, PhD, MBA, was the keynote speaker at the VI Congreso Latinoamericano de Simulación Clínica in Cancun presenting on Innovation in Simulation: from the Emergency Room to Space

THE STRATUS TEAM STRATUS’s continued success is not the result of any individual team member associated with the center, but is the culmination of the exemplary teamwork of the entire faculty and staff.  Simulation is like a Broadway show, with many moving pieces, an ever- changing cast of characters, and an expectation that each show will never be exactly the same as any prior show. This unpredictability and necessity to respond to numerous unexpected events, requires each team member to not only have their own set of individual skills, but to be able to work collaboratively with others on the team. STRATUS continues to excel at this challenging balancing act.

FAREWELL, STEVEN YULE! In January 2020, I will take up a new role as Professor and inaugural chair of Behavioral Sciences at The University of Edinburgh Medical School. I wanted to take a few moments to reflect on my time here and say thank you for having the Yule family in Boston. I am proud to say that we have built a research laboratory here at STRATUS to focus on non- technical skills that has had impact beyond the walls of our simulation center. It has been an honor and a privilege collaborating with all the simulation specialists, clinical teams, and investigators here and I have been fortunate to work locally with STRATUS, BWH Department of Surgery, Center for Surgery & Public Health, Harvard Medical School, and Ariadne Labs. It has been a very exciting and inspiring time and every day in Boston, brings new opportunities for research collaborations, grant submissions, visiting speakers, technology innovations, and travel. It has not always been easy but we have made some important breakthroughs. Some highlights (and there are many) include OR team training with simulation, developing non-technical skills program in Rwanda, peer coaching for surgeons, innovations in cardiac surgery, establishing a research program in space medicine funded by NASA, and the evolution of NOTSS. It has been a real privilege to be involved  in many new ideas and opportunities that have great potential to enhance safety and quality of care for patients.  I’m fortunate to have developed some deep working relationships and friends with many investigators not only in Boston but across the country. I didn’t expect the lifelong friendships that have emerged during my time here. The best research involves people from different backgrounds who bring their expertise and experiences together to create something that no one person could envisage or achieve alone; the power of the collective is why the relationships are so important. You need that connection, creativity, and also the confidence to take risks and try out new things, especially when trying to be innovative. I have also been fortunate to mentor many students, residents, fellows, and faculty in my time here - and learnt a lot in the process. I’m very grateful to STRATUS, the Brigham, and Harvard for creating an environment to make that possible.  We have grown to love Boston, particularly Jamaica Plain - the weather, the food, craft beer, travel, and of course, the Bruins and Patriots. As sad as I am to leave Boston, physical location is much less important than it used to be. We use technology for research and communication all the time with some face-to–face interaction but actually the world has evolved to have these more virtual, without walls type of structures, that ultimately drive innovation. We will have ongoing collaborations and the potential to develop a special relationship between Boston and Edinburgh is exciting. Steve

LEADERSHIP TEAM Roger Dias, MD, MBA, PhD Charles Pozner, MD Director of Business Executive Director Ventures & External Associate Professor of Programs Emergency Medicine, Instructor of Emergency Harvard Medical School Medicine, Harvard Emergency Physician, Medical School Brigham and Women's Hospital Sumaira Ahmed Steven Yule, PhD Director of Strategic Marketing and Business Director of Research & Development Innovation Academic Fellowship The Brigham Way Program Director recognition by Dr. Betsy Associate Professor of Nabel Surgery, Harvard Medical School Trevor Anderson, CHSOS FRCSEd (ad hominem) from the Royal College of Operations Manager Surgeons of Edinburgh Elaine Houle Valerie Dobiesz, MD, MPH Project Coordinator Director of Internal Programs International Fellowship Program Director Assistant Professor of Emergency Medicine, Harvard Medical School 2019 Mass Medical Women's Health Research Award Deborah Navedo, PhD, CPNP FNAP MD Director of Education

OPERATIONS TEAM Our incredible operations team keeps STRATUS running at full-throttle. Our simulation specialists and administrative assistants constantly strive to provide top-notch service in the professional and user-friendly manner that our customers have grown to expect. Unlike many simulation centers, the members of our operations team operate and facilitate the use of our technology; enabling our faculty to concentrate on the educational content being provided to learners. Their eagerness to “think outside the box” enables STRATUS to create various task trainers and surgical skills models that have yet to be developed by the simulation industry. Trevor Anderson, CHSOS Operations Manager Persephone Giannarikas Duc La Simulation Specialist Simulation Specialist Saja Traoui Taylor Driggers Simulation Specialist Administrative Assistant Daniel Guzman, Jr. Jil Sharpe Simulation Specialist Administrative Assistant

ASSISTANT DIRECTORS STRATUS Assistant Directors are the liaisons through which the center maintains close contact with the departments and users of simulation at Brigham and Women's Hospital, ensuring that STRATUS continues to meet the needs of our diverse hospital community. Matthew DiFrancesco, MD Andrew D. Miller, MD Department of Medicine Department of Anesthesiology, Perioperative, and Pain Medicine Lydia Helliwell, MD Michael Muto, MD Department of Surgery Department of Obstetrics and Gynecology Tanzeema Hossain, MD Helen Shields, MD Department of Pediatric Newborn Medicine Department of Medicine Mary Ann Kenyon, MSN Stacy Smith, MD Department of Nursing Department of Radiology David A. Meguerdichian, MD Kathleen Wittels, MD Department of Emergency Medicine - Residency Department of Emergency Medicine - Students) ADVISORY COUNCIL Michael Weaver, MD Department of Orthopaedic Surgery The Advisory Council is a diverse group of hospital leaders who help guide the decisions made to ensure that STRATUS maintains its commitment to the mission of Brigham and Women's Hospital. Sunil Eappen, MD, MBA Allen Smith, MD, MS Senior Vice President, Medical Affairs President, Brigham and Women's Physicians Chief Medical Officer Organization Michael VanRooyen, MD, MPH Madelyn Pearson,DNP, RN, NEA-BC Chairman, Department of Emergency Senior Vice President, Clinical Services Medicine Chief Nursing Officer Julia Sinclair, MBA Brendan Russell, MBA Senior Vice President, Inpatient and Clinical Executive Director, Department of Services Emergency Medicine

IN LOVING MEMORY OF Elise \"Butch\" Raymond Wallace (1933 - 2019) In May 2019, we lost a dear friend and an advocate of the STRATUS mission. Mrs. Elise \"Butch\" Raymond Wallace not only supported STRATUS through her generous philanthropy but maintained an ongoing presence that provided support and inspiration to our team. This dedication is a testament to a true healthcare leader and change agent. Mrs. Wallace is survived by her husband Neil Wallace, three children, five grandchildren, and loyal dog.

www.brighamandwomens.org/STRATUS