Volume 10, No. 3 • Fall 1995

Simulator Training in Anesthesia Growing Rapidly

David Gaba, M.D.

CAE Model Born at Stanford

Editor’s Note: This is the first in a series of update articles on the development and use of computerized simulators in anesthesia training and continuing education, particularly with regard to teaching patient safety and crisis management. In the next issue, Drs. Tammy Euliano and Michael Good will outline experience with the Loral/University of Florida Human Patient Simulator. Readers who have familiarity or experience with equipment other than the CAE or Loral models are invited to submit accounts of their experience for publication in this series.

Technologies involving anesthesia simulation developed separately by David Gaba, M.D., and Howard Schwid, M.D., with funding from APSF research grants have been incorporated into the CAE Patient Simulator, which a number of institutions in North America and Japan have acquired. The institutions are using their patient simulators for a variety of purposes, as described below, but many of the centers are making anesthesia crisis management training their main focus.

Crisis Management Training Developed with APSF Funding

During 1989-1990, using additional grant funding from the APSF, a team of anesthesiologists at Stanford University and the VA Palo Alto Health Care System (VA Palo Alto HCS) developed a simulator-based curriculum on Anesthesia Crisis Resource Management (ACRM). The syllabus for this curriculum has since been published as a textbook (Gaba DM, Fish KJ, Howard SK: Crisis Management in Anesthesiology. New York: Churchill Livingstone, 1994). In the fall of 1990, two successful prototype ACRM courses were held in Palo Alto, and have been held there periodically ever since.

The ACRM course includes brief didactic sessions, but it is primarily made up of a set (lasting several hours) of highly realistic simulation scenarios, each followed by a detailed debriefing session which includes reviewing videotapes of the simulation session. The course addresses medical and technical issues relevant to the simulated scenarios, but it concentrates on basic generic principles of anesthesia crisis management. These include: leadership, teamwork, distribution of workload, communication, use of all available information and resources, and constant reevaluation of the clinical situation. The ACRM course is described in detail in Howard SK, Gaba DM, Fish KJ, Yang GS, Sarnquist FH: Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviation, Space, and Environmental Medicine 63:763-770, 1992.

The Boston Anesthesia Simulation Center (BASC)

(Much of the following information was provided by Steve Small, M.D., and the BASC staff)

In 1991, Jeff Cooper, Ph.D., led a team from a consortium of Harvard-affiliated hospitals to Palo Alto to take the ACRM course to consider its adoption in Boston. In 1992, while on sabbatical, Dr. David Gaba took the CASE 2.0 simulator to Boston for a three-month project to train instructors to teach the ACRM course. The results of this project are described in: Holzman RS, Cooper JB, Gaba DM, Philip JH, Small S, Feinstein D: Anesthesia Crisis Resource Management: Real-Life Simulation Training in Operating Room Crises soon to be published in the Journal of Clinical Anesthesia.

In January 1994, the Boston Anesthesia Simulation Center (BASC) became the first dedicated Center to teach ACRM. BASC staff come from the anesthesia departments at five Harvard-affiliated hospitals (Beth Israel Hospital, Brigham & Womens’ Hospital, Childrens’ Hospital, Massachusetts General Hospital, and New England Deaconess Hospital). BASC is housed in a commercial office building next to the Copley Place mall in downtown Boston.

The first ACRM courses were held in the spring of 1994. BASC reports a successful first year of formal operations.

BASC met its primary objective of integrating Anesthesia Crisis Resource Management (ACRM) training in a realistic simulation setting into the curriculum for all Harvard anesthesia residents and fellows beyond CA-1. Altogether, 262 physicians participated in 59 small group intensive ACRM workshops. The trainee cohort consisted primarily of residents and staff from Harvard-affiliated training programs, but there were trainees from three other major New England medical centers, and also a number of private-practice clinicians from Canada and the United States. To date, no courses have been delayed or cancelled despite the numerous scheduling and technical contingencies associated with running a complex simulation program.

Solicited feedback months after training (anonymous return mailing) is being collated. High percentages of residents and staff have indicated that they are less vulnerable to distractions, ask for and use help more effectively in nonroutine situations, and communicate and act as leaders more effectively as a direct result of their ACRM training. BASC staff are in the 6-month pilot phase of a randomized, retrospective study of realistic simulation effectiveness.

The BASC team is now designing ACRM 2.0, a more advanced course for those who have completed ACRM 1.0. This will be offered to providers returning to BASC late in 1995. Another development has been the prototyping of a module targeted at recent resident arrivals. BASC has also run several two-day courses for industries supporting perioperative technologies. Industry staff unfamiliar with the operating room environment and anesthesia care receive didactic, hands-on, and facilitated discussion training for two full days. Feedback has been uniformly enthusiastic.

The Canadian Simulation Centre for Human Performance and Crisis Management Training

(Information provided by Matt Kurrek, M.D.)

In March 1995, the Canadian Simulation Centre for Human Performance and Crisis Management Training opened at the Sunnybrook Health Science Centre of the University of Toronto, under the direction of Matt Kurrek, M.D., who acquired his initial experience in simulator-based training while an instructor at BASC. The Canadian Centre recently conducted three courses aimed at training new ACRM instructors (see below). A new variant of ACRM termed “Crisis Management for Health Care Professionals” will be mandatory for each resident of the University of Toronto program on a yearly basis. This is a “combined team training course” in which one nurse, one surgeon, and up to three anesthesiologists undergo ACRM-like training together. Dr. Kurrek notes that “the responses have been overwhelmingly positive, including the surgeons!” Other simulator-based training has been conducted for medical students, for corporate customers, and during two hour workshops at the Canadian Anesthetist Society meeting. In addition, the Centre is currently the site of funded research on peer assessment of anesthetist performance during simulated clinical scenarios.

University of Pittsburgh

(Information provided by Jo Fletcher, Ed.D.)

The University of Pittsburgh Human Simulation Center was opened in May, 1995. It is dedicated to providing realistic, hands-on training to multiple levels of health-care providers. A comprehensive crisis management course utilizing full-scale simulations is currently being offered to anesthesiology residents. An on-going series of Problem-Based Learning seminars is given to University of Pittsburgh medical students during their Anesthesiology clinical clerkship.

The Human Simulation Center faculty has worked closely with the CAE-Electronics engineering staff to design and develop a difficult airway event which can be used to provide realistic, hands-on training in the ASA Difficult Airway Algorithm. Anesthesiology residents and critical care medicine fellows will be trained in acute airway management using the simulator. Simulation training with this scenario is now also a part of the University of Pittsburgh Department of Anesthesiology and Critical Care Medicine’s “Comprehensive Update on Airway Management” meeting.

Research interests of the Pittsburgh group currently focus on the evaluation of crisis management behaviors and the assessment of situation awareness skills in anesthesia providers.

The Simulation Center for Crisis Management Training in Health Care

(A joint project of the VA Palo Alto HCS and Stanford University)

Since 1990, ACRM training has been conducted in Palo Alto by the original ACRM team. These courses were held periodically on weekends, utilizing the simulator in a real operating room. In July, 1995 the team opened its dedicated Simulation Center. Similar in design to the Boston and Toronto Centers, it occupies approximately 1600 square feet on the campus of the VA Palo Alto Health Care System. Among the Center’s new and unique features are: three video cameras feed three computer-controlled VCRs, allowing all video views to be recorded and played in synchrony. The custom video-control software allows annotation of the tapes while simulation is underway and rapid access to any marked point of the simulation scenario. The simulation room is large enough so that one end can be set up as an operating room for anesthesia and surgical simulations, while the other end can be alternatively configured (using the same simulator) as an ICU or ER bay.

ACRM training is offered on a mandatory basis (once per year for each resident) for Stanford anesthesia residents. In August, Dateline NBC, a primetime television news magazine, filmed an ACRM course in progress at the Center. The Center recently conducted a three-day training course for new ACRM instructors, including two instructors from the University of California, San Francisco (UCSF). The Center is negotiating with UCSF to provide ACRM training for some of its residents. ACRM courses for CME will be offered beginning in the Fall of 1995. The Center has developed a curriculum on crisis management training geared to OR and PACU nurses, and curricula are under development for emergency room staff and for intensive care unit teams.

Among the research projects ongoing at the Center are: the development of validated performance assessment tools for measuring behavioral and technical performance in simulated critical events; the investigation of decision making by intensive care unit clinicians, to compare their decisions to those of a prototype artificial intelligence system designed to enhance patient monitoring in the ICU.

The Working Group for Crisis Management in Health Care

Instructors from three Centers offering ACRM have joined forces to form The Working Group for Crisis Management in Health Care. The Working Group has produced a 150 page ACRM Instructor Course Manual detailing the knowledge, skills, and abilities required to be an ACRM instructor. In addition, members of the group have collaborated on conducting three-day ACRM instructor training courses for each other (so far held at Toronto and Palo Alto). This course brings and The Working Group offers similar ACRM instructor training to other Centers with patient simulators. Anyone interested in obtaining the Instructor Course Manual or in taking instructor courses can contact David Gaba, M.D., on behalf of The Working Group ([email protected]; 415-858-3938).

Syracuse University

Dr. Andrew Sopchak of the Department of Anesthesia at Syracuse has sent the following update on their simulation center:

“We are just in the process of moving the simulator to an on campus site. We have found it increasingly difficult to staff our originally intended site which was off campus. We will be moving it to a conference room in the hospital which will be converted to a mock OR. Once this is completed we will begin regular training sessions with it. I am currently drafting cases/patients/scenarios which we will use for crisis management. Also, we will probably start with varying levels of cases and case difficulty for varying levels of residents…Residents will then be required to pass through different levels of case difficulty. I am trying to tie the simulator sessions in with the lecture series we run so that the cases during any particular week will be demonstrations of the lecture (and perhaps M&M) topics covered that week.”

University of Washington

In the first year of a three-year plan, the University of Washington is using its CAE Patient Simulator to train CA1 residents on handling basic intraoperative events. They are also running day-long programs for medical students doing anesthesia electives. In the future they plan to involve the surgery department in combined team training as well as to develop curricula for medical school cardiovascular physiology and pharmacology classes.

The Simulator Center at Kyushu University

(Information provided by Masamune Tominaga, M.D.)

A Simulation Center with the CAE Patient Simulator has been established in the Department of Anesthesiology and Intensive Care at Kyushu University in Fukuoka, Japan, under the leadership of Professor Takahashi and Dr. Tominaga. This Center is conducting three types of training at this time: 1. Bedside teaching of medical students on basic skills of anesthesia including basic life support; 2. Simulation training of beginning residents in basic anesthesia skills before they start giving anesthesia to real patients, and 3. Crisis Management training for experienced trainees and staff. In the future, the Kyushu University Center hopes to offer crisis management training to anesthesiologists in that local area of Japan and to staffs of other departments in Kyushu University Hospital.

New Version of CAE Patient Simulator Available

Version 2.0 of the CAE Patient Simulator has recently become available. This version incorporates a new mannequin head allowing more alterations in airway anatomy and difficulty of intubation as well as providing for cricothyrotomy or transtracheal jet ventilation. The new system uses only a single Sun workstation to handle both the math modeling of the patient’s physiology and pharmacology and the simulator user interface. Substantial improvements in software and hardware have been made, including many more simulated dysrhythmias, improved simulation of NIBP and pulse oximetry, and expanded I/O handling. An optional Gas Analysis module has been added to automatically detect gas concentrations in the simulated patient’s lungs, for O2, N2O, and Isoflurane, Enflurane, Halothane, Desflurane, and Sevoflurane. Additional drug models have been added bringing the total number of drugs and agents modeled to 76. Many existing users are planning to upgrade to version 2.0 in the Fall of 1995, starting about the time this APSF Newsletter is published.


Only a few years ago there were but two patient simulator centers in North America. Now the number is growing rapidly as simulator-based training in anesthesiology is evolving to a more common part of resident and CME training. A number of centers focus on crisis management training because of the perception that it offers a high potential impact on practitioners’ ability to offer optimal patient care. Many variations of the original crisis management curriculum (ACRM) training have emerged. Other target populations besides anesthesiologists for simulator-based training have been identified and curricula are in place or under development for these populations. As new centers adopt simulator-based training, they are likely to adopt existing curricula as well as to develop new ones for their own special needs and for expanding target populations. Mechanisms are now in place by which experienced centers can assist new ones in acquiring the expertise to begin their training activities.

Dr. Gaba, Secretary of the APSF, is from Stanford University.