Fellowship Corner: Development of Low-Cost Simulation Device to Train Multidisciplinary Teams at Pit - VHA SimLEARN
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Fellowship Corner: Development of Low-Cost Simulation Device to Train Multidisciplinary Teams at Pit

By Jorge Lara-Gutierrez, MD1
Simulation Fellow
VA Pittsburgh Healthcare System

PITTSBURGH – In September 2018, the VA Pittsburgh Simulation Center was asked to collaborate in the development of a simulation for the insertion of an esophageal tamponade balloon by members of the critical care service. This team included Lillian Emlet, MD; Bree Hansen, RN; and Holly Curinga, RN. The simulation planned would include training for multidisciplinary teams, attending physicians, fellows and nurses from the critical care units.

Variceal hemorrhage is an example of a medical emergency that requires effective care provided by a trained, rapid response team. To provide effective treatment and improve patient outcomes responding medical teams must simultaneously ensure hemodynamic stability, airway protection and management of the bleeding. The objective of this simulation was to provide education and hands-on preparation for responding to this low-volume, high-risk scenario and to identify gaps in care delivery.

Esophageal balloon tamponade is one option used to treat variceal bleeding until definitive management is arranged. Current literature recommends that only providers with experience should insert these multiple port balloon tamponade device tubes, since major complications have been observed in series where tubes were inserted by relatively inexperience providers1. After an extensive search, simulation staff did not find a simulation device that could fulfill the faculty requested criteria. We needed a full-body mannequin activated via remote control that could simulate projectile vomiting; airway intubation capability; multiple port balloon tamponade device tube insertion and inflation capability; and the ability to accommodate the administration of large volumes of IV fluids.  

The simulator was developed by a multidisciplinary team consisting of Patrick Martino, biomedical equipment support specialist; Mary Ellen Elias, RN, simulation coordinator and co-director of the clinical simulation fellowship; Dr. Eric Heckenbach, a dentist; and myself. The team repurposed an old CPR mannequin and an oropharynx and esophagus was created by incorporating an anatomical model into the upper airway of the mannequin. Through trial and error, the team made necessary adaptations to the mannequin to meet the faculty specified requirements.

An ICU room was designed to include all the appropriate equipment to provide adequate fidelity for the learners. A total of seven simulations were conducted with a total of 104 participants, to include 94 critical care nurses and eight critical care medicine fellows. Pre- and post-evaluation surveys showed a 23.5% improvement in self-confidence when responding to this simulation scenario.

During the training period, a Veteran presented with a real-world variceal hemorrhage to the VA, and two of the nurses that had attended the training responded to the medical emergency. After the event, they described how the recent training had facilitated their ability to respond quickly and appropriately and increased their confidence on responding to this event

In summary, with the development of a multidisciplinary team, we were able to create an innovation in simulation device with a budget of under $200. And, by repurposing existing equipment in our simulation center, we provided training for multidisciplinary teams from the intensive care unit. Learners demonstrated a significant improvement in their confidence responding to this medical emergency. Additionally, two learners were able to apply the training in a real-life event. We plan on expanding this training to other departments.



1. Bajaj J, Sanyal A (2019). Methods to achieve hemostasis in patients with acute variceal hemorrhage. UpToDate. Retrieve on August 28, 2019 from https://www.uptodate.com/contents/methods-to-achieve-hemostasis-in-patients-with-acute-variceal-hemorrhage?search=variceal%20hemorrhage%20emergency&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1