Planning a simulation center

The Johns Hopkins Simulation Center, built in 2008, houses programs and cutting-edge technology that play an integral role in the training of the next generation of physicians.

Photo courtesy of Johns Hopkins

One of the most effective ways to evaluate and improve patient safety is to use realistic patient care simulation, so that students and professionals can practice patient assessment, diagnostics and treatment without putting patients at risk.

Health care simulation provides a wealth of opportunities to challenge clinicians in a safe environment, where they are given permission to make mistakes and learn in a controlled environment without patient harm.

It’s no wonder that more hospitals are considering installing these facilities.

The next generation

View "Johns Hopkins expands simulation center" Gallery

The Johns Hopkins Simulation Center, built in 2008, houses program and cutting-edge technology that play an integral role in the training of the next generation of physicians who graduate from the prestigious Johns Hopkins School of Medicine. It manages a full schedule, focusing on its mission of advancing research, training, assessment, patient safety and systems integration.

Encompassing 11,000 square feet, the center includes a simulated (sim) operating room (OR), two sim intensive care patient rooms, 12 standardized patient rooms with central observation area and dual circulation, and a modular classroom for didactic or large-group skills training.

On any given day, a visitor to the space on the eighth floor of the Johns Hopkins Hospital outpatient center sees a hive of activity, with multiple courses running simultaneously. The simulated exam rooms provide students with an opportunity to interact with actors known as standardized patients who will present with various symptoms. The manikin-based simulation OR and intensive care patient rooms enable students to “practice on plastic” prior to performing procedures or participating in a real-life medical situation.

In an effort to meet the demands of the growing center and to stay current with constantly evolving technology, the director of the simulation center reached out to Johns Hopkins’ facilities design and construction teams about planning its next iteration, “Sim 21.” With the help of consulting firm Dugdale Strategy LLC, the vision grew into a new building that can capture all of the functionality that the current center cannot, as well as expand upon the existing school of medicine’s programs.

The center’s biggest underserved customers are the faculty and staff who operate the hospital. To address this need, the first part of the Sim 21 plan is to build a “sim hospital,” with a full sim nursing unit, including such patient room types as a trauma room, med-surg inpatient room, labor and delivery room, and rooms that can flex between a med-surg and an intensive care room. Added to the existing simulation OR would be a scrub station and a simulated prep and recovery area. Because the sim hospital should be easily accessible to hospital staff, it makes sense to have these spaces contiguous with the main hospital. The balance of the program would be on hold or temporarily relocated until funds could be raised for the new building.

Given Dugdale Strategy’s programming narrative, architects and planners in the facilities department began the design process with a planning template of idealized rooms. The seventh floor of The Johns Hopkins Hospital Blalock building is the site for the first phase of the sim center expansion. It housed the general operating rooms in the historic hospital until they were decommissioned in 2012.

This repurposing offered both advantages and disadvantages. On the one hand, the glazed block wall construction of the historic OR walls make it difficult to rework the existing floor plan. On the other hand, the size of these rooms easily translates into the rooms they are simulating. Furthermore, the existing medical gas and mechanical infrastructure are already in place, which saves on new piping and ductwork. To ensure that the proposed design would be in line with the projected growth of the simulation center’s programs, the lead simulation educator and manager of the manikin and procedural skills programs did a utilization overlay of the planning template with the current schedule of classes as well as requests that had been turned away because of lack of availability.

The new addition will be 13,500 square feet and will be used in conjunction with the existing sim center on the eighth floor of the outpatient center until the second phase of construction can be built. “OC 8” will accommodate the standardized patient activity, while “Blalock 7” will act as the sim hospital, accommodating the manikin-based training. The program for Blalock 7 includes two sim ORs, two sim intensive care rooms, two rooms that can flex between intensive care and med-surg, one sim labor and delivery room, and manikin staging, storage and workshop. One of the sim ORs will be used as a multifunction classroom for larger groups until a lecture hall is built in Phase 2. This provides the existing sim center with four additional manikin rooms.

On the heels of building Phase 1 of Sim 21 are plans to relocate and expand the existing OC 8 program, which include primarily standardized patient rooms and sim rooms repurposed for procedural skills training. This phase will be built in the children’s med-surg center, which will be repurposed in its entirety to office and research space. The 12,700-square-foot program includes 14 standardized patient rooms, two procedural skills rooms that can accommodate 8 to 12 learners each, two rooms that can flex between standardized patient and procedural skills training, an observation area, staff offices, training and standardized patient break rooms, a research lab and office, and orientation and waiting space. A modular lecture hall with four sections that can seat up to 40 each also will be included.

With the completion of this phase, the entire sim center will be collocated in the historic hospital. It will gain four additional standardized patient rooms, two dedicated procedural skills rooms, a lecture hall large enough to fit the full school of medicine class of 120 plus instructors, four additional manikin-based simulation rooms and enhanced manikin storage, staging and workshop space.

Key considerations

One of the biggest considerations in the sim center planning process was technology infrastructure. Technology is always advancing. If one considers high-fidelity manikins with built-in wireless technology, run by laptops, built on software, recorded through a camera with data saved to a Web-based site, one can imagine the great potential for improvements in technology in just a matter of months. With this in mind, flexibility was important.

Simulation is more effective when it is part of a larger curriculum, rather than a stand-alone activity. To manage the quantity of learners, the center needed a classroom to comfortably seat 175. This new learning space provides the ability to deliver effective training to large groups, with the flexibility to break into smaller rooms for other interactive learning activities.

An essential component of simulation training lies in the conversation between facilitator and participants after the encounter, known as debriefing. Debriefing can happen at the patient’s bedside, much as it would in a clinical environment, or it can be more formalized and away from the bedside. It can also incorporate video playback or other multimedia to reinforce teaching.

Through debriefing, learners reflect on their current performance and identify what changes need to be made to provide high-quality patient care. The team debriefing also can build camaraderie, team cohesiveness and a collaborative work ethic. Because the sim center had multiple simulation rooms, it was important to have several debriefing rooms available for different courses. The center has five such rooms that will also be used for briefing and small classroom activities.

The design of these spaces was approached as “onstage” vs. “offstage.” Onstage areas include all simulated clinical activity, where various scenarios can be played out. Offstage areas are for support activity, including observation, debriefing, equipment storage and control rooms.

Onstage areas require flexibility as well as realism. For the center’s purposes, the design sought to mimic clinical rooms in the Johns Hopkins Hospital. The hospital maternity suite shares the same components as the maternal/fetal medicine unit, and the operating suites contain the same amenities (e.g., boom with gases, patient monitoring, and dozens of outlets to support anesthesia and surgical needs).

For learners to suspend disbelief during simulation scenarios, it is important to create a realistic environment, known as environmental fidelity. This promotes the clinicians’ ability to take what they learn in the simulation and seamlessly apply it to a real clinical situation. It may include incorporating aspects of the environment not essential in simulation activities, but that play a big role in patient safety. For instance, many reports show that patient falls and injuries occur in the hospital bathroom, so the simulation rooms were designed with bathroom spaces.

In addition, different types of clinical spaces have different layouts, so it was important for the hospital to designate different spaces for inpatient, trauma and critical care, in addition to the labor and delivery and operating suites.

The size of the rooms also is an important consideration; some activities need to simulate functioning in a tight space where multiple disciplines may need to work at the same time. During cardiac arrest, for instance, the responding team includes security, clergy, nurses, physicians, pharmacy, respiratory therapy, vascular access and clinical technicians. Conversely, it is impossible to simulate in a room that is much smaller than what would be available, such as ORs too small to fit all equipment and the surgical team or a trauma bay that could not fit an X-ray machine alongside the patient and the clinical team. Having these specialized spaces allows for teaching choreography, systems integrations and utilization of resources while promoting a shared mental model of team performance.

The control room is where technology and teaching meet. Often referred to as an observation room, the control room offers multiple angles of video that can be sent remotely for observation anywhere. Instructors and operators in the control room manipulate the audiovisual (AV) equipment, lighting and patient simulators as well as observe and document performance, collect data and prepare for debriefing. Operators in the control room can trigger alarms to simulate power and gas outages and even mimic OR fires.

Control room designs vary — some centers have one room in which operators can control multiple patient rooms, and some have a 1:1 ratio of control rooms and patient rooms. The new center space design has placed control rooms in close proximity to one another, allowing for single or shared control room space. This also has streamlined AV design needs and allowed for sharing some technology.

The right tools

Finally, the right tool is imperative for successful medical outcomes. The same applies when outfitting a sim center with the best simulators to educate professionals. Health care professionals are learning how to treat specific pathologies, while administrators are learning about processes and system integration by using the latest technology in high-fidelity simulation.

Simulationists look for the latest technology — like wireless or tetherless features that allow realistically crafted care scenarios that use care-in-motion and provide real-time feedback as well as multiplex communication between the operator and the learner. Some advanced features include the ability to elicit pupillary responses, simulate difficult airways, recognize drug recognition, and advanced software that meets the needs of the learner and the operator. Among the technologies at the center is the Victoria model birthing and obstetrics simulator by Gaumard Scientific, Miami.

High-fidelity manikins can cry, bleed and sweat or deliver babies while others allow surgical procedures to be performed on them. They speak different languages, have a variety of hair and skin color, and all have different specifications that determine their uses. 

Adam Dodson, NRP, CCEMT-P, NCEE, is lead simulation specialist at Johns Hopkins Simulation Center and technical adviser for the Johns Hopkins University biomedical department. He also chairs the benchmarking subcommittee for the hospital-based section of the Society for Simulation in Healthcare, and he is the vice chair of the simulation operations and technology section. Vivian Chi Stone, AIA, LEED AP, is senior medical planner and project lead in the Johns Hopkins Health System Facilities office of Architecture+Planning. They can be reached at adodson4@jhmi.edu and vstone4@jhmi.edu, respectively.

Types of simulation center training rooms

A well-planned simulation (sim) center must provide a variety of rooms for training purposes, including:

• Classroom space. Sim activity should get priority for classroom space, recognizing that there may be high demand for classroom space by other groups in an institutional setting. Classrooms most likely will be booked together with sim rooms for supporting didactic instruction. If there is availability after sim activities have been scheduled, then outside users may be able to use classrooms.

Because there will be more integrated education in the next three to four years, there will be even greater demand for large classrooms and sim spaces.

Flexible configurations that allow for larger spaces to be subdivided into smaller ones allow multifunction usage. These would function independently as debriefing rooms or collectively as a meeting room for programs that require a large-group format.

• Debriefing rooms. A 1:1 ratio of simulation rooms to debriefing rooms is desirable to run a course. This allows back and forth use of simulation and debriefing rooms for the duration of a class. In real-life situations, debriefing rooms in critical care suites also can be used as family consult rooms.

• Control and observation rooms. For the standardized patient suite, a central observation and control room enables instructors to view student interaction with the standardized patient once the encounter is in progress. Prior to the encounter, an external corridor located at the opposite end of the room allows the simulated patient to enter the room without first interacting with the student who enters from the front of the room. This dual circulation model takes up more space than a typical clinical unit and is difficult to achieve when repurposing an existing unit.

Monitor stations for each of the sim exam rooms, as well as for the proctor who runs the course, enables observation and feedback to the rooms. A second proctor station is also useful when two different projects are running simultaneously. One-way glass between each sim exam room and the observation area allows instructors to oversee the encounter without being detected. As the nerve center of the simulation center, there is also potential to interconnect activities by observation of and communication among various simulation centers throughout an organization’s entire network.

• Patient rooms. In planning simulated patient rooms for a sim hospital, one should consider room size, room use, multifunctionality and usefulness for training purposes.

• Standardized patient rooms. The standardized patient rooms require clear communication from exam rooms to the proctor station. Separate circulation for the standardized patient and the student is also important. The standardized patient should be able to prepare for the encounter and have privacy to change into the proper attire, while students need to have a check-in station to record their participation before entering the room. 

Sim center infrastructure and equipment requirements

A fully equipped simulation (sim) center has many infrastructure and equipment requirements, including:

• Ceilings. When considering the ceiling for most rooms, designers should consider a drop ceiling. This allows for maintenance on the audiovisual equipment, lighting and gases.

• Electrical infrastructure. One capability of a sim center is the need to simulate gas and power outages. Thus, it is important to identify the zone valve box for medical gases on each floor and make sure that it does not affect other areas. Manikins and wireless cameras have significant charging requirements. Designers should consider a room for charging with many outlets.

• HVAC system. An HVAC survey is critical to ensure noise control, particularly where infrastructure upgrades are not planned.

• Gases. Gases are sometimes needed to operate the manikins, such as air to simulate pulses or to make the chest rise. Gases are used in teaching as well.

• Furnishings. Most equipment found in patient rooms is also required in the simulated environment. This includes a patient bed, overbed table, medical gas or equipment boom and charting computer. In the simulated hospital setting, supply and medication machines in the intensive care unit (ICU)/trauma rooms play a critical role in training for an emergency situation. Trauma rooms require both; ICU rooms require only a medication machine. For rooms that flex between uses, curtains can be used to screen elements that are not part of the scenario.

Recommended equipment and furnishings for procedural skills training rooms include adjustable height, folding tables on casters, “Mayo stands,” nesting chairs and wall-mounted, flat-screen monitors for training videos.

• Technology. High-definition multimedia interface (HDMI), video graphics array (VGA) and digital visual interface (DVI) connections are standard in most rooms. Cameras should be 360-degree pan-tilt-zoom and some should be high definition. Portable cameras for replacement, breakage or even additional views should be available. Several microphones should hang from each room’s ceiling, and lapel microphones may be needed for certain scenarios.

• Audiovisual infrastructure. When the program for a simulation center is spread over multiple floors or across different buildings on the same floor, a single audiovisual server room can be placed in a central location as long as sufficient floor area is provided. Video quality is an important consideration if simulations are to be recorded for training purposes. Video playback used for debriefing are of lesser quality and would not produce the resolution required for a training video.

• Networking infrastructure. The telecom server room needs to be separate from the audiovisual server room. This is part of the building infrastructure. The recording for most simulation centers is Web-based, so it can be accessed externally if needed.