abcdeSIM Simulation-based emergency training saves time and lives

Training in emergency medicine is a requirement for every doctor and nurse around the world. Naturally, expertise comes with practical experience. However, doctors and nurses must be prepared for all types of medical emergencies, even when they lack extensive experience. With abcdeSIM, health professionals can practice emergency training in different lifelike patient scenarios without putting patients at risk.

Simulation-based learning has long been used in aviation, space flights and the military as a tool to reproduce substantial aspects of the real world with guided elements. In medical ducation, simulationbased learning helps develop the knowledge and skills of health professionals while protecting patients from risks. In the digital age, improved simulation platforms that are useful for medical education come in the form of video-gaming technology. Video-gaming creates a life-like visual tool for information that needs to be absorbed. Studies have also shown that video-gaming promotes problem-solving and thus resembles the required learning environment of a health professional. Dr. Stephanie Klein Nagelvoort-Schuit, Head of the Department of Emergenc Medicine of Erasmus University Medical Center (Erasmus MC) in Rotterdam, explains gaming is, in fact, a good fit to medical learning, especially emergency medicine. They both feature stressful situations, she says, and both require quick decision-making while simulating real-life situations.

As an emergency medicine teacher, Klein Nagelvoort-Schuit explains that to learn emergency medical skills, hours of practical experience and training are essential for every doctor, nurse, or
primary care provider. This takes up a significant amount of teaching time, which could be better spent at the bedside of a patient. Klein Nagelvoort-Schuit turned to gaming technology for innovative medical training. ‘At first, the idea was e-learning–to use a simulation game, to make a game to teach young doctors to treat patients,’ she says.

Dr. Stephanie Klein Nagelvoort-Schuit (left) and Ronald Nanninga (right) use simulation to prepare doctors and nurses for all types of emergencies.

Gaming is not only attractive as a platform but is also well-suited to emergency medicine. ‘In emergency medicine, you work under stress and you make split-second decisions under pressure. So here we simulate the stress, the environment and the time constraints,’ Klein Nagelvoort-Schuit explains. E-learning and gaming, in this respect, are not mere ancillary forms of teaching but are maximised to their full didactic potential given the natural approximation of emergency situations. The abcdeSIM is a combination of gaming and simulation technology that trains physicians to work in a medical emergency setting using the internationally adopted ABCDE method. Using the online realistic platform of gaming software design principles, abcdeSIM features medical and educational expertise, as well as an immersive emergency department environment to challenge doctors and nurses to respond to sick patients.

The concept is similar to flight simulation where student pilots learn the basic theories involved in flight maneuvers and develop instrument proficiency under controlled environments. ‘The thinking was, if pilots use flight simulators to practice their skills, why do doctors not use similar tools?’ says Ronald Nanninga, co-founder and CEO of Virtual Med School B.V. Going a step further from other gaming software and regulator flight simulators, abcdeSIM made the simulation of the human patient more life-like and dynamic. Erasmus MC developed a mathematicalmodel of human physiology, covering more than 200 parameters for respiration, blood pressure, circulation, consciousness, oxygen level, and breathing. With a model simulating human body response at 500 times per second, the patient reaction to the trainee’s treatments is as real and immersive as it can be.

‘The simulation is totally new and based on physiology. The model will predict how the patient will react. The mathematical model reacts to what you do; it reacts to all the treatments you give. The model does it all by itself,’ explains Klein Nagelvoort-Schuit. This enables doctors and nurses using abcdeSIM to recognise critical illnesses and injuries more accurately; they are then able to resuscitate and stabilise accordingly. Doctors and nurses are given the opportunity to train in life-like situations without the accompanying risks. As in flight simulation, where missteps are not deadly, mistakes made in online simulation of emergency medical treatment in abcdeSIM are not fatal as in real life. Important learning points, especially towards the objective of keeping the patient alive, are learned given the accuracy of the treatment-reaction dynamic simulated by the game.

With abcdeSIM, doctors and nurses are given the opportunity to train in life-like situations without the accompanying risks.

Raising skill levels and revenue

From the development of the abcdeSIM for emergency doctors, four other versions of the abcdeSIM are now being used: abcdeSIM for emergency department nursing, for pre-hospital primary care, for severe burn victims, and for paediatrics.

Developing the abcdeSIM from concept to commercial roll-out required input from universities, medical institutions, and digital learning developers. According to Nanninga, the initial versions of abcdeSIM were developed and financed by Erasmus MC; SBOH, a Dutch foundation for the education of those training to be general practitioners; and Stichting Coolsingel, a foundation that supports the development of innovative medical solutions in the Rotterdam region.

Further development of the life-like physiological patient model was provided by the University of Twente while technical support for the game was provided by IJsfontein and Health-e-Solutions. abcdeSIM for the treatment of burns was co-created with the largest burn centre in The Netherlands, the Maasstad Hospital, while the version for paediatrics was made with the Sophia Children’s Hospital in Rotterdam. From the beginning, Erasmus MC’s Technology Transfer Office (TTO) was involved to facilitate abcdeSIM’s shift from the realm of science to market release. The TTO arranged and negotiated all collaborative contracts, ensuring that the intellectual property for the content and the software were protected.

An Erasmuc MC spin-off company, VirtualMedSchool BV, was then founded to manage the commercial roll-out, headed by co-founder and CEO, Ronald Nanninga. ‘We are direct-selling licenses, and work with partners and resellers with a strong link to the medical (educational) field, to resell our serious games and further develop or co-create new versions of abcdeSIM,’ says Nanninga on how they market abcdeSIM.

The aim of developing a game to train doctors and nurses had been primarily to improve the services that health professionals give their patients; in the process of widening the technology’s use and benefit, revenues were also earned. Raising revenues, Nanninga says, is a means to advance the technology as the income of VirtualMedSchool BV is largely re-invested in the development of new e-learning games.

Quality time, quality research

Balancing the need to provide more quality time for the bedside care of patients versus the need to teach or learn emergency medical skills to doctors and nurses had served as the impetus for the creation of the abcdeSIM game. And it ticked this objective. The serious gaming platform gave doctors and nurses more time to enhance their medical skills on their own even while off-duty. It freed up more time for doctors to care for patients and opened up more opportunities to conduct research. ‘This training at Erasmus MC led to a 50% reduction in training time and cost. Also there was increased efficiency in scientific research in using abcdeSIM,” says Nanninga. Since September 2012, abcdeSIM has been made mandatory in the training of residents and medical students at Erasmus MC, which receives up to 300 new residents a year.

Most recently, VirtualMedSchool BV, in partnership with the Royal College of Physicians, rolled out abcdeSIM in more than 60 hospitals in the UK as part of the hospitals’ IMPACT (Ill Medical Patients’ Acute Care & Treatment) course. In The Netherlands, more than 45 hospitals, including all University Medical Centers, use abcdeSIM.

The teaching software has become the first serious game to receive five hours of Continuing Medical Education credit in all medical specialist organizations in The Netherlands. It is expected to receive European accreditation soon.

The abcdeSIM’s instructive framework and excellent graphics have also impressed some organizations as it won the Dutch National Smart E-learning Award, the Valid Game Award, and the Accenture Innovation Award.

Inspired by the effectiveness of abcdeSIM as a learning tool, Klein Nagelvoort-Schuit says her team is now collaborating with other departments in Erasmus University to use the technology applied to abcdeSIM to build a game that will teach cardiopulmonary resuscitation to high school students. They are also working on an online course about serious gaming principles.

In the spotlight: Remember your alphabet

The ABCDE approach stands for Airway, Breathing, Circulation, Disability, and Exposure. This simple mnemonic spells the widely accepted approach used by health care professionals in the immediate assessment and treatment of patients who are critically ill or injured. Because clinical situations are usually complex, the ABCDE approach helps break it down for better treatment.

First, the airway is assessed and treated for life-threatening problems. Airway obstruction often causes lack of consciousness, which may lead to cardiac arrest. Second, a breathing
assessment involves checking if the respiration rate of the patient is enough and whether there is a need to assist with the patient’s ventilation. Third, circulation can be assessed by, among other aspects, inspection of the skin and overall behavior. Color changes, sweating, and reduced consciousness offer clues for circulatory problems. Fourth, checking disability involves grading the level of consciousness: whether the patient is alert, voice responsive, pain responsive, or unresponsive. Last, assessing the patient’s exposure involves judging what may have contributed to the patient’s condition by looking out, for example, for signs of trauma, bleeding or needle marks.

The success of the ABCDE approach is anchored on the fact that it is applicable to all types of patients and all clinical emergencies, whether on the street or in a health facility.