Over the past couple weeks and months the world has been scrambling to get ahead of COVID-19.  Hospitals and clinics alike are scrambling for PPE, supplies and medical equipment.  Many of us may feel there is not much we can do as we are not able to contribute supplies and or equipment. With this in mind, what role can you play during this epidemic to help improve the wellbeing of sim “customers?”  Besides staying at home and/or distancing ourselves from others, vendors/manufacturers have guidelines to cleaning and disinfecting simulation equipment, static/VR/AR trainers and manikins.

While this list is definitely not comprehensive, it does cover a wide range of simulation equipment. One thing to note is most trainers only require soap and water to clean and several mention specifically NOT to use harsh chemicals.  My recommendation is to use common sense and always contact your vendor for detailed instructions when it’s not available online or in the manual. 

As healthcare simulation professionals, we are always looking for information, data and research in an effort to offer the best simulation experience for our learners. We write scenarios to meet the objectives, create moulage, make the electronic health record (EHR) and create surveys and pre-briefs. We put in hours that most likely exceed what our HR departments would approve (your secret is safe with me).  But all of this is futile if the equipment does not work!   

Outside of healthcare simulation, there are guidelines or best practices for all kinds of equipment maintenance.  For example, it is best practice to:

• Change vehicle oil every 3,000-5,000 miles or every twelve months whichever comes first
• Dirt bikes need chains inspected and tightened after every race
• In aviation, the lavatory is required to be inspected every 6,000 flight hours

So then, what about our equipment? Vendors offer preventative maintenance plans that include a checklist upon completion of a scheduled preventive maintenance visit.  What about centers that are not afforded the “luxury” of purchasing preventative maintenance plans? What about equipment that no longer qualifies for vendor preventative maintenance support?  

Healthcare simulation parallels aviation in many ways, and being married to an Aviation Mechanic, I have seen the importance of tracking what has been performed mechanically, including knowing exactly what needs to be done and how often it needs to be done. I have always wanted to create a standard checklist and log to keep track of everything done to prolong the life of equipment. Guess what? I never had time to create a standardized process!  I was excited to see a process of documenting scheduled preventative maintenance already in place when joining a program with a ten year history.   

Cook Children’s Simulation Program has a long list of equipment that provided more than 26,000 hours of simulation for over 11,000 learners in fiscal year 2019.  This also means our calendar is booked sunup to sundown on most days.   Let’s be honest, with this type of schedule things MUST be addressed before they break.  “Prevention is worth an ounce of cure,” right?  Using the car analogy, with the mileage I drive annually (39,000 miles), I would be remiss to wait for a once a year oil change.  Accommodations must be made based on use.  The version of simulator we “beat up” the most is the Laerdal Mega Code Kid.  We lovingly call him Cody, all six of him. They range in purchase dates from 2011 to 2013.  Cook Children’s Simulation Program has been fortunate enough to purchase annual preventive maintenance visits and warranties, but there comes a date that the vendor no longer provides such support.  I feel confident that these investments, along with the simulation team completing scheduled check-ups, have increased the lifespan of our equipment.

If accreditation is in the vision for your program, now is the time to put a preventative maintenance schedule in place. As stated in SSH accreditation Core Standard Three – Resource Management:   

3. iii. Describe the process to continually assess simulation equipment and technology and how they are utilized in the Program.

Preventative maintenance will save money. Discovering a small issue such as a torn “vein” and replacing it is cheaper than buying an entire new arm due to mold! (Yes, I have seen this happen.)  Time is a limited resource, especially on simulation days!  Better to find that the EKG leads are not working and need to be replaced before the learners arrive and the entire day is off schedule. 

We call our every six-week maintenance check a “well child visit” at Cook. Sometimes the gap is bigger depending on lab usage, but we try very hard to stick to every six weeks  The checklist we use is basic, and it should be! When I attempted this at previous centers, I was putting way too much on the list. All six “Cody” manikins can be seen in about two hours, of course, barring any major issues.  BLOCK OUT THE TIME!  The check-up time causes much less stress than having a simulation event delayed.  

Another suggestion, besides the checklist, is to have as many consumable parts available as possible.  Having chest skins, extra vein tubing, IO legs, chest plates, defibrillation and EKG posts handy has helped us keep forward momentum. You have a spare tire in the trunk, right?  Same concept. If it is in the budget ALWAYS have a spare simulator. This is a major timesaver. Just make sure to put the spare in the maintenance rotation.      

Once the checklist is complete, the information is entered into an Excel spreadsheet and saved in our department drive.  This is so any team member can verify a simulators status and we can track issues.  I prefer pen and paper for completing the checklist because I am typically multitasking on “well child visit” days.  I am hopeful that this information helps at least one person.  As we end one decade and start another, take time to make certain that everything works as needed by implementing a preventative maintenance routine.   

The Importance of Manikin Maintenance Support

Last week, an engineer from CAE Healthcare came to our Simulation Center here in Doha to perform maintenance checks on our four PediaSim manikins. I have to say, it was a refreshing experience.

Let me give you some background:

Legally here in Qatar, we are required to work through third-party licensed vendors versus going straight to the organization or source. We work with companies like Al-Jazeera Medical (no, not the news!), Enzo, and others to order and procure our simulation equipment. These vendors sell your Sim Center standards like Laerdal, CAE, and Gaumard. It is because of this system that we pay almost double the price for our manikins. We are also stuck with working with third-party employees, who, when visiting our Simulation Center for maintenance and repair end up just reading the manual or users guide. They do not work for a simulation company and have little to no experience with the equipment. They do not come with checklists, or spare parts. They simply show up and usually end up making more work for us after! *This is not the case every time, but it is the case most of the time.

Unfortunately, there is no way around this process. However, we were lucky to receive a true CAE engineer from Germany last week, who reminded me how the system should work. The engineer’s name was Berk and he has been working for CAE for a few years now. He came with spare parts (even the more complex pieces) and with very thorough checklists. He came with his lists, and he checked them twice. Sometimes, even three times! I would literally have to tell him “time’s up!” (or “Yalla!” – “Let’s Go” in Arabic) at the end of the day when we all left, otherwise he would have stayed past dark. He was here for four days and worked on one PediaSim per day. He barely took ten minutes for lunch too –this guy worked hard! Luckily I wasn’t too busy last week so I had the privilege of helping him check and repair the equipment, as well as learn some fundamental things I didn’t know about PediaSim and some unique tricks-of-the-trade.

I think I can speak for a lot of Sim Techs when I say that sometimes, the everyday grind can be tiresome and dull; it can wear you out. Especially when you haven’t been to a conference lately, or a workshop or anything to refuel your innovative/creative tank… And I know I must sound especially desperate since my dose of energy and excitement was a preventative maintenance check and repair! After Berk’s visit here my fellow techs and I decided to devote more time and efforts into preventative maintenance on our manikins – to both the ones being used and the ones with more shelf life. We are setting aside “quarantined” time (as my manager calls it) to go through our in-depth checklist once a month for each manikin. For the more complex manikins (ie. SimMan3G) we are estimating it will take an entire day to go through a full check and for the less complex (ie. SimBaby) we are setting aside a half day. Having support from management to set aside time for these checks is fundamental as well, and makes it easier to justify the breadth of our job!

Congratulations to those who work at an educational facility; the spring semester is over! Manikins, task trainers and medical equipment have all been used and abused for the past several months. Often times we are too busy to clean adequately or repair. As a direct result, work-arounds are inadvertently created in order to keep simulations moving forward. During this time of year it is important to perform preventative maintenance on manikins, task trainers and medical devices.

What exactly is preventative maintenance (PM) and why is it important? PM is maintenance performed on a regularly scheduled time interval to curtail the likelihood of an equipment failure. In general, this process occurs when the resource is operating within normal limits. While there is often a cost associated while performing a PM, whether it be in personnel time &/or parts, the outcome is more often than not, going to save time and money. Once a failure occurs, simulations will cease and broken equipment will cost substantially more to repair.

How often and when should PM be performed? Everyone’s schedule will vary but, it will depend if it’s based on time or usage or a combination of both. Personally, I use a combination as this allows me to, at a minimum, verify functionality on a yearly basis. For example, you may check the oil in your vehicle monthly and change it every 5000 miles. As a kid my grandfather always said “…change it at 3000 miles or 3 months.”

There are a lot of wires, hoses, connectors….. What should the PM include? Start with the owner’s manual. Take a certification class. Familiarize yourself with the equipment, electronics, pneumatics and basic tools. Various vendors offer certification classes whereby you’ll learn proper PM standards. If you are afforded the opportunity - it is highly recommended. However, if that isn’t an option then look for the following and replace/repair:

Do:

1. Holes or crimps in air/water tubing

2. Crimped electrical wires

3. Loose or unplugged electrical connections

4. Loose bolts/screws

5. Worn or missing buttons

6. Look for oil/water outside normal areas

7. Smell for overheating electrical components

8. Verify hardware and software functionality if applicable

9. Clean interior and exterior components per manufacturer recommendations.

DON’T!!!!

1. Do NOT Remove hardware or electrical components unless authorized or certified as this may void your warranty

2. Do NOT touch circuit boards without proper grounding protection as it will likely render it useless.

3. Do NOT eat or drink near work area especially if device is open.

4. DON’T IGNORE AN OBVIOUS FAILURE AS IT WILL LIKELY LEAD TO ADDITIONAL MALFUNCTIONS AND FAILURES!!!

Check out the SimGHOSTS document library for numerous maintenance forms. 

Also, don’t forget to register for a SimGHOSTS event as they are approaching.

Just like many other simulation centers, our financial year starts in July. That being said, now it is the time to wrap up the year and ready for the new year. While every institute might have different way of closing up the year, I would like to talk about what I do in our simulation center.

1) Inventory Check

One of the most important things we need to make sure to run the lab is the inventory level. This checking process isn’t same as just keeping records monthly and purchase supplies as we go. At the end of the year, I send out email to the class instructors asking if there are any additional supplies they would like to add for the new year, as well as to stock up the general disposables about same amount from the last year to begin with.

2) Orientation Schedule

As the new academic year begins, the UME and GME program are in need of orientations for students and residents and they usually require full one to two days training. This type of training is only once a year that the UME, GME coordinators should be notified to schedule with sim center at least 2 months in advance.

3) New Onboarding Staff Training

If you are working in a hospital environment, there will be more clinical staff onboarding at the beginning of the year which means there will be more training sessions. Be sure to check with the instructors last year so they can provide you the future training plans at the earliest convenience.

4) Annual Report

The most important thing for the end of the year is the annual report. It is time to summarize what you’ve accomplished throughout the year. Also this is the place where you can finally utilize all the data you’ve been collecting such as the number of learners, learning hours, lab usage hours, and the number of activities. In the report, you may create the content on the growth of the year compared to the last year, new courses of the year, and the highlights etc.

5) Feedback Reassessment

The end of year is the good time to go through the evaluations you’ve been collecting and reassess the program discussing how to make it better. There are lots of courses repeating same yearly and they can be improved every year. We should make sure feedbacks are collected from the learners as well as the instructors.

Thank you for reading and good luck with closing year with great results!

Blog post by Mohammad Alamar
King Fahad Medical City , Saudia Arabia, Riyadh

When we say “simulator maintenance”, most people think about fixing, assembly and disassembly of simulators, while the process involves many aspects to reach the real meaning of simulators maintenance. In this article, I will discuss those aspects and list general advice on each point of them from the best practice and experience in this field.

In general, maintaining simulators involve the following aspects:

1. Security

2. Functionality

3. Materials Integrity

4. Availability

5. Cleanness

1. Maintain security by:
Proper storage and cabinets.
Limit access and handling to authorize people.
Direct monitoring especially during sessions.
Use of security cameras.
Use of required warning signs.

2. Maintain functionality by:

• Use simulator for its intended function e.g. (IV arm not to be used for suturing and basic Airway manikin not to be used in Cricothyrotomy).
• Proper use and handling as per manufacture instructions.
• Encourage users to benefit from the simulator to keep it functional e.g.(unused battery-containing manikins should be used more even).
• Alternate usage between the available simulators.

3. Maintain materials Integrity by:

• Treating as human
• Use with respect
• Use for intended purposes
• Not to use excessive force
• Not to use sharps on non-surgical models 
• Not to use ink or markers
• Not to use concentrated iodine or dye
• No drinks or food beside manikins
• Continuous prompt-maintenance and preventive maintenance 
• Watch electrical safety

4. Maintain Availability by:

• Monitor your inventory
• Manage and track usage and loaning locations
• Determine the future needs in advance
• Keep spare parts available
• Do not offer all available models for training (always keep one or 2 models in stock and alternate usage)

5. Maintain cleanness by:

• Immediate cleaning after usage especially after blood and moulage.
• Keeping them away from dust with Cabinets or Covers.
  • Before use:
    • Use proper recommended material in simulated blood, lubricant and moulage.
    • To be used with clean hands and gloves (like patients).
    • Use of baby- powder before the activity will decease staining from hands and dust. 
    • Use proper base cream before moulage like Vaseline.
    • Use prepared causality instead of apply-on.

    After use:

    • Clean skin with warm water on soft towel or gauze.
    • Use alcohol swap and rinse it with water on towel immediately.Use special rinsing solutions and creams e.g. crams come with moulage kit (e.g. Mehron), Acne Creams and makeup remover.

More advice:

Connect with your colleagues on www.SimGhosts.org and use the discussion forum to get more advices on such subject and discuss other practical needs.

Thank you!