Since its inception, the HELPS Center at the Icahn School of Medicine at Mount Sinai has been at the forefront of innovation in anesthesiology and simulation-based medicine.
Now that it is preparing to mark its 25th anniversary, the Center is poised to continue on the same path of advancement and innovation that has produced significant improvements in patient outcomes and safety.
Andrew Leibowitz, MD, Chair of the Department of Anesthesiology, Perioperative, and Pain Medicine at the Icahn School of Medicine
“This milestone is a great opportunity to reflect on our program’s remarkable accomplishments over the last quarter-century and to highlight the innovative projects we are currently involved with as we look to the future,” said Andrew Leibowitz, MD, Chair of the Department of Anesthesiology, Perioperative, and Pain Medicine at the Icahn School of Medicine.
Added Adam Levine, MD, an airway and ENT anesthesiology expert at the Center: “Nearly 25 years ago we led the way and developed one of the world’s first simulation programs. Since then, our program has achieved national and international acclaim; our faculty have been recognized as national and international leaders in simulation-based education, research, and assessment; and our residents and students have become leaders in the field and mentors to the next generation of health care simulation experts.”
Adam Levine, MD, an airway and ENT anesthesiology expert at the HELPS Center at the Icahn School of Medicine
The HELPS Center, short for Human Emulation, Education, and Evaluation Lab for Patient Safety and Professional Study, is part of the Department of Anesthesiology. Faculty members at the center have developed and conducted innovative simulation-based education and assessment programs and led multidisciplinary educational activities for levels of learners for an extensive array of disciplines.
A History of Innovation
It all began in 1994, when Mount Sinai acquired the first mannequin simulator commercialized by Loral based on one invented at the University of Florida. The acquisition required faculty to invent educational techniques and scenarios that would capitalize on the use of this novel technology. Since then, the Center has developed innovative educational programs for high school, college, and medical students, as well as residents, registered nurses, nurse practitioners, physician assistants, and physicians.
The program was one of the first to achieve the American Society of Anesthesiologists (ASA) endorsement to conduct Maintenance of Certification for Anesthesiology (MOCA) simulation for American Board of Anesthesiology Part 4 credit. It has also been one of the busiest programs in the United States providing education for practicing anesthesiologists seeking MOC.
The Clinical Anesthesia ReEntry (CARE) program is one of the most innovative educational and assessment programs at the Center. It is one of a few re-entry programs for anesthesiologists in the country. It uses simulation-based education and assessment to provide opportunities for anesthesiologists who have been on hiatus from clinical practice or have had limited scope of practice to re-enter the clinical field of anesthesiology.
Outside the simulation lab, faculty members have used “in situ” simulation (simulation integrated into a clinical setting) to evaluate, diagnose, and develop educational programs and protocols to enhance Mount Sinai’s staff preparedness for infectious disease threats such as Ebola, and to curb infectious outbreaks in clinical environments.
Time Line of HELPS Center Milestones
1994 The first Loral simulator (now known as the CAE HPS), a commercialized beta version of the University of Florida’s Gainesville Anesthesia Simulator (GAS), is installed
1995 The first Anesthesia Boot Camp for new anesthesiology residents is conducted 1996 Multidisciplinary trauma team simulations are conducted for a televised NOVA special on head trauma
1996 The first integrated simulation-based cardiac and pulmonary physiology labs for first-year medical students are conducted
1997 We become one of the first multi-simulator centers with the installation of the second HPS adult and child simulator 1998 The first Simulation Fellow graduates from the program
1999 We provide our first simulation-based competency assessment on behalf of the New York State Society of Anesthesiologists and the New York State Office of Professional Medical Conduct
2000 The first medical student participates in an elective in simulation-based education that becomes a valuable recruitment tool for the residency program
2002 The HELPS Center moves into its permanent location in the Department of Anesthesiology 2005 The first senior anesthesiology resident participates in the program’s Clinical Educator Tract
2006 Educational programs are developed and conducted for nurse practitioners from Weill Cornell and Columbia-Presbyterian hospitals as they develop adult and pediatric rapid-response teams and expand their scope of practice
2009 We become one of the first programs to achieve American Society of Anesthesiologists endorsement and one of the busiest Maintenance of Certification educational programs
2011 The first 20 anesthesiologists complete their simulation-based re-entry through our innovative Clinical Anesthesia ReEntry (CARE) program
2013 The Comprehensive Textbook of Healthcare Simulation, a multidisciplinary, multi-authored international reference textbook on health care simulation, is published
2013 HELPS faculty members are invited to join the Simulation Assessment Research Group, a research group of simulation experts funded by the Agency for Healthcare Research and Quality 2015 Multidisciplinary “in situ” simulation is used to develop the protocols and an isolation unit to manage Ebola and other infectious threats at Mount Sinai
2016 The pediatric edition, first of the series Comprehensive Healthcare Simulation, is published. Fourteen editions are under development and will result in a library of health care simulation textbooks
2016 Multidisciplinary “in situ” simulation is used to diagnosis and develop work flow strategies and environmental advancements to curb an outbreak of MRSA in a newly designed neonatal ICU
2016 Our serious game division develops modules and demonstrates skill acquisition in anesthesia for liver transplantation and central line placement and sterile technique
2017 The 50th anesthesiologist concludes the re-entry program
2017 The Chinese edition of The Comprehensive Textbook of Healthcare Simulation is published; a Chinese translation of the Pediatric Edition of the series is under development
2017 ASA releases the first SimSTAT module 2018 Modules 2 and 3 of SimSTAT released; several new editions of the Comprehensive Healthcare Simulation Series in progress
Recognizing the need for educational resources, the HELPS center faculty has also developed the definitive reference textbook, The Comprehensive Textbook of Healthcare Simulation, and the series Comprehensive Healthcare Simulation, which are being translated for the Chinese market.
The program’s gaming division developed “serious” games—in contrast to games for entertainment—to educate anesthesiology trainees to place central lines in a sterile and systematic fashion, to manage critical events during liver transplantation, and to demonstrate the efficacy of this screen-based educational technology. When the ASA embarked on a project to develop a first-of-its-kind, innovative, interactive screen-based simulation product, it sought the leadership of HELPS Center faculty to serve as experts. Serving as editor in chief and one of the editors of the interactive, computer-based education (ICE) editorial board, our faculty members were integral in the development and release of the first SimSTAT module in 2017.
“We anticipate the release of several more editions of our educational simulation series and an entire suite of SimSTAT modules, thus providing opportunity for board certified anesthesiologists to satisfy their MOCA part 4 requirements from the comfort of their own home,” said Dr. Leibowitz. “We are excited to explore and develop technologies and content to capitalize on the innovation of augmented and virtual reality for education, assessment, patient safety, and improved patient outcomes.”
A Program of Education and Mentorship
Simulation plays an integral role in the education of anesthesiology residents at the Icahn School of Medicine at Mount Sinai. At the HELPS Center, anesthesiologists experienced in high-fidelity, human-modeled physiologic mannequins, as well as a variety of other simulation training models, have designed and implemented a six-week core simulation program for new CA-1 (PGY-2) residents in anesthesiology.
The Center provides a safe learning environment for the residents, covering fundamentals in cardiopulmonary physiology and common perioperative scenarios, as well as some rare critical events in an effort to better prepare the residents and improve patient care.
The Department of Anesthesiology encourages and promotes teaching among its residents and faculty, centered on the belief that teaching reinforces and enhances one’s own knowledge. The opportunity to teach begins early in the residents’ training, and responsibilities include teaching core topics to third- and fourth-year medical students during their surgical clerkships.
A Program of Diverse Faculty
The faculty of the HELPS Center at the Icahn School of Medicine at Mount Sinai are pioneers and leaders in simulation. They serve on American Society of Anesthesiologists (ASA) editorial boards overseeing the ASA endorsement program and the development of the ASA screen-based simulation program. They also serve on the Board of Directors of the Society of Simulation in Healthcare and provide oversight of the International Meeting of Simulation in Healthcare, the largest international meeting on the discipline.
The Center garners its expertise from a variety of disciplines. Every faculty educator receives extensive training in educational techniques, including crisis resource management, learner styles, and incident debriefing, with each instructor bringing skills from various subspecialties.
• Adam I. Levine, MD, an airway and ENT anesthesiology expert, creates challenging airway scenarios that engage resident and faculty learners.
• Samuel DeMaria, Jr., MD, Alan Sim, MD, Jeron Zerillo, MD, and Natalie Smith, MD, core members of the liver transplant team, have developed intricate and clinically applicable high-fidelity transplant scenarios based on their experience.
• Yuri Khelemsky, MD, a pain specialist and program director of the pain medicine fellowship, provides one-on-one teaching sessions with part task trainers and ultrasound models to teach regional anesthetics and pain procedures.
• Francine Yudkowitz, MD, a pediatric anesthesiologist who participates extensively in medical missions, is in charge of our pediatric simulation curriculum. She ensures residents have had ample simulation experience prior to taking care of pediatric patients and also certifies all residents in pediatric advance life support (PALS) during their training.
• Daniel Katz, MD, an obstetric anesthesiologist, provides educational content for obstetric scenarios including hemorrhage and pre-eclampsia. He is also involved in serious game development and has published games and apps that can be found in the App Store.
• Eduardo Galeano, MD, a neuroanesthesiologist, provides content on neurosurgical and invasive radiologic procedures.
• Elvera Baron, MD, a cardiothoracic anesthesiologist, provides the expertise on content involving cardiac patients for non-cardiac surgery as well as transesophageal echocardiography.
• Anjan Shah, MD, who recently completed a fellowship in simulation, brings the most modern teaching techniques to his sessions.
• Marc Sherwin, MD a former teaching and administrative chief who is POCUS certified and recently joined the HELPS faculty, together with Drs. Park, Smith, and Barnett, will oversee simulation-based ultrasound/TTE/TEE education.
• Chang Park, MD, who just completed his regional anesthesia fellowship, has done scholarly work in regional anesthesia, and is also POCUS certified, recently joined the HELPS faculty.
• Garett Barnett, MD, a regional and simulation fellow, will be overseeing ultrasound education for medical students, residents, and fellows.
The program’s innovative Clinical Educator Track enables outstanding residents dedicated to teaching to become experts in simulation-based education during their residency. Several of the CA-3 residents, known as the Teaching Chief Residents, lead the resident-run educational program. They are responsible for creating the teaching schedule on a monthly basis, and also learn the operations of the high-fidelity simulation (HFS) and proper debriefing techniques under the guidance of the experienced anesthesiology staff of the HELPS Center.
The Clinical Educators are responsible for running six monthly simulations for the anesthesiology interns on both anesthesiology and pain rotations using HFS, introducing them to the core and fundamental topics of induction, emergence, difficult airway management, advanced cardiac life support (ACLS) skills, local anesthetic systemic toxicity (LAST), and the approach to a patient with altered mental status.
The Anesthesiology Department and HELPS Center promote the development of the next generation of leaders in the field of simulation through a one-year simulation fellowship. The fellowship enhances both educational and clinical skills by providing time in the simulation center as well as the operating room as an attending. Academic development is promoted through nonclinical days to perform education-based scholarly work.
“Graduates of our residency’s Clinical Educator Tract and Simulation Fellowship have gone on to develop their own ASA-endorsed simulation programs and joined our HELPS Center to continue to promote and develop unique simulation-based educational or assessment activities,” said Dr. Leibowitz. “One of our graduates was a recent president of the Society of Simulation in Healthcare and another oversees the national simulation program of the U.S. Department of Veterans Affairs.”
A Program of Assessment and Patient Safety
Faculty at the HELPS Center are experts in simulation-based retraining and assessment and have helped a growing number of anesthesiologists resume a safe and satisfying career in a confidential and respectful environment. Anesthesiologists with lapses in clinical competency due to a variety of reasons who wish to resume clinical practice or pursue a broader scope of practice have been able to do so through our innovative program of retraining using multi-modality simulation that allows clinicians to update their skills in a safe environment. The New York State Office of Professional Medical Conduct has accepted our standardized six-week course of simulation and operating room observation for physicians with prolonged clinical abstinence seeking state licensure. We also offer custom designed mini-courses to meet the needs of the individual practitioner.
“Our faculty have conducted assessments for private medical institutions, state medical licensing bodies, independent assessment entities, and self-referred independent physicians,” said Dr. Leibowitz.
Using multimodality simulation, including high-fidelity mannequin-based simulators, virtual reality equipment, and standardized patients and operating room personnel, participants can be evaluated in terms of the core competencies as identified by the Accreditation Council of Graduate Medical Education and American Board of Medical Specialties.
In 2013, in recognition of the Center’s expertise in simulation-based assessment, members of the HELPS Center faculty were invited to join the Simulation Assessment Research Group, a research group funded by the Agency for Healthcare Research and Quality (AHRQ) that investigates the process, logistics and validity of simulation based assessment.
A Program of Discovery
The faculty and residents who are part of the HELPS team are responsible for many valuable academic programs.
HELPS Center faculty present regularly at intramural, departmental, national, and international meetings each year. Faculty members have been invited to present their work at the International Meeting on Simulation in Healthcare, ASA Annual Meetings, and the New York State Society of Anesthesiologists Post-Graduate Assembly. Workshops, scientific panels, pro-con debates, and other activities, such as virtual reality demonstrations, are among the many offerings from the HELPS team.
“Research endeavors are varied and ongoing. Our group was a participating center for a recent AHRQ grant involving 10 other centers, and is actively involved in research and development of new technologies for VR learning environments and serious games,” said Dr. Levine. “We have an impressive publication list and are currently conducting studies on topics such as learning and memory, patient safety, device utilization, human factors and performance, as well as civility, communication and teamwork in the simulated environment.”
HELPS Center Bibliography
• Bryson EO, Levine A. One approach to the return to residency for anesthesia residents recovering from opioid addiction. Journal of Clinical Anesthesia, 2008; 20: 397-409
• DeMaria S, Levine AI, Cohen L. Human Patient Simulation and Its Role in Endoscopic Sedation Training. Gastrointestinal Endoscopy Clinics of North America 2008; 18(4): 801-813.
• Levine AI, Swartz MH. Standardized patients: the “other” simulation. Journal of Critical Care. 2008; 23: 179-84
• Bryson EO, Levine AI. The Simulation Theatre: A Theoretic Discussion of Concepts and Constructs that Enhance Learning. Journal of Critical Care 2008; 23: 185-187
• Levine AI, Bryson EO. The Use of Multi-Modality Simulation in the Evaluation of the Physician with suspected lapsed competence. Journal of Critical Care 2008; 23: 197-202
• Levine AI, Bryson EO. Medical Simulation, Introduction. Journal of Critical Care 2008; 23: 156
• Okuda Y, Bryson EO, DeMaria S, Jacobson L, Quinones J, Shen B, Levine AI. The Utility of Simulation in Medical Education: What is the Evidence? The Mount Sinai Journal of Medicine 2009; 76 (4):330-343.
• DeMaria S, Levine AI, Bryson EO. The Use of Multi-Modality Simulation in the Retraining of the Physician for Medical Licensure. Journal of Clinical Anesthesia 2010; 22: 294–299.
• DeMaria S, Levine AI, Mooney TJ, Silverstein J, Reich DL, Bodian C, Bryson EO. Adding stressors to an ACLS course enhances performance in simulated cardiac arrests. Medical Education 2010; 44: 1006-15.
• DeMaria S, Blasius K, Neustein S. The Incidence of Missed Steps in the Pre-Anesthesia Checkout. Anesthesia and Analgesia 2011; 113(1):84-8.
• DeMaria S, Schwartz AD, Narine V, Yang S, Levine AI. Management of Intraoperative Airway Fire. Simulation in Healthcare 2011; 6(6):360-363.
• DeMaria S, Khelemsky Y, Bodian C, Bryson EO, Levine AI. The Influence of Simulation-Based Physiology Labs Taught by Anesthesiologists on the Attitudes of First-Year Medical Students Towards Anesthesiology. The Middle East Journal of Anesthesiology 2011; 21 (3): 347-53.
• Levine AI, Schwartz AD, Bryson EO, DeMaria S. The Role of Simulation in US Physician Licensure and Certification. Mount Sinai Journal of Medicine 2011; 79(1):140-53.
• Levine AI, Bryson EO, Flynn BC, DeMaria S. Simulation-based MOCA Course Optimization: The Use of Multi-Modality Educational Activities. The Journal of Clinical Anesthesia 2012; 24(1): 68-74.
• DeMaria S, Samuelson ST, Schwartz AD, Sim AJ, Levine AI. Simulation-based Assessment and Retraining for the Anesthesiologist Seeking Reentry to Clinical Practice: A Case Series Anesthesiology 2013; 119(1): 206-17.
• DeMaria S, Bick JS, Kennedy J, Schwartz AD, Weiner M, Levine AI, Shi Y, Schildcrout J, Wagner C. Comparison of Expert and Novice Performance of a Simulated Transesophageal Echocardiography Examination. Simulation in Healthcare 2013; 8(5): 329-34.
• Katz D, Goldberg, Khanal P, Kahol K, DeMaria S. Using Serious Gaming to Improve the Safety of Central Venous Catheter Placement: A Post-Mortem Analysis. International Journal of Gaming and Computer-Mediated Simulations 2014; 6(4): 34-44.
• Goldberg A, Hochkeppel J, Levine A, DeMaria S. Death in High-Fidelity Simulation: A Bioethical Analysis. IEEE 2014; 70: 128-131.
• Wetmore DS, Gandhi NA, Curatolo C, Goldberg A, McCormick P, Levine A, DeMaria S. Simulation to Test Hard-Stop Implementation of a Pre-Anesthetic Induction Checklist. IEEE 2014; 70: 564-5.
• Goldberg A, Silverman E, Samuelson S, Katz D, Lin HM, Levine AI, DeMaria S. Learning Through Simulated Independent Practice Leads to Better Future Performance in a Simulated Crisis than Learning through Simulated Supervised Practice. BJA 2015; 114(5): 794-800.
• Wang RF, DeMaria S, Goldberg AT, Katz D. A Systematic Review of Serious Games in Healthcare Professionals Training. Simulation in Healthcare 2015; 11(1): 41-51.
• Goldberg A, Samuelson S, Levine A, DeMaria S. High-stakes Simulation-based Assessment for Retraining and Returning Physicians to Practice. Int Anesthesiol Clin 2015; 53(4): 70-80.
• Goldberg AT, Katz D, Levine AI, DeMaria S. The Importance of Deception in Simulation: An Imperative to Train in Realism. Simul Healthc 2015; 10(6):386-387.
• Katz D, Goldberg A, Zerillo J, Sim A, Schwartz A, Levine A, DeMaria S. Effectiveness of a Tablet Initiative: Decreasing Costs and Improving Patient Care. Sylwan Journal 2016; 160:1:1-4.
• Heller B, DeMaria S, Katz D, Heller J, Goldberg A. Death During Simulation: A Literature Review. Journal of Continuing Education in the Health Professions 2016; 36(4):316-22.
• Wetmore DS, Goldberg AT, Gandhi NA, Spivack J, McCormick PJ, DeMaria S. An Embedded Checklist in the Anesthesia Information Management System Improves Pre-Anesthetic Induction Setup: A Randomized Controlled Trial in a Simulation Setting. BMJ Quality and Safety 2016; 25: 739-746.
• Samuelson ST, Burnett G, Sim AJ, Chang A, Hofer I, Weinberg AD, Goldberg A, DeMaria S. Simulation as a Set-Up for Technical Proficiency: Can a Virtual Warm-Up Improve Live Fibreoptic Intubation? BJA 2016; 116(6): 398-404.
• DeMaria S, Berman D, Goldberg A, Lin HM, Khelemsky Y, Levine AI. Team-Based Model for Non-Operating Room Airway Management: Validation Using a Simulation-Based Study. BJA 2016; 117(1):103-8.
• DeMaria S, Silverman ER, Lapidus KA, Williams CH, Levine AI, Goldberg A. The Impact of Simulated Patient Death on Medical Students’ Stress Response and Learning of ACLS. Medical Teacher 2016; 38(7):730-7.
• Lipps J, Goldberg A, DeMaria S, Khelemsky Y, Levine AI, Yildiz V, Mahoney B. Presence of an Arterial Line Improves Response to Simulated Hypotension and Pulseless Electrical Activity. J Clin Monit Comput 2017; 31(5): 911-8.
• McIvor WR, Banarjee A, Boulet JR, Bekhius T, Tseytlin E, Torsher L, DeMaria S, Rask J, Shotwell M, Burden A, Cooper J, Gaba DM, Levine AI, Park C, Sinz E. A Taxonomy of Delivery and Documentation Deviations during High-Fidelity Simulations. Simul Healthc 2017; 12(1):1-8.
• Katz D, Zerillo J, Kim S, Hill B, Wang R, Goldberg A, DeMaria S. Serious Gaming for Orthotopic Liver Transplant Anesthesiology: A Randomized Controlled Trial. Liver Transpl 2017; 23(4): 430-9.
• Goldberg AT, Samuelson S, Khelemsky Y, Katz D, Weinberg A, Levine A, DeMaria S. Exposure to Simulated Mortality Affects Resident Performance During Assessment Scenarios. Simul Healthc 2017; 12(5): 282-288.
• Hunter S, Katz D, Goldberg A, Lin HM, Pasricha R, Benesh G, LeGrand B, DeMaria S. Use of an Anaesthesia Workstation Barrier Device to Decrease Contamination in a Simulated Operating Room. BJA 2017; 118 (6): 870-5.
• Goldberg A, Heller B, Hochkeppel J, Levine A, DeMaria S. Simulated Mortality-We Can Do More. Camb Q Healthc Ethics 2017; 26(3): 495-504.
• DeMaria S, Levine AI, Petrou P, Feldman D, Kischak P, Burden A, Goldberg A. Performance gaps and improvement plans from a 5-hospital simulation program for anaesthesiology providers: a retrospective study. BMJ Simulation and Technology Enhanced Learning 2017; 2017;3: 37-42.
• Weinger MB, Banerjee A, Burden AR, McIvor WR, Boulet J, Cooper JB, Steadman R, Shotwell MS, Slagle J, DeMaria S, Torsher L, Sinz E, Levine, AI, Rask J, Davis F, Park C, Gaba DM. Simulation-based Assessment of the Management of Critical Events by Board-Certified Anesthesiologists. Anesthesiology 2017; 127(3):475-89.
• Gibbs K, DeMaria S, McKinsey S, Fede A, Harrington A, Hutchinson D, Torchen C, Levine AI, Goldberg AD. A novel in-situ simulation intervention utilized to mitigate an outbreak of Methicillin Resistant Staphylococcus aureus in a Neonatal Intensive Care Unit. J Pediatr 2017; S0022-3476(17): 31451-8.
• Park C, Wetmore D, Levine AI, DeMaria S, Goldberg A. Simulated Death Enhances Learner Attitudes Regarding Simulation. BMJ Simulation and Technology Enhanced Learning 2018;4: 23-26. • McIvor WR, DeMaria S, Torsher L, Banerjee A, Boulet J, Burden AR, Cooper JB, Levine AI, Park C, Rask J, Shotwell MS, Sinz E, Slagle J, Steadman R, Weinger MB, Gaba DM. Study Design Methods from a Multicenter Simulation-Based Assessment: Challenges Faced, Choices Made, and Lessons Learned. Simulation in Healthcare 2018; (in press).
• Subat A, Goldberg A, DeMaria S, Katz D. The Utility of Simulation in the Management of Patients with Congenital Heart Disease: Past, Present, and Future. SCVA 2018; 22(1): 81-90.