Cleared for takeoff

By Celeste M. Alfes | 09/03/2015

How a leading-edge flight nursing simulation center got off the ground.

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I’ve never traveled by helicopter as a passenger, patient, or health care provider. Truthfully, I’m afraid of heights and seldom look forward to flying. Nevertheless, I found myself managing a multimillion-dollar helicopter simulator project to support the Dorothy Ebersbach Academic Center for Flight Nursing in Cleveland, Ohio, USA.
 
Alfes_Celeste_ID_embed_SFWNursing offers many career paths, and this project was a move skyward for my colleagues and me—literally and figuratively—to develop the nation’s first high-fidelity, critical-care transport helicopter simulator for flight nurse training. Our mission: to simulate, for air medical training purposes, the austere environment in which a flight nurse works. Our goal: to promote safe patient care, evaluate new concepts, and improve outcomes during critical care transport.
 
From vision to reality
The Frances Payne Bolton School of Nursing at Case Western Reserve University (CWRU) in Cleveland established a flight nurse program in 2002 as a subspecialty within the acute care nurse practitioner program. Christopher Manacci, DNP, MSN, ACNP-C, CCRN, a flight nurse enrolled in the nurse practitioner program, first wrote about formalizing graduate education for life-flight nurses in a concept analysis paper, and May L. Wykle, PhD, RN, FAAN, FGSA, dean of the school of nursing at that time, was intrigued by this novel vision of a flight nursing subspecialty.
 
Manacci believed that high-fidelity simulation could be instrumental in efficiently training interprofessional flight teams for medical transport in civilian and military environments that might otherwise take years to learn. In his paper, Manacci described the need for simulations that would merge the extrinsic variables of noise, light, vibration, time constraints, mission progression, and electronic communication with the risk of clinical demise of a patient during emergency air transport. A helicopter simulator capable of replicating all phases of flight would greatly enhance training of critical-care transport teams. Unfortunately, because of the high cost of acquiring, adapting, installing, and servicing the equipment, such training is deficient worldwide.
 
Dean Wykle, who was also president of the Honor Society of Nursing, Sigma Theta Tau International at the time, asked Manacci to develop a curriculum to support what would be the nation’s first master’s-level flight nursing subspecialty program. The next 11 years were spent recruiting students and faculty members, conducting research, giving presentations at national and international conventions, and establishing partnerships with local and regional flight teams to precept practicum students.
 
Because of its high cost, the helicopter flight simulator first envisioned in Manacci’s concept paper would not be realized for more than a decade. In 2013, the program received a multimillion-dollar donation from Dorothy Ebersbach, a World War II nurse aviator and alumna of our nursing school, which enabled our new dean, Mary Kerr, PhD, RN, FAAN, FCCM, to move the project forward.
 
The flight nursing program at CWRU prepares advanced practice nurses to care for patients in unstructured environments, organizes interprofessional disaster-response training, and conducts research to build an evidence base for air medical services. The program requires students to complete a 300-hour practicum. However, because of inconsistent and unpredictable occurrence of air medical missions, in situ experience can be logistically difficult and infrequent.
 
Wanted: Used chopper
In October 2014, as simulation consultant on the project, I was given responsibility to acquire, adapt, and implement a fully articulating helicopter simulator to train critical-care transport personnel. The project required travel to several destinations, including San Marcos and Austin, Texas; Oldsmar, Florida; and Lafayette, Louisiana. The most challenging part was locating a reasonably priced Sikorsky S-76 helicopter, the same model our students trained in at the Cleveland Clinic.

After months of searching, I located three Sikorsky S-76s online at HP Aviation, a helicopter salvage company in Florida. The fuselage we selected had been in service during Hurricane Katrina. The salvage company sold it to our school for a mere $5,000 to support our mission to improve emergency critical-care transport training and patient outcomes.
 
With the fuselage secured, we then had to locate a corresponding medical interior to ensure the most realistic training environment. By fortunate coincidence, the interior we located was salvaged from a recently retired Metro Life Flight helicopter that formerly had been stationed at the Metro Health System in Cleveland. We purchased it from Aero Aviation in Louisiana for $10,000.
 
With support from Hartzell Propeller in Piqua, Ohio, and Redbird Flight Simulations in Austin, Texas, more than $600,000 in engineering and manufacturing resources were invested to adapt the companies’ patented technologies to the scale and weight of the S-76 fuselage. The flight simulator is outfitted with a sound system and lighting controls that allow our flight nursing faculty to manage its audio and video image capabilities, replicating the noisy and sometimes poorly lit conditions of flying. Fuselage windows were replaced with double-pane Lexan screens, utilizing a rear-projection system that displays “real-world” views of mission scenarios. The simulator base provides vibration and 11 degrees of pitch and roll to simulate takeoff, landing, hovering, and transitioning through various phases of flight. Video recording capabilities give faculty members the ability to record and store data for post-training debriefings, research analysis, scholarly publications, and presentations.
 
The Sikorsky S-76 helicopter, before …
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and after its transformation into a flight simulator.
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Like being there
The program’s lectures, courses, and high-fidelity simulations were designed by acute care nurse practitioner faculty members from the school of nursing and flight physicians from Cleveland- area hospitals. To create realistic flying environments, this interprofessional team varied mission settings to reflect season, terrain, weather, and location, including semipermissive environments that require increased security considerations. Clinically, scenarios were tailored to specific patient conditions, such as stroke, septic shock, myocardial infarction, multiple trauma, burns, and other complex medical and surgical situations.
 
Simulations can be adjusted in complexity to match the knowledge and experience levels of students being trained. Training activities include crew resource management, predeployment training, and practice instruction for civilian air medical crews. The simulator also serves as a resource for faculty research topics that relate to team-building and collaboratory practice. The program’s critical-care transport simulation scenarios are shared locally with community providers, nationally with government flight teams, and internationally with CWRU’s academic exchange partners at Aichi Medical University in Nagoya, Japan.
 
There were several keys to the project’s success. We obtained generous support from industry leaders by persuasively conveying our mission: its positive impact on the emergency medical air transport industry, improved training outcomes for flight nurses, and most importantly, increased safety for patients. To accomplish our objectives within the targeted 15-month period, persistence and follow-through were necessary. I sent hundreds of emails, made numerous phone calls, and kept meticulous notes to adhere to the timeline. To design and build the flight simulator, technological expertise and attention to detail by our subcontractors were essential.
 
Next steps
Developing the flight simulator was just the beginning of this journey. In coming months, I will be traveling nationally and internationally to give presentations on the flight simulator project. Currently, I’m working with flight nursing faculty members on several proposals and research projects that involve the flight simulator. One of these projects, sponsored by the Laerdal Corporation, is to standardize patient handoffs between air medical and on-the-ground health care personnel. We’re also partnering with military personnel to explore development of team training and predeployment exercises. Our faculty members are working with the U.S. Air Force and the National Center for Medical Readiness, a 55-acre mass casualty simulation center at Wright State University in Dayton, Ohio.
 
During our search for a helicopter fuselage, we obtained a second fuselage through a generous donation from Bell Helicopter. Rather than develop a second simulator for our program in Cleveland, our school decided to place it at Wright State’s National Center for Medical Readiness with the intent of developing joint training programs and research grant proposals. A national air medical company devoted to training air transport personnel has asked to use our simulator twice a year for their life-flight training program. In addition, our flight nursing faculty members have been approached by other flight simulation companies for help in developing new high-fidelity scenarios and critical-care transport curricula for health care personnel nationwide.
 
Our flight simulator arrived in Cleveland on 5 December 2014, and the grand opening of the Dorothy Ebersbach Academic Center for Flight Nursing was held five months later. This facility, with its fully articulating, high-fidelity, critical-care transport helicopter simulator—specifically designed to train flight nurses—is the first of its kind in the United States. To view a brief video of the simulator in action, click here
 
Celeste M. Alfes, DNP, MSN, RN, is associate professor and director, Learning Resource Center, at Frances Payne Bolton School of Nursing, Case Western Reserve University, in Cleveland, Ohio, USA.
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