There has been strong growth in the use of simulation technology in emergency medicine since 2000, with the majority of accredited residency programs in the United States currently using some form of mannequin-based simulation [27]. Along with this trend has come a proliferation of simulation centers with technological resources and space dedicated to high-end clinical and procedural simulation, videoconferencing, and standardized patient encounters. Of the three professional organizations that have created accreditation standards for simulation programs (the American Society of Anesthesiologists, the American College of Surgeons, and the Society for Simulation in Healthcare), only the American College of Surgeons lists specific space and technological requirements for simulation centers. The SAEM Simulation Academy does not emphasize hardware or space requirements for simulation programs, recognizing that these are highly dependent on the educational goals and the resources available to individual programs [61]. Additionally, as high-fidelity simulators become increasingly portable and require less supporting equipment, it becomes less clear that a “fixed” simulation center is advantageous in every setting [28]. Successful in situ simulation can be conducted even within the confines of an ambulance, and its use in the clinical ­environment may indeed represent the natural evolution of the technology [62]. The following example provides a description of a dedicated space used for emergency medicine simulation but is not intended to be prescriptive.

For high-fidelity patient care scenarios, the space used for simulation should match the clinical environment in terms of equipment, patient monitoring, and available personnel as closely as possible (Fig. 20.1). For emergency medicine-specific simulation, this includes a basic cardiac monitor capable of displaying simulated vital signs and which can be manipulated remotely, IV supplies (IV catheters and start-kits, tubing, fluids, and an IV pole), equipment for managing airway emergencies (wall-mounted suction, bag–valve–mask, intubation tray), and a defibrillator and code cart. The added value of having functional equipment (e.g., suction, supplemental oxygen, defibrillator capable of delivering shocks) is debatable and should not be viewed as requisite for successful simulation. Additional equipment such as ventilators lends heightened realism to scenarios but at considerable cost and need for additional storage space. In situ simulation can mitigate many of these challenges, as scenarios can be conducted in the clinical environment with actual equipment.

In addition to the simulation space, consideration should be given to a control area from which to conduct the scenario. Ideally, this should include a “line of sight” (such as a one-way mirror) to the simulation area in order to facilitate quick adjustments during scenarios in progress, as well as adequate sound proofing to prevent interference from those conducting the scenario (Fig. 20.2). This may require some creativity in the case of in situ simulation, where the ability to create adequate distance for those conducting the simulation can be difficult. In these instances, a well-placed curtain or an adjacent doorway may be the best option. An area for observation and debriefing, ideally in a location adjacent or close to the simulation area, should also be available (Fig. 20.3). Depending on the audiovisual capabilities of the facility, this space can be used for video monitoring of ongoing simulation as well as post hoc review for debriefing. Finally, it should be emphasized that dedicated space for equipment storage, as well as for fabrication and repair of materials used in simulation, is essential to any simulation program and may be underestimated or overlooked in initial design.

Debriefing is a critical component of simulation education and is discussed extensively in Chaps. 6 and 7. For debriefing to be successful, it needs to be timely, focused, task based, and linked to established goals and objectives. The first part of developing a simulation program is identifying the learning objectives, which will be closely linked to the debriefing content. It is important that the faculty debrief to the task/learning objective rather than focusing on the learner being debriefed. In emergency medicine, video-assisted debriefing immediately after the scenario is used frequently. Most often team performances are debriefed with the entire team, and this is especially important in simulations that include a variety of healthcare professionals.

The specific debriefing model varies widely across different programs and with different learners. One common technique is the “Plus/Delta” model (what went well, the Plus vs. what can be improved, the Delta), which is useful for relatively straightforward discussions [63]. The WISER Simulation program uses a model referred to as “GAS” which stands for Gather–Analyze–Summarize. This three-step technique focuses on active listening followed by facilitating learner reflection and analysis of their actions and finally a summary of lessons learned [64]. A third technique is the “Debriefing with Good Judgment” model, which uses an advocacy–inquiry model to assist in the discovery of the participants’ “frame” or understanding of the situation that underlies the visible action [65]. This technique is useful to understand more complex individual and team behaviors. Emergency medicine educators have strongly embraced debriefing because of its important role in deliberate practice and the development of mastery skills.

Simulation programs require substantial initial investments of capital and robust sources of operational funding for both personnel and equipment [66]. To successfully cultivate an array of funding sources, the leadership team should make use of all available resources within an institution. A combination of internal and external funding sources is necessary in many cases. Fortunately, simulation training appeals to a broad audience and tends to easily address the needs and goals of administrators, department chairs, program directors, hospital and university governing boards, governmental granting agencies, private foundations, and individual philanthropists. The concepts of patient safety, healthcare quality, and efficient training and evaluation of providers resonate widely. When it is recognized that funding a simulation center is a “win–win” situation for the institution, the providers’, and most importantly the patients’, funding tends to follow.

Those in a position to initiate a simulation program will need to advocate for the utility of simulation training and the ability of well-designed programs to serve the needs of the individuals, programs, and the institution. As the center matures, the need to maintain funding will require proof of effectiveness. Robust data collection and tracking will demonstrate that a simulation center can help the institution efficiently meet its requirements from the Joint Commission, American Nurses Credentialing Center (ANCC), and the Accreditation Council for Graduate Medical Education (ACGME) [43, 45, 67–69].

Beyond even these requirements, consistent training and evaluation of providers to maintain skills and improve quality helps to justify financial outlay from administration. Reducing medical errors and improving quality through simulation may lead to a reduction in healthcare delivery costs and even a reduction in medical liability premiums [70]. Additional drivers such as maintenance of board certification make simulation a necessary element in ongoing training and provider evaluation [71]. Simulation funding should be viewed as an investment in quality, efficiency, and safety.

Emergency medicine faculty are similar to all simulation educators in that they should be familiar with the advantages and disadvantages of simulation as an educational tool. Simulation will not be effective unless it is used as a well-planned and thoughtful part of the entire curriculum [72]. Faculty time constraints and lack of training were the top two barriers to simulation use in a recent study of emergency medicine simulation users [27, 73]. Faculty members who are interested in providing educational sessions for physicians in residency training must therefore be supported with adequate release time and training. General educational competencies such as objective writing, feedback, and assessment are required skills in simulation [74–76]. All faculty should also be experts in the clinical content area. Finally, the faculty member must develop expertise in simulation-specific skills such as scenario design, debriefing, and some technical knowledge about simulator operation, capabilities, limitations, and programming. These skills can be gained through institutional level training programs or by attending specialty-specific meetings where simulation is a focus. Some examples of these include the AEM Consensus Conference, the Council of Emergency Medicine Program Directors Annual Meeting, or the ACEP Teaching Fellowships and Simulation Courses. Many emergency physicians have also received training at simulation-specific national courses such as the Institute for Medical Simulation at the Center for Medical Simulation or at the International Meeting for Simulation in Healthcare. Simulation skills should be seen as a core competency for emergency medicine faculty along with the more traditional teaching techniques.

With the almost universal use of simulation in emergency medicine training programs [27], there is growing need for educators trained in how to use the teaching method effectively. This has led to rapid growth in non-ACGME approved fellowships in simulation at a variety of simulation centers, many with active ED participation or leadership. As there is no recognizing body or regulation of such fellowships, so their content and focus varies widely. Many include master’s degree coursework in adult education or certificates. These fellowships are often conducted at interdisciplinary centers and with interdisciplinary leadership that reflect the composition of their simulation centers which often merge ­educators from different specialties. Funding can be provided by part-time clinical work, department funds, grants, or institutional budgets [28].

The Society for Academic Emergency Medicine lists six simulation fellowships (http://​www.​saem.​org/​fellowship-directory): Alpert Medical School of Brown University, Massachusetts General, St. Luke’s-Roosevelt Hospital Center, Stanford University School of Medicine, Summa Akron City Hospital, and University of California, Davis. Each of these fellowships has their own unique strengths and design that are described below. Additional fellowships are being added every year, so this list is meant to provide a sample and is not a comprehensive catalog.

The MGH Fellowship in Medical Simulation in Boston is a tailored program over 1–2 years and includes an established curriculum in the Harvard Macy Institute and the Institute for Medical Simulation. Fellows here run the “On-Demand Medical Education Service” which has been previously published [1, 9]. Certificates in teaching and learning and other advanced certificates are available. Fellows work approximately half time clinically as an EM attending at MGH or an affiliate. The St. Luke’s-Roosevelt program is one of the newest fellowships listed at SAEM and is located in New York City. Taking two people per year as about 20 h clinical, it is a 1-year fellowship and is a joint effort with other departments including critical care.

The Stanford University fellowship in California is one of the oldest and most established fellowships. It is a 1-year fellowship with work at four separate simulation centers. Fellows attend in the hospital emergency department. The Summa Akron City fellowship is a 1–2-year program in Akron, Ohio, and accepts up to two fellows per year. Fellows work in several simulation laboratories and attend in the emergency department at one of three local EDs. The University of California, Davis, simulation fellowship is a 1- or 2-year program, and fellows participate both at the center and in local disaster preparedness training. Fellows work part-time as attending physicians in the emergency department at the UC Davis Medical Center. The STRATUS Center for Medical Simulation Brigham and Women’s Hospital has a 2-year fellowship that includes matriculation into Harvard Graduate School of Education for a master’s degree in education.