The emphasis of this research is on the Human Research Program (HRP) Exploration Medical Capability’s (ExMC) “Risk of Unacceptable Health and Mission Outcomes Due to Limitations of In-flight Medical Capabilities”. Specifically, this project aims to contribute to the closure of gap ExMC 2.02: We do not know how the inclusion of a physician crew medical officer quantitatively impacts clinical outcomes during exploration missions. The experiments are specifically designed to address clinical outcome differences between physician and nonphysician cohorts in both near-term and longer-term (mission impacting) outcomes. Medical simulations will systematically compare success of individual diagnostic and therapeutic procedure simulations performed by physician and nonphysician crew medical officer (CMO) analogs using clearly defined short-term (individual procedure) outcome metrics. In the subsequent step of the project, the procedure simulation outcomes will be used as input to a modified version of the NASA Integrated Medical Model (IMM) to analyze the effect of the outcome (degree of success) of individual procedures (including successful, imperfectly performed, and failed procedures) on overall long-term clinical outcomes and the consequent mission impacts. Multiple assessment techniques will be used, centered on medical procedure simulation studies occurring at 3, 6, and 12 months after initial training.
Clinical Outcome Metrics for Optimization of Robust Training
Douglas Ebert, Ph.D.
Wyle Integrated Science & Engineering, Houston, TX
The objective of this research is to develop clinical outcome metrics and training tools for physician and non-physician crew medical officers (CMOs) in support of likely medical conditions. Multiple assessment techniques will be employed, centered on medical procedure simulation studies occurring at 3, 6, and 12-month after initial training (e.g. endotracheal intubation, fundoscopic examination, renal stone detection). These simulations will systematically compare success of individual diagnostic and therapeutic procedure simulations performed by physician and non-physician crew medical officer (CMO) analogs using clearly defined short-term (individual procedure) outcome metrics. In the subsequent critical step of the project, the procedure simulation outcomes will be used as input to a modified version of the NASA Integrated Medical Model (IMM) to analyze the effect of the outcome (degree of success) of individual procedures (including successful, imperfectly performed, and failed procedures) on overall long-term clinical outcomes and the consequent mission impacts. Thus, procedure outcomes in the physician and non-physician groups and their subsets (tested at different post-training elapsed times) will allow us to:
1) define differences between physician and non-physician CMOs in terms of both procedure performance (pre-IMM analysis) and overall mitigation of the mission medical impact (IMM analysis);
2) refine the procedure outcome and clinical outcome metrics themselves;
3) refine or develop innovative medical training products and solutions to maximize CMO performance; and
4) validate the methods and products of this experiment for operational use in the planning, execution, and quality assurance of CMO training process.
There are multiple challenges to crew health care during extended spaceflight. Medical procedure performance could be affected by asynchronous communications (time delays), inability to evacuate, and prolonged time from initial CMO training to actual mission medical operations (including emergency and non-emergency care, diagnosis, and treatment). In the extreme resource-limited environment of exploration spaceflight a high degree of medical autonomy is expected, hence it is critical to consider not only the immediate outcome for each procedure, but also the consequences of a missed diagnosis or improperly performed procedure on the entire mission. Therefore, this experiment uses a two-tiered approach. The first tier will examine procedure outcome metrics by evaluating the performance of physician and non-physicians in a medical simulation laboratory human test subjects and patient simulators to present the conditions and specific procedures being evaluated. The second tier will examine the effects of procedure success outcomes on the mission medical impacts using IMM.
The IMM is an evidence-based decision support tool that provides estimates of crew health, and probabilities of evacuation and loss of crew life due to medical illnesses and injuries. The current version of IMM assumes that all diagnoses are 100% accurate and that all therapeutic procedures are 100% successful. A modified version of the IMM will be created which will accommodate diagnoses that are not 100% accurate and procedures that are not 100% successful. Tier 1 simulation output will become IMM input, with model results informing a novel set of outcome metrics which will demonstrate the true mission impact of medical procedure outcomes. Comparison of physician and non-physician outcomes in both tiers will directly address the value of including physician CMOs on Exploration missions. Based on results from both tiers, deficiencies in training procedures and tools will be identified, and training products refined to improve future outcomes. Our experienced multidisciplinary team includes physicians, medical trainers, remote guidance experts, and imaging/technology specialists, and human factors experts. This research is expected to produce physician and non-physician clinical outcome metrics and medical condition training tools that will reduce the Human Research Program Exploration Medical Capabilities’ “Risk of Unacceptable Health and Mission Outcomes Due to Limitations of In-flight Medical Capabilities”. In addition to these benefits, the IMM enhancements will allow for the variable success of diagnostic and interventional procedures that could strengthen crew health predictions and expose unidentified medical resource gaps.
While NASA missions (particularly exploration class missions) have special requirements for medical training and knowledge retention, this is not a problem specific to spaceflight. The problem of maintaining the proficiency of minimally trained medical caregivers and the changing recommendations associated with this training (e.g. CPR training) are evidence of the need for more information in this area. This research is expected to provide a set of refined metrics to link both short- and long-term clinical outcomes to training deficiencies. These metrics can easily transfer to the medical teaching arena and be applied to levels from medical schools to basic CPR classes. Further, this research will yield refined procedural training tools which can also be transferred to educational settings. These tools are expected to become a template for expanded use in medical training (terrestrial and space applications) and because of their intuitive nature are expected to become excellent outreach tools as well.