Project Closure Report

KJA RECOMMENDATION (7th KJA MEETING ON SEP 7,

2017)

N. Sreekanth Nayak, Pavan Sridharan and B Gurumoorthy, Centre for Product Design and Manufacturing, IISc

Contents Acknowledgements ...... 5 Executive Summary ...... 6 1. Introduction ...... 7 i. Background ...... 7 ii. Emergence of the NTS Concept ...... 7 iii. Design and Development of the NTS System...... 7 iv. Structure of the NTS...... 8 2. Content and Scenario Structure ...... 11 i. Learning Objectives of Simulation for Nurses ...... 11 ii. Scenario Definition ...... 11 A. Beginner Scenarios ...... 12 Hemodynamics - ...... 12 Ventilator ...... 12 Manikin ...... 13 B. Intermediate Scenarios ...... 14 Example - Hypotension ...... 15 C. Advanced Scenarios ...... 16 iii. Scenario Difficulty...... 18 A. Easy ...... 18 B. Medium ...... 18 C. Difficult...... 18 Scenario Scoring ...... 18 3. Product Testing ...... 19 Feedback from Nurses - St. John's Medical College Hospital ICU ...... 20 Demonstration of NTS to Dr. Devi Shetty at KJA on 24th January 2017 ...... 21 Nurses Training- Bangalore Medical College Research Institute ...... 22 Training Methodology ...... 22 Summary of Feedback from the trainees ...... 23 Sustainable Training Plans ...... 24 4. Deployment ...... 26 NTS as a Deployable Product ...... 26 Status, gaps, critical areas ...... 27 Benchmarking/Gaps ...... 28 Taking NTS to market and its Sustained Development ...... 30

5. Presentation in the 7th KJA Meeting ...... 30 6. Conclusions and Recommendations for Sustained Development and Deployment of NTS ...... 32 Annexures ...... 33 Annexure I ...... 33 Roadmap for translation of NTS to commercial deployment through a start-up ...... 33 Annexure II ...... 34 Annexure III ...... 37 Nurses Simulation Training Program in BMCRI...... 37 - Minutes of the Meeting ...... 37 Annexure IV ...... 39 Simulation training Feedback form ...... 39 Annexure VI ...... 40

Acknowledgements

The project team would like to sincerely thank Dr. K Kasturirangan, hon’ble Chairman, KJA for his valuable guidance and vision of improving the skill of nurses across the country- to deliver better outcomes in healthcare to all. We would like to thank Dr. Mukund Rao, hon’ble Member Secretary, KJA, for his valuable guidance, scientific input and support, to enable us to execute this complex and challenging project. We would like to thank Sister Sherin Susan Thomas, Nurse Mentor in St. John’s ICU, for her insights into nursing education pedagogy, and for scenario content. We would like to thank the administrative staff at KJA for their timely organization of review meetings, prompt communication of the minutes and followup. We would like to thank Dr. S Sachidanand, (Director, Medical Education Dept and Director, BMCRI), Dr. Balaji Pai, (Special Officer, Trauma Care Centre), BMCRI and Dr. Asima Banu (Nodal Officer, Trauma Care Center, BMCRI), for facilitating the training in BMCRI and for their support and encouragement,

Executive Summary

This report describes the design and development of a medical simulator for nurses to practice diagnosis and procedures that are carried out in a post operative critical care unit (CCU) with an emphasis on cardiac care. The product consists of physical representations of a human patient in the form of a manikin and the instrumentation found in the CCU. Both are integrated with an electromechanical and computational back end. Interaction with clinicians helped define a broad set of requirements of the simulator. Based on these, the cut-outs in the manikin and the physical instrumented modules required were conceptualized and prototyped. The electronics in the physical modules and the software that integrates them were design and developed

After a prototype was designed, a database of medical scenarios was created based on the nurses' training requirements. This information was collected by interviewing the stakeholders involved, namely nurses (who will use the product), doctors, hospital technicians. The information was structured as scenarios that then form the context for presenting questions for the nurses to respond to. The scenarios would be further modified based on their response, manifesting in changes in the behaviour of the manikin or changes in the vitals monitors further seeking proper response from the nurses.

Report on the testing of the simulator with nurses during a nurses training workshop is also presented. Presently, the simulator has been tested in multiple locations, multiple times. The simulators are being installed in both a teaching hospital setting as well as a specialist hospital setting.

To address the needs for sustained development of the product and related technologies as well as field support for the installed base, a start-up has been incubated at IISc by licensing the know-how from IISc. The company will be ready to deploy and support these simulators starting October 2017.

1. Introduction i. Background

The Nursing Training Simulator (NTS) is a project that is being executed by the Centre for Product Design and Manufacturing (CPDM) in the Indian Institute of Science (IISc), with clinical input from Narayana Health (NH), Sri Jayadeva Institute of Cardiology and St. John’s Medical College and Hospital, with guidance and funding from Karnataka Jnana Ayoga (KJA).The NTS system itself is based on the existing Advanced ICU Simulator platform that was developed by the same team in CPDM, IISc, in collaboration with St. John’s Medical College Hospital under a project funded by Department of Bio Technology, part of the Ministry of Science and Technology, Government of India. The Simulator has been used to train over 1500 doctors since May 2015 in several workshops. A start-up, M/s Meduplay Systems, has been founded to take this technology to market under license from the Indian Institute of Science.

ii. Emergence of the NTS Concept

The Advanced ICU Simulator is a system that was developed as a tool for training doctors and nurses in the field of Critical Care and Emergency medicine. It is used to practice and perform clinical diagnosis, critical decision making, hand-eye coordination skills and communication/team working skills. In operation, the system was designed such that it could be autonomous, or manipulated by a trainer depending on the complexity of the medical scenarios being presented to the trainees. The system was designed to use medical simulation to challenge both doctors and nurses. During the development of this project, doctors from Narayana Hrudayalaya approached the project team for developing a simulator to train nurses in post-operative cardiac critical care. The Karnataka Jnana Ayoga also expressed interest in the development of an automated simulation system solely for the training of nurses. The development team then consulted with the doctors and nursing staff in Narayana Hrudayalaya to understand their specific requirements of such a system. From these visits, a list of functionalities was compiled, along with conceptual solutions that might be integrated on the existing simulator platform. Based on these activities, a detailed proposal was presented before KJA, along with a detailed cost estimate. These were scrutinized by the honourable Chairman and Member Secretary of KJA, until the proposal was sufficiently comprehensive to be brought before a medical technical review by a committee that would be formed for this purpose. This expert panel consisted of the imminent cardiologist, Dr. Valiathan and Dr. Ramkumar of Manipal Hospitals, who reviewed the project proposal from a clinical point of view. It was their opinion that such a system would find use in nursing training, along with advice on design and functionality to maximize usefulness. Following the technical review, the KJA, after further consultation with the technical committee, accepted the proposal from the development team and decided to fund and support the NTS project. iii. Design and Development of the NTS System

The NTS is a medical training tool focusing on nurses in the post-operative cardiac critical care domain. It trains the observation, diagnoses, hand-eye co-ordination and team work skills of the nurses. It is an automated tool that does not require the presence of a teacher/trainer during operation. 7

The Deliverables of this project will be four NTS devices, one in each of the partner hospitals, as well as one in a non-urban healthcare provider, which is to be decided.

The rationale behind the Nursing Simulator is to train the nurse to handle various scenarios that occur in patients in the post-operative CCU. Since the nurse is usually present at the bedside, she should be able to keep an eye on the condition of the patient from the information available to her (vital signs, charts etc.). More importantly, she should recognize the onset of clinical complications. Experienced nurses will be able to intervene to some extent. Other nurses would report the condition to them or the duty doctor. The simulator would serve as a platform for training these abilities in a hands-on manner, without having to wait for the complications to arise in real patients. It should also reduce the training workload of experienced nurses, allowing them to spend more time in the wards. The system should be simple and low cost, and yet realistic to make it effective and commonly available in hospitals. iv. Structure of the NTS The device mimics a hospital setting – it consists of a manikin (the “patient”) and instrumentation that is generally found in a critical care ward. The diagram shows the various modules of the NTS.

Mask Ventilation

Steth Auscultation

Picture of Nursing Training Simulator, showing manikin and monitors- hemodynamic and ventilator

The following physical modules of the NTS have been built and are undergoing testing in the lab before being deployed in the partner hospitals. These include- 1. The manikin (outer shell) 2. Movements mechanisms - Chest rise, stomach distension, calf swell 3. Variable palpable pulse- radial and anterior tibial 4. Surgical drains – Mediastinal and Intercostal 6. Patient to monitor connections – ECG leads and Pulse Oxymeter probe 7. Patient to Ventilator physical connection 8. CPR (cardiopulmonary resuscitation) – musculoskeletal response and CPR sufficiency report 9. Bag Valve mask ventilation with volume delivery

Software has been completed for the following modules 1. Vitals Monitor 2. Ventilator 3. Console- patient information and trainee interaction The software architecture for trainee testing has been developed and has been used to implement scenarios received from St. John’s Nursing College, Bangalore.

Based on initial discussions with the partner hospitals, the decision was made that the NTS must be a standalone system – one of the key requirements being that it should not require the presence of any training staff. Thus, a trainee interaction system needed to be conceptualized which would ensure that the training was not entirely software based -given the preliminary idea of having a purely multiple choice question (MCQ) database. Deeper interaction with doctors and nursing staff revealed that a system which would gauge the trainee’s physical responses as well as a more linear system of questions would be the most preferable. As a first step to achieving such a system, the software architecture integrates database entries for each scenario and algorithms to navigate between the scenarios in sequence. The physical actions taken by the trainees are captured by sensors on the manikin or by the monitors and are processed by the software.

Based on the discussions with the doctors and nursing staff in Sri Jayadeva Institute, NH and St. John’s, the structure of the following modules were revised from physical mockups to virtual interfaces- 1. Syringe Pump 2. Intra-Aortic Balloon Pump The decision was made to make these devices virtual due to the addition of physical modules to the NTS after the initial requirements. These physical modules were requirements of St. John’s, based on their training needs. Thus, in order to keep within the budget and physical complexity of the system, the tradeoff made was the virtualization of the above mentioned modules. The reduction in physical complexity also results in an increase in reliability and robustness of the system.

Simulator installed in a simulation lab 10

2. Content and Scenario Structure

In the follow up to the previous reviews, the development team was tasked with data collection for medical scenario definition with the aim of effective nursing training. The nursing educators in St. John's Nursing College, one of the premiere nursing institutions in the country were kind enough to provide interviews based on their extensive experience in nursing education. The scenario structure, and ultimately the structure of the simulator, depends largely on the objective of the learning that is intended to be delivered. The following sections describe the definition and synthesis of medical scenarios for simulation based nursing training.

i. Learning Objectives of Simulation for Nurses

The aim of simulation for nurses is to serve as a platform upon which nurses can apply their knowledge and skill individually and as a team in a timely and effective manner to provide the necessary treatment to the patient. To this end, the scenarios have been defined as (i) Hand -eye coordination skills for most common tasks (ii) Clinical Diagnoses and critical thinking skills (iii)Emergency and Critical Care actions With these requirements in mind, the functionalities of the Nurses Training Simulator were focused on Emergency and Critical Care Nursing Simulation. Thus, the added functionalities required: (i) CPR, following the American Heart Association (AHA) 2015 Guidelines, which mandate the depth, recoil and frequency of chest compressions. Additionally, the simulator measures the volume of ventilation and displays a performance report using these parameters. (ii) Stethoscope Auscultation for lung and heart sounds, for nurses to diagnose breathing and cardiac performance of the patient. This functionality was provided to extend the capability of nurses, as auscultation is a valuable and non-invasive method to aid diagnosis. (iii) Bag valve mask ventilation with volume delivery (iv) Bilateral radial and carotid pulses (v) Tests and Investigations database - X-rays, Arterial Blood Gas reports and other information that might be readily available, and useful for a nurse in her diagnosis.

ii. Scenario Definition In keeping with the requirement of being and training and practice tool for student nurses as well as experienced nurses, medical scenarios are defined for the spectrum, from students to experienced nurses for assessment purposes. The scenarios are classified by their content - (i) Beginner (ii) Intermediate (iii) Advanced

A. Beginner Scenarios These scenarios are primarily intended as a teaching/testing exercise for student nurses, to test their theoretical knowledge learned in the classroom, but before they are exposed to live patients in a ward, critical care unit or emergency room. These also serve to familiarize the trainee with the simulator system. Each scenario consists of a series of questions, each of which involve the identification of an observable parameter, randomly generated on the simulator followed by a question displayed on the trainee console, with multiple options. The questions progress with increasing difficulty - Hemodynamics - (i) ECG rhythms - ECG rhythms are graphical traces of electrical activity in the heart, and displayed on the hemodynamic monitors. The rhythms are presented from commonly encountered rhythms, such as tachycardia, ventricular fibrillation to the rarely encountered, but life threatening rhythms, such as sinus arrest and heart blocks. There are approximately 20 distinct such rhythms. (ii) Arterial Blood Pressure (ABP) Trace - These are graphical waveform traces of the blood pressure in the artery. The waveforms show various conditions which the nurses identify. Further, the waves could be incorrectly displayed, which would also need to be identified by the trainee nurse. There are approximately 15 such rhythms. (iii) A combination of ECG and ABP rhythms, for e.g. Premature Ventricular Contractions. There are approximately 17 such distinct rhythms (iv) End Tidal CO2- A graphical trace of exhaled carbon dioxide from the ventilator, as displayed on the hemodynamic monitor. There are approximately fifteen distinct rhythms.

Ventilator Nurses’ operation of the ventilator is limited, the main settings being handled by doctors. However, since nurses are usually always present at the bedside, observation of the parameters on the ventilator display is a necessity when complications develop and quick action is required. Hence, the beginner scenarios on the ventilator are geared towards basic understanding of ventilator operation and respiratory ailments. These are – I. Ventilator circuit – Basic questions on tubing kinks, leakages, blocks, which are exclusively in the domain of the nurses II. Ventilator Screen Layout – Basic questions on scalars and loops, what they are and the function they serve. III. a. Pressure Scalar - Nurse should be able to identify the mode, and determine the pressure values from the scalar b. Volume Scalar- The nurse should be able to identify the mode and determine volume and related cut off values from the scalar c. Flow Scalar - The nurse should be able to identify the mode. d. Layout of the Ventilator Screen - The nurse should be able to identify all the variables that are displayed along with their meaning and implication. IV. Compliance Issues - Lung compliance is increased or decreased randomly, with a consequent alarms and parameter changes. V. Resistance Issues – Lung resistance is also varied. This would simulate a patient with asthma or secretions. The trainee will have to identify these issues from the curves

Manikin Beginner scenarios which require the trainee nurse to interact with the manikin are as follows- 1. Stethoscope auscultation – While this is not commonly used by nurses for making a diagnosis, stethoscopes are always available at the bedside in emergency and critical care units. Moreover, they offer a non-invasive method into examining and diagnosing a patient. The standard sites for auscultation are – a. Bronchial breath sounds – the entry into the right or left lung, these sounds will show the presence of secretions or a blockage in any passage in the airway b. Vesicular breath sounds – on the left and right sides, in the middle of the torso. These show the activity of the lungs, whether breathing is taking place or not c. Heart Sounds – at the apex beat, the nurse can hear if the heart is beating or not, whether fibrillation is taking place, or whether the beat is abnormal Each breathing site can have a combination of air entry, silence, wheezes etc, which the trainee will have to diagnose whether an abnormality is present in the patient. The heart sound library. 2. CPR – With rate, depth and recoil measurement as per American Heart Association 2015 guidelines. The scenario will require the trainee to satisfy the guidelines for assessment. 3. Bag Valve Mask Ventilation- The volume of air delivered measured, as well as time of delivery relative to the CPR being performed.

B. Intermediate Scenarios

Once the students are familiarized with the simulator, and are in a frame of mind to apply the theoretical concepts learned from the beginner scenarios into handling slightly more complex medical issues, they move into intermediate scenarios. These scenarios involve medical complications that require immediate attention from the nurse, who will most likely be alone at the bedside. Therefore, these scenarios can be carried out by a single trainee, without the need of an observer. The situation is introduced to the nurse via the trainee console, and her reactions are captured either as actions on the manikin, settings and changes on the ventilator or hemodynamics monitor, or as a multiple choice question. A single scenario is therefore, composed of a series of such actions. Each action is timed based on how critical or complex the action is. The complication that is manifested on the monitor or the manikin might have a variety of reasons, and each reason can be dealt with sequentially based on the symptoms displayed. Thus, some amount of flexibility is possible, with the path being determined by the trainee's choices and actions. Therefore, a graphical representation of the intermediate scenarios would show as follows -

Thus, some scenarios which might be classified as Intermediate are - 1. Ventilator High Pressure Alarm 2. Ventilator Low Pressure Alarm 3. Hypertension 4. Hypotension 5. Low Saturation 6. Cardiac Arrest immediate response 7. Tachycardia response 8. Bradycardia response

Example - Hypotension An example of an intermediate scenario will be a diagnosis of Hypotension. In the first step, the nurse is presented with a set of symptoms which are shown on the monitor and the manikin. She will observe these symptoms and firstly, identify the developing complication in the patient. She will then be directed to suggest what actions might be suitable to stabilize the patient's condition. Then, the reasons for this complication are tackled one by one. The various inputs available to the nurse for identifying the complications and symptoms might even include Arterial Blood Gas reports (ABG) and Ultrasound scans (USG). These are not normally interpreted by nurses. They have been included with the object of extending the capability of the nurses. However, the symptoms can be diagnosed from the other available inputs and thus the ABG and USG are merely to supplement their theoretical learning. In the hypotension scenario described, the three causes are due to hypovolemia by bleeding, hypovolemia by increased cardiac output, and lastly due to pneumothorax. As expected, each will manifest in different ways. Thus, at the end of the scenario, the nurse will be acquainted with the identification of Hypotension in a patient, it's various causes, as well as the actions to be taken to prevent the patient from worsening.

C. Advanced Scenarios

These scenarios deal with advanced complications - their symptoms and maneuvers to overcome them. They generally deal with a single life threatening complication, and they progress with the step by step management of the complications. These scenarios will generally follow an Intermediate scenario as a continuation. However, the progression into this sequence will depend on the performance of the trainee in the Intermediate scenario. Another noteworthy commonality between various advanced scenarios is their criticality, and it is for this reason that there are protocols developed to ensure standard responses for timely intervention. These situations are generally addressed by a rapid response team of nurses and doctors, acting in concert. Thus, for the simulation of advanced scenarios, an experienced observer might be required to judge the performance of nurses on the timeliness of their actions, their individual knowledge and their teamwork ability. These teams are also led by another of the nursing staff, who is instrumental in coordinating among the team members. This leader will also need to be judged for their performance. However, in the single trainee mode, theoretical multiple choice question and a sequence of actions that will correspond with the advanced complications in question. Scenarios such as pneumothorax protocol, Advanced Cardiac Life Support protocol (ACLS), Septic shock, Cardiogenic shock, Acute Respiratory Distress Syndrome (ARDS) etc.

In the following page, the algorithm for ACLS is shown, as specified by the American Heart Association as per their 2015 guidelines. A team of nurses is gathered, each assigned specific roles for action to be carried out. The team is led by a coordinator, and each nurse will switch roles in pre-defined time periods. For example, one nurse will be performing CPR, one will be providing bag valve mask ventilation at specified intervals, another will be operating the defibrillator and checking the patient's heart activity, and another will be administering drugs as specified in the algorithm. Since CPR is a physically exhausting process, the nurses will switch their roles every few minutes. Thus, a simulation of this process can be carried out on the simulator; however, as stated earlier, an observer would be required to assess the performances of the leader and the various team members. In single trainee mode, the trainee can be tasked with performing each of the required actions in time and satisfactorily, and answering multiple choice questions about the clinical theory.

Thus, the other advanced scenarios play out in a similar manner, although they differ in objective and action.

17 iii. Scenario Difficulty

Within the framework of Beginner, Intermediate and Advanced scenarios, the scenarios are also categorized as Easy, Medium and Hard, based on the forgiveness that they afford the trainee.

A. Easy Easy scenarios offer the easiest experience for the trainee. If the trainee chooses the wrong option, she will be shown the correct answer, along with an explanation. If the nurse trainee requires a second attempt, she will be allowed to redo the scenario. In this mode, the results are logged in a database in easy mode, to indicate that this would not be a reliable metric for performance of the trainee nurse. Optional hints will also appear from time to time depending on the severity and complexity of the scenario. The easy mode primarily facilitates learning - explanations as to why the incorrect options are indeed wrong.

B. Medium Medium difficulty scenarios will offer the trainee the correct response when a wrong action is made. However, the justification for the correct response will not be provided, nor will any hints for the progression of the scenario. The trainee will not be allowed to repeat any steps that are answered incorrectly. A set number of incorrect actions will result in the end of the scenario with a failed score.

C. Difficult This mode is the default mode for assessment of the performance of the trainee. In this case, after an incorrect answer, the scenario proceeds to the next step with no further information being given. After a predefined number of incorrect steps, the scenario will end.

Scenario Scoring Every correct action done in the required time will be scored at 3 points, with the score diminishing for extra time taken. Every wrong answer will result in a negative 1 point. Thus, the trainee will be evaluated for every scenario. The individual scores for the trainee will be stored on a database, and retrieved for assessment and certification purposes. The future intent is to analyze this data to be able to determine individual training plans based on existing theoretic knowledge and abilities.

3. Product Testing

The NTS was tested as part of a Critical Care Nurses Training Workshop (ASTRiCc), held on 8 December 2016, in St. John’s National Academy of Health Sciences, and thirty-five nurses from across the country were in attendance. Their backgrounds were varied – from PG students to experienced ICU nurses. The nurses were exposed to the NTS scenario system in post-lunch session of the day.

Feedback from Nurses - St. John's Medical College Hospital ICU

1. From the more experienced nurses, the feedback was almost unanimous that the beginner scenarios were invaluable in their purpose as a post theory classroom refresher. 2. They found the libraries of the monitor waveforms and ventilator scalars a very unique feature not encountered before. Currently, they were being taught on the blackboard, and the transition to an actual patient monitor was difficult. 3. A special mention was made of the ventilator setting scenario questions. Almost all of the student nurses present expressed their anxiety in operating an expensive machine like a ventilator for the first time. The simulator gave them the confidence to examine ventilator parameter settings and functionalities in actual ventilators. 4. Regarding the CPR training, the nurses found it valuable, although there are other CPR only simulation trainers which they practice on frequently. 5. The stethoscope auscultation scenarios were also received warmly by both the student and experienced nurses. They were happy to consider the prospect of extending their capabilities to include auscultation, and they went over the entire libraries of breath and heart sounds. 6. With respect to the intermediate scenarios, the more experienced nurses were able to navigate through the content quite easily, despite not being told the scenario objectives beforehand. However, the student nurses expressed their difficulty in understanding some of the content displayed. These results were heartening, in that if they could be brought to that level early on in their careers, then there might be a marked improvement in their performance in the early stages of their careers. 7. For the advanced scenarios, the experienced nurses felt that the situations were unrealistic in that they would not be handled by a single nurse – a team with a leader would be required. Since the object of the Nurses Training Simulator is to allow a single student to be trained using an automated system, the advanced scenarios were kept as is for observed team simulation training, but a single trainee stepwise question series was created, which broke up the scenario into a mix of theory questions and timed actions.

This testing was vital to tuning the functionalities of the NTS to align it with the pedagogy of nursing educators. More importantly, the NTS system was given exposure to nurses from across the country and across the spectrum of experience. There are several communication issues that might have arisen from people from different parts of India – however, this was not the case, as the nurses found the language of the simulator simple and easy to comprehend.

Demonstration of NTS to Dr. Devi Shetty at KJA on 24th January 2017

As planned by the honourable Chairman, Dr. K.Kasturirangan and Member Secy Dr. Mukund Rao, the Nurses Training Simulator was demonstrated to Dr. Devi Shetty and Dr. Alex Thomas at KJA premises in Vidhana Soudha on 24h January 2017. The structure and functionality of the simulator was explained broadly before the demonstration commenced. The medical scenario and training pedagogy was then enumerated. The beginner scenarios were the shown first, wherein the trainee nurse had to identify ECG rhythms and answer multiple choice questions. Then the basic ventilator training module was demonstrated and explained, wherein various physiological conditions are recreated on the ventilator graphics and must be identified by the trainee nurse. This was then followed by the demonstration of a more complex scenario of a patient on dialysis going into cardiac arrest, with only a single nurse as the first responder. The manikin functionalities, such as stethoscope auscultation, CPR and Bag Valve Mask ventilation were demonstrated by this scenario. This was followed by an evaluation and discussion of the NTS by Dr. Devi Shetty, the KJA members and the NTS development team. Dr. Shetty explained that such a device would have tremendous scope in the training of nurses in a country like India, and that he would serve as an anchor customer for the NTS product. He further stated that his nursing team at Narayana Hrudayalaya (NH) would work with the NTS team to define custom content that would be specifically suited for the needs of a super specialty hospital like NH. He concluded the demonstration by confirming that the NTS project team had delivered a product as per his vision, and that the project could be closed.

Nurses Training- Bangalore Medical College Research Institute

A week long comprehensive training was undertaken for nurses in Trauma Care Center, BMCRI. The training format was changed to suit the hectic schedules of the nurses of the ICU and Casualty wards. The nurses, in groups of two or three, attended a three hour session per day for five days, which was in the first week of July 2017. The NTS team would like to acknowledge the roles of Dr. Sachidanand (Director, Medical Education Dept), Dr. Balaji Pai (Special Officer, Trauma Care Center) and Dr. Asima Banu (Nodal Officer, Trauma Center) in making this training and product testing a reality in BMCRI.

Training Methodology The nurses that underwent the training were a randomized set. An announcement was made for simulator training for nurses, and interested candidates could enroll. Therefore, the candidates varied in experience from over a decade to a few months. A few of the candidates had served as faculty in government nursing colleges for several years. Their insight into the knowledge and behaviour of junior nurses served as a form of validation of simulation as an important training method in government hospitals in India. On the advice of the hospital authorities, the trainees were given the option of remaining anonymous. However, some of them were comfortable revealing their identities on the feedback forms. The feedback not only included the written forms, but a personal interview was conducted with each nurse to clearly articulate what their opinions were of the system. Another issue to be pointed out is that there were several power disruptions which interrupted the training, needing the system to be reset and restarted. This has been recorded in the feedback as technical issues with the system. The NTS team states that an Uninterrupted Power Supply (UPS) attached to the system is a necessity, and will completely prevent this problem from recurring. The trainee nurses were introduced to the simulator system and the various scenario modules. They were then left as a group to intuitively adapt to the user interface of the system while simultaneously undergoing the simulation exercise. The trainees instinctively solved the ECG and auscultation scenarios, as well as the basic hypertension and hypotension scenarios. However, the basic ventilator module was

22 found to be challenging to all of them, the reason given being that on a day to day basis, the ventilator operation was restricted to acknowledgement of alarms and reporting to the duty doctor for non-trivial interventions such as tube leakage. Hence, a basic theoretical lecture was given to the nurses to understand the scalars and loops that are found on all ventilators today. This was followed by the simulator exercise on basic ventilation. It was also for this reason, that the feedback from the nurses particularly mentions the ventilator exercise as being among the most useful modules in the training. Although the simulator was intended to be an autonomous trainer, with no trainer input, for the purposes of "up-skilling" nurses (to extend their capabilities as the case may be for the nurse practitioner program) there needs to be a method by which lesson content is delivered for the simulation exercises to have greater meaning and effective. The feedback received also indicated the need for a trainer giving lectures or a kiosk for disseminating theoretical content and context. The NTS team has recognized the need for this, and is working on building the content delivery system. However, this is independent of the simulation system as a whole. Overall, the training received an overwhelmingly positive response from the participants and organization alike. The feedback form and trainee responses have been attached as annexure to this report.

Summary of Feedback from the trainees System 10% 8% Easy 82% Difficult Medium

Content 23% Effective Neutral 77%

Learning

24% Enjoyabl e Neutral 76%

Sustainable Training Plans Following the training of nurses, plans are being formulated to extend simulation training for interns and PG students of BMCRI. The premises have also been earmarked for the same. In order to implement the hospital wide training program, the NTS team plan to start a pilot to train a number of senior nurses as faculties who will further go on to train the junior nurses over a longer period of time. The senior nurses can also be chosen from among the pools who have previously served as faculty in nursing colleges across the state. During the course of the training, suggestions to that effect were made to the senior nurses, who responses positively and enthusiastically. The same pilot model is intended to be applied for the interns and PG students, with interventions if necessary. It should be noted, however, that this activity is beyond the scope of the NTS project

4. Deployment

NTS as a Deployable Product

In order to make the NTS a deployable, sustainable product from a validated prototype, the following activities have been carried out. Several of these were completed in parallel with the NTS development, as part of the Advanced ICU Simulator production. These activities vary with each component of the system, but broadly include: 1. Redesign and re-engineering of prototype component for durability and manufacture. This phase of the design process is done to ensure that each component meets every requirement arising in the working environment and for every possible user, while maintaining functionality and cost.

2. Vendor identification for material supply, manufacture and establishment of supply chain. Higher volumes of components ensure lower unit cost, but entail higher initial investment. Since the medical simulator industry in India is in its infancy, the focus is shifted onto producing smaller number of components with the same precision and as little cost overrun as possible. 3. Software optimization for better user experience. 4. Electronics optimization for minimal power consumption and system safety. 5. Optimization of data handling and communication for seamless interfacing of system components between themselves as well as with remote server. This server is used for system maintenance, remote troubleshooting as well as data-analytics for better training outcomes. 6. Reliability tests, to ensure that warranties can be fulfilled within the product cost. 7. Procurement of cases for shipping and storage of the various components. This is critical as the manikin is composed of soft, flesh like material (which can be damaged), and the system consists of delicate electronics, besides the computer screens. All of these items must remain safe during transport.

Status, gaps, critical areas Current Status i. The simulator has been built and populated with 11 cases and an initial scenario that can generate several questions which test the nurses' basic knowledge and understanding of rhythms randomly. ii. The simulator was used in a half day training workshop for nurses with a participation of 40 nurses. Feedback was largely positive with the main inputs being that the simulator should integrate the trainer and also allow team based response. Response: These two have been implemented; the first has been already done in the earlier simulator for doctors; the original specification for the NTS was a standalone testing configuration which is why trainer was not included in the simulator. It must be mentioned that adding the second feature to the simulator was accomplished in less than a week. iii. Discussions are ongoing with Nursing Instructor in Narayana Hrudayalaya to further test and validate the NTS. A prototype is being deployed in Narayana Hrudayalaya for testing and feedback. iv. Customization is done on a case by case basis. The time needed generally depends on the software to be coded and tested, and the hardware that has to be conceptualized, designed, tested and manufactured. For example, a critical feedback received from training was the need for team based simulations such as the code blue scenario. For this, a fully controllable mode was required to be implemented into the NTS. Such a customization took a period of 1 week to implement. Another case was the hypotension scenario, which was purely a software scenario, took a period of one week for content to be encoded into the scenario system.

Deployment In an earlier review it was decided that the simulator would be placed in nursing colleges. Currently, training has been finished at St. Johns and BMC. Two simulators (one each) will be delivered and installed at these two locations once the paper-work is completed. Testing and customization is underway at Narayana Hrudayalaya. As mentioned earlier, there is interest from them to buy this simulator. In this case two other locations have to be identified for deployment. The Indira Gandhi Hospital (for Perdiatrics) has been suggested for training with a view to explore its acceptability in that setting. Once the venues

27 are identified, installation can be done in 2 weeks time. This will be followed by training a set of master trainers at the institution.

Opportunities/ Critical inputs Deployment opportunities for the NTS are in the following domains: • Nursing College All the nurses and the instructors in the workshop were unanimous in the value the simulator brings to the training of nurses. The decision to buy however lies elsewhere and unless the colleges are driven by the desire for better education of nurses some intervention from the regulatory bodies will be necessary - this despite the fact that colleges can use the simulator facility as a profit centre based on our interaction with some medical service providers. Nursing colleges in the developed world are already moving or planning to move more than half the practice hours onto simulators. Integration of simulation in current curriculum therefore will be an important stimulus to deployment. • Hospitals Hospitals can use the NTS to provide on-site training and assessment of nurses. If hospitals do not face attrition (as was the case with one of the hospitals in our original cohort) then the need reduces. Space is another constraint for hospitals. Again a requirement for regular assessment of nursing staff (that is self generated or imposed) can lead to increased deployment of NTS. • Nurse Practitioner program This is a new program under the aegis of the Nursing Council of India that has mandated simulators as part of the training. NTS is well positioned here. One of the Nursing colleges being considered for this program is actively looking at NTS to meet this requirement. Once there is clarity on the course/training content the need for additional scenarios can be identified. Since the scenarios are for a different level of capability there will be some modifications to the hardware. • Skill Development Under the Skill India program, the NTS can be used to provide training and skill development in health care. A couple of medical service providers in Kerala and Telengana respectively have approached the team for use of NTS to run skill training workshops.

Benchmarking/Gaps

A comparison with the commercially available simulators is shown in the table below. As can be seen the NTS is on par or better in terms of the features available in the commercial (and more expensive simulators). It must be mentioned that only the critical ICU related scenarios and capabilities are being compared. Some of the other features available in the commercial simulators include Pupil dilations, Drains, Injection sites with RFID based drug recognition, which the NTS can accommodate based on demand/requirements.

NTS Laeradal CAE Vitals Monitor Similar Features in all three ECG readouts Virtual/ Simulated Can attach to real Can attach to real printer/ Electrically printer/ Electrically generated generated 28

ABP trace Virtual; Manipulations Virtual; from library; Virtual; from library; to show damping co- limited manipulation limited manipulation efficients, age and tap location. SpO2 trace Similar features in all three etCO2 trace Similar features in all three Ventilator Virtual Hospital supplied Hospital supplied Ventilator Possible Not possible Not Possible Manipulations by AI Airway Manipulation Virtually unlimited 4-20 settings 4-20 settings Manikin pulse Similar features Bag Valve Mask Similar features Airway difficulty N/A Possible Possible (Physical variation) Auscultation Sounds Similar Features Cost ~12-15Lakhs 75Lakhs 1.4 Crore

The commercial simulators provide additional `scenarios’ for nurses training but these involve nurses interacting with the manikin but no feedback from the manikin. Nurses perform a task (such as preparing the patient for a procedure) that is then observed by the trainer. These `scenarios’ can be added in the NTS with little effort, as the system is designed as a platform. As example the learning objectives of one of the scenarios is reproduced below

(http://www.mysimcenter.com/Product/preoperative-bowel-obstruction-spiritual- needs-sms5459.aspx):

Learning Objectives

General:

• Identifies the primary nursing diagnosis • Implements patient safety measures • Evaluates patient assessment information including vital signs • Implements therapeutic communication • Implements direct communication with multidisciplinary team members • Demonstrates effective teamwork • Prioritizes and implements Physician Orders appropriately

Scenario Specific:

• Recalls indications, contraindications, and potential adverse effects of prescribed medications • Implements the 5 rights of medication administration • Implements preoperative preparation of the patient 29

• Recalls policies related to legal informed consent and information security • Recognizes and manages spiritual needs

As can be seen the scenario does not involve any feedback from the mannequin or the simulator. The simulator is only used to present a situation to the nurse. The complete list of features that are supported by the simulator is shown in Annexure II. It is therefore believed that the NTS in its present form is ready for deployment. Taking NTS to market and its Sustained Development

In the final expert review committee meeting in April, Chairman KJA raised the concerns of continued development of the technology, deployment in the market and sustained support. The project team had informed the committee that the translation, sustained development and support of the product and technology would be ensured through the medium of a start-up company that would be incubated by SID, the incubator of IISc. Chairman wanted a plan of the incubation and translation process. The plan submitted is in Annexure I.

As per the plan, a company MeduPlay has been formed and the procedures for licensing the know how to this company and incubate this in SID is underway. As per the plan, it is envisaged that starting October, two simulators will be ready for deployment every two weeks. Each deployment will also include a training session for master trainers at the location so that expertise is locally available for continued training. The start-up will benefit from having representatives of KJA, Department of Medical Education and domain experts who could monitor and mentor the deployment of the NTS in different locations.

Based on inputs from KJA, the Government of Karnataka (GOK) has earmarked a sum of Rupees Five Crores for deployment of simulators for training nurses across the state. The IISc team demonstrated the NTS to ACS, Medical Education. Subsequently the NTS was used in the Bangalore Medical College for training nurses and other medical staff. Based on the feedback (Annexure VI), it is believed that the NTS more than meets the requirement of a simulator that will be used for training nurses.

ACS, Medical Education Department, GOK had recommended (see Annexure III) that the DHE co-opt experts from IISc in planning a roadmap for further development of the Simulator technology for medical education. It will also be useful if the committee to decide on the deployment of the simulators for health education in the state under the GOK scheme announced in the last budget also includes experts from IISc. This will enable the committee to take advantage of all the feedback received from the stakeholders in the use of simulators in nurses training. 5. Presentation in the 7th KJA Meeting

The closure of the NTS project was considered in the 7th KJA Meeting held on the 7th September, 2017. A presentation was made by the team and the simulator was demonstrated to the Hon. Minister of Higher Education and other members of the KJA.

Dr. Balakrishna Shetty was enthusiastic to demo the Simulator to the Higher education minister and shared his experience with rest of members, His opinion as a doctor and educator was that the NTS would definitely be a game changer if implemented successfully.

The Hon. Minister was quite impressed with the simulator. When informed that the NTS would be mass deployed by the Govt. of Karnataka, mentioned that he looks forward to the implementation of NTS in Karnataka.

During his presentation on Health Care, Dr. Devi Shetty, member KJA mentioned that, "The Nursing Simulator project of KJA will help enable nurses to adapt and respond to a wide range of scenarios. These boys have successfully executed the project and have also made simulators for training cardio thoracic surgeons".

Dr. Kasturirangan mentioned that the Hon’ble CM has already considered the KJA Recommendation for providing NTS to nursing and medical training institutions in the state and has earmarked specific budget of INR 5 crores for NTS utilisation. Now that NTS is ready after development IISc must ensure that proper commercial production and deployment is addressed. Dr. Kasturirangan, post-presentation applauded Prof. B. Gurumoorthy and his teams efforts in successfully implementing the project.

6. Conclusions and Recommendations for Sustained Development and Deployment of NTS

i. The Nursing Training Simulator has been successfully developed and tested in multiple locations and on multiple occasions. Based on the feedback from both the trainers and trainees, it is concluded that the NTS as developed has met the stated objectives of the project.

ii. Four simulators have been built and are being deployed at St. Johns, Narayana Hrudayalaya, Bangalore Medical College and one more location to be identified.

iii. The translation of this product to market will be achieved through a start-up incubated by IISc. The know-how generated in the project is being licensed to this start-up based on approvals from the KJA expert committee and IISc.

iv. It is recommended that representatives of the KJA, Department of Medical Education, IISc and one or two experts be part of a committee that works with the start-up to monitor and mentor it in the process of the deployment of the NTS under the GOK scheme.

v. As suggested by ACS, Medical Education, GOK, a committee of experts from Department of Medical Education, GOK, Clinicians and Experts in Simulation and VR from IISc be formed to both plan the future roadmap for simulation technology in medical education and to ensure that the NTS gets embedded in continuous training of nurses in the state and the country.

vi. The KJA recommends that IISc must ensure that commercial production of NTS is ensured - else all effort of NTS would be nought. The incubated start up must have capability to take up and meet the commercial needs of immediate deployment in Karnataka state for which budget is provided. vii. IISc must also ensure that large number of medical scenarios must be included in the NTS so that all scenarios can be addressed. viii. IISc to constantly interface with ME Department for deploying and maintaining the NTS.

ix. IISc must constitute a Joint GOK - IISc Committee to monitor and further guide the NTS development, deployment and further commercial development

Annexures Annexure I

Roadmap for translation of NTS to commercial deployment through a start-up

1. Startup to take the simulator to market to initiate agreements with IISc. This includes – discussion on business plan for the startup, licensing of IP and knowhow and, incubation agreements. (May 1 – May 31)

2. Raising seed grant for growing the team. (June 1 – July 30)

3. Hiring product development and marketing team (July 2017)

4. Identification of supply chain for scaling up production. Manufacturers and suppliers have already been identified, and quality issues have been addressed based on thousands of usage cycles of the ICU simulator. Agreements to be entered into with the partners. (July 2017)

5. Obtaining necessary certification: a. Identifying all the certification that is required (for example, NABH) to commercially sell the NTS product (June 1- June 15) b. Initiate procedures to obtain the required certification (August 1 – September 31).

6. Hire and train system support personnel (August 2017)

7. Initiate marketing activities a. Develop product collateral (August 2017) b. Plan for product workshops in select regions of the state (3 during September 2017)

c. Skill training Workshops with training Institutions (September 15th onwards).

8. Initiate sales activities (October 1st onwards)

It is believed that starting in October, the company will be well placed to deliver two simulators every fortnight.

Annexure II Advanced Features developed

As discussed with many stakeholders, customization of the simulator may be required depending on the user facility or circumstance. Following is a list of modules developed for the Advanced ICU Simulator. They can be deployed in the NTS depending on a specific need. In addition, the NTS team can also integrate the NTS into a purpose built simulation lab, with Audio/Video capture, debrief room, operator cockpit etc.

▪ Internal electrical and pneumatic power ▪Wirelessly integrates with existing computer networks. ▪Swappable, rechargeable batteries ▪Approximately 4-6 hour’s continuous operation in wireless mode ▪Rugged, highly portable and reliable for use in multiple environments. ▪Controllable open/closed airway; automatically or manually controlled. ▪Head tilt / chin lift ▪Jaw thrust w/articulated jaw ▪Suctioning(oral & nasopharyngeal) ▪Bag-mask ventilation ▪Oro tracheal intubation ▪Nasotracheal intubation ▪Combitube , LMA, and other airway placement ▪Endo tracheal tube intubation ▪Retrograde intubation ▪Fiber optic intubation ▪Trans tracheal jet ventilation [Development] ▪Needle cricothyrotomy ▪Surgical cricothyrotomy ▪Variable lung compliance – 4 settings ▪Variable airway resistance – 4 settings ▪Right main stem intubation ▪Stomach distension ▪Automatic airway devices recognition system ▪Tongue oedema ▪Pharyngeal swelling [Development] ▪Laryngospasm [Development] ▪Decreased cervical range of motion [Development] ▪Tirsmus [Development] ▪Simulated spontaneous breathing ▪Bilateral and unilateral chest rise and fall ▪CO2 exhalation [Development/Present as simulated waveform] ▪Normal and abnormal breath sounds ▪5 anterior auscultation sites ▪6 posterior auscultation sites ▪Oxygen saturation and waveform ▪Extensive ECG library ▪Heart sounds – four anterior locations

▪ECG rhythm monitoring (3 wires) ▪Defibrillation and cardio version ▪Pacing [Development] ▪BP measured manually by auscultation korotkoff sounds ▪Carotid, femoral, brachial, radial, dorsalispedis, popliteal and posterior tibialis pulses synchronized with ECG ▪Pulse strength variable with BP ▪Pulse palpation is detected & logged [Development] ▪IV access (right arm) ▪Introsseous access (tibia and sternum) [Development] ▪Compliant with latest AHA guidelines ▪CPR compressions generate palpable pulses, blood pressure wave form and ECG artefacts ▪Realistic compression depth and resistance ▪Detection of depth, release and frequency of compression ▪Real time feedback on quality of CPR ▪Blinking-slow, normal, fast and winks ▪Open, closed and partially open ▪Pupillary Accommodation ▪Synchrony/ asynchrony ▪Normal and sluggish speed of response ▪Simulation of bleeding at multiple sites [Development] ▪Arterial and venous access ▪Vital signs automatically respond to blood loss &therapy [Development] ▪Work with various wounds modules & moulage kits [Development] ▪Urine output (variable) ▪Foley catheterization ▪Secretions- eyes,ears, nose, mouth, blood, mucous, CFSetc, Diaphoresis ▪Bowel sounds – four quadrants ▪Patient voice ▪Instructor should be able to simulate patient’s voice wirelessly [Development] ▪Instructor communication [Development] ▪Multiple instructors communicate using integrated voice over IP [Development] ▪Amputated left arm [As a swappable part] ▪Amputated left leg [As a swappable part] ▪Right leg IM skin [As a swappable part] ▪Amputated right arm [As a swappable part] ▪Amputated right calf skin [As a swappable part] ▪Wireless iPad controls simulator ▪Remotely Control simulations from anywhere on your network ▪Multiple interfaces can control/observe a single simulation ▪Pause ▪Save/restore ▪Optional video debriefing ▪Data logging ▪Wireless ▪Highly customisable

▪ECG ▪SpO2 ▪CO2 ▪ABP ▪CVP ▪PAP  ▪PCWP ▪NIBP ▪Cardiac output ▪ETCO2 ▪Temperature (core & peripheral) ▪Additional and programmable parameters ▪X-ray display ▪12 lead ECG display

Annexure III

Nurses Simulation Training Program in BMCRI

- Minutes of the Meeting

*VENUE* - Victoria Hospital Trauma Care Center, Bangalore

*Date and Time* - 18th July 2017, 10:30AM

*Attendees* - Ms. V Manjula, ACS to Medical Education Dept Dr. Sachidanand (Director, BMCRI and Medical Education Dept) Dr. Balaji Pai, Special Officer- HOD Neurosurgery and Trauma Centre, BMCRI Dr. Asima Banu, Nodal Officer, BMCRI Medical Superintendant, Victoria Hospital Director, Minto Hospital Prof B.Gurumoorthy, Principal Investigator, NTS Team, IISc Ms. Rashmi Raj, Senior RA, KJA Pavan K Sridharan, NTS Team, IISc Sreekanth Nayak, NTS Team, IISc Chandramouli S, NTS Team, IISc

Minutes -

1. Prof. B. Gurumoorthy welcomed ACS Ms. Manjula and other attendees. 2. The NTS Team described the training that was given to the nursing staff from Victoria Hospital, and presented a summary of the feedback that was received from the participants. The participants were unanimous in their appreciation of the simulator and its value in training. One useful suggestion that came through the feedback was the incorporation of a learning mode. ACS suggested that this be incorporated. The team will incorporate this before providing the simulator to be placed in BMCRI/Victoria Hospital. 3. The ACS made several observations on the optimal location of the simulator in the college/hospital setting. Two options were discussed – a dedicated simulator lab and, having the simulator in one of the beds in the ward itself. Both were found to have pros and cons. The development team was agreeable to both options. 4. KJA brought up the need to identify a fourth institution (college/hospital) for placing the simulator. The ACS suggested Indira Gandhi Institute, which would be beneficial to the nurses serving pediatric cases. The NTS team said that the trainees were primarily from the ICU, Trauma and Casualty Depts, and that if these scenarios could be applied to pediatric cases, then the simulator could be installed directly. However, if special pediatric scenarios were to be applied, then the team would need medical data which would then be integrated into the system. The ACS very kindly contacted the concerned authorities to enable placement of the NTS at Indira Gandhi Institute for feedback and training. 4. Due to the overwhelmingly positive response from the nurses who underwent training in Victoria, Dr. Balaji Pai (head of the Trauma Care Center) was desirous of extending the training using the simulator to all the staff members, students and PG interns. The NTS team responded positively, saying that it will be done once the NTS system is installed in their premises as per the agreement with KJA. Some senior nurses 37 will be identified as Master Trainers and trained to deliver training on the theoretical content and usage of the system for a few days. Also, the BMCRI authorities said they would identify a space and security arrangements for the system. 5. Dr. Sachidanand and Dr. Balaji Pai also pointed out to the ACS the need for advanced functionalities for specific medical procedures to be simulated. The NTS team pointed out that while the main objective in the NTS project done with KJA was the automated training of nurses, several advanced functionalities have been developed for the ICU Simulator that was developed for doctors under a different project. These functionalities could be integrated, but the costs involved would be high. The ACS said that more time and resources could be examined for this purpose. The NTS team said they would have further discussions with the staff of BMCRI for this purpose. As a next step it was suggested to demonstrate to Dr. Sachidanand and Dr. Pai all the features that have been developed thus far. 6. ACS then queried about testing at the other locations and the preparedness of the NTS team for deployment. The NTS team responded that the team will be ready for deployment starting October and currently the target was to be able to provide two simulator every fortnight. Interaction with nursing instructors at St. Johns has been completed and with NH is underway. Testing at both these locations will be completed shortly to be followed up by testing at IGI. 7. ACS suggested that the team at BMCRI and Victoria Hospital could interact with IISc in finalising the future roadmap for development of additional capabilities in the use of simulators in medical education and training. 8. The meeting concluded with a vote of thanks from Prof. B Gurumoorthy, to the ACS and the staff of BMCRI and Trauma Center for their gracious hospitality and cooperation in making the nurses training program a success.

Annexure IV

Simulation training Feedback form

Date: Time:

1. How easy is the simulation system to understand and use? (Scale of 1-10, 1 being easy, 10 being difficult)

2. How useful is the training to your profession and specialty? (Scale of 1-10, 1 being useful, 10 being not useful)

3. How effectively was the content delivered to you? (Scale of 1-10, 1 being effective, 10 being not effective)

4. Did you find the learning experience "enjoyable"? (Scale of 1-10, 1 being enjoyable 10 being not enjoyable at all)

5. What is your opinion on the perceived usefulness of this simulation system? (Scale of 1-10, 1 being very useful, 10 being not useful at all)

6. Please write down any comments/observations in the space given below.

Personal details (optional) Name: Dept: Designation:

Annexure VI