Mobile In Situ Obstetric Emergency Simulation and Teamwork Training to Improve Maternal-Fetal Safety in Hospitals

Simulation-Based Education in the Training of Newborn Care Providers-A Malaysian Perspective

Simulation-based education (SBE) is increasingly used as an education tool to improve learning for healthcare providers. In newborn care practice, SBE is used in the Neonatal Resuscitation Program (NRP) and training in procedural skills. The NRP is a mandatory course in Malaysia for all house officers (interns) and medical officers (residents) during their pediatric rotation. Almost 30,000 of NRP providers have been trained over the last 5 years. The recent establishment of the Allied Healthcare Center of Excellence (AHCoE), an organization dedicated to promoting SBE, and Malaysian Society for Simulation in Healthcare (MaSSH) aims to enhance the integration of SBE into the healthcare training curriculum and set up a local healthcare simulation educator training program. Our experience in implementing SBE necessitated that we made several important choices. As there was no strong evidence to favor high-fidelity over low-fidelity simulation, and because simulation centers can be very costly to set up with limited resources, we chose SBE mainly in the form of low-fidelity and in situ simulation. We also identified an important developmental goal to train Malaysian instructors on structured debriefing, a critical activity for learning in SBE. Currently, debriefing is often carried out in our centers at an ad hoc basis because of time limitation and the lack of personnel trained. Finally, we aim to implement SBE further in Malaysia, with two axes: (1) the credentialing and recertification of physicians and nurses, and (2) the education of lay caregivers of high-risk infants before discharge from the neonatal intensive care unit.

Bridging the Stressful Gap Between ICU and Home: Medical Simulation for Pediatric Patients and Their Families

OBJECTIVES

Introduce an expanding role for pediatric critical care and medical simulation to optimize the care for children with technology dependence.

DATA SOURCES

Limited review of literature and practice for current teaching paradigms, vulnerability of the patient population, and efficacy of simulation as a medical educational tool.

CONCLUSIONS

In accordance with new care models and patient need, critical care requires parallel evolution of care practices, including new educational and care models, in order to maximally reduce risk, fear, and anxiety and to insure quality and consistent care in the community for patients and families transitioning between the ICU and home environments.

In-situ Interprofessional Perinatal Drills: The Impact of a Structured Debrief on Maximizing Training While Sensing Patient Safety Threats

Introduction In-situ interprofessional emergency team training improves participants' with confidence and knowledge and identifies latent safety threats. This study examined the impact of a structured debrief on an interprofessional perinatal team's ability to identify latent safety threats and assess competency in managing perinatal emergencies. It was hypothesized that latent safety threats would be reduced and checklist compliance would increase during subsequent in-situ perinatal team training. Methods Two in-situ training sessions were held six months apart. The perinatal emergency response team provided care for a standardized patient with preterm twin gestation. Each session included off-ward delivery and resuscitation of the first infant, transportation to appropriate inpatient units, cesarean delivery, and resuscitation of the second twin. Postpartum hemorrhage ensued, requiring massive transfusion protocol activation. Medical experts assessed team performance with critical action checklists. A structured debrief identified latent safety threats, developed action plans, and reviewed checklist compliance. Checklist compliance rates were analyzed using a z-ratio test. Results The first training session: seven teams (75 staff) completed 75% (292/391) critical action checklist items and identified 34 latent safety threats. Second training session: four teams (45 staff) completed 89% (94/106) critical action checklist items. Ten latent safety threats were mitigated during the second session. Utilizing a z-ratio, a significant difference was detected between the overall checklist compliance rates of the two sessions, z = -3.069, p = .002. Post-hoc power calculation was <10%. Conclusions In-situ interprofessional perinatal emergency team training is feasible, identifies latent patient safety threats, and may improve team competency.

An In Situ Simulation-Based Training Approach to Active Shooter Response in the Emergency Department

With an increased number of active shooter events in the United States, emergency departments are challenged to ensure preparedness for these low frequency but high stakes events. Engagement of all emergency department personnel can be very challenging due to a variety of barriers. This article describes the use of an in situ simulation training model as a component of active shooter education in one emergency department. The educational tool was intentionally developed to be multidisciplinary in planning and involvement, to avoid interference with patient care and to be completed in the true footprint of the work space of the participants. Feedback from the participants was overwhelmingly positive both in terms of added value and avoidance of creating secondary emotional or psychological stress. The specific barriers and methods to overcome implementation are outlined. Although the approach was used in only one department, the approach and lessons learned can be applied to other emergency departments in their planning and preparation. (Disaster Med Public Health Preparedness. 2019;13:345–352)

Opinions and attitudes of obstetricians and midwives in Turkey towards caesarean section and vaginal birth following a previous caesarean section

Aim

To determine the opinions and attitudes of Turkish obstetricians and midwives to caesarean section (C-section) and vaginal birth following a C-section.

Methods

The study involved obstetricians and midwives who were working in a state women’s hospital and two private hospitals in Gaziantep, Turkey. Participants were asked to complete questionnaires on sociodemographic data and provide opinions about C-section.

Results

A total of 88 midwives and 22 obstetricians participated in the study. Approximately one-third of midwives believed caesarean rates were high at their institution and more than 50% thought that the rate should be reduced. In contrast, although approximately 80% of obstetricians thought that caesarean rates in their institutions ranged between 25–50%, only 18% believed the rate was high and 68% believed that the rate of should be reduced. Midwives and obstetricians tended to agree on most suggested reasons for high C-section rates. When asked about interventions that may reduce the C-section rates, midwives and obstetricians had opposing views. However, most participants agreed that prenatal childbirth preparation courses would be beneficial.

Conclusions

This study showed that most midwives and obstetricians believe the rate of C-section at their institution is high and should be reduced.

Designing in situ simulation in the emergency department: evaluating safety attitudes amongst physicians and nurses

BACKGROUND

This intervention study aimed to enhance patient safety attitudes through the design of an in situ simulation program based on a needs analysis involving thematic analysis of patient safety data and short-term ethnography. The study took place at an Emergency Department (ED) in the Central Region of Denmark. Research suggests that poor handover communication can increase the likelihood of critical incidents and adverse events in the ED. Furthermore, simulation is an effective strategy for training handover communication skills. Research is lacking, however, on how to use patient safety data and a needs analysis to the design of in situ simulation communication training.

METHODS

This is a prospective pre-post study investigating the interventional effects of in situ simulation. It used a three-pronged strategy: (1) thematic analysis of patient safety data consisting of reported critical incidents and adverse events, (2) a needs analysis based on short-term ethnography in the ED, and (3) pre-post evaluation using the validated Safety Attitudes Questionnaire (SAQ) and the Trainee Reactions Score.

RESULTS

Sixteen different healthcare teams participated composed by 9 physicians and 30 nurses. In the SAQ, participating staff scored their safety attitudes in six categories (n = 39). Two measures where significantly higher for the post-SAQ than those for the pre-SAQ: teamwork climate (p < 0.001) and safety climate (p < 0.05). The Trainee Reactions Score showed that the training was positively evaluated.

CONCLUSIONS

This study designed a feasible strategy for implementing in situ simulation based on a needs analysis of critical incidents and adverse events and short-term ethnography.

Effect of Nurse-Led Review Plus Simulation on Obstetric/Perinatal Nurses' Self-Assessed Knowledge and Confidence

Simulation may help both novice and experienced clinicians maintain competence in managing high-risk, low-frequency obstetric and perinatal complications and emergencies. Therefore, we designed a pre-/posttest study to determine whether a day of nurse-led lecture plus low-fidelity simulation would increase registered nurses' self-assessed knowledge and confidence in managing five high-risk obstetric/perinatal situations. The Nursing Management of OB/Perinatal Complications & Emergencies (NursOB) scale was distributed to 67 labor/birth and postpartum nurses before and after a simulation training day. Preliminary findings supported validity and reliability of the NursOB scale, but nurses' knowledge and confidence did not improve after the simulation (p < .05). Anecdotally, nurses' interest in competence reviews was reinvigorated, and we gained practical knowledge in simulation delivery. Future simulations could enhance outcome measures, improve drills, and establish criterion-related validity of the NursOB scale. More research is warranted.

Integrated Approach to Reduce Perinatal Adverse Events: Standardized Processes, Interdisciplinary Teamwork Training, and Performance Feedback

OBJECTIVE

To improve safety practices and reduce adverse events in perinatal units of acute care hospitals.

DATA SOURCES

Primary data collected from perinatal units of 14 hospitals participating in the intervention between 2008 and 2012. Baseline secondary data collected from the same hospitals between 2006 and 2007.

STUDY DESIGN

A prospective study involving 342,754 deliveries was conducted using a quality improvement collaborative that supported three primary interventions. Primary measures include adoption of three standardized care processes and four measures of outcomes.

DATA COLLECTION METHODS

Chart audits were conducted to measure the implementation of standardized care processes. Outcome measures were collected and validated by the National Perinatal Information Center.

PRINCIPAL FINDINGS

The hospital perinatal units increased use of all three care processes, raising consolidated overall use from 38 to 81 percent between 2008 and 2012. The harms measured by the Adverse Outcome Index decreased 14 percent, and a run chart analysis revealed two special causes associated with the interventions.

CONCLUSIONS

This study demonstrates the ability of hospital perinatal staff to implement efforts to reduce perinatal harm using a quality improvement collaborative. Findings help inform the relationship between the use of standardized care processes, teamwork training, and improved perinatal outcomes, and suggest that a multiplicity of integrated strategies, rather than a single intervention, may be essential to achieve high reliability.

Neonatal outreach simulation

Numerous factors contribute to neonatal morbidity and mortality, and inexperienced providers managing crisis situations is one major cause. Simulation-based medical education is an excellent modality to employ in community hospitals to help refine and refresh resuscitation skills of providers who infrequently encounter neonatal emergencies. Mounting evidence suggests that simulation-based education improves patient outcomes. Academic health centers have the potential to improve neonatal outcomes through collaborations with community hospital providers, sharing expertise in neonatal resuscitation and simulation. Community outreach programs using simulation have been successfully initiated in North America. Two examples of programs are described here, including the models for curricular development, required resources, limitations, and benefits. Considerations for initiating outreach simulation programs are discussed. In the future, research demonstrating improved neonatal outcomes using outreach simulation will be important for personnel conducting outreach programs. Neonatal outreach simulation is a promising educational endeavor that may ultimately prove important in decreasing neonatal morbidity and mortality.

Obstetric team simulation program challenges

OBJECTIVE

To describe the challenges associated with the development and assessment of an obstetric emergency team simulation program.

DESIGN

The goal was to develop a hybrid, in-situ and high fidelity obstetric emergency team simulation program that incorporated weekly simulation sessions on the labor and delivery unit, and quarterly, education protected sessions in the simulation center. All simulation sessions were video-recorded and reviewed.

SETTING

Labor and delivery unit and simulation center.

PARTICIPANTS

Medical staff covering labor and delivery, anesthesiology and obstetric residents and obstetric nurses.

MEASUREMENTS

Assessments included an on-line knowledge multiple-choice questionnaire about the simulation scenarios. This was completed prior to the initial in-situ simulation session and repeated 3 months later, the Clinical Teamwork Scale with inter-rater reliability, participant confidence surveys and subjective participant satisfaction. A web-based curriculum comprising modules on communication skills, team challenges, and team obstetric emergency scenarios was also developed.

MAIN RESULTS

Over 4 months, only 6 labor and delivery unit in-situ sessions out of a possible 14 sessions were carried out. Four high-fidelity sessions were performed in 2 quarterly education protected meetings in the simulation center. Information technology difficulties led to the completion of only 18 pre/post web-based multiple-choice questionnaires. These test results showed no significant improvement in raw score performance from pre-test to post-test (P=.27). During Clinical Teamwork Scale live and video assessment, trained raters and program faculty were in agreement only 31% and 28% of the time, respectively (Kendall's W=.31, P<.001 and W=.28, P<.001). Participant confidence surveys overall revealed confidence significantly increased (P<.05), from pre-scenario briefing to after post-scenario debriefing.

CONCLUSION

Program feedback indicates a high level of participant satisfaction and improved confidence yet further program refinement is required.

Simulation-based multiprofessional obstetric anaesthesia training conducted in situ versus off-site leads to similar individual and team outcomes: a randomised educational trial

OBJECTIVE

To investigate the effect of in situ simulation (ISS) versus off-site simulation (OSS) on knowledge, patient safety attitude, stress, motivation, perceptions of simulation, team performance and organisational impact.

DESIGN

Investigator-initiated single-centre randomised superiority educational trial.

SETTING

Obstetrics and anaesthesiology departments, Rigshospitalet, University of Copenhagen, Denmark.

PARTICIPANTS

100 participants in teams of 10, comprising midwives, specialised midwives, auxiliary nurses, nurse anaesthetists, operating theatre nurses, and consultant doctors and trainees in obstetrics and anaesthesiology.

INTERVENTIONS

Two multiprofessional simulations (clinical management of an emergency caesarean section and a postpartum haemorrhage scenario) were conducted in teams of 10 in the ISS versus the OSS setting.

PRIMARY OUTCOME

Knowledge assessed by a multiple choice question test.

EXPLORATORY OUTCOMES

Individual outcomes: scores on the Safety Attitudes Questionnaire, stress measurements (State-Trait Anxiety Inventory, cognitive appraisal and salivary cortisol), Intrinsic Motivation Inventory and perceptions of simulations. Team outcome: video assessment of team performance. Organisational impact: suggestions for organisational changes.

RESULTS

The trial was conducted from April to June 2013. No differences between the two groups were found for the multiple choice question test, patient safety attitude, stress measurements, motivation or the evaluation of the simulations. The participants in the ISS group scored the authenticity of the simulation significantly higher than did the participants in the OSS group. Expert video assessment of team performance showed no differences between the ISS versus the OSS group. The ISS group provided more ideas and suggestions for changes at the organisational level.

CONCLUSIONS

In this randomised trial, no significant differences were found regarding knowledge, patient safety attitude, motivation or stress measurements when comparing ISS versus OSS. Although participant perception of the authenticity of ISS versus OSS differed significantly, there were no differences in other outcomes between the groups except that the ISS group generated more suggestions for organisational changes.

TRIAL REGISTRATION NUMBER

NCT01792674.

Initial steps in designing a simulation center and program to support the opening of a new women and children's hospital in Qatar

Designing and building a simulation program and center is a complex endeavor. This is considerably compounded by the simultaneous planning and construction of new hospital in which it will be house. To support the opening of a new healthcare facility in Doha, Qatar, simulation was chosen as a primary educational solution for the required onboarding of an international workforce, and to help collect data on systems to ensure processes and systems are optimal for patient safety. The following article provides a high-level overview of some of the key considerations and solutions that were made to overcome the many variables that are inherent in the planning phase of designing a center and program for a new hospital.

Impact of simulation and team training on postpartum hemorrhage management in non-academic centers

OBJECTIVE

Prompt recognition and response to postpartum hemorrhage (PPH) are vital in preventing maternal morbidity and mortality. We conducted a multi-center study to evaluate in situ simulation and team training for PPH among experienced clinical teams in non-academic hospitals in urban and rural communities.

METHODS

A longitudinal intervention study was performed in six Oregon community hospitals. All teams responded to an in situ simulated delivery and postpartum hemorrhage using trained actors and an obstetric birthing simulator, followed by a debriefing and training session. The simulation scenario was then repeated in 9-12 months. All sessions were digitally video recorded and independently reviewed by two obstetricians using a structured evaluation form. PPH management including clinical response times were compared before and after team training using Student's paired t-test and McNemar's test.

RESULTS

Twenty-two teams completed paired case simulations. Team training significantly improved response times in the management of PPH, including the recognition of PPH, time to administer first medication, performance of uterine massage and time to administer second medication. Medical management (use of three indicated medications) improved after training from 27.3% to 63.6%, p = 0.01.

CONCLUSIONS

Simulation and team training significantly improved postpartum hemorrhage response times among clinically experienced community labor and delivery teams.

Effect of education and clinical assessment on the accuracy of post partum blood loss estimation

Background

This research aimed to assess the effect of health care provider education on the accuracy of post partum blood loss estimation.

Methods

A non-randomized observational study that was conducted at King Abdulaziz Medical City, Riyadh, Saudi Arabia between January 1, 2011 and June 30, 2011. Hundred and twenty three health care providers who are involved in the estimation of post partum blood loss were eligible to participate. The participants were subjected to three research phases and an educational intervention. They have assessed a total of 30 different simulated blood loss stations, with 10 stations in each of the research phases. These phases took place before and after educational sessions on how to visually estimate blood loss and how to best utilize patient data in clinical scenarios. We have assessed the differences between the estimated blood loss and the actual measure. P-values were calculated to assess the differences between the three research phases estimations.

Results

The participants significantly under-estimated post partum blood loss. The accuracy was improved after training (p-value < 0.0001) and after analysing each patient’s clinical information (p-value = 0.042). The overall results were not affected by the participants’ clinical backgrounds or their years of experience. Under-estimation was more prominent in cases where more than average-excessive blood losses were simulated while over-estimations or accurate estimations were more prominent in less than average blood loss incidents.

Conclusion

Simple education programmes can improve traditional findings related to under-estimation of blood loss. More sophisticated clinical education programmes may provide additional improvements.

Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82

Over the past two decades, there has been an exponential and enthusiastic adoption of simulation in healthcare education internationally. Medicine has learned much from professions that have established programs in simulation for training, such as aviation, the military and space exploration. Increased demands on training hours, limited patient encounters, and a focus on patient safety have led to a new paradigm of education in healthcare that increasingly involves technology and innovative ways to provide a standardized curriculum. A robust body of literature is growing, seeking to answer the question of how best to use simulation in healthcare education. Building on the groundwork of the Best Evidence in Medical Education (BEME) Guide on the features of simulators that lead to effective learning, this current Guide provides practical guidance to aid educators in effectively using simulation for training. It is a selective review to describe best practices and illustrative case studies. This Guide is the second part of a two-part AMEE Guide on simulation in healthcare education. The first Guide focuses on building a simulation program, and discusses more operational topics such as types of simulators, simulation center structure and set-up, fidelity management, and scenario engineering, as well as faculty preparation. This Guide will focus on the educational principles that lead to effective learning, and include topics such as feedback and debriefing, deliberate practice, and curriculum integration - all central to simulation efficacy. The important subjects of mastery learning, range of difficulty, capturing clinical variation, and individualized learning are also examined. Finally, we discuss approaches to team training and suggest future directions. Each section follows a framework of background and definition, its importance to effective use of simulation, practical points with examples, and challenges generally encountered. Simulation-based healthcare education has great potential for use throughout the healthcare education continuum, from undergraduate to continuing education. It can also be used to train a variety of healthcare providers in different disciplines from novices to experts. This Guide aims to equip healthcare educators with the tools to use this learning modality to its full capability.

'In situ simulation' versus 'off site simulation' in obstetric emergencies and their effect on knowledge, safety attitudes, team performance, stress, and motivation: study protocol for a randomized controlled trial

BACKGROUND

Unexpected obstetric emergencies threaten the safety of pregnant women. As emergencies are rare, they are difficult to learn. Therefore, simulation-based medical education (SBME) seems relevant. In non-systematic reviews on SBME, medical simulation has been suggested to be associated with improved learner outcomes. However, many questions on how SBME can be optimized remain unanswered. One unresolved issue is how 'in situ simulation' (ISS) versus 'off site simulation' (OSS) impact learning. ISS means simulation-based training in the actual patient care unit (in other words, the labor room and operating room). OSS means training in facilities away from the actual patient care unit, either at a simulation centre or in hospital rooms that have been set up for this purpose.

METHODS AND DESIGN

The objective of this randomized trial is to study the effect of ISS versus OSS on individual learning outcome, safety attitude, motivation, stress, and team performance amongst multi-professional obstetric-anesthesia teams.The trial is a single-centre randomized superiority trial including 100 participants. The inclusion criteria were health-care professionals employed at the department of obstetrics or anesthesia at Rigshospitalet, Copenhagen, who were working on shifts and gave written informed consent. Exclusion criteria were managers with staff responsibilities, and staff who were actively taking part in preparation of the trial. The same obstetric multi-professional training was conducted in the two simulation settings. The experimental group was exposed to training in the ISS setting, and the control group in the OSS setting. The primary outcome is the individual score on a knowledge test. Exploratory outcomes are individual scores on a safety attitudes questionnaire, a stress inventory, salivary cortisol levels, an intrinsic motivation inventory, results from a questionnaire evaluating perceptions of the simulation and suggested changes needed in the organization, a team-based score on video-assessed team performance and on selected clinical performance.

DISCUSSION

The perspective is to provide new knowledge on contextual effects of different simulation settings.

TRIAL REGISTRATION

ClincialTrials.gov NCT01792674.

Developing a program, a curriculum, a scenario

Simulation in obstetrics and maternal-fetal medicine is an educational tool that can be employed to address local and national learning objectives for residents and fellows. Simulation may also be incorporated as part of a comprehensive patient safety program to improve maternal and neonatal outcomes. Our objective is to identify steps in designing an effective simulation program, curricula, and scenario using available evidence and drawing on experience. Identification of needs, leadership, and financial and logistic resources is the first step in program design. An appropriate curriculum may be crafted with the intended audience and clear learning objectives in mind. Simulation scenario design is best achieved in a stepwise, layered fashion and must incorporate time for debriefing, feedback, and didactics. Simulation programs of any size, budget, and scope can be successfully implemented at the local, regional, and national levels to enhance education and improve patient safety.

In situ simulation: identification of systems issues

The Institute of Medicine's report, To Err is Human, concluded that "medical errors are not a result of isolated individual actions but rather faulty systems, processes, and conditions that lead people to make mistakes." In situ simulation offers the unique opportunity to train the teams of people who deliver healthcare while enhancing policies, evaluating new technologies, and improving the systems that support the delivery of safe healthcare. For this reason, the Institute of Medicine, the Joint Commission, and the Agency for Healthcare Research and Quality recommend medical simulation as one of the most important safe practice interventions to reduce errors and risks associated with the process of care. This review builds on other reports in this issue and discusses the application of in situ simulation to identify, address, and test systems improvements.

High-reliability emergency response teams in the hospital: improving quality and safety using in situ simulation training

INTRODUCTION

In situ simulation training is a team-based training technique conducted on actual patient care units using equipment and resources from that unit, and involving actual members of the healthcare team. We describe our experience with in situ simulation training in a major children's medical centre.

MATERIALS AND METHODS

In situ simulations were conducted using standardised scenarios approximately twice per month on inpatient hospital units on a rotating basis. Simulations were scheduled so that each unit participated in at least two in situ simulations per year. Simulations were conducted on a revolving schedule alternating on the day and night shifts and were unannounced. Scenarios were preselected to maximise the educational experience, and frequently involved clinical deterioration to cardiopulmonary arrest.

RESULTS

We performed 64 of the scheduled 112 (57%) in situ simulations on all shifts and all units over 21 months. We identified 134 latent safety threats and knowledge gaps during these in situ simulations, which we categorised as medication, equipment, and/or resource/system threats. Identification of these errors resulted in modification of systems to reduce the risk of error. In situ simulations also provided a method to reinforce teamwork behaviours, such as the use of assertive statements, role clarity, performance of frequent updating, development of a shared mental model, performance of independent double checks of high-risk medicines, and overcoming authority gradients between team members. Participants stated that the training programme was effective and did not disrupt patient care.

CONCLUSIONS

In situ simulations can identify latent safety threats, identify knowledge gaps, and reinforce teamwork behaviours when used as part of an organisation-wide safety programme.

Using Data to Drive Emergency Department Design: A Metasynthesis

Objective:

There has been an uptick in the field of emergency department (ED) operations research and data gathering, both published and unpublished. This new information has implications for ED design. The specialty suffers from an inability to have these innovations reach frontline practitioners, let alone design professionals and architects. This paper is an attempt to synthesize for design professionals the growing data regarding ED operations.

Methods:

The following sources were used to capture and summarize the research and data collections available regarding ED operations: the Emergency Department Benchmarking Alliance database; a literature search using both PubMed and Google Scholar search engines; and data presented at conferences and proceedings.

Results:

Critical information that affects ED design strategies is summarized, organized, and presented. Data suggest an optimal size for ED functional units. The now-recognized arrival and census curves for the ED suggest a department that expands and contracts in response to changing census. Operational improvements have been clearly identified and are grouped into three categories: input, throughput, and outflow. Applications of this information are suggested.

Conclusion:

The sentinel premise of this meta-synthesis is that data derived from improvement work in the area of ED operations has applications for ED design. EDs can optimize their functioning by marrying good processes and operations to good design. This review paper is an attempt to bring this new information to the attention of the multidisciplinary team of architects, designers, and clinicians.

Sustaining simulation training programmes--experience from maternity care

There is little scientific evidence to support the majority of simulation-based maternity training programmes, but some characteristics appear to be associated with sustainability. Among these are a clear institutional-level commitment to the course, strong leadership in course organisation, a curriculum relevant to clinical practice, a nonthreatening learning environment, the establishment of multiprofessional training and the use of simulators appropriate to the learning objectives. There is still some debate on whether simulation-based sessions should be carried out in dedicated training time outside normal working hours or in ad-hoc drills that are run during clinical sessions, whether they should be located in clinical areas, simulation centres, or both, and whether or not they should include standardised generic teamwork training sessions. In this review, we discuss the main characteristics that appear to make a simulation-based training programme a sustainable initiative.