PEARLS for Systems Integration: A Modified PEARLS Framework for Debriefing Systems-Focused Simulations

Simulation based education in paediatric resuscitation

There is increasing use of clinical Simulation Based Education (SBE) in healthcare due to an increased focus on patient safety, the call for a new training model not based solely on apprenticeship, a desire for standardised educational opportunities that are available on-demand, and a need to practice and hone skills in a controlled environment. SBE programs should be evaluated against Kirkpatrick level 3 or 4 criteria to ensure they improve patient or staff outcomes in the real world. SBE programs have been shown to improve outcomes in neonatology - reductions in hypoxic ischaemic encephalopathy, in brachial plexus injury, rates of school age cerebral palsy, reductions in 24hr mortality and improvements in first pass intubation rates. In paediatrics SBE programs have shown improvements in paediatric cardiac arrest survival, PICU survival, reduced PICU admissions, reduced PICU length of stay and reduced time to critical operations. SBE can improve the non-technical tasks of teamwork, leadership and communication (within the team and with patients and carers). Simulation is a useful tool in Quality and Safety and is used to identify latent safety issues that can be addressed by future programs. In high stakes assessment simulation can be a mode of assessment, however, care needs to be taken to ensure the tool is validated carefully.

Validation of a Novel Mobile Application for Assessing Pediatric Tracheostomy Emergency Simulations

Objective

Pediatric tracheostomy is associated with high morbidity and mortality, yet clinician knowledge and quality of tracheostomy care may vary widely. In situ simulation is effective at detecting and mitigating related latent safety threats, but evaluation via retrospective video review has disadvantages (eg, delayed analysis, and potential data loss). We evaluated whether a novel mobile application is accurate and reliable for assessment of in situ tracheostomy emergency simulations.

Methods

A novel mobile application was developed for assessment of tracheostomy emergency in situ simulation team performance. After 1.25 hours of training, 6 raters scored 10 tracheostomy emergency simulation videos for the occurrence and timing of 12 critical steps. To assess accuracy, rater scores were compared to a reference standard to determine agreement for occurrence or absence of critical steps and a timestamp within ±5 seconds. Interrater reliability was determined through Cohen's and Fleiss' kappa and intraclass correlation coefficient.

Results

Raters had 86.0% agreement with the reference standard when considering step occurrence and timing, and 92.8% agreement when considering only occurrence. The average timestamp difference from the reference standard was 1.3 ± 18.5 seconds. Overall interrater reliability was almost perfect for both step occurrence (Fleiss' kappa of 0.81) and timing of step (intraclass correlation coefficient of 0.99).

Discussion

Using our novel mobile application, raters with minimal training accurately and reliably assessed videos of tracheostomy emergency simulations and identified areas for future refinement.

Implications for Practice

With refinements, this innovative mobile application is an effective tool for real-time data capture of time-critical steps in in situ tracheostomy emergency simulations.

Applying Human Factors and Systems Simulation Methods to Inform a Multimillion-Dollar Healthcare Decision

PURPOSE

This article describes a case study of a collaborative human factors (HF) and systems-focused simulation (SFS) project to evaluate potential patient and staff safety risks associated with a multimillion-dollar design and construction decision.

BACKGROUND

The combined integration of HF and SFS methods in healthcare related to testing and informing the design of new environments and processes is underutilized. Few realize the effectiveness of this integration in healthcare to reduce risk and improve decision-making, safety, design, efficiency, patient experience, and outcomes. This project showcases how the combined use of HF and SFS methods can provide objective evidence to help inform decisions.

METHODS

The project was initiated by a healthcare executive team looking for an objective, user informed analysis of a current connector passageway between two existing buildings. The goal was to understand the implications of keeping the current route for simultaneous use for public and patients service flow versus building and financing a new passageway for separate flow and transport. An interprofessional team of intensive care unit professionals participated in two simulations designed to test the current connector. A failure mode and effects analysis and qualitative debrief feedback was used to evaluate risks and potential failures.

RESULTS

The evaluation resulted in data that enabled informed executive decision making for the most effective, efficient, and safest option for public, staff, and patient transport between two buildings. This evaluation resulted in the decision to go forward with building a multimillion-dollar new connector passageway to improve integrated care and transport.

Proactive patient safety: enhancing hospital readiness through simulation-based clinical systems testing and healthcare failure mode and effect analysis

BACKGROUND

Recognizing and identifying latent safety threats (LSTs) before patient care commences is crucial, aiding leaders in ensuring hospital readiness and extending its impact beyond patient safety alone. This study evaluated the effectiveness of a combination of Simulation-based Clinical Systems Testing (SbCST) with Healthcare Failure Mode and Effect Analysis (HFMEA) with regard to mitigating LSTs within a newly constructed hospital.

METHODS

Three phases of the combined SbCST and HFMEA approach were implemented across all hospital settings. The scenarios tested system functionalities, team responses, and resource availability. The threats thus identified were categorized into system-related issues, human issues, and resource issues, after which they were prioritized and addressed using mitigation strategies. Reassessment confirmed the effectiveness of these strategies before hospital commissioning.

RESULTS

More than 76% of the LSTs were mitigated through the combined approach. System-related issues, such as nonfunctional communication devices and faulty elevators, were addressed by leadership. Human issues such as miscommunication and nonadherence to hospital policy led to improvements in interprofessional communication and teamwork. Resource issues, including missing equipment and risks of oxygen explosion, were addressed through procurement, maintenance, and staff training for equipment preparation.

CONCLUSION

The SbCST and HFMEA were highly effective with regard to proactively identifying and mitigating LSTs across all aspects of hospital preparedness. This systematic and comprehensive approach offers a valuable tool for enhancing patient safety in new healthcare facilities, thereby potentially setting a new standard for proactive hazard identification and risk management in the context of healthcare construction and commissioning.

Simulation in pediatric anesthesiology: current state and visions for the future

PURPOSE OF REVIEW

Simulation is a well established practice in medicine. This review reflects upon the role of simulation in pediatric anesthesiology in three parts: training anesthesiologists to care for pediatric patients safely and effectively; evaluating and improving systems of care for children; and visions for the future.

RECENT FINDINGS

Simulation continues to prove a useful modality to educate both novice and experienced clinicians in the perioperative care of infants and children. It is also a powerful tool to help analyze and improve upon how care is provided to infants and children. Advances in technology and computational power now allow for a greater than ever degree of innovation, accessibility, and focused reflection and debriefing, with an exciting outlook for promising advances in the near future.

SUMMARY

Simulation plays a key role in developing and achieving peak performance in the perioperative care of infants and children. Although simulation already has a great impact, its full potential is yet to be harnessed.

[Latent safety threats in a pediatric emergency department: Using in situ simulation to test a new trauma room concept]

INTRODUCTION

Structured emergency room concepts have been shown to contribute to patient safety. Until now there has been no uniform emergency room concept for critically ill and seriously injured children and adolescents in the emergency room at the Altona Children's Hospital in Hamburg. This concept has been newly developed in interdisciplinary cooperation and includes the use of new clinical premises as well as new responsibilities and team compositions. The introduction of new processes and rooms for handling emergencies is associated with a risk of overlooking latent safety deficiencies or detecting them only after the process has been implemented. This may have a direct impact on patient safety. Before moving to new clinical premises, in situ simulation can be helpful to identify and to resolve latent safety threats in advance. Therefore, this method was chosen to test the newly created emergency room concept in the future emergency room at the Altona Children's Hospital.

METHODS

Two in situ simulations were carried out in the future real emergency room. Latent safety threats detected by the observation team and the participants (medical and nursing staff of the Altona Children's Hospital from the departments of pediatric surgery, traumatology, orthopedics, pediatrics, anesthesia, intensive care medicine, radiology, emergency medicine) were collected using free text notes after the simulations and evaluated retrospectively. In order to better deal with these latent safety threats, the observations were classified into different categories: working environment (e.g., lack of equipment, unfavorable positioning of material), process (e.g., lack of defined responsibilities in the team) and other safety threats that did not fall into one of the two categories defined.

RESULTS

A total of 51 latent safety threats were identified during the two in situ simulations. Of these, 22 (43.1%) were assigned to the "working environment" category, 20 (39.2%) to the "process" category and 9 (17.7%) to the "other safety threats" category. Of the latent safety threats identified, 46 (90.2 %) could be resolved before the emergency room was put into operation. For the non-recoverable safety threats, safety concepts were developed in order to further minimize the risk of patient hazard.

DISCUSSION

With the help of this study, it could be shown that the implementation of in situ simulation before the commissioning of new clinical premises and the introduction of new processes can contribute to the detection of latent safety threats in an interdisciplinary German pediatric emergency department.

Translational simulation revisited: an evolving conceptual model for the contribution of simulation to healthcare quality and safety

The simulation community has effectively responded to calls for a more direct contribution by simulation to healthcare quality and safety, and clearer alignment with health service priorities, but the conceptual framing of this contribution has been vague. The term 'translational simulation' was proposed in 2017 as a "functional term for how simulation may be connected directly with health service priorities and patient outcomes, through interventional and diagnostic functions" (Brazil V. Adv Simul. 2:20, 2017). Six years later, this conceptual framing is clearer. Translational simulation has been applied in diverse contexts, affording insights into its strengths and limitations. Three core concepts are identifiable in recently published translational simulation studies: a clear identification of simulation purpose, an articulation of the simulation process, and an engagement with the conceptual foundations of translational simulation practice. In this article, we reflect on current translational simulation practice and scholarship, especially with respect to these three core concepts, and offer a further elaborated conceptual model based on its use to date.

Harnessing In Situ Simulation to Identify Human Errors and Latent Safety Threats in Adult Tracheostomy Care

BACKGROUND

Tracheostomies are associated with high rates of complications and preventable harm. Safe tracheostomy management requires highly functioning teams and systems, but health care providers are poorly equipped with tracheostomy knowledge and resources. In situ simulation has been used as a quality improvement tool to audit multidisciplinary team emergency response in the actual clinical environment where care is delivered but has been underexplored for tracheostomy care.

METHODS

From July 2021 to May 2022, the study team conducted in situ simulations of a tracheostomy emergency scenario at Montefiore Medical Center to identify human errors and latent safety threats (LSTs). Simulations included structured debriefs as well as audiovisual recording that allowed for blind rating of these human errors and LSTs. Provider knowledge deficits were further characterized using pre-simulation quizzes.

RESULTS

Twelve human errors and 15 LSTs were identified over 20 simulations with 88 participants overall. LSTs were divided into the following categories: communication, equipment, and infection control. Only 50.0% of teams successfully replaced the tracheostomy tube within the scenario's five-minute time limit. In addition, knowledge gaps were highly prevalent, with a median pre-simulation quiz score of 46% (interquartile range 36-64) among participants.

CONCLUSION

An in situ simulation-based quality improvement approach shed light on human errors and LSTs associated with tracheostomy care across multiple settings in one health system. This method of engaging frontline health care provider key stakeholders will inform the development, adaptation, and implementation of interventions.

How theories of complexity and resilience affect interprofessional simulation-based education: a qualitative analysis of facilitators' perspectives

BACKGROUND

Quality of care and patient safety rely on the ability of interprofessional teams to collaborate effectively. This can be trained through interprofessional simulation-based education (IPSE). Patient safety also relies on the ability to adapt to the complexity of such situations, an ability termed resilience. Since these needs are not explicitly addressed in IPSE, the aim of this study was to explore how central concepts from complexity-theory and resilience affect IPSE, from facilitators' perspective, when applied in debriefings.

METHODS

A set of central concepts in complexity-theory and resilience were introduced to facilitators on an IPSE course for nursing and medical students. In five iterations of focus groups interviews the facilitators discussed their application of these concepts by reviewing video recordings of their own debriefings. Video recordings of the interviews were subjected to coding and thematic analysis.

RESULTS

Three themes were identified. The first, Concepts of complexity and resilience are relevant for IPSE, points to the applicability of these concepts and to the fact that students often need to deviate from prescribed guidelines/algorithms in order to solve cases. The second theme, Exploring complexity, shows how uncertainty could be used as a cue to explore complexity. Further, that individual performance needs to account for the context of actions and how this may lead to certain outcomes. Moreover, it was suggested that several ways to approach a challenge can contribute to important insight in the conditions for teamwork. The third theme, Unpacking how solutions are achieved, turns to needs for handling the aforementioned complexity. It illustrates the importance of addressing self-criticism by highlighting how students were often able to overcome challenges and find solutions. Finally, this theme highlights how pre-defined guidelines and algorithms still work as important resources to help students in transforming perceived messiness into clarity.

CONCLUSIONS

This study suggests that IPSE provides the possibility to explore complexity and highlight resilience so that such capability can be trained and improved. Further studies are needed to develop more concrete ways of using IPSE to account for complexity and developing resilience capacity and to evaluate to what extent IPSE can provide such an effect.

Web-based standardized patient simulation for taking anamnesis: an approach in nursing education during the pandemic

BACKGROUND

To address the challenges in nursing education brought about by the pandemic, this study aimed to evaluate the use of a web-based standardized patient practice in the development of nursing students' anamnesis taking skills and their views about its application.

METHOD

We conducted a descriptive intervention study with 39 s-year nursing students. The students completed anamnesis using the standardized patient practice in line with a scenario with real standardized patients in a web-based environment with audio and video.

RESULTS

The total scores of students' anamnesis skills were low. The agreement between the total scores, scores obtained from the health patterns, and each item in the control list was statistically significant (p < 0.05).

CONCLUSION

Web-based standardized patient practice is an alternative for clinical practice facilitating the gaining of competencies in making holistic nursing diagnoses under conditions that limit face-to-face interactions, such as pandemics.

Making a move: Using simulation to identify latent safety threats before the care of injured patients in a new physical space

BACKGROUND

In today's rapidly changing health care environment, hospitals are expanding into newly built spaces. Preserving patient safety by identifying latent safety threats (LSTs) in advance of opening a new physical space is key to continued excellent care. At our level 1 pediatric trauma center, the hospital undertook a 5-year project to build a critical care tower, including a new emergency department with five trauma bays. To allow for identification and mitigation of LSTs before opening, we performed simulation-based clinical systems testing.

METHODS

Eight simulation scenarios were developed, based on actual patient presentations, incorporating a variety of injury patterns. Scenarios included workflow and movement from the helipad and squad entrance as well as to radiology, the operating room, and the pediatric intensive care unit. A multiple resuscitation scenario was also designed to test the use of all five bays simultaneously. Multidisciplinary high-fidelity simulations were conducted in the new tower. Key trauma and emergency department stakeholders facilitated all sessions, using a structured framework for systems integration debriefing framework and failure mode and effect analysis to identify and prioritize LSTs, respectively.

RESULTS

Eight sessions were conducted for 2 months. A total of 201 staff participated, including trauma surgeons, respiratory therapists, nurses, emergency physicians, x-ray technicians, pharmacists, emergency medical services, and operating room staff. In total, 118 LSTs (average of 14.8/session) were identified. Latent safety threats were categorized. An action plan for mitigation was developed after applying failure mode and effects analysis prioritization scores (based on severity, probability, and ease of detection).

CONCLUSION

Systems-focused trauma simulations identified a large number of LSTs before the opening of a new critical care building. Identification of LSTs is feasible and facilitates mitigation before actual patient care begins, improving patient safety.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Let us to the TWISST; Plan, Simulate, Study and Act

Translational Work Integrating Simulation and Systems Testing (TWISST) is a novel application of simulation that augments how we discover, understand, and mitigate errors in our system. TWISST is a diagnostic and interventional tool that couples Simulation-based Clinical Systems Testing with simulation-based training (SbT). TWISST tests environments and work systems to identify latent safety threats (LSTs) and process inefficiencies. In SbT, improvements made to the work system are embedded in hard wire system improvements, ensuring optimal integration into clinical workflow.

Methods

Simulation-based Clinical Systems Testing approach includes simulated scenarios, Summarize, Anchor, Facilitate, Explore, Elicit debriefing, and Failure Mode and Effect Analysis. In iterative Plan-Simulate-Study-Act cycles, frontline teams explored work system inefficiencies, identified LSTs, and tested potential solutions. As a result, system improvements were hardwired through SbT. Finally, we present a case study example of the TWISST application in the Pediatric Emergency Department.

Results

TWISST identified 41 latent conditions. LSTs were related to resource/equipment/supplies (n = 18, 44%), patient safety (n = 14, 34%), and policies/procedures (n = 9, 22%). Work system improvements addressed 27 latent conditions. System changes that eliminated waste or modified the environment to support best practices mitigated 16 latent conditions. System improvements that addressed 44% of LSTs cost the department $11,000 per trauma bay.

Conclusions

TWISST is an innovative and novel strategy that effectively diagnoses and remediates LSTs in a working system. This approach couples highly reliable work system improvements and training into 1 framework.

In Situ Simulation as a Quality Improvement Tool to Identify and Mitigate Latent Safety Threats for Emergency Department SARS-CoV-2 Airway Management: A Multi-Institutional Initiative

BACKGROUND

In situ simulation has emerged as a powerful quality improvement (QI) tool in the identification of latent safety threats (LSTs). Following the first wave of SARS-CoV-2 at an urban epicenter of the disease, a multi-institutional collaborative was formed to integrate an in situ simulation protocol across five emergency departments (EDs) for systems improvement of acute airway management.

METHODS

A prospective, multi-institutional QI initiative using two Plan-Do-Study-Act (PDSA) cycles was implemented across five EDs. Each institution conducted simulations involving mannequins in acute respiratory failure requiring definitive airways. Simulations and systems-based debriefs were standardized. LSTs were collected in an online database, focused on (1) equipment availability, (2) infection control, and (3) communication.

RESULTS

From June 2020 through May 2021, 58 of 70 (82.9%) planned simulations were completed across five sites with 328 unique individual participants. Overall LSTs per simulation (7.00-4.69, p < 0.001) and equipment LSTs (3.00-1.46, p < 0.001) decreased from cycle 1 to cycle 2. Changes in mean LSTs for infection control and communication categories varied among sites. There was no correlation between total LSTs or any of the categories and team size. Number of beds occupied was significantly negatively correlated with total and infection control LSTs.

CONCLUSION

This study was unique in simultaneously running a structured in situ protocol across numerous diverse institutions during a global pandemic. This initiative found similar categories of threats across sites, and the protocol developed empowered participants to implement changes to mitigate identified threats.

Stress Testing the Cardiac Catheterization Laboratory: A Novel Use of In Situ Simulation to Identify and Mitigate Latent Safety Threats During Acute Airway Management

INTRODUCTION

Although uncommon, cardiac arrests in the cardiac catheterization laboratory (CCL) are often catastrophic and likely to increase with rising case complexity. In situ simulation (ISS) has been used to identify latent safety threats (LSTs) in inpatient units but has not yet been studied in the CCL.

METHODS

Three Plan-Do-Study-Act (PDSA) cycles leveraging ISS were conducted focused on acute airway management. Data collected through debriefs focused on (1) airway management, (2) equipment availability, and (3) interdepartmental communication. The LSTs were subcategorized and plotted on the Survey Analysis for Evaluating Risk (SAFER)-Matrix. A SAFER score was calculated based on quantifying the likelihood of harm, scope, and the number of times a threat was identified during simulation. Time to definitive airway was collected as a secondary measure. Interventions were developed using cause and effect and driver diagrams between PDSA cycles.

RESULTS

Eleven total simulations through 3 PDSA cycles were conducted between January and December 2021 (5 in PDSA 1, 4 in PDSA 2, and 2 in PDSA 3). One hundred one LSTs were identified with 14 total subcategories. The mean SAFER score decreased from 5.37 in PDSA 1, to 2.96 in PDSA 2, and to 1.00 in PDSA 3. Bivariate regression analysis showed a decrease in SAFER score of 2.19 for every PDSA cycle (P = 0.011). Ordinary least squares regression had a decrease of 1.65 in airway-related threats every PDSA cycle (P < 0.01) as well as an increase in intubation time of 35.0 seconds for every 1-unit increase in communication threat identified (P = 0.037).

CONCLUSIONS

This study successfully leveraged ISS and existing quality improvement initiatives in the CCL, resulting in a decrease in airway-related threats as measured through simulation.

Taking the Pulse of the Current State of Simulation

Simulation in health-care professions has grown in the last few decades. We provide an overview of the history of simulation in other fields, the trajectory of simulation in health professions education, and research in medical education, including the learning theories and tools to assess and evaluate simulation programs. We also propose future directions for simulation and research in health professions education.

A Novel Approach to Emergency Department Readiness for Airborne Precautions Using Simulation-Based Clinical Systems Testing

STUDY OBJECTIVES

Emergency department (ED) COVID-19 preparations required rethinking workflows and introducing the potential for errors. Simulation provides a nimble methodology integrating into situ training and systems testing to prepare staff, detect potential workflow latent safety threats and provide recommendations for mitigation.

METHODS

We developed 5 onsite rapid-cycle ED simulation cases using "tipping points" related to new protocols coupled with a structured observation tool. Staff observed simulations, recorded adherence to protocols, identified safety threats, discussed mitigation strategies, and participants completed an evaluation using a 5-point Likert scale. Latent safety threats were prioritized by risk and escalated to leadership.

RESULTS

Through 44 simulations, 76 staff identified 31 unique latent safety threats in the following categories: job aids 9 (29%), isolation measures 8 (26%), communication and personnel 6 (19%), and technology and equipment 8 (26%). Eleven high-priority safety threats were escalated to ED leadership. Sixty-five staff (86% of participants) completed a web-based evaluation reporting that simulations were worth the time (86% strongly agreed), an effective way to test the system (92% strongly agreed), and an acceptable way to improve (92% strongly agreed).

CONCLUSION

Our study demonstrated that simulation-based clinical systems test methods are adaptable for rapid preparedness evaluation and training. In combination with rapid-cycle deliberate practice, many latent safety threats were identified prior to clinical implementation. Our work highlights a novel application of simulation systems to increase system preparedness and reduce the potential for errors which may be applicable in diverse settings for designing, evaluating, and training staff in new protocols and procedures.

In Situ Simulation as a Tool to Longitudinally Identify and Track Latent Safety Threats in a Structured Quality Improvement Initiative for SARS-CoV-2 Airway Management: A Single-Center Study

BACKGROUND

In situ simulation has emerged as a powerful tool for identifying latent safety threats (LSTs). After the first wave of the SARS-CoV-2 pandemic, an urban community emergency department (ED) identified opportunities for improvement surrounding acute airway management and particularly focused on infection control precautions, equipment availability, and interprofessional communication during acute resuscitation. Using the Model for Improvement, a hybrid in situ/quality improvement initiative was implemented using Plan-Do-Study-Act (PDSA) cycles to enhance systems for intubating patients with SARS-CoV-2.

METHODS

Three PDSA cycles consisting of 10 simulations each were conducted from June 2020 through February 2021. Latent safety threats (LST) were identified through an in situ simulation scenario involving a patient with SARS-CoV-2 in acute respiratory failure. LSTs were collected through structured debriefs focused on (1) infection control, (2) equipment availability, and (3) communication. The SAFER-Matrix was used to score LSTs according to frequency and likelihood of harm by members of the ED QI team (SAFER score). The research team worked with the same QI leaders to implement action plans based on scored threats using cause-and-effect and driver diagrams. The Donabedian model was used to conceptually evaluate the quality of interventions upon conclusion of the third PDSA cycle.

RESULTS

The median SAFER score decreased from 10.94 in PDSA cycle 1 to 6.77 in PDSA cycle 2 to 4.71 in PDSA cycle 3. Across all identified LSTs, the SAFER score decreased by 3.114 for every additional PDSA cycle ( P = 0.0167). When evaluating for threats identified as being primarily structure based, there was a decrease in SAFER score of 1.28 per every additional PDSA cycle ( P = 0.001). There was a decrease in total count of LST of 0.20 per additional simulation run ( P = 0.02) after controlling for shift type, census, perceived workload, team size, and prior attendance in simulations across all PDSA cycles.

CONCLUSIONS

This study presents a blueprint for the utilization of in situ simulation through multiple waves of the SARS-CoV-2 pandemic to identify LSTs and use the SAFER score as a surrogate marker to monitor the impact of interventions for a safer environment for both medical staff and patients.

Interprofessional In Situ Simulation to Identify Latent Safety Threats for Quality Improvement: A Single-Center Protocol Report

In situ simulation has frequently been used to improve team performance and provide an opportunity for the practice of critical skills and identify latent safety threats, which are undetected risks that may lead to adverse outcomes. However, the use of known quality improvement tools to prioritize and mitigate these safety threats is an area requiring further study. Over the course of 9 in situ simulations of a pediatric shock case, postcase debriefs were held to identify latent safety threats in an emergency department and a mixed pediatric and adult inpatient unit. Latent safety threats identified included structure-related threats such as inability to locate critical equipment, knowledge-based threats relating to rapid intravenous fluid administration, and communication-based threats such as lack of role designation. Identification of latent safety threats in the health care environment may assist clinician leaders in mitigating risk of patient harm. The protocol described may be adopted and applied to other critical event simulations, with structured debriefing used as a tool to identify and mitigate threats before they affect the patient.

Using simulation-based training during hospital relocation: a controlled intervention study

BACKGROUND

During hospital relocations, it is important to support healthcare professionals becoming familiar with new settings. Simulation-based training seems promising and in situ simulation has been suggested as a beneficial educational tool to prepare healthcare professionals for relocation. This study aimed to investigate the impact of a simulation-based training intervention on health professionals´ readiness to work in their new environment, as well as investigate sick leave before and after relocation.

METHODS

The study was a controlled intervention study implemented at a university hospital in Denmark. Simulation was used to prepare employees for workflows prior to relocation. Before relocation, 1199 healthcare professionals participated in the in situ simulation-based training program. Questionnaires on readiness to perform were distributed to participants at pre-, post-, and follow-up (6 months) measurement. In addition, data on participants' sick leave was gathered from a business intelligence portal. To compare dependent and independent groups, paired and unpaired t tests were performed on mean score of readiness to perform and sick leave.

RESULTS

Compared to the control group, healthcare professionals participating in the intervention felt significantly more ready to work in a new hospital environment. As a measure of psychological wellbeing, register data indicated no difference in sick leave, when comparing intervention and control groups before and after participating in the in situ simulation-based training program.

CONCLUSIONS

Healthcare professionals felt significantly more ready to work in a new environment, after participating in the in situ simulation-based training program, indicating that the intervention supported healthcare professionals during relocations. This may mitigate feelings of uncertainty; however, further research is needed to explore such effects.

TRIAL REGISTRATION

The study was approved by The Regional Ethics Committee (no. 1-16-02-222-22).

Getting Ready for 2021 Joint Commission Perinatal Standards: Lessons From the Field

SUMMARY STATEMENT

The new Joint Commission requirements on perinatal safety present a unique opportunity for the simulation community to actively engage with labor and delivery units nationwide. Considerations for implementation using "real-life" experience with the programmatic development of an in situ team-based simulation training program in obstetric emergencies are discussed. We urge simulationists to explore opportunities to promote culture change on a large scale to move the needle of maternal morbidity and mortality.

An innovative interprofessional education simulation for athletic training and prelicensure nursing students: Development, implementation, and student perspectives

BACKGROUND

The purpose of this article is to describe the development, implementation, and evaluation of a Simulation Interprofessional Education (Sim-IPE) activity for healthcare students from different disciplines (athletic training [AT] and nursing). The objective for the Sim-IPE activity was to engage AT and prelicensure nursing students in a realistic healthcare scenario to enhance knowledge about one another's profession, develop interprofessional skills, collaborate with one another, and communicate effectively as a team as they performed care.

METHODS

This mixed methods study employed a one-time posttest design for a convenience sample of AT and prelicensure nursing students following a simulation intervention. Students completed the Student Perceptions of Interprofessional Clinical Education-Revised (SPICE-R) survey and answered open-ended response questions.

RESULTS

Thirteen students (N = 13) from Cohort 1 and 12 students (N = 12) from Cohort 2 completed the SPICE-R survey. Most students strongly agreed/agreed for each of the SPICE-R survey questions. Qualitative findings indicated the students positively perceived the Sim-IPE activity as it helped them discover the value of interprofessional patient care.

DISCUSSION

The quantitative findings indicated that the students found the Sim-IPE an effective learning methodology to achieve the objectives while the qualitative findings gave further insight into the students' perceptions of interprofessional teamwork and the value of the prebrief session conducted before the simulation. The findings will inform future Sim-IPE activities involving additional groups of healthcare students.

„Die Puppe hat Luftnot“ – Simulation zum interprofessionellen Lernen im Team: aber sinnvoll!

Ausbildungskonzepte, die eine Simulation von Fällen und Szenarien aller Art nutzen, haben breiten Eingang in Curricula und Praxis gefunden. Ein Vertrauen in technische Simulationsmethoden ohne qualifizierte Ausbildung in der Methode kann schaden. Deswegen sollte nach der Auswahl der korrekten Simulationsmethode großer Wert auf die Durchführung der Simulation gelegt werden. Neben einem strukturierten Design der simulierten Szenarien und der korrekten technischen Durchführung ist für den Lernerfolg vor allem das Debriefing, die Nachbesprechung, entscheidend. Prüfungen mit Simulation als Methode sind nur zu empfehlen, wenn sie von Trainings getrennt durchgeführt werden und die Bewertung nach transparenten, validierten Kriterien erfolgt.

Be Prepared: A Pediatric Simulation Center's Early Pandemic Contributions

INTRODUCTION

The COVID-19 pandemic forced healthcare institutions to rapidly adapt practices for patient care, staff safety, and resource management. We evaluated contributions of the simulation center in a freestanding children's hospital during the early stages of the pandemic.

METHODS

We reviewed our simulation center's activity for education-based and system-focused simulation for 2 consecutive academic years (AY19: 2018-2019 and AY20: 2019-2020). We used statistical control charts and χ 2 analyses to assess the impact of the pandemic on simulation activity as well as outputs of system-focused simulation during the first wave of the pandemic (March-June 2020) using the system failure mode taxonomy and required level of resolution.

RESULTS

A total of 1983 event counts were reported. Total counts were similar between years (994 in AY19 and 989 in AY20). System-focused simulation was more prevalent in AY20 compared with AY19 (8% vs. 2% of total simulation activity, P < 0.001), mainly driven by COVID-19-related simulation events. COVID-19-related simulation occurred across the institution, identified system failure modes in all categories except culture, and was more likely to identify macro-level issues than non-COVID-19-related simulation (64% vs. 44%, P = 0.027).

CONCLUSIONS

Our simulation center pivoted to deliver substantial system-focused simulation across the hospital during the first wave of the COVID-19 pandemic. Our experience suggests that simulation centers are essential resources in achieving safe and effective hospital-wide improvement.

Harnessing system-focused simulation, debriefing and FMEA to inform healthcare blood transfusion safety and policy

Healthcare systems improvement using simulation and debriefing is an increasingly employed, yet underutilized quality improvement tool to enable user-centred design. This approach allows users to experience real-life systems and processes through simulation and then provide feedback on how a system supports them within their role. Understanding this interaction of people and their systems is critical to safe, quality, reliable and efficient care and bridges the gap between how we think a system is working and how it is working.

This novel project was collaboratively developed and led by simulation, human factors and patient safety experts and used existing organizational safety data to target further high-risk safety threats surrounding administering, cross-checking and labelling blood products for transfusion. A system-focused simulation-based approach was used to identify system issues for a large healthcare organization’s transfusion policy redesign. A Failure Mode and Effects Analysis (FMEA) was then used to apply a risk score to the findings from the simulation user feedback to inform a large high-risk policy redesign.

Multiple recommendations were provided to the participating units and policy and procedure redesign teams surrounding environmental issues, standards, interpretation and usability of the policy.

Our collaborative patient safety, simulation and human factors project was successful in proactively identifying both active and latent factors contributing to adverse events and identifying recommendations using FMEA methodology to improve patient safety, including revisions to the physical space within the lab, and the provincial blood transfusion policy and procedure.

Simulathon 2020: Integrating Simulation Period Prevalence Methodology Into the COVID-19 Disaster Management Cycle in India

SUMMARY STATEMENT

The disaster management cycle is an accepted model that encompasses preparation for and recovery from large-scale disasters. Over the past decade, India's Pediatric Simulation Training and Research Society has developed a national-scale simulation delivery platform, termed the Simulathon , with a period prevalence methodology that integrates with core aspects of this model. As an exemplar of the effectiveness of this approach, we describe the development, implementation, and outcomes of the 2020 Simulathon, conducted from April 20 to May 20 in response to the nascent COVID-19 pandemic disaster. We conclude by discussing how aspects of the COVID-19 Simulathon enabled us to address key aspects of the disaster management cycle, as well as challenges that we encountered. We present a roadmap by which other simulation programs in low- and middle-income countries could enact a similar process.

Hospital-wide cardiac arrest in situ simulation to identify and mitigate latent safety threats

BACKGROUND

Cardiac arrest resuscitation requires well-executed teamwork to produce optimal outcomes. Frequency of cardiac arrest events differs by hospital location, which presents unique challenges in care due to variations in responding team composition and comfort levels and familiarity with obtaining and utilizing arrest equipment. The objective of this initiative is to utilize unannounced, in situ, cardiac arrest simulations hospital wide to educate, evaluate, and maximize cardiac arrest teams outside the traditional simulation lab by systematically assessing and capturing areas of opportunity for improvement, latent safety threats (LSTs), and key challenges by hospital location.

METHODS

Unannounced in situ simulations were performed at a city hospital with multidisciplinary cardiac arrest teams responding to a presumed real cardiac arrest. Participants and facilitators identified LSTs during standardized postsimulation debriefings that were classified into equipment, medication, resource/system, or technical skill categories. A hazard matrix was used by multiplying occurrence frequency of LST in simulation and real clinical events (based on expert opinion) and severity of the LST based on agreement between two evaluators.

RESULTS

Seventy-four in situ cardiac arrest simulations were conducted hospital wide. Hundreds of safety threats were identified, analyzed, and categorized yielding 106 unique latent safety threats: 21 in the equipment category, 8 in the medication category, 41 in the resource/system category, and 36 in the technical skill category. The team worked to mitigate all LSTs with priority mitigation to imminent risk level threats, then high risk threats, followed by non-imminent risk LSTs. Four LSTs were deemed imminent, requiring immediate remediation post debriefing. Fifteen LSTs had a hazard ratio greater than 8 which were deemed high risk for remediation. Depending on the category of threat, a combination of mitigating steps including the immediate fixing of an identified problem, leadership escalation, and programmatic intervention recommendations occurred resulting in mitigation of all identified threats.

CONCLUSIONS

Hospital-wide in situ cardiac arrest team simulation offers an effective way to both identify and mitigate LSTs. Safety during cardiac arrest care is improved through the use of a system in which LSTs are escalated urgently, mitigated, and conveyed back to participants to provide closed loop debriefing. Lastly, this hospital-wide, multidisciplinary initiative additionally served as an educational needs assessment allowing for informed, iterative education and systems improvement initiatives targeted to areas of LSTs and areas of opportunity.

A novel approach to operating room readiness for airborne precautions using simulation-based clinical systems testing

BACKGROUND

The emergence of the COVID-19 disease as a global pandemic caused major challenges and strained busy operating room environments. This required institutions to rethink current system functioning and urgently develop safe medical practices and protocols.

PURPOSE

To use a novel approach combining simulation-based clinical system testing with rapid cycle deliberate practice concepts for identifying latent safety threats presented by newly developed operating room COVID-19 protocols and collecting frontline staff recommendations for mitigation.

METHODS

This study design combined a training/education approach with probing the systems function. The primary outcomes were the number of latent safety threats and staff evaluations of this approach for feasibility and utility on immediate and four-month post surveys. Participants started the simulation which took place in the operating room, in the assistant role before graduating to the primary airway manager. Simulation staff members observed the simulations and noted whether elements in the protocols/checklists were followed and whether latent safety threats were present using an observation form. Solutions to latent safety threats were sought during the debriefing period.

RESULTS

This approach identified 17 latent safety threats not foreseen during the planning stages and allowed for corrections to the protocols prior to impacting patient outcomes. Post-simulation surveys indicated that the program was well received and all who responded agreed that it was worth the time it took. Fifty-seven percent of respondents to four-month follow-up survey reported using the work products to care for an actual COVID-19 patient.

CONCLUSIONS

This study demonstrated a flexible methodology that effectively integrated simulation-based training and systems tests to train staff and detect latent safety threats in the new workflows and provide recommendations for mitigation. While COVID was the specific prompt, this approach can be applicable in diverse clinical settings for training medical staff, testing system function, and mitigating potential latent safety threats.

Safety Considerations for In Situ Simulation in Closed SARS-CoV-2 Units

SUMMARY STATEMENT

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic placed a tremendous strain on the healthcare system, which led to the deployment of new personnel into acute care settings, early graduation of medical students, and development of new treatment spaces. Education teams at the Montefiore Health System and New York Health and Hospitals/Jacobi Medical Center found simulation, both laboratory-based and in situ, critical to the training of medical staff and investigation of latent safety threats. Through our experience, we encountered unique infection control concerns based on in situ sessions, which prompted us to redesign our programs for the treatment of SARS-CoV-2. Using this experience, we outline our rationale for the use of in situ simulation for newly developed SARS-CoV-2 spaces along with recommendations on safety checks to consider before starting.

Improving Safety Recommendations Before Implementation: A Simulation-Based Event Analysis to Optimize Interventions Designed to Prevent Recurrence of Adverse Events

INTRODUCTION

Pediatric inpatients are at high risk of adverse events (AE). Traditionally, root cause analysis was used to analyze AEs and identify recommendations for change. Simulation-based event analysis (SBEA) is a protocol that systematically reviews AEs by recreating them using in situ simulated patients, to understand clinician decision making, improve error discovery, and, through guided sequential debriefing, recommend interventions for error prevention. Studies suggest that these interventions are rarely tested before dissemination. This study investigates the use of simulation to optimize recommendations generated from SBEA before implementation.

METHODS

Recommendations and interventions developed through SBEA of 2 hospital-based AEs (event A: error of commission; event B: error of detection) were tested using in situ simulation. Each scenario was repeated 8 times. Interventions were modified based on participant feedback until the error stopped occurring and data saturation was reached.

RESULTS

Data saturation was reached after 6 simulations for both scenarios. For scenario A, a critical error was repeated during the first 2 scenarios using the initial interventions. After modifications, errors were corrected or mitigated in the remaining 6 scenarios. For scenario B, 1 intervention, the nursing checklist, had the highest impact, decreasing average time to error detection to 6 minutes. Based on feedback from participants, changes were made to all but one of the original proposed interventions.

CONCLUSIONS

Even interventions developed through improved analysis techniques, like SBEA, require testing and modification. Simulation optimizes interventions and provides opportunity to assess efficacy in real-life settings with clinicians before widespread implementation.

Commissioning Clinical Spaces During a Pandemic: Merging Methodologies of Human Factors and Simulation

OBJECTIVES

The objective of this case study is to demonstrate the value of applying tabletop and simulation techniques to highlight high-risk, high-impact outcomes and organizational recommendations in the commissioning of a new clinical spaces.

PURPOSE/AIM

Generalizability of lessons learned from this case study aim to support other health organizations in commissioning of clinical spaces during communicable disease outbreaks.

BACKGROUND

COVID-19 challenged our healthcare system, requiring teams to prepare in a short span of time. Bridging expertise of human factor and simulation teams provided a novel, interdisciplinary, and timely approach to evaluate and commission spaces.

METHODS

Human factors and simulation teams were enlisted to conduct an evaluation of a new space prior to readiness for delivery of safe patient care. An adapted tabletop evaluation and subsequent systems integration simulation was conducted. The goal of the tabletop exercise was to identify and define processes and risks to tested in the physical space using simulation.

RESULTS

Applying both human factors science and systems simulation proactively identified the highest risk, highest impact outcomes, validated existing processes and allowed for refining of potential solutions and recommendations of the new space. A strong working relationship between teams fostered an opportunity to share information, debrief, evaluate, and adapt methods while applying timely changes based on emergent findings.

CONCLUSIONS

These combined methodologies are important tools that can be learned and applied to healthcare commissioning of new clinical spaces in the identification of high-risk, high-impact outcomes affecting staff and organizational preparedness and safety.

189 A Simulation With No Participants Only Co-Faculty: Using Simulation for Systems Integration On the Large Scale

The large-scale relocation of a paediatric hospital is a significant undertaking. New environments change the system, and ways of working must adapt to maintain quality healthcare. There are risks to patients and staff well-being, with high anxiety around change. There is evidence for the efficacy of simulation as a tool for safe training and rehearsal of staff and teams

How can simulation-based methodology be used to support clinical departments on a large scale to adapt/integrate/prepare in moving to a brand-new hospital?

Collaboration with authors of PEARLS for system integration use

Pre-phase work involved meeting stakeholders and establishing aims of testing. Ward managers were key departmental links, meeting with members of PESSI to plan scenarios. System testing days involved familiarizing themselves with the environment, followed by ‘day in the life’ simulations with a representation of the whole team. All participants were called ‘co-faculty’ and knew exactly what would happen. Debrief involved facilitated conversations with the whole team describing reactions, and deeper analysis of the key events, with concerted efforts by facilitators to give a balanced approach of positives and challenges. A short report was given back to the department detailing the findings teams would need solutions to. Solutions from simulation were implemented prior to the move, increasing staff confidence, with many feeling PESSI played a major role in feeling prepared for the new site. The PESSI framework is being utilized in adult services and we hope to publish our methodology to share with the wider simulation community.

Dynamic Plus-Delta: an agile debriefing approach centred around variable participant, faculty and contextual factors

The current coronavirus pandemic has necessitated rapid intensive care infrastructure expansion with corresponding demand for training healthcare staff. At the NHS Nightingale Hospital, London, the staff underwent a training programme prior to entering the clinical environment with simulation being a core component. This paper describes the rationale for choosing an initial debriefing model which evolved overtime to consider multiple contextual factors: demands of the clinical environment, the diverse participants and their learning needs, the variable experience of faculty, and the dynamic nature of available debriefing time. The new approach, termed here as the Dynamic Plus-Delta model, blends the traditional Plus-Delta approach with specific dynamic elements which considers the unique demands of rapidly training large number of staff. We outline the core features of this model and detail specific considerations around psychological safety. This debriefing approach can be used in similar simulation intervention settings where rapid training of participants is required with multiple and varying contextual factors.

Optimising frontline learning and engagement between consultant-led neonatal teams in the West Midlands: a survey on the utility of an augmented simulation training technique

Background

In England, neonatal care is delivered in operational delivery networks, comprising a combination of the Neonatal Intensive Care (NICU), Local-Neonatal (LNU) or Special-Care Units (SCU), based on their ability to care for babies with different degrees of illness or prematurity. With the development of network care pathways, the most premature and sickest are mostly triaged for delivery in services linked to NICU. This has created anxiety for teams in LNU and SCU. Less exposure to sicker babies has resulted in limited opportunities to maintain expertise for when these babies unexpectedly deliver at their centre and thereafter require transfer for care, to NICU. Simultaneously, LNU and SCU teams develop skills in the care of the less ill and premature baby which would also be of benefit to NICU teams. A need for mutual learning through inter-unit multidirectional collaborative learning and engagement (hereafter also called neonatal networking) between teams of different designations emerged. Here, neonatal networking is defined as collaboration, shared clinical learning and developing an understanding of local systems strengths and challenges between units of different and similar designations. We describe the responses to the development of a clinical and systems focussed platform for this engagement between different teams within our neonatal ODN.

Method

An interactive 1-day programme was developed in the West Midlands, focussing on a non-hierarchical, equal partnership between neonatal teams from different unit designations. It utilised simulation around clinical scenarios, with a slant towards consultant engagement. Four groups rotating through four clinical simulation scenarios were developed. Each group participated in a clinical simulation scenario, led by a consultant and supported by nurses and doctors in training together with facilitators, with a further ~two consultants, as observers within the group. All were considered learners. Consultant candidates took turns to be participants and observers in the simulation scenarios so that at the end of the day all had led a scenario. Each simulation-clinical debrief session was lengthened by a further ~ 20 min, during which freestyle discussion with all learners occurred. This was to promote further bonding, through multidirectional sharing, and with a systems focus on understanding the strengths and challenges of practices in different units. A consultant focus was adopted to promote a long-term engagement between units around shared care. There were four time points for this neonatal networking during the course of the day. Qualitative assessment and a Likert scale were used to assess this initiative over 4 years.

Results

One hundred fifty-five individuals involved in frontline neonatal care participated. Seventy-seven were consultants, supported by neonatal trainees, staff grade doctors, clinical fellows, advanced neonatal nurse practitioners and nurses in training. All were invited to participate in the survey. The survey response rate was 80.6%. Seventy-nine percent felt that this learning strategy was highly relevant; 96% agreed that for consultants this was appropriate adult learning. Ninety-eight percent agreed that consultant training encompassed more than bedside clinical management, including forging communication links between teams. Thematic responses suggested that this was a highly useful method for multi-directional learning around shared care between neonatal units.

Conclusion

Simulation, enhanced with systems focussed debrief, appeared to be an acceptable method of promoting multidirectional learning within neonatal teams of differing designations within the WMNODN.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41077-021-00181-1.

Use of Virtually Facilitated Simulation to Improve COVID-19 Preparedness in Rural and Remote Canada

Background

The Alberta Health Services' Provincial Simulation Program (eSIM) is Canada's largest simulation program. The eSIM mobile simulation program specializes in delivering simulation-based education (SBE) to rural and remote communities (RRC). During the COVID-19 pandemic, a quality improvement project involving rapid cycle in situ virtually facilitated simulation (VFS) for COVID-19 airway management and health systems preparedness in RRC was successfully implemented.

Methods

Between April 24 and July 31, 2020, a team of six rural simulationists (four nurses and two physicians) provided 24 VFS sessions with virtual debriefing to 200 health care providers distributed across 11 RRC in Alberta and the Northwest Territories, covering a geographic area of approximately 169,028 km².

Results

Video analysis of sequential VFS rapid cycle sessions using a standardized observational tool indicated decreased personal protective equipment (PPE) breaches by 36.6% between the first and third cycles. Teams demonstrated increased competency with airway management such as correct use of bag-valve-mask ventilation, and implementation of health system process improvements, such as incorporation of an intubation checklist. Improvements occurred on average over 2.2 rapid cycles completed within 1.3 weeks per RRC. Postsession self-reported participant electronic surveys indicated self-reported improvement in clinical management, teamwork behavior, and health systems issues outcome measures which were categorized based on the Crisis Resource Management and Systems Engineering Initiative for Patient Safety (SEIPS) frameworks. Of the 48 survey respondents, 86.1% reported that VFS was equivalent or superior to in-person simulation. The cost of VFS was 62.9% lower than comparable in-person SBE.

Conclusion

VFS provides a rapidly mobilizable and cost-effective way of delivering high-quality SBE to geographically isolated communities.

Improving Simulation Accessibility in a Hospital Setting: Implementing a Simulation Consultation Service

SUMMARY STATEMENT

This article documents the creation and implementation of a unique approach to translational simulation in a large, tertiary hospital setting. By creating a simulation consultation service, the ethos of translational simulation can be made more accessible to all areas of the hospital. Through the referral-consultation process, simulation exercises can be specifically designed, in conjunction with the referring individual/team, to directly address specific objectives. The service provides a wide range of multiprofession, multidiscipline simulation expertise and ensures simulation facilitation in a consistent, safe, and objective specific manner accessible to all areas of a large, hospital setting.

Debriefing: A Tool to Enhance Education and Practice in NICU

Debriefing, a facilitator-guided reflection of an educational experience or critical incident, is an important tool in improving the safety and quality of practice in the NICU. Unlike feedback, which is often a one-way discussion, debriefing is a purposeful, 2-way reflective discussion which is based on experiential learning theory. The purpose of this article is to review the theoretical basis of debriefing and describe styles and tools for debriefing that can be applied in the NICU.

Prevention of Latent Safety Threats: A Quality Improvement Project to Mobilize a Portable CT

Introduction:

Transporting critically ill patients to diagnostic imaging for needed studies can be challenging and even prohibitive. A portable computerized tomography (CT) scanner allows the patient to remain in the intensive care unit, but presents new positioning and team challenges. Before activation of a portable CT scanner in our pediatric intensive care unit and through the use of iterative simulation-based Plan-Do-Study-Act (PDSA) cycles in the clinical environment, a multidisciplinary team of bedside caregivers determined optimal patient positioning, equipment needs, and specific staffing and choreography to develop detailed portable CT guidelines.

Method:

Our team engaged stakeholders from radiology, critical care, respiratory therapy, environmental services, facilities operations, and the CT vendor to develop scenarios. Simulations included infant and pediatric patients who required critical invasive monitoring and treatment devices, such as ventilators, and high-risk intracardiac and intravascular lines. Scenario objectives centered on the safe positioning, transfer, and scanning of the patient. Trained simulation specialists from the hospital’s simulation center facilitated simulation sessions.

Results:

Simulation-based PDSA testing identified 31 latent safety threats, including the need for a custom bed adapter due to pediatric patients’ variable size. We paused portable CT activation pending the custom adapter’s availability and remediation of other latent safety threats. Additional simulation-based PDSA cycles further refined the process once the custom adapter was available.

Conclusions:

Simulation identified unanticipated latent safety threats before the implementation of a portable CT scanner.

A novel approach to explore Safety-I and Safety-II perspectives in in situ simulations-the structured what if functional resonance analysis methodology

OBJECTIVES

With ever increasingly complex healthcare settings, technology enhanced simulation (TES) is well positioned to explore all perspectives to enhance patient safety and patient outcomes. Analysis from a Safety-II stance requires identification of human adjustments in daily work that are key to maintaining safety. The aim of this paper is to describe an approach to explore the consequences of human variability from a Safety-II perspective and describe the added value of this to TES.

METHODS

The reader is guided through a novel application of functional resonance analysis methodology (FRAM), a method to analyse how a system or activity is affected by human variability, to explore human adaptations observed in in situ simulations (ISS). The structured applicability of this novel approach to TES is described by application to empirical data from the standardised ISS management of paediatric time critical head injuries (TCHI).

RESULTS

A case series is presented to illustrate the step-wise observation of key timings during ISSs, the construction of FRAM models and the visualisation of the propagation of human adaptations through the FRAM models. The key functions/actions that ensure the propagation are visible, as are the sequelae of the adaptations.

CONCLUSIONS

The approach as described in this paper is a first step to illuminating how to explore, analyse and observe the consequences of positive and negative human adaptations within simulated complex systems. This provides TES with a structured methodology to visualise and reflect upon both Safety-I and Safety-II perspectives to enhance patient safety and patient outcomes.

Virtual Interprofessional Learning Due to COVID-19

BACKGROUND

The COVID-19 pandemic necessitated sweeping changes in a neonatal nurse practitioner (NNP) program's approach to distance-accessible learning. Prioritizing student learning and safety, we developed a new alternative model for individualized simulation.

METHOD

The scenario created for a student to deliver an unexpected diagnosis of trisomy 21, or Down syndrome, to a postpartum mother was redesigned to take place using web-conference technology.

RESULTS

We successfully transitioned the planned in-person individualized simulation for NNP students delivering an unexpected diagnosis to a web-conference environment and added nurse-midwifery (NM) students.

CONCLUSION

This simulation presented an authentic clinical situation encountered in practice, supporting the specialty-specific competencies for the NNP, NM, and core competencies for interprofessional collaborative practice. The web-conference platform is an effective strategy for simulation. Advanced practice nurses completing individualized simulation through technology are uniquely poised to leverage these skills as telemedicine increasingly influences their future clinical practice. [J Nurs Educ. 2021;60(6):346-351.].

Building impactful systems-focused simulations: integrating change and project management frameworks into the pre-work phase

Healthcare organizations strive to deliver safe, high-quality, efficient care. These complex systems frequently harbor gaps, which if unmitigated, could result in harm. Systems-focused simulation (SFS) projects, which include systems-focused debriefing (SFD), if well designed and executed, can proactively and comprehensively identify gaps and test and improve systems, enabling institutions to improve safety and quality before patients and staff are placed at risk.

The previously published systems-focused debriefing framework, Promoting Excellence and Reflective Learning in Simulation (PEARLS) for Systems Integration (PSI), describes a systematic approach to SFD. It includes an essential “pre-work” phase, encompassing evidence-informed steps that lead up to a SFD. Despite inclusion in the PSI framework, a detailed description of the pre-work phase, and how each component facilitates change management, was limited.

The goal of this paper is to elucidate the PSI “Pre-work” phase, everything leading up to the systems-focused simulation and debriefing. It describes how the integration of project and change management principles ensures that a comprehensive collection of safety and quality issues are reliably identified and captured.

The COVID-19 Online Learning Transition and the Plus/Delta Debriefing Model

As a result of the COVID-19 pandemic, the Harvard Medical School Master of Medical Sciences in Medical Education program implemented the Plus/Delta debriefing model to collect real-time learner feedback and facilitate continuous quality improvement within our assessment and program evaluation module, which rapidly transitioned online. The model is grounded in quality improvement methodology and encourages bidirectional rather than top-down feedback. Learners identified specifically what went well with each module session (Plus) and how to improve for the next time (Delta). After each session, narrative responses were reviewed, aggregated into meaningful categories, and implemented when possible. Implemented improvements focused on increasing session interactivity and enhancing communication. Learners pointed to the uniqueness of the model and applauded efforts to embed them in the cocreation process. Asking learners to debrief their experience-especially during a module which is iteratively redesigned week-by-week-can offer a realistic view of what is working and what needs further refinement. As we continue to navigate the COVID-19 pandemic, rapid, continuous educational quality improvement deserves renewed emphasis. Implementing the Plus/Delta debriefing model into longitudinal online teaching sessions is a translatable, easily replicable, and free method of receiving immediate and valuable learner feedback.

Evaluations for New Healthcare Environment Commissioning and Operational Decision Making Using Simulation and Human Factors: A Case Study of an Interventional Trauma Operating Room

PURPOSE

The aim of this article is to provide a case study example of the preopening phase of an interventional trauma operating room (ITOR) using systems-focused simulation and human factor evaluations for healthcare environment commissioning.

BACKGROUND

Systems-focused simulation, underpinned by human factors science, is increasingly being used as a quality improvement tool to test and evaluate healthcare spaces with the stakeholders that use them. Purposeful real-to-life simulated events are rehearsed to allow healthcare teams opportunity to identify what is working well and what needs improvement within the work system such as tasks, environments, and processes that support the delivery of healthcare services. This project highlights salient evaluation objectives and methods used within the clinical commissioning phase of one of the first ITORs in Canada.

METHODS

A multistaged evaluation project to support clinical commissioning was facilitated engaging 24 stakeholder groups. Key evaluation objectives highlighted include the evaluation of two transport routes, switching of operating room (OR) tabletops, the use of the C-arm, and timely access to lead in the OR. Multiple evaluation methods were used including observation, debriefing, time-based metrics, distance wheel metrics, equipment adjustment counts, and other transport route considerations.

RESULTS

The evaluation resulted in several types of data that allowed for informed decision making for the most effective, efficient, and safest transport route for an exsanguinating trauma patient and healthcare team; improved efficiencies in use of the C-arm, significantly reduced the time to access lead; and uncovered a new process for switching OR tabletop due to safety threats identified.

Translational simulation: from description to action

This article describes an operational framework for implementing translational simulation in everyday practice. The framework, based on an input-process-output model, is developed from a critical review of the existing translational simulation literature and the collective experience of the authors' affiliated translational simulation services. The article describes how translational simulation may be used to explore work environments and/or people in them, improve quality through targeted interventions focused on clinical performance/patient outcomes, and be used to design and test planned infrastructure or interventions. Representative case vignettes are used to show how the framework can be applied to real world healthcare problems, including clinical space testing, process development, and culture. Finally, future directions for translational simulation are discussed. As such, the article provides a road map for practitioners who seek to address health service outcomes using translational simulation.

Incorporating Simulation Into Your Plan-Do-Study-Act Cycle

Plan-Do-Study-Act (PDSA) cycles are nearly universal within various quality improvement (QI) methodologies as a way of testing change prior to implementation. Simulation in health care has traditionally been used to improve teaching, enhance learning, and assess performance; however, it can also be powerful when used in the realm of QI work. Simulation is incredibly versatile and can be incorporated into the different phases of a PDSA cycle. Investigators often encounter situations in which a test of change in the real clinical environment may not be ideal; however, simulation is not considered because many practitioners are not familiar with its use. This article reviews the basics of PDSA cycles and provides examples of how simulation can be used for testing in each phase. Included are clear indications to help practitioners decide when simulation is appropriate to use and how to apply it to a variety of different QI projects. [Pediatr Ann. 2021;50(1):e25-e31.].

Development and implementation of an end-of-shift clinical debriefing method for emergency departments during COVID-19

BACKGROUND

Multiple guidelines recommend debriefing after clinical events in the emergency department (ED) to improve performance, but their implementation has been limited. We aimed to start a clinical debriefing program to identify opportunities to address teamwork and patient safety during the COVID-19 pandemic.

METHODS

We reviewed existing literature on best-practice guidelines to answer key clinical debriefing program design questions. An end-of-shift huddle format for the debriefs allowed multiple cases of suspected or confirmed COVID-19 illness to be discussed in the same session, promoting situational awareness and team learning. A novel ED-based clinical debriefing tool was implemented and titled Debriefing In Situ COVID-19 to Encourage Reflection and Plus-Delta in Healthcare After Shifts End (DISCOVER-PHASE). A facilitator experienced in simulation debriefings would facilitate a short (10-25 min) discussion of the relevant cases by following a scripted series of stages for debriefing. Data on the number of debriefing opportunities, frequency of utilization of debriefing, debriefing location, and professional background of the facilitator were analyzed.

RESULTS

During the study period, the ED treated 3386 suspected or confirmed COVID-19 cases, with 11 deaths and 77 ICU admissions. Of the 187 debriefing opportunities in the first 8-week period, 163 (87.2%) were performed. Of the 24 debriefings not performed, 21 (87.5%) of these were during the four first weeks (21/24; 87.5%). Clinical debriefings had a median duration of 10 min (IQR 7-13). They were mostly facilitated by a nurse (85.9%) and mainly performed remotely (89.8%).

CONCLUSION

Debriefing with DISCOVER-PHASE during the COVID-19 pandemic were performed often, were relatively brief, and were most often led remotely by a nurse facilitator. Future research should describe the clinical and organizational impact of this DISCOVER-PHASE.