Advanced medical simulation applications for emergency medicine microsystems evaluation and training

Stress Testing the Resuscitation Room: Latent Threats to Patient Safety Identified During Interprofessional In Situ Simulation in a Canadian Academic Emergency Department

OBJECTIVES

Emergency department (ED) resuscitation is a complex, high-stakes procedure where positive outcomes depend on effective interactions between the health care team, the patient, and the environment. Resuscitation teams work in dynamic environments and strive to ensure the timely delivery of necessary treatments, equipment, and skill sets when required. However, systemic failures in this environment cannot always be adequately anticipated, which exposes patients to opportunities for harm.

METHODS

As part of a new interprofessional education and quality improvement initiative, this prospective, observational study sought to characterize latent safety threats (LSTs) identified during the delivery of in situ, simulated resuscitations in our ED. In situ simulation (ISS) sessions were delivered on a monthly basis in the EDs at each campus of a large tertiary care academic hospital system, during which a variety of scenarios were run with teams of ED health care professionals. LSTs were identified by simulation facilitators and participants during the case and debriefing and then grouped thematically for analysis.

RESULTS

During the study period, 22 ISS sessions were delivered, involving 58 cases and reaching 383 ED health care professionals. 196 latent safety threats were identified through these sessions (mean = 3.4 LSTs per case) of which 110 were determined to be "actionable" at a system level. LSTs identified included system/environmental design flaws, equipment problems, failures in department processes, and knowledge/skill gaps. Corrective mechanisms were initiated in 85% of actionable cases.

CONCLUSIONS

Effective quality improvement and continuing education programs are essential to translate these findings into more resilient patient care. ISS, beyond its role as a training tool for developing intrinsic and crisis resource management skills, can be effectively used to identify system issues in the ED that could expose critically ill patients to harm.

Five Topics Health Care Simulation Can Address to Improve Patient Safety: Results From a Consensus Process

OBJECTIVES

There is little knowledge about which elements of health care simulation are most effective in improving patient safety. When empirical evidence is lacking, a consensus statement can help define priorities in, for example, education and research. A consensus process was therefore initiated to define priorities in health care simulation that contribute the most to improve patient safety.

METHODS

An international group of experts took part in a 4-stage consensus process based on a modified nominal group technique. Stages 1 to 3 were based on electronic communication; stage 4 was a 2-day consensus meeting at the Utstein Abbey in Norway. The goals of stage 4 were to agree on the top 5 topics in health care simulation that contribute the most to patient safety, identify the patient safety problems they relate to, and suggest solutions with implementation strategies for these problems.

RESULTS

The expert group agreed on the following topics: technical skills, nontechnical skills, system probing, assessment, and effectiveness. For each topic, 5 patient safety problems were suggested that each topic might contribute to solve. Solutions to these problems and implementation strategies for these solutions were identified for technical skills, nontechnical skills, and system probing. In the case of assessment and effectiveness, the expert group found it difficult to suggest solutions and implementation strategies mainly because of lacking consensus on metrics and methodology.

CONCLUSIONS

The expert group recommends that the 5 topics identified in this consensus process should be the main focus when health care simulation is implemented in patient safety curricula.

Human Factors and Simulation in Emergency Medicine

This consensus group from the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes" held in Orlando, Florida, on May 16, 2017, focused on the use of human factors (HF) and simulation in the field of emergency medicine (EM). The HF discipline is often underutilized within EM but has significant potential in improving the interface between technologies and individuals in the field. The discussion explored the domain of HF, its benefits in medicine, how simulation can be a catalyst for HF work in EM, and how EM can collaborate with HF professionals to effect change. Implementing HF in EM through health care simulation will require a demonstration of clinical and safety outcomes, advocacy to stakeholders and administrators, and establishment of structured collaborations between HF professionals and EM, such as in this breakout group.

Translational simulation: not 'where?' but 'why?' A functional view of in situ simulation

Healthcare simulation has been widely adopted for health professional education at all stages of training and practice and across cognitive, procedural, communication and teamwork domains. Recent enthusiasm for in situ simulation-delivered in the real clinical environment-cites improved transfer of knowledge and skills into real-world practice, as well as opportunities to identify latent safety threats and other workplace-specific issues. However, describing simulation type according to place may not be helpful. Instead, I propose the term translational simulation as a functional term for how simulation may be connected directly with health service priorities and patient outcomes, through interventional and diagnostic functions, independent of the location of the simulation activity.

Simulation as a toolkit-understanding the perils of blood transfusion in a complex health care environment

Background

Administration of blood is a complex process requiring vigilance and effective teamwork. Despite strict policies and training on blood administration, errors still occur and can lead to mistransfusion with adverse patient outcomes. We used an in situ simulated scenario within an operating room (OR) to identify weaknesses in the current process and hazards that could contribute to mistransfusion.

Methods

A process checklist of critical steps of safe transfusion was developed based on a large academic centre’s internal hospital policy and practice. Ten standardized operating room scenarios were conducted involving management of postoperative bleeding. Scenarios lasted 20 min or until blood transfusion was started. Debriefing followed immediately. Video recordings were reviewed, scored, and evaluated for team performance. Latent safety threats were identified. Focus groups further helped to identify rationale for decisions made. Participants completed questionnaires to evaluate the exercise.

Results

Forty-three experienced OR professionals participated. Of the 19 steps identified as essential for the safe administration of blood components, the median number of steps correctly completed per team was 11. The largest number of errors occurred when different team members interacted and during the immediate pre-transfusion check. We report that this type of learning immediately increased participants’ self-reported ability to perform in a team (90%) and to improve clinical care (88%).

Conclusions

In situ simulation is valuable in identifying common susceptibilities in blood administration error in a complex healthcare organization. Administrators and clinicians may wish to use simulation as an opportunity for system improvement in the delivery of quality care.

The use of in situ simulation to detect latent safety threats in paediatrics: a cross-sectional survey

Background

In situ simulation (ISS) has been reported as an innovative method to identify and mitigate latent safety threats (LSTs) in healthcare. Little is known about the current utilisation of ISS across academic simulation programmes.

Objective

This study aims to describe the use of ISS to identify LST across paediatric academic simulation programmes.

Methods

A 25-question cross-sectional survey was conducted at two simulation meetings in January 2014 to recruit leaders from paediatric simulation programmes. The total eligible sample was 82 individuals representing 48 distinct academic medical centres. The 25 survey questions were created to describe the constructs of: (1) utilisation of ISS (location, participants, cancellations and coordination) and (2) the outcomes of ISS (detection of and response to safety threats). Descriptive statistics were carried out using SPSS V.21.0 (IBM Corp released 2012).

Results

The response rate was 68% (56/82), representing 79% (38/48) of the eligible academic medical centres. The majority of respondents (52/56) reported that their programmes utilised ISS. ISS was most commonly conducted in acute care settings. Almost all respondents (48/52) detected an LST during ISS. More than half of the respondents (28/52) utilised a formal reporting process after ISS sessions to feedback the LST to other individuals within their institution. 23% (12/52) of respondents reported the detection of a serious LST in ISS that was not resolved and subsequently led to a safety event during real patient care.

Conclusions

The use of ISS to identify and mitigate LST is common in this cross-sectional survey of paediatric simulation programmes. Diverse processes and organisational structures exist for reporting and mitigating LSTs identified in ISS. A more integrated and systematic approach to ISS and LST could help ensure the mitigation of LSTs before they impact on patients.

In situ simulation: detection of safety threats and teamwork training in a high risk emergency department

OBJECTIVE

Implement and demonstrate feasibility of in situ simulations to identify latent safety threats (LSTs) at a higher rate than lab-based training, and reinforce teamwork training in a paediatric emergency department (ED).

METHODS

Multidisciplinary healthcare providers responded to critical simulated patients in an urban ED during all shifts. Unannounced in situ simulations were limited to 10 min of simulation and 10 min of debriefing, and were video recorded. A standardised debriefing template was used to assess LSTs. The primary outcome measure was the number and type of LSTs identified during the simulations. Secondary measures included: participants' assessment of impact on patient care and value to participants. Blinded video review using a modified Anaesthetists Non-Technical Skills scale was used to assess team behaviours.

RESULTS

218 healthcare providers responded to 90 in situ simulations conducted over 1 year. A total of 73 LSTs were identified; a rate of one every 1.2 simulations performed. In situ simulations were cancelled at a rate of 28% initially, but the cancellation rate decreased as training matured. Examples of threats identified include malfunctioning equipment and knowledge gaps concerning role responsibilities. 78% of participants rated the simulations as extremely valuable or valuable, while only 5% rated the simulation as having little or no value. Of those responding to a postsimulation survey, 77% reported little or no clinical impact. Video recordings did not indicate changes in non-technical skills during this time.

CONCLUSIONS

In situ simulation is a practical method for the detection of LSTs and to reinforce team training behaviours. Embedding in situ simulation as a routine expectation positively affected operations and the safety climate in a high risk clinical setting.

Simulation in emergency medicine training

Simulation provides a range of educational tools that have increasingly been incorporated into emergency medicine (EM) curricula. Standardized patients and some partial task trainers, such as intubation heads, have been used for decades. More recently, a growing number of computer-screen simulations, high-fidelity mannequins, and virtual-reality simulators have expanded the number of procedures and conditions, which can be effectively simulated.The Accreditation Council for Graduate Medical Education transitioned to a competency-based assessment of residency programs in 2001 and included simulation as a method for incorporating the 6 core competencies into graduate medical education curricula. Over the past decade, numerous peer-reviewed publications have promoted simulation as an effective educational tool for each of the core competencies.The advanced technology used to operate many current simulators can erroneously become the focus of efforts to create a simulation-based curriculum. Simulation can most effectively be incorporated into EM curricula through the use of time-proven concepts, which start with defining the targeted learners, assessing their general and specific educational needs, defining learning objectives, and selecting the best educational strategy for achieving each objective. In many, but not all, instances, simulation can be the best tool for achieving EM learning objectives.