Tensing Maa, Ellen Heimberg and Jennifer R. Reid
© Springer International Publishing Switzerland 2016
V. J. Grant, A. Cheng (eds.), Comprehensive Healthcare Simulation: Pediatrics, Comprehensive Healthcare Simulation, DOI 10.1007/978-3-319-24187-6_12 T. Maa ()
Department of Pediatrics, Department of Critical Care Medicine, Ohio State University College of Medicine, Nationwide Children’s Hospi- tal, Columbus, OH, USA
e-mail: [email protected] E. Heimberg
Department of Pediatric Cardiology, Pulmology, Intensive Care Medicine, University Children’s Hospital, Tuebingen, Germany e-mail: [email protected]
J. R. Reid
Department of Pediatrics, Division of Emergency Medicine, Univer- sity of Washington School of Medicine, Seattle Children’s Hospital, Seattle, WA, USA
e-mail: [email protected]
Simulation Pearls
1. In addition to predetermined learning objectives, in situ simulation can concurrently identify latent safety threats and opportunities for process and systems improvement.
2. In situ training may be better suited for intermediate and experienced practitioners. The novice learner, who is still developing basic knowledge, skills, and attitudes, may benefit from the controlled environment of a center: with- out time limits, distractions, risk of unintended observers, and lesscomplex physical and functional fidelity.
3. Unique challenges include scheduling interprofessional teams, frequent distractions, lastminute room and staff cancellations, and missing or malfunctioning equipment.
Facilitators need to be resilient to this lack of consistency and work to adjust learning objectives to the changing learning environment.
4. Mobile simulation, taking simulation to hospitals or clin- ics in the community, can make in situ simulation meth- odologies accessible across institutions, geographical re- gions, and international boundaries. It can inspire interest in simulation, patient safety, and cultural change in these institutions.
Introduction
In situ simulation describes training that occurs in real pa- tient care environments, rather than in a simulation center or off-site training area. By utilizing actual patient care spaces, simulation training can be performed in specialized settings such as a trauma bay, operating room (OR), hospital lobby, or prehospital site. Mobile simulation, taking simulation to hospitals or clinics in the community or to rural environ- ments, can make in situ simulation methodologies accessible across institutions, broad geographical regions, and interna- tional boundaries.
This chapter reviews opportunities and challenges spe- cific to in situ simulation, including applications where it has been shown to be particularly effective as compared to center-based training. We outline guidelines on setting up a successful in situ session, common challenges that may be encountered, as well as possible solutions. Strategies for planning and executing effective multi-institutional mobile in situ simulations are included.
Advantages
One of the main advantages of in situ simulation is that of increased fidelity, both from physical and functional per- spectives. Physical fidelity refers to the realism of the physi- cal environment. Performing simulation exercises in actual patient care locations and using real equipment minimizes environmental and physical differences between simulation training versus real patient care. This may make it easier for the learner to suspend disbelief and identify the relevance of the simulation. Functional fidelity refers to the realism of the content and process. Training that occurs in a native work setting can provide functional fidelity of content (what to do) and context (how to do it) combined in one educational session. Choosing clinical scenarios that approximate real patient experiences can support generalization of acquired competencies. By integrating physical and functional fidel-
ity, in situ simulation can maximize transfer of knowledge, skills, and behaviors learned during training to actual prac- tice [1, 2].
In situ simulation offers improved efficiency when it comes to space and cost. Highly specialized environments such as a cardiac catheterization lab or an operating room are difficult and expensive to fully replicate. In 2009, the esti- mated cost to start up an in situ program, including a high-fi- delity human simulator, was US$41,000 versus US$472,000 for a simulation center [3]. Rather than a dedicated simula- tion space, in situ sessions borrow from clinical space, need- ing only a smaller secured storage area. Figure 12.1 shows two examples of an in situ cart for storing and transporting a high-fidelity simulator and equipment. Figure 12.2 shows a hospital stretcher modified for carrying a mannequin, simulation equipment, and supplies, which can be wheeled through the hospital for in situ simulation. Additional sav- ings come from being able to use real but expensive equip-
ment, such as a defibrillator or bronchoscope, rather than purchasing those separately for training or using decommis- sioned units that have been collected for training use and are out of date. Furthermore, the authenticity of the environment provides such high fidelity that learning objectives may still be successfully accomplished using less costly, lower fidel- ity mannequins.
The core staff needed to run an in situ session (e.g., opera- tor and facilitator) is similar to that at a center [3]. However, more time is required for transport of equipment, setup, and tear-down for sessions, and this must be taken into account when considering human resource costs [4]. Some institu- tions utilize creative solutions for deferring staffing costs such as redirecting mandatory academic educational time of faculty members who act as facilitators and content experts for simulation sessions [5]. The affordability of starting an in situ program has allowed institutions with fewer resources to benefit from simulation-based education.
Fig. 12.2 Example of an in situ stretcher modified for carrying a mannequin, simulation equip- ment and supplies, which can be wheeled through the hospital for in situ simulation. (Photo courtesy of KidSIM Pediatric Simulation Program, Calgary, Canada)
Fig. 12.1 Examples of in situ simulation carts. a Minimal equipment needed: mannequin, basic supplies, and monitor versus b comprehensive console that contains mannequin, supply storage, technician console, cam- eras for video, and debriefing capabilities and connections to power sources. (Photo courtesy of Seattle Children’s Hospital)
Additional potential cost savings benefits can come from educating healthcare personnel while they are on duty rather than having to set aside separate time and money for off-site education. By bringing training to the learners, in situ ses- sions can be incorporated throughout all clinical shifts, pro- moting increased access to learning experiences for a larger number of staff.
Challenges
There are unique challenges with in situ simulation. Educa- tional time may be limited as simulations may happen while staff are working and thus cannot leave their clinical respon- sibilities for long. There are increased distractors such as fre- quent interruptions from pagers, phone calls and patient care duties. Last-minute cancellations can occur when staff or pa- tient rooms become unavailable due to high patient census or acuity. Debriefings, arguably the most important part of the simulation experience, may not be optimal; physical space may be confining and interfere with confidential debriefing or make video feedback challenging. Alternatively, in situ space may not physically accommodate all participants and observers that would like to attend.
The physical and cognitive demands on the simulation educator team are different for in situ simulation than for simulations performed within a center. For each simulation session, there is more time and effort needed for transpor- tation of equipment, set-up, and tear-down, particularly for elaborate simulations (e.g., extracorporeal membrane oxy- genation (ECMO)) [4, 6]. Inadequate cleanup after an in situ session has the potential to harm patients if real medical equipment or medications become contaminated with those used for simulation, and thus not for patient use. If the clini- cal area is not appropriately restocked, this may result in in- advertent threats to safety during a real-patient emergency if key supplies are missing or damaged [3, 7]. Rehearsal of the simulation may not be possible until just prior to training, if at all, due to limited availability of clinical simulation space.
This may place additional cognitive burden on the educator team when equipment is forgotten or unexpectedly malfunc- tioning, and there are no resources immediately available for replacement.
Finally, there are psychological safety concerns for par- ticipants and unintended observers. A goal of simulation is to provide a safe learning environment but confidentiality may be difficult to preserve while in the hospital setting.
During team training, an individual’s clinical weaknesses and knowledge gaps may be revealed to teammates who then later need to trust each other and work together. Other healthcare personnel who are not part of the educational ses- sion may potentially observe and cast judgment on faults and
mistakes that are made. In addition, families, patients, and visitors may experience anxiety after seeing chest compres- sions or procedures performed, not understanding that it was a simulation [3, 7].
Effectiveness of In Situ Simulation
In situ simulation makes it easier to gather and train intact, interprofessional teams if the sessions occur while they are already on duty together. Training is more effective when healthcare teams rehearse communication and nontechni- cal skills in their normal clinical setting, using real medical equipment, and learners function in their actual professional roles (e.g. nurse, respiratory, physician, pharmacy) [3, 8–10].
Hearing the perspectives of other healthcare professionals or clinical disciplines can further enrich the debriefing process.
Immersive simulation training in teamwork and communica- tion has been shown to improve recognition and management of deteriorating pediatric inpatients [11], survival outcomes after pediatric cardiac arrest, and time to task completion and team communication in the trauma bay [12–14].
In situ simulation also has the unique ability to examine the clinical environment, specific care processes, and healthcare systems in action for previously unidentified patient and staff safety concerns (see Chap. 5). Latent safety threats can be defects in design, organization, training, or mainte- nance and can include equipment failure, personnel/system resource failures, and procedural failures. They can occur at the microsystem level (e.g., patient unit), or they might be rooted in organizational processes, at a macrosystem level (see Chap. 6). The simulation group of Cincinnati Children’s Hospital Medical Center performed a series of unannounced, recurring multidisciplinary in situ training sessions in an emergency department (ED) and on inpatient units and dis- covered a higher rate of latent safety threats with in situ com- pared to lab-based trainings [10, 15, 16]. Multiple examples in the literature have used in situ to test existing and newly designed clinical space and have shown discovery of missing or malfunctioning equipment, unsuitable room layout, medi- cation errors, and knowledge and clinical skill deficits [10, 15, 17–20].
Setting Up a Successful In Situ Simulation Depending on the specific needs and target learners, in situ simulations have unique considerations to ensure that objec- tives are met. In this section, we will discuss the why, who, what, where, when, and how of in situ simulation: the practi- cal considerations of conducting successful in situ simula- tion.
Why?
Determining the specific learning objectives is one of the most critical steps in planning. Learning objectives should be observable, measurable, and meaningful. Objectives can focus on (1) instruction to develop and facilitate application of cognitive, technical, or teamwork competencies, (2) as- sessment of performance or a healthcare delivery process, or (3) diagnostics of potential risks or system defects [21].
Most learning objectives depend on target learners. Target learners may be at the level of an individual (e.g., physician, nurse, or therapist), a healthcare team (e.g., code response team), a unit (e.g., representatives of all professions within an emergency department), or an organization (e.g., repre- sentatives of various departments, enterprise-wide systems, and leadership or culture influencers) [22].
Let us examine three examples to illustrate how target ob- jectives and learners drive practical decisions (who, what, where, when, and how).
Example One: Intubation Process in the Emergency Department
1. Target objective—instruction of technical and teamwork competencies.
2. Target learners—healthcare team.
The focus is training in the emergency department, with specific objectives including selection and preparation of equipment and medications, securement of the airway, and arrangement for safe patient transport.
Example Two: A New Chemotherapy Verification Process
1. Target objective—assessment of healthcare delivery pro- cess.
2. Target learners—inpatient cancer unit.
The focus is assessment of a new process requiring a physi- cian review of chemotherapy orders and medications with two nurses, immediately prior to administration.
Example Three: Evaluation of a New Critical Care Unit1. Target objective—identification of patient safety and
environmental threats.
2. Target learners—organization.
The goal is to identify and mitigate patient safety risks prior to opening a new critical care unit.
Who?
In situ training may be better suited for intermediate and ex- perienced practitioners because the sessions and debriefings are often time-limited, leaving less time for teaching new
concepts. The novice learner, who is still developing basic knowledge, skills, and attitudes, may benefit more from in- struction in the controlled environment of a center: without time limits, distractions, and risk of unintended observers.
Target objectives and learners define the participants, content experts, and observers required. Participants may be part of active patient care teams, pulled from clinical duties, or be on standby, ready to simulate. Using on-duty teams provides an opportunity to assess competing clinical demands and the full impact of a process. Some programs use just-in-time training to simulate the likely deterioration of a current patient. This type of training acts as a dress re- hearsal if that situation occurs. At risk is lack of engagement if participants remain focused on actual patient care, and the potential creation of real-patient safety risks while removed from their clinical duties. Choosing observers or facilitators with knowledge of the specific unit’s protocols and practices can maximize the richness of the debrief.
Let us examine our examples to help ensure you include WHO; you will need to participate in your simulation-based event to reach your target learners.
Example One: Intubation Process in the Emergency Department
The participant team would include the physician who makes medication selections for intubation and physically performs the procedure, the respiratory therapist who sets up and assists with all the equipment, the nurse who administers the medications and prepares all supplies for patient trans- fer, and the technician who assists with transport. Observers may include educators responsible for training other team members or departmental quality improvement leaders who determine policies and procedures. As the target objective involves technical and teamwork competencies, the facilita- tor should be capable of providing feedback on the medical knowledge and clinical skill specific to the procedure (endo- tracheal intubation) as well as communication among team members.
Example Two: A New Chemotherapy Verification Process
Participants should include individuals physically and men- tally involved in each step of the process. In this example, a unit clerk notifies providers that medications have arrived, and then a physician and two nurses review chemotherapy orders and the medication in the patient room independently.
Use of staff actively involved in patient care to participate in the simulation would provide the richest insight into iden- tifying barriers and tracking delays. Using auxiliary staff, designated only for the simulation, may fail to identify dis- ruptions in workflow or patient safety risks created as real- team members attempt to implement the new process. In this example, target learners include stakeholders who developed
this process and educators who will implement and support the change. Stakeholders are good candidates to monitor for safety risks, process breakdown, and opportunities for im- provement.
Example Three: Evaluation of a New Critical Care UnitParticipants could include a representative care team: at- tending and resident physicians, nurses, technicians, respira- tory therapists, unit clerks, environmental services, security, pharmacy, and family representatives. Observers could in- clude leadership for each of these groups plus engineering, supply delivery, construction, patient safety, human factors, marketing, etc. The more complete the participant and ob- server team, the broader the range of experience available to identify safety risks, and the more invested and prepared the organization will be to respond.
What?
The target objectives determine the content of the session, including necessary equipment and issues to discuss in the debrief. Best practice is to utilize only existing equipment in the clinical environment. If training materials are substitut- ed, placing them in the exact locations of actual equipment will facilitate the learners going through as many of the real mental and physical steps in the process as possible. With higher levels of physical fidelity, participants may be able to suspend their disbelief with lower fidelity mannequins or task trainers.
Example One: Intubation Process in the Emergency Department
The objective of instruction includes the acquisition of all medications and equipment, the physical placement, confir- mation and securement of the endotracheal tube, and the ap- plication of all safety monitors and devices for transport, in addition to teamwork competencies. A low-fidelity simulator could meet the technical and teamwork objectives. However, if recognition of respiratory failure is also a learning objec- tive, a high-fidelity patient simulator may be needed to pro- vide the appropriate physical cues.
Example Two: A New Chemotherapy Verification Process
Content of this simulation and debrief should focus on the new process from arrival of the chemotherapy, to physician and nurse notification, to completion of medication verifica- tion. Equipment should include all communication systems (e.g., paging systems or phones) utilized in real time. Skip- ping the real-time use of communication systems may fail to identify barriers or delays. Since the target objective does
not involve administration of the medication or a patient, this scenario may not include a patient simulator.
Example Three: Evaluation of a New Critical Care UnitThe scope of this simulation could include a day in the life series of simultaneous simulations that mimic an actual day on that unit: for example, admissions, transfers, procedures, medication administration, complete care teams rounding on patients, and unexpected patient decompensation. Alterna- tively, it may focus on a limited number of high risk, low frequency patient scenarios such as cardiopulmonary arrest.
Both approaches could meet the objective of testing the new environment and identification of latent safety hazards. A broader scope will uncover a more exhaustive list of risks but require more resources.
Discussions with key stakeholders should weigh benefits of risk identification against resource limitations such as availability of staff, equipment, and simulators, in deciding the scope of testing. Ideally, any new technology (e.g., new defibrillator or bedside monitor) to be rolled out with the new unit should be incorporated into the scenarios. Equipment should be stocked in the expected locations where it will be once the unit is functional. Simulators may include multiple low- and high-fidelity mannequins and standardized patients being utilized in tandem, or in a resource-limited setting, one mannequin progressing through a series of simulations.
Where?
Clinical space availability may be volatile, affecting the du- ration or scope of planned simulations and can be challeng- ing to standardize, particularly for high-stakes assessment or research [21, 22]. If the space is needed for real patient care and participants/observers have been scheduled, it helps to have an alternate plan. This could be an unconventional space, such as a treatment room, bathroom, stairwell, or hallway, if it still addresses target objectives and learners. If not, rescheduling the session may be the best way to achieve targets. In either case, the more the simulation educator can anticipate and prepare participants and observers for contin- gency plans, the more likely the session and future sessions are to be successful.
Progressive simulations follow a patient as they move from one clinical area to the next and can involve different clinical teams. Patient flow processes, transport skills, envi- ronmental challenges, handovers, and communication issues or systems can be examined with a simulation that physically transitions from one space (e.g., ED to elevator to OR) and team (e.g., ED team to OR team) to the next.
Finding private space for participants to debrief can be challenging. Instructors can facilitate this process by moving