Elaine Gilfoyle, Elaine Ng and Ronald D. Gottesman
© 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_4 E. Gilfoyle ()
Department of Pediatrics, Department of Critical Care, University of Calgary, Alberta Children’s Hospital, Calgary, AB, Canada
e-mail: [email protected] E. Ng
Department of Anesthesia, Department of Anesthesia and Pain Medicine, University of Toronto, Hospital for Sick Children, Toronto, ON, Canada
e-mail: [email protected] R. D. Gottesman
Department of Pediatrics, Department of Pediatric Critical Care, McGill University, Montreal Children’s Hospital/McGill University Health Center, Montreal, QC, Canada
e-mail: [email protected]
Simulation Pearls
• Human factors are a major source of error in healthcare and should be the focus of specific training in the simu- lated clinical environment.
• Simulation-based education has been effectively utilized for pediatric acute care team training with demonstrated improvements in confidence, knowledge, skills, team- work behaviors, and patient outcomes.
• There are many teamwork assessment tools available.
Some tools are developed to assess the entire team versus the leader alone, while others are developed as a stand- alone teamwork tool versus embedded in a tool used for resuscitation performance overall.
• Developing simulation-based team training must include consideration of the purpose of such training, understand- ing the needs of the participants and careful planning of the learning environment.
Team Training: Burden of Medical Error and the Role of Teamwork
Human error is common across all areas of healthcare, and those errors result in significantly increased patient morbi- dity and mortality [1, 2]. Errors are more likely to occur in complex environments such as the intensive care unit and emergency department [3, 4]. This is due to several factors:
the higher number of interventions performed per patient [5]; the need for multiple care providers to interact with each other to achieve common goals [6, 7]; and the provision of care in a high-stakes, high-stress environment, which may further impair healthcare providers’ performance [8, 9]. Re- suscitation events are at particularly high risk of error [10, 11]. Errors usually relate to either not adhering to esta blished resuscitation guidelines or medication errors, with the un- derlying reason being healthcare providers not working effectively as a team [12, 13].
Team training for pediatric resuscitation team members has become a common component of medical, nursing, and allied health professional education (Fig. 4.1). A significant volume of simulation-based research has been published recently, suggesting that simulation-based team training (SBTT) has a positive effect on healthcare provider perfor- mance [14]. Research linking team training with real-life performance and actual patient outcome is more difficult to conduct; therefore, there are fewer published studies exam- ining these outcomes. However, a recent study demonstrated that hospital-wide adoption of team training (among other changes to how resuscitation teams are educated) improved survival from cardiac arrest at an American pedaitric hospi- tal compared to historical outcome data [15]. Hopefully, we will see more studies examining the impact of team training on real-life patient outcomes published in the near future.
Team Training: A Competency Framework As described above and in other sections of this book, human factors play a significant role in terms of healthcare provider performance. The errors that clinicians make are more often related to human factors, rather than lack of knowledge or technical issues with medical equipment. Formalized team training has been developed in many areas of healthcare in order to address these types of errors, including pediatrics [16, 17]. Each group of educators uses their own set of learn- ing objectives or list of competencies [18]; however, there is substantial overlap among those that are published. The section below describes a user-friendly framework, which organizes educational content under four main teamwork competencies: role responsibility, communication, situation- al awareness, and decision-making (Table 4.1) . This frame- work fits nicely with a teamwork performance assessment tool developed in obstetrics but is also applicable to any area of acute care, including pediatrics [19].
Role Responsibility
Acute care teams consist of several members from differ- ent clinical professions, most commonly medicine, nursing, and respiratory therapy, among others. These team mem- bers take on different roles (leader, airway person, medica- tion person, documenter, etc.). These roles must be assigned but are often assumed based on the profession of the team member. For example, the team leader is usually a physician and the medication person is usually a nurse. The leader is ultimately responsible for assigning roles. Furthermore, all tasks (i.e., workload) required during the resuscitation must be assigned and distributed, so that team members take own-
ership of tasks to ensure completion. Tasks ordered into thin air are not as likely to be completed since this ownership is lacking. Finally, team members must recognize and verba- lize their performance limitations so that tasks are assigned to the most appropriate member. For example, if some of them have not been trained in how to operate the defibril- lator, then they are not the best person to be assigned this important task.
Communication
There are many different aspects to good communication during an acute situation, ten of which will be discussed here (Table 4.1). Communication of both clinical observa- tion and orders must be handled very carefully, so that they are not missed or misunderstood. There are three important overarching aspects to the proper communication of or- ders: (1) Team members must direct their communication by using names or other ways (e.g., tap on the shoulder) of
Fig. 4.1 Team photo. (Photograph courtesy of KidSIM Pediatric Simu- lation Program)
Table 4.1 Teamwork competency and behavior framework Teamwork competency Teamwork behavior
Role responsibility Assign roles Distribute workload
Recognize and verbalize performance limitation
Verbalize overload Cross-monitor roles Communication Use directed communication
Give clear and concise orders Use closed communication loop Think out loud
Leader seeks input from team members Team members suggest ideas/plans to leader
Orient new members, if required Give all information to leader Speak with calm voice
Resolve conflicts and deal with distractions quickly and effectively
Situational awareness Quickly develop a shared mental model Conduct frequent re-assessment and re- evaluation of patient
Prioritize attention effectively as situation requires
Avoid fixation errors Anticipate and plan
Allocate resources (human and equipment) effectively
Call for help when needed
Decision-making Team members receive orders only from leader
Use all available relevant information Set priorities dynamically
identifying the specific recipients of their communication (i.e., eye contact alone is not enough given that people some- times are not listening even when they are looking directly at someone talking to them). (2) Team leaders must give clear and concise orders (miscommunication occurs when orders are incomplete, short forms or abbreviations are used, or assumptions are made that the person receiving the order understands some unsaid detail of the order—this is espe- cially true for medication orders). (3) Team members must use a closed communication loop when sharing information or giving/receiving orders. A proper closed communication loop includes the following steps: team member shares in- formation with another team member or leader gives order, person receiving information/order repeats it back to ensure accuracy, and (in the case of an order) person carrying out order lets leader know when task is complete.
In order to ensure that all team members have shared situ- ational awareness (see below), free sharing of ideas must occur. This is accomplished by team members thinking aloud when ideas come to them, with the leader asking for input from team members, and when team members share their ideas with the leader for consideration. Since leaders are receiving all information and trying to process it quickly in real time in order to formulate a management plan, it is not uncommon for them to miss clinical information or to not consider possible diagnoses or plans for management. Team members may think of an idea that has not yet occurred to the leader. These ideas should be shared, so that all ideas are considered before a final plan is proposed by the leader.
The challenge, though, is that while it is desirable to share ideas and important information, one should be strategic and avoid distraction or disruption at crucial moments during a resuscitation event. Finally, when a new member joins the team, then they must be oriented to what is happening with the patient, so that they can be most helpful in accomplishing tasks, as well as offer useful ideas.
The leader must receive all relevant information about the status of the patient so that they are in the best position possible to make informed decisions about ongoing patient management (see below).
Finally, establishing a collegial and collaborative team environment is essential to good team functioning. This is accomplished by speaking with a calm voice (so that other team members do not misinterpret a raised tone of voice to be anger), as well as resolving all conflicts and dealing with all distractions (volume of noise in the room, number of people at the bedside, etc.) as quickly as possible.
Situational Awareness
Situational awareness (SA) is defined as “a person’s percep- tion of elements in the environment, comprehension of that
information, and the ability to project future events based on this understanding” [20]. It is vital that all team members maintain as much SA as possible but recognizing that there are certain times where team members must pay full atten- tion to performing a task, which will result in temporarily losing SA for a short period of time.
A shared understanding of the diagnosis and overall treat- ment plan, called sharing a mental model, will ensure that team members can all be as helpful and efficient as possible in carrying out their duties. Ensuring that a shared mental model exists is accomplished by some of the communica- tion behaviors listed above, such as thinking aloud and shar- ing ideas. Ensuring that the correct mental model is shared is accomplished by conducting frequent reassessments and re-evaluations of the patient. This will ensure that changes to the patient’s status will not go unrecognized by the team.
These reassessments are best done: (a) after a clinical deteri- oration, (b) after an intervention, (c) during a pause in the ac- tion, and (d) when there is uncertainty to the cause of events.
In addition, team members must prioritize their attention ef- fectively, since people are only capable of holding a small number of pieces of information in our short-term memory at any one time. It would be easy for a key change in patient status to be missed if no one is paying attention at the time when the change happened. A concrete example of this is the suggestion that the leader remains hands off and does not participate in performing procedures directly on the patient.
In addition, it is essential that team members avoid making fixation errors, which are defined as a “persistent failure to revise a diagnosis or plan in the face of readily available evi- dence suggesting that a revision is necessary” [21].
High-functioning teams can anticipate and plan, whenev- er possible, so that future tasks can be completed in a shorter period of time. For example, nurses in charge of the drug cart often draw up multiple doses of a medication, in anticipation that they will be needed, since it is more efficient to calcu- late the dose and volume only once, instead of repeating the calculation again in a few minutes.
Finally, the resources required (both human and equip- ment) for a team to complete their tasks may need to be considered. New equipment may have been brought to the patient’s bedside, or the team might need to call for help (for advice or for someone to attend in person to help perform all necessary tasks). All these must be coordinated, typically by the leader. If there are not enough people on the team to per- form all the tasks required at any given time, then the leader may have to prioritize the tasks.
Decision-Making
Decisions regarding patient diagnosis and treatment must be made at several points during an acute situation such as a
resuscitation. It is important that all orders come from the leader because they are in the best position to make the most informed decision. The leader is the person least likely to make a fixation error or miss important information because he/she should not have had their attention diverted at any time during the event. The leader (and other team members) should use all available information in order to come up with the best diagnosis and treatment plan, since not includ- ing certain information can lead to misdiagnosis and fixa- tion errors. Finally, priorities may need to change at different points during the event, with changes in patient status, the in- corporation of new information, or response to previous in- terventions. Therefore, the team should be ready and willing to set their priorities dynamically, so that they can quickly change course with minimal delays in providing optimal care to the patient.
Team Training: The Evidence
SBTT began in earnest in 1992 when the concepts of crisis resource management (CRM) were first introduced in an- esthesiology practice [22]. Over the past 2 decades, SBTT has been extensively adopted by many healthcare profes- sionals with the view of improving patient care and avoiding errors. With the exponential creation of simulation centers and the increasing allocation of scarce resources to SBTT, it has become imperative to review the merits and outcomes of these activities. A systematic review of published studies up until November 2012 was conducted, looking at the effect of SBTT on patient safety outcomes. Despite study variability, there was evidence that simulation training improved tech- nical performance of individuals and teams during critical events and complex procedures [23]. Furthermore, limited evidence also supported improvements in patient outcome at the healthsystem level [15].
Another critical synthesis and literature review dem- onstrated significant gaps in the literature, with the need for a specific research framework to advance the ability to relate patient outcomes to SBTT, or at a minimum, risk mitigation [24]. Rigorous attention to the evidence-based development, implementation and assessment of SBTT will be needed to properly affect knowledge transfer. A similar systematic review of the transfer of learning and patient outcomes using simulated CRM management has also been conducted [25]. The authors included studies that demonstrated evidence of Kirkpatrick’s levels 3 (behavior:
transfer of learning to the workplace) and 4 (results: patient outcome) [26]. A total of 9 out of 7455 eligible simulation studies (up to September 2012) met those criteria. Of the nine selected studies, four showed measurable transfer of CRM learning into the clinical environment. Five studies
measured patient outcomes, with one demonstrating signif- icantly improved patient mortality by 37 % [27]. This sys- tematic review also highlights how few CRM studies assess outcomes in the real clinical environment. Finally, a review of multiple studies in neonatal, pediatric, and adult resusci- tation simulation training showed evidence of improvement in the performance of CRM team skills (e.g., leadership, interpersonal skills, distribution of workload, communica- tion, and professional behavior), further supporting the ef- fectiveness of CRM training in improving team functioning and dynamics [23].
A sine qua non of highstakes, highacuity teams is that they are interprofessional and multidisciplinary by neces- sity. The added complexity of team dynamics is especially true in the operating room with team members represent- ing various surgical specialties, anesthesiology, nursing, and respiratory therapy, with a inherent historical hierarchy amongst surgical teams. A systematic review of simulation for interprofessional and multidisciplinary teams in the op- erating room included 18 studies from ten centers [28]. All scenarios were conducted in situ and utilized computerized mannequins and/or partial task trainers. The variable nature of technical and nontechnical (CRM) outcomes prevented direct comparisons between studies. Common barriers to implementation were reported including difficulties with recruitment, lack of surgical model fidelity, and costs. An- other significant and commonly reported barrier was the challenge of providing time for in situ team training in a busy operating room environment. Contributors to success included pre-briefing, allowing adequate time for learning, and creating a safe environment of equality between nurses and physicians.
Another systematic review of interprofessional and multi- disciplinary teams in the operating room included 26 studies published from 1990 to 2012 [29]. About half of the studies were conducted off-site in simulated operating rooms with an emphasis on technical skills. Two of the studies involved new procedure acquisition and led to the creation of novel safety checklists that were incorporated into clinical practice.
The other point-of-care (in situ) studies were noted to be more psychologically engaging, enhanced interprofessional communication, and helped to identify and solve problems within the actual work environment.
Trauma resuscitation also requires high-functioning teams who practice excellent CRM principles. A systematic review of the trauma literature for the efficacy of simulation- based trauma team training of nontechnical skills reveals a total of 13 studies that were included for final review [30].
Seven studies were subcategorized per Kirkpatrick’s levels of learning [26]. Only two studies were at the patient out- come level (level 4). One study demonstrated an improve- ment in time from arrival to computed tomography scanning,
endotracheal intubation and final disposition to the operating room [31]. The second study found an improvement in task completion and timing to definitive treatment [32]. Neither study had an overall effect on the duration of ICU/hospital stay, morbidity, or mortality.
Finally, a systematic review of 29 articles analyzed in situ simulation for continuing healthcare professions education [33]. The salient conclusions were that appropriate needs as- sessments were rarely used, instructors were rarely provided with specialized assessment and feedback skills, scenarios frequently inappropriately mixed multiple levels of perfor- mance, outcome measures were informal, and evaluation methods were poor. Studies could not be properly cross–ana- lyzed. This really reflects the current ad hoc nature of in situ professional development training for healthcare practitio- ners. Overall, there appears to be a lag in the appropriate de- velopment of quality continuous professional development simulation-based team training compared to curriculum- driven simulation-based team training in undergraduate and postgraduate professions’ education.
Taken as a whole, the current body of evidence suggests a need to move towards more meaningful research that utilizes evidence-based best practices in developing validated tools of SBTT instruction and assessment. Very little is known about the potential impact on organizations and practice. Fu- ture studies assessing patient outcomes will help in the quest for ultimately mitigating errors and improving patient safety.
Team Training: Incorporation into Established Curricula
Simulation has been used extensively in pediatric acute care team training and assessment including resuscitation, pediat- ric medicine, anesthesia, critical care medicine, and trauma care.
Resuscitation
The pediatric advanced life support (PALS) course deve- loped and offered by the American Heart Association offers the fundamentals of resuscitation education for those in- volved in providing pediatric acute care. PALS is a 2-day, 14-h course that provides guidelines and protocols for iden- tification and acute management of airway, respiratory and cardiac problems [34]. Use of mannequins and task trainers has always been a feature of these courses. Over the years, there has been a transition away from didactic presentations to video-based discussions and small-group learning using simulation and hands-on practice. The most recent editions have placed an additional emphasis on teamwork skills,
with the integration of video-based discussion. Scripted de- briefing to aid in the debriefing of simulation scenarios has also been incorporated into the most recent iterations of the course [35]. One of the challenges in the delivery of these courses is that frequently the participants are from diverse backgrounds and professional designations with variable ed- ucation needs. Many of these courses also take place outside of the participants’ home institution and are likely not in the context of the participants’ usual clinical environment. Some learners are placed in leadership roles, even though they may never assume a similar position in their normal work envi- ronment. Many institutions require their employees to have active certification in these courses as a minimal requirement to participate on pediatric acute care teams. PALS is meant to be part of a larger continuing education program [36], but there is a historical reliance on PALS training itself and its recertification every 2 years to maintain essential compe- tencies. It has been demonstrated that PALS knowledge is actually insufficient for in-hospital resuscitation and is not sustained over time [37]. Simulation-based studies have re- vealed inadequate training for leadership and equipment use leading to delays in treatment [38].
Pediatrics
Limitations with the PALS model suggest that it is necessary to provide an ongoing practice for acute resuscitation with hospital-based care providers. The knowledge and skills that are used in everyday practice may not be sufficient to deal with the variety of medical issues that may be encountered during cardiopulmonary arrest situations. A number of studies have demonstrated the effectiveness of mock code programs in terms of self-perception of confidence and preparedness and a decrease in anxiety [39]. Incorporation of team training and human error curriculum into a Neonatal Resuscitation Program has led to an increase in team behavior, including in- formation sharing, inquiry and assertion, evaluation of plan, vigilance, and workload management. Simulated resuscita- tion practices were completed in a shorter time. The effect on team behaviors persisted for at least 6 months after the initial training [40, 41]. Impact on clinical outcome was dem- onstrated in a study that observed increased survival rates that correlated with increased number of mock codes [42].
In a modular, standardized, simulation-based resuscitation curriculum for pediatric residents, objective assessment dem- onstrated correlation of increased training with higher perfor- mance scores in medical management and teamwork skills [43]. Other innovative teaching methods, such as just-in-time training [44], PALS reconstructed [45], and rapid cycle delib- erate practice [46] have been developed to improve the learn- ing outcomes of pediatric acute care providers.