Simulation “Crash Testing the Dummy”: In-Situ Simulation in the Emergency Department

Crash Testing the Dummy” In-Situ Simulation in the Emergency Department

By Suzanne Bentley, MD, MPH, Kate Lin, Muhammad Waseem MD, and Miriam Kulkarni, MD, on behalf of the SAEM Simulation Academy

Emergency Medicine teams are experts in the management of critically ill and injured patients, relying heavily on maximized teamwork and communication to work effectively and collaboratively in an expedited fashion. In addition to team factors and dynamics, physicians must be prepared to identify and manage an extensive range of clinical pathologies including high acuity, low occurrence (“HALO”) procedures, and rare, timecritical, but life-threatening conditions, some of which clinicians may never have previously encountered. Medical education in teamwork training has evolved significantly over the years, with simulation education as an established standard and recognized technique for conveying necessary knowledge about teamwork, developing the skill of teamwork among participants, and enhancing attitudes and shared understanding regarding teamwork. Simulation is a technique, not simply a tool, that can be employed to meet a variety of educational and systemsbased objectives for practice, learning, evaluation, testing, or to gain an understanding of systems of human actions. In-situ or unit-based simulation training takes simulation directly into the workplace environment. Potential applications include its use to examine workflow, improve culture, practice teamwork, familiarize oneself with equipment, improve communication, orient staff to new policies and procedures, assess the efficiency of a system, identify gaps, and practice rare events, without risk of patient harm. It allows teams to test their effectiveness in a controlled manner and to interrogate departmental and hospital processes in real-time and in real locations. In-situ simulation can formally be used as a “team-based training technique conducted in actual patient care units using equipment and resources from that unit and involving actual members of the healthcare team.” Less formally, in-situ simulation has been described as “crash testing the dummy.” Deliberate practice and integration of teamwork skills in a time-pressured environment generates realism and is a rich resource for identifying latent threats and system issues. While simulation has often been used as a strategy to train individuals in both technical and nontechnical (e.g., leadership, communication, and continued on Page 46

SIMULATION

continued from Page 45

teamwork) skills, in-situ simulation is used to evaluate system competence and identify medical errors. Given that the simulations are conducted in actual clinical space, there are opportunities to identify hazards and safety threats in clinical systems, the environment, and the provider team.

The benefits of conducting simulations in-situ in the clinical environment include everything from improved training logistics to adult learning theory. Kolb’s theory of experiential learning, for example, provides a rationale for conducting in-situ simulation from the perspective of the educator and the learner. This theory relies on experiences, reflections, and active experimentation so that “new ideas and concepts can be used in actual practice.” Experiences in simulation labs may accomplish this to some degree, but in-situ simulation is more closely aligned with the actual “work” of the health care provider and is more likely to achieve teamwork training objectives.

In-situ simulations also offer the advantage of training efficiency. In-situ simulations occur during the workday, often utilizing on-duty clinical providers, thus alleviating the need to schedule participants, pay overtime, or schedule additional providers to “backfill” while one team of clinical workers is in the simulation training center. Additionally, because they are conducted with on-duty clinical providers, in-situ simulations are most commonly conducted with interdisciplinary teams, offering great benefit to teamwork and communication training. It also provides an opportunity to more frequently review the skills related to high-risk, infrequent events. This enhanced efficiency must be balanced by conducting in-situ simulations for all shifts, not just the more convenient day shift to achieve, competencies for all health care professionals.

Most in-situ studies focus on behavioral skills (sometimes called “nontechnical skills”) and interprofessional education, shown to be paramount for patient safety. Notable outcomes by researchers using insitu simulation include improving individual participant technical proficiency and clinical competency evaluations, continual reinforcement of communication and teamwork, improved safety culture of the system, capture and mitigation of latent safety threats, and improvement in clinical outcomes. Additionally, in-situ simulations, like in-center simulations, allow opportunities to formally debrief participants, something that infrequently occurs after actual patient encounters.

Despite these many benefits, the implementation of in-situ simulation with working clinical teams presents challenges related to time pressures, acuity, patient census in a busy ED, technical issues and equipment availability and costs, lack of privacy, frequent distractions, and logistical issues. Performance anxiety of health care providers poses a significant challenge with reluctance on the part of staff to participate in the care of simulated patients. Concerns are frequently raised regarding the impact of in-situ simulations on patient care and reinforce the need for the creation of institution-specific “no go” criteria developed and agreed to by the simulation team and the ED leadership

“In-situ simulation can formally be used as a “team-based training technique conducted in actual patient care units using equipment and resources from that unit and involving actual members of the healthcare team.”

“The benefits of conducting simulations in-situ in the clinical environment include everything from improved training logistics to adult learning theory.”

(e.g., census limits or staffing constraints under which the in-situ simulation will be postponed). Additionally, patient and family perceptions have been expressed and some providers noted concerns that family members would find the in-situ simulation exercises disruptive or intimidating; however, many providers noted that families have expressed appreciation for the training their providers receive. This suggests that deliberate attention and provision of information to patients and family members in the department during simulation can advertise the benefits of the educational exercise versus “scare” those that may observe the in-situ case in progress.

In conclusion, in-situ simulation is a well-supported technique that offers a multitude of potential benefits for emergency medicine. Multiple publications and guidelines exist discussing strategies and best practices for implementing effective in-situ simulations, however, conduction will vary based on local emergency department factors, needs, and culture. A structured approach to in-situ simulation training and assessment based on systems thinking, coupled with awareness of unique departmental needs, is required for a sustained improvement of team performance and patient safety. Some tips for implementing in-situ simulation from Spurr et. al, the AHRQ, and the New York City Health + Hospital Simulation Center for implementing in-situ simulation are provided.

Kate Lin is a current senior at NEST+m High School in New York City and is an aspiring premed student.

Dr. Kulkarni is the program director for the emergency medicine residency at St. John's Riverside Hospital in Yonkers, NY. She has been a resident educator and simulationist for the last 15 years.

Dr. Waseem is a professor of emergency medicine and Pediatrics at Weill Cornell Medicine, New York. He serves as the research director for the Emergency Medicine Department and vice chair for the Institutional Review Board at Lincoln Medical Center in the Bronx, New York. Dr. Bentley is an associate professor of emergency medicine and medical education at the Icahn School of Medicine and the chief wellness officer and director of Simulation Innovation & Research at NYC Health + Hospitals/Elmhurst in Queens, NY.

TIPS AND CONSIDERATION FOR IMPLEMENTING IN-SITU SIMULATION

1Secure interprofessional leadership buy-in and support.

2

Needs assessment: discuss departmental needs that can best be addressed using in-situ simulation and/or perform a formal needs assessment to identify the problem or gap.

3

Start simple before scaling up complexity: consider a lower stake, more straightforward team scenario to simulate as your in-situ simulation program initially starts (both to introduce the in-situ simulation concept, minimize the size of the team to start, and streamline your debriefing). Over time, endeavor to work up to “multi-team” training inclusive of scenarios such as high acuity trauma involving participation by the ED, surgery, radiology, and other departments.

4Agree on your learning objectives for participants and the department.

5Structure your simulations to be as close to real life as possible.

6

Conduct interdisciplinary simulations, ideally run such that any member of the team who would be present if it was a real patient is in the simulation.

7

Work to maximize psychological safety: Pre-brief participants, ensure everyone knows goals and how the simulation will proceed, emphasize confidentiality, reinforce the “basic assumption” and need for mutual respect among participants, and ensure participants are aware of the planned use of findings (e.g. not punitive but to correct identified safety threats).

8

9

The debriefing is key: plan on how it will be structured (hint: many published tools and guides are available), who will lead it, and allow 1-2 times the length of the simulation itself to conduct the debriefing. Proactively establish a system to link what you find in simulation to your clinical governance systems to ensure closed-loop debriefing and mitigation of identified safety threats. Consider closed-loop debriefing structure to close loop with participants afterwards and share lessons learned (e.g. post-event email to participants or shared with department). 10 Utilize formalized and agreed upon “no go” considerations to keep the real patients safe and protect staff such that the simulation does not add additional stress to an already over-stressful shift. 11 Start small, start somewhere, learn a lot, iteratively improve, and keep expanding your program!

About Simulation Academy

The Simulation Academy focuses on the development and use of simulation in emergency medicine education, research, and patient care. Membership in SAEM's academies and interest groups is free. To participate in one more groups: 1.) log into SAEM.org; 2.) click “My Participation” in the upper navigation bar; and 3) click “Update (+/-) Academies or Interest Groups.”