In Situ Simulation to Train Interprofessional and Multidisciplinary Teams

1. In Situ Simulation to Train Interprofessional and Multidisciplinary Teams Prospective Identification and Mitigation of Clinical Hazards Nicole Shilkofski MD, MEd

2. Objectives Define a framework for patient care teams to prospectively identify and mitigate clinical hazards through use of in situ simulation as a patient safety tool Discuss integration of in situ sim into existing curricular structures to address cognitive, procedural, communication and teamwork skills Define pros and cons of an in situ framework Explore trainee perspectives on the in situ paradigm

3. Defining “In Situ” Simulation at the point of clinical care Naturalistic approach- Physically integrated into actual clinical environment Diagnostic method to identify gaps Learning objectives differ from sims conducted in sim center environment Perfect model for andragogy

4. Assumptions related to the motivation of adult learning Need to Know- Adults need to know the reason for learning something Foundation- Experience (including error) provides the basis for learning activities Self concept- Adults need to be responsible for their decisions on education Readiness- Adults are most interested in learning subjects having immediate relevance to their work and/or personal lives Orientation- Adult learning is problem-centered rather than content-oriented Motivation- Adults respond better to internal versus external motivators

6. Patient Safety Perspective Most valuable benefits of in situ are related to identification of: Latent hazards Knowledge or skill gaps Resource limitations- issues related to personnel, meds, equipment

7. Patient Safety Perspective- Mitigation of Hazards and Defects Hazard = any event that could harm a patient Defect = any clinical or operational occurrence that should not be repeated In situ sim can identify and mitigate hazards and defects before patient harm occurs

8. Stressing the System

9. An Interprofessional Model- Multiple Stakeholder Approach IN SITU TEAM

10. In Situ to FacilitateInterprofessional Meta-communication Communication about the situation in which interactions take place Making the implicit become explicit Learners may not be aware of all the messages they send during an interaction Includes context, tone, volume, body language involved in communications Use of interprofessional debriefing for team feedback regarding communication, overcoming cultural differences

11. In Situ Increases Verisimilitude Appearance of being true or real In simulation = face validity Increased by embedding in actual clinical environment As a result, lower fidelity equipment may be well accepted

12. In Situ Enhances Environmental Fidelity

13. High Psychologic Fidelity In Situ Degree to which scenario perceived by learner as duplicative of operational equipment and task situation Increased if trainee perceives scenario as being highly “realistic” Critical with both novice and expert learners Strong impact on learner engagement

14. Patient Safety FrameworkPronovost et al Identify existing knowledge of hazards/defects Anticipate what can go wrong Simulate the process to identify latent failure modes embedded in system Analyze hazards/defects Design the system to defend against hazards

15. In Situ Simulation to Enhance Patient Safety on Medical Missions Provide means of training ad hoc teams to prevent emergencies Provide means of establishing safety net/ emergency protocols Identify latent threats to patient care in under-resourced environments Improve shared cognition/mental models Provide team awareness of resource limitations

16. Resource Limitations = Hazards

17. Design Systems to Defend Against Hazards- Physical Changes to the Clinical Environment

18. Challenges of In Situ Technical issues- transport, setup, labor intensive Logistics- long debriefings, particularly with multidisciplinary sims (complexity of classifying “whole system” investigations) Cultural obstacles- clinician motivation, medicolegal concerns

19. Outcomes Associated with In Situ Improved participant technical proficiency Reinforcement of desirable individual and team behaviors Identification of active and latent systems issues Catalyst for change in clinical care systems Increased situational awareness and identification of operational/ environmental challenges in specific care environments

20. Trainee Orientation using In Situ Telephone triage from outside hospitals Helicopter transport Ambulance transport Patient care wards- Rapid Response Trauma bay PICU- using actual patient census (“Just in Time” Training)

21. Identifying Operational Challenges in “Hostile Environments” • “Riding in a helicopter for a simulation made me understand better that I completely lose my ability to assess airway with my ears, and for the most part my eyes.  I used this just the other day on my first air transport.  Because of in situ I planned and thought about my end tidal CO2 detector as my one lifeline to assessing the patient’s respiratory status.  I feel that it is priceless to do simulations where you will actually be applying them to patient care”

22. Trainees Perspecitves: Becoming Consciously Competent “A significant portion of my anticipation-related anxiety about how I would perform were allayed by in situ sim orientation. I felt empowered because I figured out my strengths and weaknesses. I went from unconscious incompetence in a lot of things to conscious incompetence which afforded me a great starting point for seeking closures to knowledge gaps”

23. In Situ Implementation: Lessons Learned Low fidelity is OK- compensated by high environmental and psychologic fidelity Focus on operational issues and interprofessional communication Focus on orientation to environment and situational awareness Engage stakeholders for each discipline to maximize buy in- agree on objectives

24. Implementation Lessons Learned • Inter-professional teams work best • Use actual in situ equipment to maximize fidelity and identify latent threats • Focus on in situ barriers that impact patient care to maximize patient safety

25. Implementation Lessons Learned • Logistics- Have a plan B and be flexible • Have a set aside debriefing area that is private • Inter-professional/ multidisciplinary debriefs take a LONG time

26. Lessons Learned- Designing Appropriately “SMART” Objectives Tailored to In Situ Environment Specific Measurable Attainable Realistic Time-Bound

27. Examples of Environmental Impact Recognized In Situ Extra observers in trauma bay creating “fishbowl effect” Limitations in auscultation/ assessment in ambulance and helicopter Necessary communication system changes in helicopter Location and mobilization of resources in PICU vs. ward etc.

28. Team Mobilization for Initiation of ECMO- Patient Arrest on Ward vs. ICU vs. ER

29. Trainee Comments and Reflections “Riding in a helicopter for a simulation made me understand better that I completely lose my ability to assess airway with my ears, and for the most part my eyes.  I used this just the other day on my first air transport.  Because of in situ I planned and thought about my end tidal CO2 detector as my one lifeline to assessing the patients respiratory status.  I feel that it is priceless to do simulations where you will actually be applying them to patient care”

30. Reflections on In Situ Disadvantages “…just being able to see all of the people in the trauma bay, and understand their roles as well as better understanding my role was priceless.  I felt much more prepared, I knew what I was responsible for, and I better understood the skill sets of those I was interacting with.  If this had not been interdisciplinary, perhaps I would have the ICP algorithm memorized because we ran it so many times... but if I was then so overwhelmed by the number of people and inability to use my resources, what good would having the algorithm down cold do me?”

31. Additional Comments “I was able to experience handling pediatric crisis situations in the most realistic manner using the specific resources (tools and people) that I would use in a real-life crisis situation” “The lessons I learned were encoded so well that, when I have encountered similar real life situations, I have felt prepared and not over-whelmed” “I got to know what was expected of me in different arenas I may find myself. What will the floor need from me during an RRT, what would an outside hospital need from me on a transport? All this before I started in the PICU. Great situational awareness” “It was great to meet people in the various arenas--floor, PICU, trauma bay, pharmacy etc. We were able to iron out some kinks that can naturally arise when a multidisciplinary group of strangers is assembled quickly to deal with a crisis situation. This allowed for improved team dynamics when it truly counts--when a life is at stake”

32. Summary of In Situ Advantages Authenticity- naturalistic approach Native teams practicing together Suspension of disbelief = positive educational transfer Point of care training enhances feasibility AND fidelity Consistent with andragogic approach Novice trainee recognition of conscious incompetence in hostile environments

33. Thank you!!!