In situ simulation in the ED: powerful tool for quality improvement

1. In situ simulation in the ED: powerful tool for quality improvement Julie Mardon Consultant Emergency Medicine University Hospital Crosshouse

2. In situ simulation • High fidelity mannequins • In the ED • Video debrief • Real multidisciplinary teams • Identify human factors in team working • Also latent risks • Process evolution

3. 2 projects • Paediatric asthmatic patients discharged from department • Sepsis 6 bundle delivery

4. Near Miss • 8 year old asthmatic • Seen in the paeds ED • Sent home x2 • Both times treated with a nebuliser • No observation charts filled out • Re-attended on the third occasion unwell and required a long hospital stay • Made a full recovery

5. Cause Analysis • Insufficient understanding of the difference between use of nebulisation and multi-dosing in patients DC home • Non technical skills of nurses vital to ensure safe clinical practice • Poor understanding of indications and techniques required to multi-dose children with wheeze • Lack of PAWS charts, PEFR and discharge information for paediatric asthmatics

6. Simulation Scenario Designed • Technical and non technical learning objectives mirrored cause analysis of near miss • Importance of clear communication between nurses and doctors especially around clinical decision making • Technical skills allowing safe patient care were key learning objectives

7. simulation • Wireless sim boy • Run in paeds area of the ED • Real clinical scenario • 65% of nursing staff of all levels ED and ED Paeds trained across region over 8 teaching days • Medical staff also trained all levels • Nursing and medical students and paramedics also exposed to teaching module • Video recording to assist debrief

8. Multi dosing

9. PAWS Chart

10. Non technical learning • Communication skills • Handover • Real environmental latent errors uncovered • Simulation learning objective mirrored learners own objectives • Examples of non technical skills

11. Handover to medical staff

12. Results 1 year post intervention

13. Sepsis • Delivery of “sepsis 6” within the ED • Part of ongoing priority to deliver the bundle within the ED • Based on robust evidence nationally agreed • SPSP priority target • Challenging within the ED due to conflicting priorities, overcrowding, complex process requiring multiple steps and clear communication resulting in true sense of urgency around sepsis management

14. Process Mapping

15. Simulation scenario • Process Mapping identified the challenging parts of the process • Prioritisation of patient and communication of sense of urgency with team • Scenario designed to reflect these non technical skills as core learning objectives

16. In situ simulation • 9 in situ simulation sessions delivered over 1 month period • Real teams in the workplace nurses medical staff undergraduate medical and nursing students radiographers cardiac technicians clinical decision unit staff all participating. • Video debrief allowed analysis of human factors such as team communication situational awareness, decision making, prioritisation, latent challenges to the process • Use of the “simulated box”

17. The box

18. Team prioritisation

22. Sepsis 6 delivery before in-situ simulation

23. Sepsis 6 after in situ simulation

24. Summary and future • In situ simulation training in human factors in the ED can show improvement in safe patient care in 2 patient groups • Role out to other areas eg Dialysis unit and Frail elderly team • Link with organisational risk management and patient safety governance systems • Repeat sepsis work in Forth Valley ED to show spread in other areas