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Using Multi-D Simulation To Prepare For Pediatric Trauma Designation In The Community 

This study explores the use of multi-dimensional simulation to prepare for pediatric trauma designation in the community, with a focus on evaluating systems and processes that optimize safety and minimize errors in complex medical environments.

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Using Multi-D Simulation To Prepare For Pediatric Trauma Designation In The Community 

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  1. Using Multi-D Simulation To Prepare For Pediatric Trauma Designation In The Community  Gemma Elegores MSN, RN,CCRN-K Simulation Education Specialist Katherine Gautreaux, MSN, RN, CEN, CPEN Trauma Education Coordinator

  2. Introduction

  3. Trauma System • Includes components required for optimal care • Prevention • Access • Prehospital care and transportation • Acute hospital care • Rehabilitation • Research activities • “Inclusive” trauma system • Includes all members/facilities in the system, not just major trauma centers • Identifiable roles for facilities based on resources and community needs • Various levels of trauma centers need to cooperate to care for the injured patient and prevent waste American College of Surgeons, 2014

  4. Trauma System • Network required to provide spectrum of care for injured patients • Trauma stratification • Levels I – IV and non designated • NOT a ranking of medical care but of resource depth American College of Surgeons, 2014

  5. Levels I – IV Stratification Responsibilities & Resources Greatest amount of resources and personnel for care of the injured patient Provides regional leadership in education, research, and prevention programs Offers similar resources to a Level I facility, possibly differing only in continuous availability of certain subspecialties or sufficient prevention, education, and research activities Not required to be resident or fellow education centers Capable of assessment, resuscitation, and emergency surgery, with severely injured patients being transferred to a Level I or II facility Capable of providing 24-hour physician coverage, resuscitation, and stabilization to injured patients before transfer to a facility that provides a higher level of trauma care.” Level I Level II Level III Level IV Centers for Disease Control and Prevention, 2012

  6. Trauma Department Responsibilities American College of Surgeons, 2014

  7. Case Study • Chief Complaint • 12 y.o. M who fell from a skateboard and hit his head • Unknown LOC • Father reported AMS, syncopal episodes, vomiting, and difficulty walking once patient returned home

  8. Timeline

  9. The Trauma Activation Process • The trauma activation process provides the right patient with the right resources at the right time

  10. Trauma Activation • Resources mobilized through the activation process • Emergency Department • Equipment: airway, IV, chest tube, crash cart, warming measures, monitors etc… • Team preparation: roles and responsibilities, pre-huddle, PPE • House-wide • Trauma surgery team • Pharmacy • Blood bank • Radiology • Anesthesia/OR • Critical care • Surgical subspecialties • Chaplaincy, social work • Security • Etc…

  11. Full Trauma system activation

  12. Simulation in Healthcare

  13. Simulation-based Clinical System Test: A Human Factor Engineering Tool Simulating in a realistic environment to evaluate a process, workflow,  environments and systems to ensure safety, effectiveness, and ease of use Focus on how systems and environments work in actual practice with REAL and error prone human beings caring for patients in a new hospital environment Goal of evaluating systems and processes that optimize safety and minimize error in complex medical environments

  14. The Process Simulation-based  Clinical System Test (SbCST)

  15. What is SbCST Robust process improvement tool that can be used to proactively test the complex systems (people + physical environment + processes) involved in new patient care settings.  By involving front-line personnel in clinical simulations aimed at stressing systems to find potential threats to patient/provider safety (LST – latent safety threats).

  16. Simulation-based Clinical System Test (SbCST) • A specific concern in a new patient care process is the existence of unrecognized or latent threats to safety that could affect actual patients once the facility opens • System changes, although intended to be beneficial, may also result in negative, unanticipated outcomes

  17. Best Practice for Simulation-based Clinical Systems Test (SbCST) Outcomes/Metrics Stakeholders Priority Themes Action Plans Simulation Design Scenario Location Personnel Timeline Leaders Core Team Members Departments Identification of Priorities What to continue What to change Methodologies Needs Assessment

  18. Needs Assessment • Facilities and Environment • Functionality of EMS docking sheet • Technology/Devices/Equipment • Easy access to rapid infuser, thoracotomy tray • Communication flow during activation  • Processes of Care/Workflows • Test paging process using *9999 to activate a trauma • Activate Trauma Team • Functionality of “red phone” during activation • Staffing coverage  • Activate MTP • Roles and Responsibilities • Roles of PCA/UCA • PICU support- MD, RN • Role of transport team • Clinical Knowledge/Performance Gaps • Difference between activation criteria and code levels • Facilities and Environment • Technology/Devices and equipment • Processes of Care/Workflows • Roles and Responsibilities • Clinical Knowledge and Performance Gaps Stakeholders

  19. Simulation Design

  20. The DebriefingSafety 1 and Safety 2 Safety I  “Safety” is interpreted as absence of unwanted outcomes – focus is on the few things that go wrong to understand and prevent recurrence Safety II “Safety” is interpreted as consistent presence of desired outcomes - focus is on the many things that go right to enhance reliability in complex systems

  21. Outcomes and Metrics Failure Modes and Effects Analysis (FMEA)  is an established and widely used means of proactively seeking out both latent and active weaknesses and failures in healthcare systems in order to analyze causes, assess risk, and address resolutions (The Joint Commission, 2005). 

  22. FMEA Scoring Tool

  23. Action Item Review

  24. Action Item Review • “Question regarding the ETA… If short time, do you even want to tell them you have ETA of 5 minutes?” • “Concerns that no one’s pagers went off and concerns about Voalte connectivity” • “Level 1 tubing was needed but it wasn’t yet stocked- the tubing is in-house but was not stocked yet.” • “Security never responded to the call. It was unclear to the participants if they received the page/voalte call” • “Unclear about a transport via air- who does this process? will this be the house supervisor or the transfer” • “Participants expressed some confusion about what is meant by “stabilize and transfer” for a level 4 trauma center.”

  25. What would you do: Unavailable Equipment • The following equipment is either missing, started to malfunction or there is no one present competent to use it. • How would you handle this? • What other resources could you use? • Video laryngoscope (CMAC) • Ventilator • Chest tube • Rapid infuser • Sufficient blood products • IO insertion device • CT scanner • Bair hugger/mistral air

  26. What would you do: Unavailable Resuscitation Team • The following members of the resuscitation team are unavailable • How would you handle this? • Is anyone else capable of fulfilling their role? • Emergency Medicine Physician • Emergency Room Nurses • Radiology Tech for XR or CT • OR Resources: Surgeon (general or specialty); Anesthesia; OR team • Security • Social Work and/or Chaplain

  27. What would you do: IT Issues • You experience problems with the primary form of communication at your facility (e.g., pagers not delivering messages, Voalte connectivity is not functioning, Spectralinks are unable to dial) • What is your back up form of communication for trauma activation?

  28. What would you do: Transport Delays • You would like to use a rotor wing service but when you call they tell you they are grounded due to weather. • What else can you do? • What if you are 3 hours away from the nearest Level I or II? • You would like to send the patient using your contracted transport service (e.g., Acadian, AMR etc…) but they will not be able to arrive for 2 hours. • What else can you do?

  29. Conclusion • Simulation-based systems testing helps develop critical new processes (Trauma Designation) • Unique multidisciplinary process that directly impacts patient safety and quality of care 

  30. References • American College of Surgeons (2014, 6th ed.). Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of Surgeons • Barleycorn, Donna, and Geraldine A. Lee. "How Effective is Trauma Simulation as an Educational Process for Healthcare Providers within the Trauma Networks? A Systematic Review." International Emergency Nursing, vol. 40, 2018, pp. 37-45. • Centers for Disease Control and Prevention (2012, January 12). Guidelines for Field Triage of Injured Patients. Retrieved from https://www.facs.org/~/media/files/quality%20programs/trauma/vrc%20resources/6_guidelines%20field%20triage%202011.ashx • Sullivan, Sarah, et al. "Identifying Nontechnical Skill Deficits in Trainees through Interdisciplinary Trauma Simulation." Journal of Surgical Education, vol. 75, no. 4, 2018, pp. 978-983.

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