Team Based Sims for the Win
Imagine you’re on a basketball team. The members of the team all practice individually with team members that play their respective positions, e.g. with other point guards or forwards. They never practice as an entire team until the actual game. Sounds crazy right? Yet, this is what we frequently do in healthcare. Perhaps the residents get together for a sim day, and there’s a nursing skills rodeo day, but rarely, if ever do we train together.
I have worked in 8 emergency departments as an attending physician; only one location employed regular in situ simulations. In situ simulations occur inside the clinical practice environment, e.g. in the emergency department, clinic or operating room. The advantage of conducting these simulations inside the clinical space is it allows for utilizing the actual physical space that medical care occurs. For example, a trauma simulation can occur in the trauma room and staff can assemble and work through how they will actually stand or how equipment needs to be organized to facilitate easy access and accommodate movement of the team members and patients.
In situ simulations face several potential barriers:
1) Clinical environments are often busy- there is a resistance to devoting time and resources towards a simulation event, especially in the current budget strapped healthcare environment.
2) Team based in situ simulations require coordination of various staff members and their schedules, e.g. physicians, PAs, NPs, nurses, RTs, etc.
3) Staff may be resistant to participating due to feeling self-conscious in front of peers, subordinates, or superiors.
The potential benefits of in situ simulations are huge:
1) Increased familiarity with the location and how to use equipment in the clinical space. Frequently in situ simulations uncover expired or missing equipment or methods to improve organization and access to key equipment.
2) Enhanced teamwork, communication and leadership via practicing closed looped communication, call-outs, check backs.
Strategies to create an in situ program:
1) Buy-in from key clinical leaders, e.g. Physician director and nursing director.
2) Agree and adhere to time limits on the simulation and debrief, i.e. if the team agrees to protecting clinical responsibilities for 30 minutes, don’t go over. There’s always more to talk about…it can wait. Don’t sabotage your program by running over time.
3) Define “no-go” scenarios, e.g. if the emergency department is in disaster or highly saturated state.
4) Examine patient flow data to determine ideal time for in situ simulations, e.g. most emergency departments have low patient volume early in the morning.
5) Plan for the simulation participants to have no clinical responsibilities, e.g. the simulation occurs when they arrive for the day, prior to patient care.
How to design the curriculum:
Align the case curriculum to address potential educational gaps or high-risk scenarios. For example, a non-trauma center may choose a case in which they receive a drop-off penetrating trauma patient. An ED that mainly sees adults may select a precipitous delivery followed by neonatal resuscitation. Both cases include high stakes, time sensitive scenario in which rarely used equipment must be used. Additionally, both scenarios incorporate many team members responding and the opportunity to practice where to stand, how to get key equipment in the room and set up correctly is very valuable. Meeting with your department or hospital’s risk management and quality assurance teams can provide valuable insights to areas that your department have historically struggled with and that you can target through simulation.
The Pre-brief and debrief are key to program success:
1) Ensure the pre-brief frames the purpose of the simulation, i.e., enhanced patient safety, improve teamwork, communication, and equipment familiarity.
2) Keep the debrief focused on teamwork, communication, and equipment. Avoid getting into the weeds of a detailed medical debrief. If there are participants that want to discuss the medical aspects more, save this for a separate debrief.
3) When possible, allow the team to provide feedback to each other. A team member pointing out how they couldn’t hear a med order because the room was too loud is more effective than the facilitator telling the group.
In situ simulations are often early in the morning and require a lot of planning. Yet, these are my favorite simulations. Healthcare is a team sport, and these simulations allow for the most realistic and robust preparation for patient care. The work pays off when a nurse, tech or physician comes up to you and says, “You know that sim we did? That case happened a few days later. We did a lot better because of that sim.”
References:
Read more on No Go Considerations for Simulation Safety.
Suggested framework for teamwork and communication can be found at https://www.ahrq.gov/teamstepps/index.html. Check out the tools section for pocket guides and other materials to train your teams.
Check out these resources to build cases (never start writing a case without doing a quick search first):
https://jetem.org/search-by-modality/?_sft_modalities=simulation