I N SITU SIMULATION IN THE ED: POWERFUL TOOL FOR QUALITY IMPROVEMENT Julie Mardon Consultant Emergency Medicine University Hospital Crosshouse.

IN SITU SIMULATION IN THE ED: POWERFUL TOOL FOR QUALITY IMPROVEMENT Julie Mardon

Consultant Emergency Medicine

University Hospital Crosshouse

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

2 PROJECTS

Paediatric asthmatic patients discharged from department

Sepsis 6 bundle delivery

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

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

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

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

MULTI DOSING

PAWS CHART

NON TECHNICAL LEARNING

Communication skills Handover Real environmental latent errors uncovered Simulation learning objective mirrored

learners own objectives Examples of non technical skills

HANDOVER TO MEDICAL STAFF

RESULTS 1 YEAR POST INTERVENTION

MD ED PF PAWS0

10

20

30

40

50

60

70

80

90

100

before after

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

PROCESS MAPPING

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

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”

THE BOX

TEAM PRIORITISATION

SEPSIS 6 DELIVERY BEFORE IN-SITU SIMULATION

june july august sept0

10

20

30

40

50

60

70

80

90

100

SEPSIS 6 AFTER IN SITU SIMULATION

june july aug sept oct nov dce jan feb0

10

20

30

40

50

60

70

80

90

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