Establishing a Program of In Situ Simulations: Slide Presentation

Slide 1: AHRQ Safety Program for Perinatal Care

Establishing a Program of In Situ Simulations

Slide 2: Learning Objectives

Image: Four ascending steps show the learning objectives:

• Describe in situ simulation training.
• Describe how in situ simulation supports perinatal safety.
• Demonstrate how to execute in situ simulations.
• Identify ways to measure and evaluate a program of in situ simulation.

Slide 3: Simulation Skill Development¹

• Technical skills related to clinical assessment or intervention:
  • Cervical exams, physical maneuvers, surgical procedures.
  • Appropriate clinical management of a specific condition.
  • Effective organization and use of supplies and equipment.
• Teamwork and communication (four core TeamSTEPPS® skills):
  • Leadership.
  • Communication.
  • Mutual support.
  • Situational awareness.

Slide 4: In Situ Simulation Defined^1,2,3,4

• In situ simulations are physically integrated into the usual clinical environment, allowing for practice in one's own hospital setting with familiar resources and equipment.
  • Each person involved performs his or her own role as if the scenario were real.
  • All disciplines participate, including support personnel (lab, pharmacy, etc.).
• In situ simulation complements simulation training conducted in a dedicated simulation center.

Slide 5: Benefits of In Situ Simulation^3,5,6,7

• Provides a method to improve reliability and safety in high-risk areas such as labor and delivery (L&D).
• Allows for experiential learning and practice related to teamwork and communication.
• Improves ability to address latent threats and systems issues.

Slide 6: Evidence for Using Simulations in L&D

• Multiple studies have demonstrated that teamwork training using simulation as an independent intervention results in improvement in knowledge, practical skills, communication, and team performance in acute maternity care situations.^8-10

Slide 7: Scenarios for Simulation

• Simulation scenarios can be designed to replay real events that have occurred on your unit.
• Simulation scenarios can be designed for uncommon, but serious, obstetric emergencies requiring rapid recognition and response (e.g., shoulder dystocia, postpartum hemorrhage, cord prolapse).
• Simulation scenarios can be designed to fine-tune existing processes or to train staff on new processes and protocols (e.g., use of safe cesarean section checklist).

Slide 8: Three Components of an In Situ Simulation¹¹

1. Briefing.
2. Facilitating the simulation.
3. Debriefing.

Slide 9: Briefing

• Immediately before the simulation, the facilitator briefs participants about the purpose and ground rules; this usually takes about 10 minutes. The facilitator will—
  • Ask participants to treat the simulated event like an actual patient situation.
  • Emphasize the primary focus is on how teams communicate and perform as a unit.
  • Share information about the timeframe for simulation, use of simulation equipment (if applicable), and rules of participation.

Slide 10: Briefing: Using Video

• Video recording the simulation can be a useful tool for reviewing team performance during the debriefing.³
  • Video recording can induce anxiety in participants.
• Explain the purpose of video recording prior to simulation.
  • Seek legal guidance and signed releases from simulation participants if the video may be used for purposes other than debriefing, such as for education or training.

Slide 11: Facilitating the Simulation: Scenario Design¹

Components of a well-designed scenario include—

• Clinical context:
  • Not all contexts are equal for training purposes.
  • Context should be appropriate for eliciting the team behavior of interest.

Slide 12: Facilitating the Simulation: Scenario Design¹

Components of a well-designed scenario include—

• Event sets (typically 3 to 5 per simulation):
  • Triggers: The incident to elicit the team behavior.
  • Distractors: Characteristics that may divert the team’s attention (e.g., family member asking questions).
  • Expected Responses: The appropriate behavioral responses to each event-set trigger.

Slide 13: Facilitating the Simulation: Execution

• Simulation facilitators are primarily observers.
  • Facilitators introduce new information into the simulation as needed.
• Avoid facilitating or "scripting" the simulation too tightly; this makes it difficult to observe targeted responses to a specific trigger.
  • Simulations that lead to "one right answer" are not realistic and won’t help teams develop the ability to recognize and adapt to changing circumstances.

Slide 14: Facilitating the Simulation: Execution

• Keep the simulation going for a prespecified period of time, typically up to 15 to 20 minutes.

Slide 15: Debriefing: Definition

• Debriefing helps participants understand the complex team skills and knowledge required for quality patient care.^3,11
  • Provides a structure for understanding the scenario.
  • Helps ensure everyone takes away similar lessons from the experience.
  • Helps to keep the discussion focused on events relevant to the learning objectives of the simulation.

Slide 16: Debriefing: Logistics

• Takes about 3 to 5 minutes to debrief for every minute of the actual simulation.
  • So a simulation run for 15 minutes will need at least 45 minutes to debrief. (This does not include time needed to review video if the simulation is being recorded.)
• Consider reserving a separate space for the debrief, especially if a screen to review a video recording of the simulation is needed.

Slide 17: Debriefing: Introduce the Debrief Process

• All team members in the simulation participate.
• The focus is primarily on team performance.
  • Teamwork and communication skills are the focus of the debriefing questions.
  • So that clinical/technical issues or questions are not overlooked, can use debrief to quickly clarify an issue, but individually directed remediation should be handled outside of the debrief.
  • Consider a dual debrief, where one portion focuses on teamwork and communication, and a separate portion focuses on the clinical/technical response.

Slide 18: Debriefing: Describe What Happened

• First, each participant states their name, role, and what they think went well during the simulation.
• If simulation was recorded, watch the video. Pause at intervals to discuss the following:
  • What went well?
  • What could have gone better?
  • What would you want to do differently next time?

Slide 19: Debriefing: Describe What Happened

• It is important for the participants to realize it is "their debriefing."
  • An internal discussion of teamwork and communication principles is one of the goals of the debriefing.
  • Video review is extremely helpful in allowing the participants to see exactly what communication occurred and what kind of teamwork was employed.
  • Ideally everyone participates so that their unique perspective (such as their role) is heard.

Slide 20: Debriefing: Conduct a Performance Analysis

• Consider using a simulation assessment tool:
  • It can be used by any observers of the simulation.
  • If the simulation was video recorded, participants can use it to evaluate themselves as they watch the video.
• Compare the team’s performance with expected responses:
  • Were the expected behaviors performed when necessary?
  • If so, were they performed correctly, or could they be improved?

Slide 21: Debriefing: Identify Lessons Learned

• The final step is to look ahead to how the team members can generalize what they learned in the scenario to their daily practice.
  • The team discusses what behaviors it should begin performing.
  • Explicit measures associated with the simulation scenario can help promote reflection about how to transfer what went well in the simulation to the actual clinical environment.

Slide 22: Planning

Planning

Slide 23: Engage Leadership

• Discuss and determine a shared vision for the unit’s program of in situ simulation training.
  • Be clear about the purpose of simulation training (i.e., teamwork development vs. individual performance evaluation).
  • Identify concrete training goals.

Slide 24: Staff Readiness

• Ensure unit staff receive teamwork and communication training (e.g., TeamSTEPPS) before implementing an in situ simulation training program.
  • This provides the team with a common language and communication framework.
• Ensure enough staff members know how to facilitate simulations.

Slide 25: Participants

• All disciplines involved in providing services or care to patients on L&D units should participate in simulations, including—
  • Maternity care providers (obstetricians/family physicians/midwives).
  • Nursing staff.
  • Neonatal providers.
  • Anesthesiology staff.
  • Residents (all specialties that provide care on labor and delivery).
  • Operating room technicians/assistants.
  • Administrative support personnel (unit clerks).
  • Lab and pharmacy staff.

Slide 26: Participants

• Define clear requirements for staff participation:
  • Decide how often to conduct simulations. How many different scenarios?
  • Will incentives or consequences be used to drive staff participation?

Slide 27: Simulation Scenarios

• Determine the simulation scenarios your unit or program will use.
• Sample simulation scenarios for the following topics are available through the Safety Program for Perinatal Care:
  • Postpartum hemorrhage.
  • Shoulder dystocia.
  • Umbilical cord prolapse.
  • Uterine tachysystole.
  • Antepartum hemorrhage.
  • Preeclampsia/seizure.
  • Severe abdominal pain/vaginal birth after cesarean.
  • Postoperative cesarean section complication.
  • Magnesium toxicity.

Slide 28: Simulation Scenarios

• Other sample scenarios are available from professional organizations, perinatal quality and safety organizations, and commercial entities.^12-14
• An accompanying video offers an example of an in situ simulation, including the briefing and debriefing process:
  • Link to video: https://youtu.be/UhIuGgZB60g
  • Also located in the AHRQ Toolkit for Improving Perinatal Safety: https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ.html

Slide 29: Equipment

• In situ simulations generally use the equipment of the clinical area in which the simulation takes place.
• Some simulations may require a pelvic model or birthing simulator.
• The use of standardized patients ("actors") may replace simulators in many cases.

Slide 30: Logistics

• Create a schedule for simulation trainings that aligns with the unit’s shared vision and staff participation criteria.
• Plan for transportation of simulation equipment to/from unit.
  • Store equipment in L&D unit, if possible.
  • Set aside time for transport, setup, and dismantling.

Slide 31: Logistics

• Consider whether real or simulated medical supplies (e.g., drugs, blood) and equipment will be used.
  • Use of real supplies—
    • May prevent simulated drugs/medication/equipment from accidentally being used with real patients.
    • Is wasteful, particularly when supply shortages exist.
  • Use of simulated supplies—
    • Requires vigilance to ensure supplies and equipment are clearly marked so will not mistakenly be used on actual patients.
    • Requires use of infection-control practices for reuse of simulation equipment.

Slide 32: Conflicts With Patient Care

Prospectively designate standards and limits for conducting simulations on the unit.

• Scheduled in situ simulations may be cancelled or end early because of competing patient care demands.
• A time limit may be imposed on simulations and debriefing to reduce impact on clinical care.

Slide 33: Conflicts With Patient Care

Prospectively designate standards and limits for conducting simulations on the unit.

• Discussions with your hospital’s patient advocacy groups, if possible, may be beneficial.
  • A Hospital Medical Center reported support from its family advocate group because benefits of simulation training outweighed disadvantages.³

Slide 34: Evaluation

Evaluation

Slide 35: Data for Evaluation

A successful in situ simulation training program requires evaluation and continuous improvement.¹¹

• Consider using data from "safety culture" surveys.
• Collect participant evaluation forms.
• Collect qualitative feedback from staff participants who have participated in simulations.
• Use other measures to track the impact of the simulation program.

Slide 36: Designing Measures: Clarify Purpose¹

• Diagnose root causes of performance deficiencies:
  • Identify specific weaknesses, such as poor "SBAR."
• Provide feedback:
  • Relay information regarding strengths and weaknesses as a remediation plan.
• Conduct assessment:
  • Evaluate the level of proficiency or readiness.

Slide 37: Designing Measures: What To Measure¹

• Outcomes (Measures of Effectiveness):
  • Provide an indication of the extent to which the outcome of the task was successful.
    • Accuracy: Precision of performance (e.g., correct diagnosis, appropriate treatment).
    • Timeliness: How long? (e.g., time to incision, time to transfusion).
    • Productivity: How much? (e.g., patient volume in L&D).
    • Efficiency: Ratio of resources required versus used (e.g., operating room supplies).

Slide 38: Designing Measures: What To Measure¹

• Processes (Measures of Performance):
  • Explain how and why certain outcomes may have happened—"Was the decision made right (correctly)?" versus "Was the right decision made?"
  • Important when diagnosing root causes of performance deficiencies and providing feedback or follow-on training:
  • Types of process.
    • Procedural: Task work.
    • Nonprocedural: Task work.
    • Teamwork.

Slide 39: Unit Next Steps

• Obtain support from leadership for establishing a program of in situ simulation training.
• Build foundation needed for simulation with TeamSTEPPS teamwork training.
• Develop participation criteria, choose scenarios, plan logistics, and secure equipment.
• Pilot-test program on a small scale prior to widespread unit implementation.

Slide 40: References

1. Agency for Healthcare Research and Quality. Using Simulation in TeamSTEPPS Training: Classroom Slides. Rockville, MD: AHRQ; October 2014. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/simulation/simulationslides/simslides.html.
2. Casper L. Simulations and Drills. In: CMQCC Obstetric Hemorrhage Toolkit: Obstetric Hemorrhage Care Guidelines and Compendium of Best Practices. Jan 2010.
3. Patterson MD, Blike GT, Nadkarni VM. In situ simulation: challenges and results. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Rockville, MD: Agency for Healthcare Research and Quality; August 2008.
4. Deering S, Johnston LC, Colacchio K. Multidisciplinary teamwork and communication training. Seminars in Perinatology April 2011;35(2):89-96. PMID: 21440817.
5. Riley W, Davis S, Miller K, Hansen H, Sainfort F, Sweet R. Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital. Jt Comm J Qual Patient Saf 2011 Aug;37(8):357-64. PMID: 21874971.
6. Riley W, Davis S, Miller KM, Hansen H, Sweet RM. Detecting breaches in defensive barriers using in situ simulation for obstetric emergencies. Qual Saf Health Care 2010 Oct;19 Suppl 3:i53-6. PMID: 20724391.
7. Riley W, Davis SE, Miller KK, McCullough M. A model for developing high-reliability teams. J Nurs Manag 2010 Jul;18(5):556-63. PMID: 20636504.

Slide 41: References

8. Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol July 2008;112(1):14-20. PMID: 18591302.
9. Phipps MG, Lindquist DG, McConaughey E, et al. Outcomes from a labor and delivery team training program with simulation component. Am J Obstet Gynecol Jan 2012;206(1):3-9. PMID: 21840493.
10. Ellis D, Crofts JF, Hunt LP, et al. Hospital, simulation center, and teamwork training for eclampsia management: a randomized controlled trial. Obstet Gynecol March 2008;111(3):723-31. PMID: 18310377.
11. Miller KK, Riley W, Davis S, Hansen, HE. In situ simulation: a method of experiential learning to promote safety and team behavior. J Perinat Neonat Nurs 2008;22(2):105-13. PMID: 18496069.
12. Wisconsin Association for Perinatal Care. Postpartum Hemorrhage: Resources. https://www.perinatalweb.org/major-initiatives/postpartum-hemorrhage/resources. Accessed May 9, 2016.
13. California Maternal Quality Care Collaborative. OB Hemorrhage Toolkit V 2.0. Improving Health Care Response to Obstetric Hemorrhage, Version 2.0: A California Toolkit to Transform Maternity Care. Released March 2015. https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit. Accessed May 9, 2016.
14. American Congress of Obstetrics and Gynecology. ACOG Simulations Consortium Learning Objectives: Postpartum Hemorrhage Caused by Uterine Atony. n.d. https://www.acog.org/~/media/Departments/Simulations%20Consortium/Learning%20Objectives/Postpartum_Hemorrhage.pdf. Accessed May 9, 2016.

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