High-Fidelity Simulation High-Fidelity Simulation to Teach Communication to Teach Communication

Skills:Skills:Potentially Difficult Potentially Difficult

DiscussionsDiscussions Stephanie N. Sudikoff, MDStephanie N. Sudikoff, MDMedical Director, SYN:APSE Simulation Medical Director, SYN:APSE Simulation

CenterCenterYale New-Haven Health SystemYale New-Haven Health SystemAssistant Professor of PediatricsAssistant Professor of Pediatrics

Pediatric Critical CarePediatric Critical CareDirector, Pediatric SimulationDirector, Pediatric Simulation

Yale University School of Medicine Yale University School of Medicine

Many types of Many types of discussionsdiscussions

Between caregiver and patientBetween caregiver and patient Between caregiver and familyBetween caregiver and family Among interdisciplinary care teamAmong interdisciplinary care team

Delivery of Bad NewsDelivery of Bad News Manner of delivery has significant Manner of delivery has significant

impact on patients and familyimpact on patients and family All caregivers (all levels) report All caregivers (all levels) report

discomfort and lack of sufficient trainingdiscomfort and lack of sufficient training Many studies into best pedagogical Many studies into best pedagogical

strategystrategy LecturesLectures Small groups/role playingSmall groups/role playing One on one with standardized patientOne on one with standardized patient

Ideal strategy…Ideal strategy… InteractiveInteractive Learner centeredLearner centered Draws on prior experienceDraws on prior experience RelevantRelevant Allows for timely applicationAllows for timely application Opportunity for repetitive practiceOpportunity for repetitive practice Opportunity for feedback and reflectionOpportunity for feedback and reflection

Provides basic steps practice, discuss Provides basic steps practice, discuss concerns, receive feedbackconcerns, receive feedback

Delivery of Bad News: Delivery of Bad News: PediatricsPediatrics

Frequently delivering news to parent Frequently delivering news to parent and family, who are often present at and family, who are often present at the bedsidethe bedside

In acute care settings, news must In acute care settings, news must often be delivered in the midst of often be delivered in the midst of complex patient carecomplex patient care

Why simulation?Why simulation? Simulation facilitates:Simulation facilitates:

Repetitive practiceRepetitive practice Safe environment for practice, Safe environment for practice,

reflection, discussion, and feedbackreflection, discussion, and feedback Hybrid model creates realistic situation Hybrid model creates realistic situation

involving simultaneous patient care and involving simultaneous patient care and family interactionfamily interaction

Faculty teaching without competing Faculty teaching without competing clinical responsibilities/time pressureclinical responsibilities/time pressure

Previous Simulation Previous Simulation WorkWork

Gaba “Death Scenario”Gaba “Death Scenario” Rosenzweig Standardized Patients Rosenzweig Standardized Patients

Choose cases relevant to learnersChoose cases relevant to learners

Overly F, Sudikoff SN, Duffy S, Anderson A, Kobayashi L

Teaching Difficult Discussions in Pediatric

Emergency Medicine:  1) Sudden Infant Death 2) Child Abuse

with Domestic Violence and 3) Medication Error.

Simulation in Healthcare. Accepted December 2008

Participant FeedbackParticipant FeedbackSurvey question

Relevance to your training/duties

Realism of simulation scenario

Realism of simulation

environment

Quality of simulation debriefing

Overall simulation training

experience

Score Average

(SD)

4.9 (0.4) 4.5 (0.7) 4.5 (0.5) 4.8 (0.4) 4.9 (0.4)

CommentsComments ““The SIDS case is very worthwhile. The SIDS case is very worthwhile.

Traumatizing but worthwhile”Traumatizing but worthwhile”

““Great experience- very valuable to try Great experience- very valuable to try out these situations first at sim center out these situations first at sim center rather than on the floors.”rather than on the floors.”

““Very real, excellent learning Very real, excellent learning experience”experience”

Stages of debriefingStages of debriefing ReactionsReactions

““How did that feel?”How did that feel?” UnderstandingUnderstanding

““What results were What results were produced?”produced?”

SummarySummary ““How can we How can we

extrapolate this extrapolate this information to a information to a larger context?”larger context?”

EventsEvents

EmotionsEmotions

EmpathyEmpathy

ExplanationsExplanations

“ “The four E’s”The four E’s”

Critical characteristics of Critical characteristics of an effective debriefing an effective debriefing

Safe for the learnerSafe for the learner Confidential and trustingConfidential and trusting RespectfulRespectful InteractiveInteractive Non-threateningNon-threatening Non-confrontationalNon-confrontational Non-judgmentalNon-judgmental

Debriefing for this caseDebriefing for this case Allow sufficient time for reactions stageAllow sufficient time for reactions stage Sensitivity to powerful emotional responsesSensitivity to powerful emotional responses Supportive environmentSupportive environment Allow for reflection on learner Allow for reflection on learner

performance: use their observations to performance: use their observations to transition to teaching “best practice” transition to teaching “best practice” conceptsconcepts

Consider providing “gold standard” for Consider providing “gold standard” for frame of referenceframe of reference

Disclosure ofDisclosure ofMedical Errors: Medical Errors:

The Art (and The Art (and Science) of Science) of

ApologyApology

Medical errorMedical error The failure of a planned action to be The failure of a planned action to be

completed as intended or the use of a wrong completed as intended or the use of a wrong plan to achieve an aimplan to achieve an aim Serious errorSerious error Minor errorMinor error Near missNear miss

An error that could have caused harm but An error that could have caused harm but did not …by chance or timely interventiondid not …by chance or timely intervention

Most are due to system breakdown vs. Most are due to system breakdown vs. individual failureindividual failure

The ImportanceThe Importance To Err is HumanTo Err is Human

U.S. National Institute of Medicine U.S. National Institute of Medicine report, 1999report, 1999

Over 100,000 deaths annually in the Over 100,000 deaths annually in the U.S.U.S.

Hospitals 'more dangerous' than Hospitals 'more dangerous' than air travel (Reuters, 2005)air travel (Reuters, 2005)

If you feel safer in hospital than on a airplane, think again.If you feel safer in hospital than on a airplane, think again. The risk of being killed in a hospital in a developed country due to The risk of being killed in a hospital in a developed country due to

medical error is around one in 300, while the risk of dying in an air medical error is around one in 300, while the risk of dying in an air accident is one in 10 millionaccident is one in 10 million, Britain's chief medical officer said on , Britain's chief medical officer said on Monday. Monday.

"Paradoxically, people are more frightened of air travel than they "Paradoxically, people are more frightened of air travel than they are of healthcare," Liam Donaldson, who also chairs the World are of healthcare," Liam Donaldson, who also chairs the World Health Organization's (WHO) World Alliance for Patient Safety, told Health Organization's (WHO) World Alliance for Patient Safety, told a conference. a conference.

He argued such a gulf in safety standards was unacceptable - even He argued such a gulf in safety standards was unacceptable - even allowing for the poor condition of many patients entering hospital - allowing for the poor condition of many patients entering hospital - and healthcare professionals needed to learn from other sectors on and healthcare professionals needed to learn from other sectors on how to make safety a top priority. how to make safety a top priority.

""Other high-risk industries have systematically improved safety over Other high-risk industries have systematically improved safety over a period of decades in a way that healthcare has not, the airline a period of decades in a way that healthcare has not, the airline industry being the most high-profile exampleindustry being the most high-profile example," Mr Donaldson said. ," Mr Donaldson said.

What we knowWhat we know Medical errors occur frequentlyMedical errors occur frequently Agreement exists that errors should Agreement exists that errors should

be disclosedbe disclosed FamilyFamily StaffStaff Risk managementRisk management

Caregivers receive little training Caregivers receive little training

What can we do?What can we do? Simulation as a tool to Simulation as a tool to

decrease medical errorsdecrease medical errors Errors are multi-factorialErrors are multi-factorial

““Shed light” on the problemsShed light” on the problems PracticePractice Teamwork and communicationTeamwork and communication

What can we do?What can we do? Simulation as a tool to teach disclosureSimulation as a tool to teach disclosure

AdvantagesAdvantages Includes medical management Includes medical management

Requires focus, multi-taskingRequires focus, multi-tasking Interaction with standardized patient or actorInteraction with standardized patient or actor

Practice the wordsPractice the words View on videoView on video

DisadvantagesDisadvantages Limitations of the simulatorLimitations of the simulator Requires “buy in”Requires “buy in”

Disclosure of Medical Disclosure of Medical ErrorsErrors

Video clipVideo clip DebriefDebrief Medical error disclosureMedical error disclosure

The literatureThe literature AttitudesAttitudes How we teach (and learn)How we teach (and learn)

What families want to What families want to knowknow

????

What families want to What families want to knowknow

What happened?What happened? Why did it happen?Why did it happen? What are the implications for their What are the implications for their

loved one?loved one? How can the problem be corrected?How can the problem be corrected? How can future errors be prevented?How can future errors be prevented?

ApologyApology 4 components:4 components:

Acknowledgement of the offenseAcknowledgement of the offense Explanation for committing the offenseExplanation for committing the offense

““There is no excuse for what happened”There is no excuse for what happened” ““We are still trying to find out what We are still trying to find out what

happened”happened” Expression of shame, remorse, humilityExpression of shame, remorse, humility Reparation: making amendsReparation: making amends

Important factorsImportant factors Important to choose who offers the Important to choose who offers the

disclosuredisclosure Timing is importantTiming is important Insincere apology is worse than no Insincere apology is worse than no

apologyapology

General General recommendationsrecommendations

Listen without interruptingListen without interrupting Relay full informationRelay full information Use easy-to-understand languageUse easy-to-understand language Ensure that the parents comprehend Ensure that the parents comprehend

the informationthe information Give a Give a sinceresincere apology apology Use nonverbal communication to Use nonverbal communication to

express concernexpress concern

General General recommendationsrecommendations

Communicate your commitment to Communicate your commitment to the patient’s safetythe patient’s safety

Convey the patient’s medical status Convey the patient’s medical status and your expectationsand your expectations

Solicit families opinionSolicit families opinion Use open ended questionsUse open ended questions Communicate to family members Communicate to family members

that you understand their concernsthat you understand their concerns Communicate what you plan to do to Communicate what you plan to do to

prevent this in the futureprevent this in the future

Communication among Communication among the interdisciplinary the interdisciplinary

team:team:

The HandoffThe Handoff

High RiskHigh Risk One of the most common scenarios One of the most common scenarios

in which significant in which significant miscommunication can occurmiscommunication can occur

Also high risk for patient Also high risk for patient deterioration while traveling deterioration while traveling throughout hospitalthroughout hospital

Why simulation?Why simulation?

Response to need for Response to need for process improvementprocess improvement

MultidisciplinaryMultidisciplinary ““Vetting” and refinementVetting” and refinement ImplementationImplementation

Well received by entire teamWell received by entire team Real opportunity for all members to Real opportunity for all members to

collaborate to create collaborate to create multidimensional toolmultidimensional tool

Improved buy inImproved buy in