Simulation Based Training: Simulation Based Training: Are You Ready?Are You Ready?

Julie Arafeh MSN, RNJulie Arafeh MSN, RN

Julie Arafeh has no Julie Arafeh has no disclosures to announcedisclosures to announce

ObjectivesObjectives

Define the components of simulation Define the components of simulation based trainingbased training

Review how simulation can be used Review how simulation can be used in obstetricsin obstetrics

Describe how obstetric units have Describe how obstetric units have used simulation to improve patient used simulation to improve patient carecare

Your Last Obstetrical Crisis:

How can simulation play a role How can simulation play a role in improving team response?in improving team response?

What is simulation based What is simulation based training?training?

An educational methodology An educational methodology NOTNOT technologytechnology

Realistic team practice for Realistic team practice for application of cognitive and technical application of cognitive and technical skills skills

Opportunity to observe and learn Opportunity to observe and learn about team (behavioral) skillsabout team (behavioral) skills

Scenario basedScenario based Designed to challenge & instructDesigned to challenge & instruct We DO NOT expect a perfect We DO NOT expect a perfect

performanceperformance Rare opportunity to see your practice Rare opportunity to see your practice

on videotapeon videotape

Simulation Based TrainingSimulation Based Training

Components of simulation Components of simulation based trainingbased training

Research to determine topic of Research to determine topic of trainingtraining

Develop measurable learning Develop measurable learning objectives for all learnersobjectives for all learners

Write scenario that supports learning Write scenario that supports learning objectivesobjectives

Plan for debriefingPlan for debriefing

DebriefingDebriefing

Facilitated discussion not a lectureFacilitated discussion not a lecture Where the learning from simulation Where the learning from simulation

occursoccurs Based on learning objectivesBased on learning objectives Covers incorrect actions Covers incorrect actions Long complex healthcare scenarios Long complex healthcare scenarios

are more difficult to debriefare more difficult to debrief

What can we learn about What can we learn about simulation based training simulation based training

from other industries? from other industries?

High Functioning Teams:High Functioning Teams:Aerospace IndustryAerospace Industry

"black box" revelations"black box" revelations 2/3 of disasters due to 2/3 of disasters due to

poor communicationpoor communication response: response:

Crew Resource Management (CRM)Crew Resource Management (CRM) cognitive, technical and cognitive, technical and behavioralbehavioral

skillsskills high fidelity training environmenthigh fidelity training environment annual training mandated by FAAannual training mandated by FAA

Helmreich R, et al. Cockpit Resource Management. 1993.

Translated to Obstetric Translated to Obstetric Practice…..Practice…..

BJOG 2006 Feb;113(2):177-BJOG 2006 Feb;113(2):177-8282

Retrospective cohort obs studyRetrospective cohort obs study Tertiary referral hospitalTertiary referral hospital 5 min APGAR score and incidence of 5 min APGAR score and incidence of

HIE compared pre and post HIE compared pre and post simulation trainingsimulation training

Significant reduction in low 5 min Significant reduction in low 5 min APGAR scores and HIEAPGAR scores and HIE

Obstet Gynecol Obstet Gynecol 2008;112:14-20.2008;112:14-20.

Retrospective observational study Retrospective observational study shoulder dystocia mgment, neo shoulder dystocia mgment, neo injuryinjury

Mgment and neo injuries pre and Mgment and neo injuries pre and post simulation trainingpost simulation training

Use of maneuvers for shoulder Use of maneuvers for shoulder dystocia increased, significant dystocia increased, significant reduction in neonatal injuryreduction in neonatal injury

Joint Commission J Qual Patient Joint Commission J Qual Patient Safety Aug 2011;37(8):357-64Safety Aug 2011;37(8):357-64

3 small size community hospitals3 small size community hospitals Comprehensive interdisciplinary Comprehensive interdisciplinary

team training using in-situ simulationteam training using in-situ simulation Weighted Adverse Outcome score Weighted Adverse Outcome score

and Safety Attitudes Questionnaireand Safety Attitudes Questionnaire Persistent 37% improvement in Persistent 37% improvement in

perinatal morbidity perinatal morbidity

J Healthc Qual, Jan/Feb J Healthc Qual, Jan/Feb 2012;34(1):6-152012;34(1):6-15

Large tertiary medical centerLarge tertiary medical center Comprehensive perinatal safety Comprehensive perinatal safety

initiativeinitiative Mod Adv Outcome Index Mod Adv Outcome Index from 2% from 2%

to 0.8% and was sustainedto 0.8% and was sustained Improvements in staff preception of Improvements in staff preception of

safety, pt perception of teamwork, safety, pt perception of teamwork, mgment abnl EFM and hemorrhagemgment abnl EFM and hemorrhage

Return on InvestmentReturn on Investment

Interdisciplinary OB simulation Interdisciplinary OB simulation program started with seed money program started with seed money from risk managementfrom risk management

After 6 + years lawsuits and claims After 6 + years lawsuits and claims decreaseddecreased

Return on investment calculated > Return on investment calculated > 300%300%

Publication pendingPublication pending

Simulation Based Training Simulation Based Training to Impact Patient Careto Impact Patient Care

System barriers to evidence System barriers to evidence based practicebased practice

Establish evidence based policies, Establish evidence based policies, procedures, guidelinesprocedures, guidelines

In-situ simulation run to see where In-situ simulation run to see where barriers are to implementing barriers are to implementing evidence based careevidence based care

Address system issues before staff Address system issues before staff education and wide-spread education and wide-spread implentationimplentation

Rare event preparationRare event preparation

Simulation to prepare for rare eventsSimulation to prepare for rare events Train staff on procedureTrain staff on procedure Uncover and address system issuesUncover and address system issues Further refine patient management Further refine patient management

planplan Anticipate complications and Anticipate complications and

solutionssolutions

Targeted trainingTargeted training

Selected group (code team)Selected group (code team) 15 minute training session at beginning 15 minute training session at beginning

of day and night shiftof day and night shift Goals: Goals:

Introduce team membersIntroduce team members Review role of each team memberReview role of each team member Resuscitation drill with feedback Resuscitation drill with feedback

based on AHA guidelinesbased on AHA guidelines

Orientation to hospitalOrientation to hospital

Series of simulations for new staff that Series of simulations for new staff that review key tasksreview key tasks Admission, transferAdmission, transfer Preparation for surgeryPreparation for surgery Blood administrationBlood administration Wound careWound care RRTRRT

JONA 2010;40(10):424-31JONA 2010;40(10):424-31

Determination of best unit Determination of best unit practicepractice

Staff participated in stat CS in situ Staff participated in stat CS in situ drilldrill

Time from beginning of drill to time in Time from beginning of drill to time in room measuredroom measured

Video of staff with best times Video of staff with best times examinedexamined

Best practice determined, Best practice determined, disseminated to staffdisseminated to staff

Sentinel event reviewSentinel event review

In situ drill of staff involved in event In situ drill of staff involved in event Clinical record also used to guide Clinical record also used to guide

scenarioscenario Goal: Goal:

Determine what circumstances led Determine what circumstances led to event to event

Address issues to prevent repetition Address issues to prevent repetition of above circomstancesof above circomstances

Preparation for opening Preparation for opening patient care areapatient care area

Simulation depicting every day Simulation depicting every day scenarios to uncover system barriersscenarios to uncover system barriers

Uncover any physical changes that Uncover any physical changes that need to be madeneed to be made

Prepare staff to use equipment, Prepare staff to use equipment, become familiar with spacebecome familiar with space

Practice emergency responsePractice emergency response

Interdisciplinary trainingInterdisciplinary training

Staff training for a particular Staff training for a particular diagnosisdiagnosis

Ideal time to include learning Ideal time to include learning objectives for behavioral skills objectives for behavioral skills CommunicationCommunication Role delegationRole delegation LeadershipLeadership

Research – Knowledge Research – Knowledge deficitdeficit

Study that launched research seriesStudy that launched research series Cohen, Andes, Carvalho Cohen, Andes, Carvalho

Assessment of knowledge Assessment of knowledge regarding CPR of pregnant womenregarding CPR of pregnant women

Anes, OB and EM staff tested; 25-Anes, OB and EM staff tested; 25-40% questions for preg specific 40% questions for preg specific interventions answered incorrectlyinterventions answered incorrectly

Int J Obstet Anes 2008;17:20-25Int J Obstet Anes 2008;17:20-25

Research – Analysis of Research – Analysis of performanceperformance

18 interdisciplinary OB teams eval in 18 interdisciplinary OB teams eval in unrehearsed unannounced OB codeunrehearsed unannounced OB code

Proper compressions and Proper compressions and ventilations delivered in slightly ventilations delivered in slightly more than 50%more than 50%

Pregnancy specific interventions Pregnancy specific interventions frequently neglectedfrequently neglected

Am J Obstet Gynecol 2010;203:179.e1-5Am J Obstet Gynecol 2010;203:179.e1-5

Research - RCTResearch - RCT

Labor Room Setting Compared With Labor Room Setting Compared With the Operating Room for Simulated the Operating Room for Simulated Perimortem Cesarean DeliveryPerimortem Cesarean Delivery

15 interdisciplinary teams randomized 15 interdisciplinary teams randomized to deliver in LDR vs ORto deliver in LDR vs OR

Significantly faster in LDRSignificantly faster in LDR

Obstet Gynecol 2011;118:1090-4.Obstet Gynecol 2011;118:1090-4.

Publication – Life Support Publication – Life Support Simulation ProgramSimulation Program

Combination of BLS, ACLS, NRPCombination of BLS, ACLS, NRP Interdisciplinary staff that work Interdisciplinary staff that work

together on L&Dtogether on L&D On-line programs completed before On-line programs completed before

simulation daysimulation day Mega code – combined Mega code – combined

maternal/neonatal arrestmaternal/neonatal arrest

JPNN 2012;26(2):126-35.JPNN 2012;26(2):126-35.

ResearchResearch

Compare quality of chest compressions Compare quality of chest compressions and ventilation stationary vs during and ventilation stationary vs during transporttransport

“…“…data confirm our hypothesis and data confirm our hypothesis and demonstrate that transport negatively demonstrate that transport negatively affects the overall quality of affects the overall quality of resuscitation on a mannequin during resuscitation on a mannequin during simulated maternal arrest.”simulated maternal arrest.”

Anesth Analg 2013;116:162-7Anesth Analg 2013;116:162-7

““These findings, together with These findings, together with previously published data on previously published data on transport-related delays when transport-related delays when moving from the labor room to the moving from the labor room to the operating room further strengthen operating room further strengthen recommendations that perimortem recommendations that perimortem cesarean delivery should be cesarean delivery should be performed at the site of maternal performed at the site of maternal cardiac arrest. “cardiac arrest. “

Anesth Analg 2013;116:162-7Anesth Analg 2013;116:162-7

Consensus StatementConsensus Statement

Anesth Analg 2014;118:1003-16Anesth Analg 2014;118:1003-16 The Society for Obstetric Anesthesia The Society for Obstetric Anesthesia

and Perinatology Consensus and Perinatology Consensus Statement on the Management of Statement on the Management of Cardiac Arrest in PregnancyCardiac Arrest in Pregnancy

Consensus StatementConsensus Statement

SOAP statementSOAP statement “…“…improve maternal resuscitation by improve maternal resuscitation by

providing health care providers providing health care providers critical information (including point-critical information (including point-of-care checklists) and operational of-care checklists) and operational strategies relevant to maternal strategies relevant to maternal cardiac arrest.”cardiac arrest.”

Preparation for Simulation Preparation for Simulation Based TrainingBased Training

PreparationPreparation

Determine what kind of simulation Determine what kind of simulation needed/impact on patient careneeded/impact on patient care

Instructors attend/have attended a Instructors attend/have attended a simulation instructor training simulation instructor training programprogram

Time designated for developing Time designated for developing simulationsimulation

LogisticsLogistics

Staff attendance supportedStaff attendance supported Location (sim center or in situ)Location (sim center or in situ) Number and mix of learners should Number and mix of learners should

mimic response needed to manage mimic response needed to manage scenarioscenario

For entire unit training, determine For entire unit training, determine how many simulation sessions how many simulation sessions neededneeded

Learner preparationLearner preparation

Give learners information about Give learners information about cognitive skills neededcognitive skills needed

Technical skill practice before Technical skill practice before scenario supports muscle memory scenario supports muscle memory and familiarizes learners with and familiarizes learners with simulation equipmentsimulation equipment

Record It!Record It!

Record/audio Record/audio videovideo

No disputes about No disputes about actual eventactual event

Analysis for Analysis for research, metricsresearch, metrics

Visualization of Visualization of positive behavior, positive behavior, areas for areas for improvementimprovement

Changing Culture: Changing Culture: The Circle of SafetyThe Circle of Safety

Analysis of training/Analysis of training/Correction of issuesCorrection of issues

Care of real patientsCare of real patients

Risk Management, Risk Management, Quality AssuranceQuality Assurance

datadataSimulation trainingSimulation training

Mannequin ManufacturersMannequin Manufacturers

Simulaids Simulaids www.simulaids.com Laerdal Laerdal www.laerdal.com METI METI www.meti.com Gaumard Gaumard www.gaumard.com Limbs and things Limbs and things www.golimbs.com

ReferencesReferences

Riley W et al. Didactic and Simulation Riley W et al. Didactic and Simulation Nontechnical Skills Team Training to Improve Nontechnical Skills Team Training to Improve Perinatal Patient Outcomes in a Community Perinatal Patient Outcomes in a Community Hospital. Joint Commission J Qual Patient Safety Hospital. Joint Commission J Qual Patient Safety Aug 2011; 37(8): 357-364. Aug 2011; 37(8): 357-364.

Boston-Fleischhauer C. Enhancing Healthcare Boston-Fleischhauer C. Enhancing Healthcare Process Design with Human Factors Engineering Process Design with Human Factors Engineering and Reliability Science, JONA 38(1) pp 27-32.and Reliability Science, JONA 38(1) pp 27-32.

Andreatta P et al. Interdisciplinary team training Andreatta P et al. Interdisciplinary team training identifies discrepancies in institutional policies identifies discrepancies in institutional policies and practices. AJOG 2011 Oct;205(4):298-301.and practices. AJOG 2011 Oct;205(4):298-301.

ReferencesReferences

Weaver SJ et al. Twelve best practices for team training Weaver SJ et al. Twelve best practices for team training evaluation in health care. Jt Comm J Qual Patient Saf 2011 evaluation in health care. Jt Comm J Qual Patient Saf 2011 Aug;37(8):341-9.Aug;37(8):341-9.

  Hansen SS et al. Implementing and sustaining in situ drills Hansen SS et al. Implementing and sustaining in situ drills to improve multidisciplinary health care training. JOGNN to improve multidisciplinary health care training. JOGNN 2012;41(4):559-702012;41(4):559-70

Buljac-Samardzic M et al. Interventions to improve team Buljac-Samardzic M et al. Interventions to improve team effectiveness: a systematic review. Health Policy 2010 effectiveness: a systematic review. Health Policy 2010 Mar;94(3):183-95Mar;94(3):183-95

Riley W et al. Detecting breaches in defensive barriers Riley W et al. Detecting breaches in defensive barriers using in situ simulation for obstetric emergencies. Qual Saf using in situ simulation for obstetric emergencies. Qual Saf Health Care 2010 Oct;19 Suppl 3:i53-6Health Care 2010 Oct;19 Suppl 3:i53-6

jarafeh@stanford.edujarafeh@stanford.edu