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Use simulation training to boost your facility's culture of safety


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Many hospitals and medical schools offer some variation of simulation-based training in which nursing and medical students learn clinical techniques of suturing and administering medication by using lifelike mannequins. This strategy of helping clinicians develop skills on mannequins before treating actual patients is nothing new, but some hospitals are taking things to the next level by tying simulation to a newer concept: a culture of safety.

With the involvement of multiple levels of clinicians and nonclinicians in simulation centers designed with patient rooms, nurses’ stations, and physician rooms, hospitals now use simulation training to improve patient safety through communication and teamwork.

Patient safety starts with teamwork

When the 450-bed Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, NH, renovated its second floor, hospital leaders made part of it into an 8,000-square-foot simulation center. The center is equipped with six patient rooms, an ICU, mannequins, and a nurses’ station.

“It’s a mini hospital,” says George Blike, MD, quality and patient safety officer at DHMC and medical director at its Patient Safety Training Center. Having hospital leadership support the idea of investing in a simulation center is important to Blike, who says it can be tough to convince people that the answer is not always more production space, but rather more space to make production better.

“It’s a place where people can learn how to learn,” says Blike, emphasizing how quickly medicine changes. “The day you finish your training is the day you start becoming incompetent.” He adds that the center helps fight such complacency and keeps staff members entrenched in new methods and technologies.

“People learn technical skills here, but they are also learning peer communication,” says Blike. “It’s not just medical students and residents, but 7,000 staff who need and want to maintain their skills.”

Patient safety begins with learning simple behaviors, such as how to brief and debrief, says Blike. He notes that a surgical safety checklist—something most hospitals use—is simply a way to ensure teams are briefing and debriefing. Simulation, he says, is all about enforcing these behaviors.

“That’s a good habit to instill in people,” Blike says. “That’s what shifts culture ... they’re learning how to have a [type of] behavior that is useful in every single patient encounter. Hopefully, it is unleashing and moving people over time toward being more reflective practitioners.”

At the Tulane Center for Advanced Medical Simulation and Team Training in New Orleans, medical director James Korndorffer Jr., MD, FACS, is hoping Tulane’s months-old center will benefit the medical students at Tulane University’s School of Medicine, as well as staff members at the Tulane Medical Center. As with DHMC’s simulation center, students and professionals use simulation training with a focus on teamwork. Using an incomplete team for simulation doesn’t make good sense, says Korndorffer.

“When you’re doing a coronary angiogram, for example, it’s not just the cardiologist in there. It’s the cardiologist, the radiation technicians, the nurses ... everybody’s involved,” says Korndorffer. He notes that different simulation events also contribute to a culture of safety by providing a less stressful environment in which clinicians might be more likely to speak up when things aren’t going right.

A good exercise for every hospital

The Agency for Healthcare Research and Quality (AHRQ) is currently funding research studies to determine how simulation training affects patient safety. Among them is a study run by David Gaba, MD, associate dean for immersive and simulation-based learning at Stanford (CA) University and director of the Patient Simulation Center of Innovation at VA Palo Alto Health Care System.

Gaba’s team conducted a baseline safety culture assessment in three diverse hospitals: a large tertiary care academic hospital, a medium-sized suburban hospital, and a 25-bed rural critical access hospital. His team developed three 2.5-day simulation training programs, one for each hospital. The study is ongoing, but Gaba says the training is working.

“No matter how small a hospital is, it’s possible for them to do very useful and beneficial simulation training,” he says. “A lot of people think it’s only for the big academic hospital, and really, that isn’t true.”

Like the other simulation centers, Gaba’s focus is on behavior and teamwork as well as skills.

“In many courses we run, we shoot for about 40% on particular medical and technical issues ... and 60% on generic behavioral principles of decision-making and teamwork, such as using all available information, cross-checking information, calling for help early, team management, leadership, communication, and distribution of workload,” says Gaba.

Simulation, he says, takes many forms: verbal, paper to pencil, standardized patient actors, on-screen simulators, virtual worlds that mimic online video games, surgical and procedural task trainers to practice suturing and other technical skills, team simulation, mannequin simulation in a full simulated clinical environment, or simulation in working hospital areas. Most of the training in centers at Stanford and the three hospitals in the AHRQ study focus on crisis management.

“We give them challenging clinical situations to deal with that address important issues in patient safety. Whether that is done with people in a single discipline or multidiscipline, usually you are addressing import- ant aspects of teamwork,” says Gaba. A lot of the simulation focuses on ICU crises, such as cardiac arrest, sepsis, and anaphylaxis. Gaba says these are common simulation focuses because clinicians don’t always get the chance to work on these events while in the hospital, and the clinical and teamwork procedures in the stressful environment are complicated.

Use simulation training to evaluate learning methods

A simulation exercise is a good and necessary opportunity in which to test staff members’ skills and communication techniques as well as the learning process they’re using.

“One of the big aspects of the center is to determine what works and what doesn’t work [in terms of learning],” says Korndorffer. Part of the testing planned for Tulane is to determine whether practicing central line insertion in the simulation center helps decrease central line infections.

“Everyone that deals with putting in, taking care of, and taking out a central line in the surgical intensive care unit is going to go through a course in the simulation center together—resident and faculty alongside the nurses that work in the ICU,” says Korndorffer. “The goal is to determine any differences in infection rates or complications before and after the course.”

Is simulation training for your hospital?

Although Gaba admits there’s no hard evidence to support the benefits of simulation training for patient safety, a look into other industries’ simulation training, such as aviation, is a strong cue that it’s effective.

Korndorffer notes that not every hospital can afford a massive simulation center or hire the personnel to run it. Still, he advises hospitals to look into options, such as partnering with a local simulation center to perform scenarios at the center or within the hospital or encouraging staff members to learn the curriculum from experts and provide internal training. He says when it comes to simulation training, the focus is not the technology but the curriculum.

“You really have to have the appropriate curriculum to drive [simulation],” Korndorffer says. Without proper learning objectives and goals, all three simulation experts agree that high-tech mannequins can only do so much.