Multiple patient encounter simulations in emergency medicine

Introduction

The use of simulation-based education in emergency medical curricula has been widely established and reported in the literature. The simulations, however, are often a single patient simulation. That is, either one, or a small group of learners, approach one simulated manikin or human actor patient and perform tasks as appropriate to the educational learning objectives. Unfortunately, however, this does not mirror clinical practice with clinicians reportedly spending at least 21% of their time multitasking and performing simultaneous activities due to the very nature of their work.¹ Reports of multiple patient encounter simulations (MPESs), whereby learners are exposed to more than one patient simultaneously, are scarce. Kobayashi et al^{2 3} describe using multiple high-fidelity manikins to test cognitive strategies and teamwork effectiveness when dealing with multiple clinical scenarios and also outline a prehospital disaster scenario combining a mixture of manikins and actors to test a prehospital response to a ‘dirty bomb’ incident. We describe how an emergency medical-based MPES was staged for a group of emergency medicine (EM) trainees, challenges associated with MPES as well as the potential benefits MPESs have to offer.

Multiple patient encounter simulation

An MPES activity was created for a group of emergency department (ED) trainees based in the UK as part of their educational programme (figure 1). It was decided that three patients would be the optimal number to simulate for this pilot session to assess feasibility in terms of technical ability, geographical space required and learning objectives desired. Three real cases were selected from one night shift that were appropriate for an ED simulation and adjusted appropriately. Copies of real blood results, ambulance documentation and ECGs were used to add realism to the scenarios. Learners were introduced to the exercise via a presimulation briefing and orientated to the simulation ward where the simulations were to occur. For this session, two manikin-based simulators (Simman 3G and Simman essential, Laerdal) were used and one human patient actor.

Figure 1.

Outline of the three-patient (two manikin, one human actor) emergency medical multiple patient encounter simulation. Each scenario has specified learning objectives outlined with overarching MPES outcomes including situational awareness, delegation and multitasking skills, clinical decision-making and teamwork. MPES, multiple patient encounter simulation.

Objectives were predefined pertaining to each individual clinical scenario as well as for the global MPES. A team leader was identified prior to scenario immersion. Participants, in groups, were exposed to the first scenario (diabetic ketoacidosis) before being given information pertaining to one of the other patients (cardiac tamponade) and later on the final patient (chronic obstructive pulmonary disease with sepsis). A nurse acting as a confederate within the simulation gave participants additional pieces of information pertaining to the three patients throughout the simulation. Participants had to manage the clinical issues for each of the three scenarios as well as employing skills such as teamwork, leadership, situational awareness and multitasking. Finally, at the end of the exercise, a facilitated debrief was conducted including facilitators, learners and confederates (including the human patient actor) covering both individual clinical learning objectives for each scenario as well as the overarching MPES objectives.

Benefits and challenges of MPES

MPESs require careful planning beforehand to ensure smooth running. Clear learning objectives for both individual patient scenarios and the whole MPES have to be defined prior to the exercise. Indeed, having more than one scenario running adds a significant level of complexity to the simulation exercise, which requires careful management. MPES has a number of benefits: exposure to multiple patients is similar to that which occurs in real-life practice. Indeed, the role of the ED trainee often involves managing the whole department as well as being involved in the individual management of clinical cases. This role, particularly for more junior trainees, is daunting and it may be that simulation-based education aids in the transition from novice (managing one patient) to expert (can manage a team managing multiple patients).⁴ Furthermore, the MPES enables particular elements of non-technical skills to be practised. These additional skills include situational awareness (in our example, identifying the number and acuity of unwell patients and responding to confederates cues); multitasking (multiple tasks required for each patient and the patients as a group); prioritising (deciding in which order to see patients and perform particular tasks for each patient); delegating and teamwork skills and managing distractions and interruptions. These areas, as well as the clinical and technical aspects of the simulations, were also addressed in the postsimulation debrief.

MPESs require a significant amount of time in the planning, production and postevent debrief compared with traditional one-patient simulations. In our example, the faculty included a technician, a simulation-facilitator, a human patient actor and a nurse confederate. The faculty required pre-event briefing and each ‘patient’ required the generation of relevant paperwork. Organisation was key to its success; to ease confusion between ‘patients’, each scenario was printed on different coloured paper to ensure that the facilitator could easily identify additional pieces of information (eg, ECGs and arterial blood gases) for each patient at the required time during the scenario. Issues requiring to be addressed when conducting MPES include considering the numbers of learners participating, thought of the fidelity of the simulations required to achieve learning objectives, consideration of cost and value, outlining individual and whole scenario storyboards with learning objectives, practising with all staff prior to conducting the simulations and paying particular attention to the briefing and debriefing aspects of the simulation-based exercise.

By outlining our experience of MPES, we hope to add to the evidence that MPESs are feasible to conduct and that the additional effort required in preparing and conducting MPES is worth the investment as additional, relevant learning outcomes of increased complexity for EM trainees and trainees from other specialties requiring simultaneous patient contacts can be achieved.