Off-ward paediatric in situ simulation: are we ready?

Introduction

In our tertiary paediatric centre, we carry out frequent unannounced in situ simulations. While conducting simulations on acute wards, we have encountered a variety of latent safety threats (LSTs) and barriers to effective patient care. There are numerous off-ward areas in the hospital in which children are assessed and may receive treatment. Some of these areas are difficult to access and are located in parts of the hospital with which staff may be unfamiliar. We designed a project to determine how prepared staff working in these areas would feel if required to manage an unwell child in an emergency. We explored this further using simulation to detect any potential barriers to the effective management of emergencies and to initiate a process by which these could be addressed. The aim of the project was to develop systems to improve patient safety and ensure efficient care could be delivered throughout the entire hospital.

Methods

The project was registered with the Standards, Quality and Audit Department and our Service Manager was consulted. We conducted surveys in five off-ward areas. We asked staff about their previous resuscitation training and whether they had any previous experience of managing emergencies in the area in which they work. We also asked if there was an agreed process for managing emergencies in their area. The departments included were the electroencephalogram (EEG) department, radiology, paediatric outpatients, physiotherapy and speech and language therapy (figure 1). Following this, we conducted unscheduled simulations within these areas. We recorded any identified LSTs and barriers to patient care. Postsimulation feedback was obtained from the staff involved during a structured debrief. Discussion around the challenges encountered during the emergency scenario was actively encouraged. Typed feedback was provided to each department, including an action plan on how systems and safety issues raised during the simulation would be addressed (figure 1). We plan to further expand our project to include additional areas including the new MRI unit and the oncology outpatient treatment unit.

Figure 1.

Off-ward simulation in radiology department and a copy of the feedback report provided to electroencephalogram (EEG).

Results

In the initial survey, all staff reported having received hospital life support training. Four out of the five areas felt confident to manage an emergency. Three of the areas reported prior experience of a child becoming unwell in the area. Three areas also stated that they had a departmental protocol for managing emergencies. It is interesting to note that the three areas with a departmental protocol for emergencies were not the same three areas in which children had previously become unwell.

The in situ simulations involved medical, nursing and allied healthcare staff including radiographers, physiotherapists and clinical physiologists. We identified one actionable safety threat. During the scenario in the EEG department, the ‘crash team’ was called but incorrect team members were bleeped. This was actioned by the completion of an incident report form. A number of other more minor issues resulted in confusion and delays in management. In some cases, there was a lack of a clear pathway for whom to contact in an emergency, particularly if the child was attending as an outpatient. Staff identified having some difficulty in knowing how to structure a telephone request for help. It was noted that a number of clinical areas did not have monitoring equipment or other resuscitation aids and would have to source these pieces of equipment from the wards if they were required in an emergency. Each issue was discussed with the staff present and plans were made to address them.

All staff either strongly agreed or agreed that the simulations were worthwhile. In addition, 15 out of the 17 either strongly agreed or agreed that they felt more confident in managing an emergency in the clinical area following the simulation. Ninety-four per cent of staff (16 out of 17) reported agreeing or strongly agreeing to being more aware of and more confident of the procedures for managing and emergency in their particular area.

Discussion

In situ is a Latin phrase which translates as ‘on site’ or ‘in location’. Furthermore, in situ simulation have been defined as ‘simulation that occurs in the actual clinical environment and whose participants are on-duty clinical providers during their actual working day’.¹ Physically integrating simulation into the clinical environment enhances realism and ensures that staff are participating in authentic roles. These have been identified by participants as important factors in enhancing the authenticity of the learning experience.² Perhaps more importantly, there is a significant wealth of literature emerging advocating the use of in situ simulations in identifying LSTs and system issues which may compromise patient safety.^{3 4} By performing simulations in off-ward areas, we were able to identify and address potential safety threats and factors which may delay the administration of appropriate emergency management in the case of a real resuscitation. It has been cited that implementation of in situ simulation training may be hindered by cultural issues, performance anxiety, time pressures and patient perceptions.⁵ However, we found that all staff involved agreed that the simulations were worthwhile and 88% of staff felt that the simulation had improved their confidence in managing an emergency in their clinical area. We did not encounter any objections from the staff involved. This differs from previous experience in acute care areas and perhaps stems from a recognition by staff that they are located in an isolated area feel the need for further training. In a separate project, we have also surveyed parent opinion and found that they are overwhelmingly in favour of ongoing training for health professionals including the use of in situ simulation.

We recognise that there are practical challenges associated with delivering in situ simulation and that it is difficult to prove that it directly improves patient outcomes. However, our experience in the use of off-ward in situ simulation has been very positive. We have identified a number of LSTs which could have led to patient harm and would therefore strongly advocate the use of in situ simulation in off-ward areas by all centres.