Translational simulation in action: using simulation-based multidisciplinary teaching to introduce ward-level high-flow oxygen care in bronchiolitis

Introduction and aims

Acute bronchiolitis is the most common respiratory condition under 1 year of age. In the UK and Ireland, approximately one in three infants will develop bronchiolitis in the first year of life and ~2%–3% of all infants require hospitalisation.¹ In severe cases, children are admitted to paediatric intensive care (PICU) for ventilation and supportive treatment. An admission to a critical care unit is an extremely stressful time for children and their families. It also has significant implications on workload and resources.

High-flow nasal cannula oxygen (HFNCO) is a treatment where oxygen is delivered at high rates via a tight-fitting nasal mask. This treatment has recently been increasingly used to manage bronchiolitis. Recent evidence has suggested that this may have a role as rescue therapy to reduce the proportion of children requiring high-cost intensive care.² Prior to this initiative, this treatment option was only available in PICU in our trust.

In 2016, our team acquired one HFNCO unit in a bid to introduce this treatment at ward level. These attempts to do so, prior to developing an introductory simulation-based collaborative teaching event, failed because of

• Lack of background knowledge.

• Lack of familiarity with new equipment.

• Pre-existing service demands.

• Patient safety concerns.

We identified simulation-based training as an ideal tool to enhance procedural exposure and decrease staff anxiety related to a new treatment option, as well as aiding embedment of a new medical service to the hospital.

Methods

The Paediatric Respiratory and Simulation Education departments designed and co-ordinated a package of five multiprofessional simulated teaching sessions. This approach provided a safe learning environment for staff to familiarise themselves with new protocols, equipment and care pathways before implementation at ward level on real patients. It empowered our teams to be actively involved in a new service provision, which helped overcome their concerns about its impact on an already pressurised workload.

The focused 1-hour teaching session was divided into the following format (table 1):

Table 1.

Teaching session programme

Time	Session
12:00–12:10	Introduction to high-flow oxygen—indications, contraindications and specific role in bronchiolitis
12:10–12:20	Familiarisation with the new RBHSC guidelines for high-flow use in bronchiolitis
12:20–12:30	Practical demonstration of high-flow equipment
12:30–12:45	Simulated scenario
12:45–13:00	Debrief and summary

RBHSC, Royal Belfast Hospital for Sick Children.

Results

Thirty-three staff members received HFNCO teaching—14 medics (10 trainees, 4 consultants), 1 advanced paediatric nurse practitioner, 15 nurses and 3 healthcare assistants. Participants completed a questionnaire following the training sessions to collect both quantitative and qualitative data on the educational experience.

One hundred per cent of participants stated that training as a team in a simulated environment improved their practical skills before using this in a real clinical setting. Ninety-five per cent (31/33) felt significantly more confident in approaching ‘high flow’ after the session.

Qualitative comments were extremely positive, particularly from nursing colleagues. These included

• ‘Practical application and simulated scenario was very useful. Teaching away from the ward was an invaluable opportunity to completely focus on learning’.

• ‘A novel approach to teaching for a new system being introduced to us on the wards. We are involved in the training and feel part of this, which aids relevance and learning’.

• ‘Excellent nursing and medic teaching session. Please use this simulation session as a tool for future teaching on different topics’.

Following this initiative, ‘high-flow’ therapy is now available to infants with bronchiolitis at ward level. Since introduction in November 2017, four patients have been managed entirely at ward level with this treatment. Previously, all of these children would have required admission to PICU. The average length of stay for a patient in Royal Belfast Hospital for Sick Children PICU is two nights,³ and at estimated cost of £3784 per night for an Advanced Critical Care Level 4 Bed,⁴ this initiative has potentially saved the trust £30 272 in the first 10 months (table 2).

Table 2.

Potential financial savings from initiative since inception

	Average unit cost per bed day	Number of patients not admitted to PICU since introduction of ward-level HFNCO	Average length of stay if admitted to PICU	Total estimated savings for first year since inception
PICU Level 4 Critical Care Unit (RBHSC)	£3784	4	2 nights	£30 272

HFNCO, high-flow nasal cannula oxygen; PICU, paediatric intensive care unit; RBHSC, Royal Belfast Hospital for Sick Children.

Discussion

The introduction of any new clinical service to a hospital can be an arduous journey. Staff members can often feel anxious with regards to pre-existing service demands, lack of theoretical knowledge or lack of familiarity with procedural skills (eg, setting up equipment), and thus successful implementation can be met with many barriers.

Simulation training, combined with an interactive training session, has been suggested to be a ‘useful tool for improving procedural competence and decreasing anxiety levels, particularly among those at an earlier stage of training’.⁵

Translational simulation describes those efforts which focus directly on improving patient care and healthcare systems, through identifying safety and performance issues and delivering simulation-based interventions.⁶ While the National Health Service is regarded as a global leader in the field of simulation-based education, and significant investment has been made in personnel, technologies and infrastructure within the healthcare system, further work is needed to develop and strengthen the link between simulation-based initiatives and patient safety, experience and clinical outcomes.⁷

Using multiprofessional simulation, we have worked together to overcome barriers by implementing a new, more appropriate treatment for children with bronchiolitis. We were able to safely shift care from the critical care environment to the ward. This allows these children to be cared for in a less stressful environment in keeping with our commitment to family-centred care. We have saved money and freed up capacity in the regional intensive care department providing cost-effective, patient-centred high-dependency care at ward level.