Emergency situations arise in health care every

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1 KSENIA ZUKOWSKY, PHD, APRN, NNP-BC Section Editor Simulation Training A Multidisciplinary Approach Leigh Ann Cates, MSN, RN, NNP-BC, RRT-NPS ABSTRACT Emergency situations arise in health care every day. High-risk environments such as Neonatal Intensive Care Units and labor and delivery units are more susceptible to such emergencies. Occasionally, newborns require assistance with their breathing in the delivery room, while others demand intensive resuscitation including intubation and chest compressions. Delivering resuscitative efforts can be difficult when the team trains in separate venues. This article will discuss the importance of multidisciplinary high-fidelity simulation training as an effective tool in the development and maintenance of resuscitation expertise across disciplines, the history of simulation, simulation legislation, and the evidence behind simulation and explore the art and utilization of medical simulation in a multidisciplinary setting. KEY WORDS: debriefing, multidisciplinary, healthcare, scenario, simulation, simulator Emergency situations arise in health care every day. High-risk environments such as NICU and labor and delivery units are more susceptible to such emergencies. Approximately 10% of all newborns require assistance with their breathing in the delivery room, 1 and 1% to 10% of newborns require intensive resuscitation including intubation and chest compressions. 1 The World Health Organization estimates that skillful resuscitation of neonates can protect 1 million infants per year. 1 So, the question remains that how do health care providers acquire and maintain experience and expertise if during their training and practice, it is not possible to encounter all types of patients, clinical situations, and diseases? This difficulty is compounded by the fact that we learn and train separately in our own disciplines. The airline, military, and nuclear power industry suggest that multidisciplinary simulation can safely bridge the gap between education and clinical practice. This article will discuss the importance of multidisciplinary high-fidelity simulation training as an effective tool in the development and maintenance of resuscitation expertise across disciplines, the history of simulation, simulation Author Affiliations: Texas Children s Hospital, Houston; and University of Texas Medical Branch, Galveston. Correspondence: Leigh Ann Cates, MSN, RN, NNP-BC, RRT-NPS (lacates@texaschildrens.org). DOI: /ANC.0b013e318210d16b legislation, and the evidence behind simulation and explore the art and utilization of medical simulation in a multidisciplinary setting. SIMULATION HISTORY Simulation as a primary tool for developing critical skills training did not begin in the health care field. In the 1930s, simulation became popular in the aviation industry with the advent of the Link trainer, which was used in flight and military applications. After further review of postcrash black box recordings and analysis of in-flight crises, the aviation industry discovered that 67% of mistakes made during flight involved deficiencies in communication. 2 This finding motivated the aviation and space industries to mandate annual training in crew resource management (CRM) and flight simulation and require trainees to display true cognitive, technical, and behavioral skills, while working in a realistic environment. 3 By placing emphasis on effective teamwork, communication, and skill demonstration, simulation training effectively increased safety and reliability within aviation, space, military, and nuclear power industries. Although long recognized as effective, simulation in health care has been slow to evolve secondary to past limitations in technology and cost-effectiveness. Anesthesiologists and members of the operative health care teams were the first to embrace medical simulation for resident training in high-risk operations where human error can result in patient morbidity and mortality. 4 Video recordings of mock Advances in Neonatal Care Vol. 11, No. 2 pp

2 96 Cates resuscitations on human patient simulators led to the creation of an effective medical flight simulator, which then underwent further technological development and standardization by the military. As a result, medical simulation today is an affordable, standardized, and highly effective method of training and reducing human error in the health care industry. SIMULATION LEGISLATION Despite the high incidence of medical errors, health care is one of the few high-risk industries that do not currently require routine rehearsals and debriefings. In 1999, the Institute of Medicine issued a report entitled To Err is Human: Building a Safer Health System. This report illustrated that 70% of mistakes in medicine are due to human error. Surprisingly, these sentinel mistakes were not due to gaps in medical knowledge. Rather, the majority of errors resulted directly from a lack of teamwork and effective communication. 5 In 2004, the Joint Commission Issued a Sentinel Event Alert where 47 sentinel event cases were reviewed. The root causes were found to be errors in communication (72%) and safety culture (55%). 6 Problems identified included rare use of closed-loop communication and health care provider discomfort when publicly identifying impending errors. As a result, the Joint Commission recommended team training to teach health care staff to communicate more effectively during critical events and debriefings to evaluate performance within hospital systems. 6 Randy Forbes (Republican-Virginia) and Patrick Kennedy (Democrat-Rhode Island) reintroduced legislation in 2009 that supports simulation in health care. The Enhancing SIMULATION Act of 2009 HR 855 focus is safety in medicine utilizing leading advanced simulation technologies to improve outcomes now. Specifically, this act will help to create medical simulation centers of excellence across the United States of America, as well as provide leadership and research into advancing the field of simulation. Furthermore, it will assist to establish medical simulation grants for academic and professional organizations, promote innovation in medical simulation within the Department of Health and Human Services, and will aid in establishing a coordinating council for federal government collaboration on medical simulation efforts. 7 This act has been referred to the House Committee on Energy and Commerce, where as of publication, it awaits further action. THE ART OF MULTIDISCIPLINARY HEALTH CARE SIMULATION Multidisciplinary health care simulation is an attempt to recreate one or more aspects of medical care by creating a realistic and safe learning environment. Through simulation, members of different health care disciplines are able to practice their skills as a team in areas of communication, assessment, diagnosis, and treatment of the patient just as they would in a real situation. The team training is not only interactive and realistic, but also provides immediate feedback for learners through the debriefing process. Simulation is also designed to train to the team s weaknesses rather than strengths, thus minimizing the risk of repeated failures and false confidences. Finally, multidisciplinary health care simulation helps improve outcomes that are difficult to teach or assess by conventional methods of education. The art of multidisciplinary health care simulation involves 3 main teaching methods. The first method is the scenario. A well-planned scenario will ensure that the participant(s) are immersed in a realistic situation. Simulated events are often most effective when they have been experienced and documented by the person(s) creating the scenario. In addition, the experience is best thought through for a multitude of possible responses that the learner might take and the realistic consequence of each separate action. These situations might encompass immediate events such as those surrounding the unexpected delivery of a critically ill infant with congenital heart disease or a congenital diaphragmatic hernia. They may also include training for ongoing high-risk procedures such as full body cooling, extracorporeal life support, or the transport of a sick infant. In addition, simulation can be used to teach better communication techniques including the delivery of bad news. Finally, scenarios offer excellent assessment modules for certifications. The next method involves the simulator, which mimics a patient, physical space, and/or equipment designed to replicate a critical event. SimNewB is a high-fidelity simulator especially intended for the neonatal arena designed by Laerdal, headquartered in Wappingers Falls, New York, with the assistance of the American Academy of Pediatrics. Its functions consist of realistic anatomy with variations in tone and color ranging from pink and vigorous to limp and cyanotic. The simulator can cry, grunt, and hiccup. The airway is designed to allow for training in all aspects of newborn airway management including the use of positive-pressure airway devices and the placement of ETT and LMA. SimNewB provides realistic heart and breath sounds, and can respond to the learner s actions by altering its chest rise and lung compliance. The simulator has a patent umbilicus with a life-like pulse that can be palpated, cut, and catheterized for intravenous access. Intraosseous access in both legs is also possible. Gaumard, based in Miami, Florida, produces another effective newborn simulator called Newborn Hal that has many of the above features and is also tetherless for use in mobile or transport scenarios. Gaumard also produces Noelle, a high-fidelity birthing maternal simulator for training personnel in

3 Simulation Training: A Multidisciplinary Approach 97 obstetrical fields. In addition to displaying realistic vital signs and chest movement, Noelle can deliver an infant vaginally or by cesarean section. She is able to communicate with trainees by programmed 1-line answers or via a microphone and a confederate actor. In addition, Noelle displays both maternal and fetal vital signs via electrocardiographic monitoring. When used appropriately, the simulator should replicate the desired hospital location as closely as possible. Methodology may include use of the simulator in the actual unit or hospital workspace or implementation of simulation areas designed to match the usual flow of activity in these areas. For example, a high-risk delivery scenario may be best set in an operating room with a radiant warmer nearby for immediate infant resuscitation following delivery. The equipment must also be similar to that used in the facility and should be located exactly as the team would usually find it. Participants should be also dressed in their usual hospital clothing such as scrubs and or laboratory coats to assist in a sense of immersion in the scenario. Finally, simulation uses a method of teaching known as the experience (Figure 1). Effective simulation creates a realistic environment to achieve suspension of disbelief on the part of the participant(s). This is accomplished by recreating expected sights, sounds, and smells, as well as through the use of moulage (the art of applying make-up or using theater techniques to provide elements of realism) and standardized patients or actors playing the parts of staff, patients, and/or family members at the bedside. For example, an infant covered in thick meconium may be created by covering the simulator in pea soup or baby food to replicate meconium on the baby. These sensory cues deliver a more realistic experience. The most important part of simulation is debriefing. Dr David Gaba once stated that [s]imulation is just an excuse to debrief, and a survey conducted in 2000 by Rall et al 8 determined that debriefing following simulation is crucial to the learning process. Debriefing the participants immediately following the simulation gives him or her the opportunity to be part of a detailed review of the simulation scenario and his or her responses to critical events. Each aspect of the simulation including level of teamwork, communication, technical skills, and critical decision making can be effectively analyzed and discussed as a group. This is best accomplished using video debriefing, 9 whereby participants watch their own performances and the video feed is stopped at critical moments for discussion and teaching. Debriefing also allows for immediate feedback, an important technique found to increase the effectiveness of adult knowledge acquisition (Figure 2). UTILIZATION OF MULTIDISCIPLINARY HEALTH CARE SIMULATION As discussed earlier, multidisciplinary health care simulation provides exposure to complicated and highrisk clinical events without putting either the patient or the team members at risk. It constructs a safe, nonpunitive atmosphere for unlimited practice of technical skills and training in risky procedures; enables direct observation and assessment of competency and skill FIGURE 2. FIGURE 1. Simulation Control Room at Texas Children s Hospital Simulation Center. This is an actual simulation in progress at Texas Children s Hospital Simulation Center as seen from the control room. The participants are on the other side of a 1-way glass. They are conducting a resuscitation with all the equipment and surroundings that would usually be present. Photo Courtesy of Texas Children s Hospital. Infant moulage, which represents a meconium-covered newborn. SimNewB is pictured as a newborn infant covered in pea soup to represent the visual cues and smell of meconium. This is done to aid in the suspension of disbelief for the participants. Photograph by Leigh Ann Cates. Advances in Neonatal Care Vol. 11, No. 2

4 98 Cates FIGURE 3. FIGURE 4. Video debriefing at Texas Children s Hospital Simulation Center. Pictured is an actual video debriefing during an neonatal resuscitation program course at Texas Children s Hospital Simulation Center in which video of the scenario is replayed. The participants can see and discuss their performance first hand under the guidance of a trained lead debriefing specialist. Photograph by Jim Engle. level of each team member in a realistic situation; immerses participants in the learning environment; and provides immediate feedback to participants. As a result, multidisciplinary health care simulation increases communication and teamwork within a multidisciplinary team to more effectively deliver urgent care to a critically ill patient and concerned family members (Figure 3). The most exciting part of multidisciplinary health care simulation is that we must no longer be in our separate training silos. Simulation can train a multidisciplinary team to perform in their role that would actually perform at the bedside or in the field. The group of participants can be composed of physicians, nurses, nurse practitioners, respiratory therapists, pharmacists, and even child life specialists, just to name a few. This unique manner of training is invaluable in ensuring that a team not only accurately performs an assessment and executes the tasks required, but also communicates and works well as a team, while delivering compassionate care. Figures 4, 5, 6, 7, and 8 show multidisciplinary health care simulation at Texas Children s Hospital Simulation Center. These are examples of how Texas Childrens Hospital untilizes multidisciplinary health care simulation in training scenarios. A multidiciplinary team runs through a complete gamut of situations to develop team work and optimal crisis management. EVIDENCE-BASED PRACTICE There is mounting evidence that health care simulation training is extremely beneficial. Hospitals Delivery. A team of labor and delivery nurses, the obstrtrical postdoctoral fellow and attending obstetrician work as Noelle pushes while in active labor with meconium stained fluid. The neonatology delivery room team awaits delivery of the infant. The baby s father is at the bedside coaching his wife and is excited to see the delivery of their child. Photo Courtesy of Texas Children s Hospital. funded under a US Department of Defense medical simulation trial program in 2009 found that when simulation was used as a training tool, the medical error rate decreased from 30% to 4%. 10 These numbers suggest that simulation could possibly reduce medical error costs by at least $17 billion across the United States. In addition, Shapiro and Simmons in 2002 found that high-fidelity multidisciplinary health care simulation reduced the clinical error rate from 30.9% to 4.4% and significantly improved teamwork attitudes and staff assessments of institutional support. 11 Further support for increased use for health care simulation can be found in several studies. In 1998, FIGURE 5. Handoff. Infant is delivered and is handed quickly to the waiting delivery team for prompt reuscitation. The pictured multidisciplinary team is composed of a peditriacian and a pediatric registered nurse. Photo Courtesy of Texas Children s Hospital.

5 Simulation Training: A Multidisciplinary Approach 99 FIGURE 6. FIGURE 8. Newborn resuscitation. After immediate intubation and suctioning below the cords for meconium, Newborn Hal is quickly stabilzed. His anxious father looks-on at the bedside. Because of the infant s need for higher level of care, the team calls for transport. Photo Courtesy of Texas Children s Hospital. Relief of tension pneumothorax. Upon arrival to the NICU, the infant (Sim NewB) deteriorates and must be further resuscitated by techniques including reintubation and relief of a pneumothorax by needle aspiration. Photo Courtesy of Texas Children s Hospital. Kaczorowski et al 12 found on repeat testing of family medicine residents 6 to 8 months after participation in the traditional neonatal resuscitation program that there was a marked decrease in knowledge and skill performance. However, in 2006, Morgan et al 13 studied 299 students using high-fidelity simulation to evaluate learning specifically in the management of unstable cardiac arrhythmias. They found that their improved performance was statistically significant on a written test. Simulation has been found to be helpful in increasing technical skill proficiencies, particularly in airway management. A study by Overly et al 14 in 2007 discovered that high-fidelity simulation provided a more FIGURE 7. Transport stabilization. The transport team arrives. They are multidisciplinary team composed of a neonatal nurse practioner, registered nurse, and a registered respiratory therapist. The infant (Newborn Hal) is quickly intubated, stabilized, and transfered to the level III NICU. Photo Courtesy of Texas Children s Hospital. detailed evaluation of both institutional teaching efficacy and practitioners ability to manage a patient s airway. Anderson et al 15 in 2006 also found that after exposure to high-fidelity simulated ECLS emergencies, subjects tested demonstrated significant improvements in their technical and communication skills. In conclusion, high-fidelity multidisciplinary health care simulation is an excellent tool for improving teamwork across disciplines, fostering communication, practicing technical skills, and improving patient outcomes and safety. For this reason, simulation-based training will likely soon become the standard for advanced licensure and board certification. 16 The time has come to embrace health care simulation as a key component of quality improvement in our hospitals and multidisciplinary training programs. For more information on multidisciplinary health care simulation at Texas Children s Hospital, please view this video on our Web site at mms://video. texaschildrenshospital.org/presentationvideofinal MixCopyQuickTimeH.264.wmv. References 1. Kattwinkel J, Niermeyer S, Nadkarni V, et al. ILCOR advisory statement: resuscitation of the newly born infant an advisory statement from the pediatric working group of the International Liaison Committee on Resuscitation. Circulation. 1999;99: Accessed May 20, Billings CE, Reynard WD. Human factors in aircraft incidents: results of a seven year study. Aviation Space Environ Med. 1984;55: Weiner EL, Kanki BG, Helreich RL, eds. Cockpit Resource Management. San Diego CA: Academic Press; Howard SK, Gaba DM, Fish KJ, et al. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviation Space Environ Med. 1992;63: Kohn L, Corrigan J, Donaldson M, eds. To Err is Human: Building a Safer Health System. Committee on Quality in America. Washington DC: National Academy Press; Joint Commission on Accreditation of Healthcare Organizations. JCAHO 2004 sentinel Event alert on perinatal death and disability. simulation/jcahosentinelevent.pdf. 7. Advanced Initiatives in Medical Simulation. H.R. 855 The Enhancing SIMULATION Act of Advances in Neonatal Care Vol. 11, No. 2

6 100 Cates 8. Rall M, Manser T, Howard S. Key elements of debriefing for simulator training. Eur J Anaesthesiol. 2000;17: Fanning FM, Gaba DM. The role of debriefing in simulation-based learning. Soc Simul Healthc. 2007;2(2): Forbes RJ, Ortiz S. Congressional modeling and simulation caucus Accessed May 20, Shapiro MJ, Simmons W. High fidelity medical simulation: a new paradigm in medical education. Med Health. 2002;85(10): Kaczorowski J, Levitt C, Hammond M, et al. Retention of neonatal resuscitation skills and knowledge: a randomized controlled trial. Fam Med. 1998;30(10): Morgan PJ, Cleave-Hogg D, Desousa S, Lam-McCulloch J. Applying theory to practice in undergraduate education using high fidelity simulation. Med Teacher. 2006;28(1): Overly FL, Sudikoff SN, Shapiro MJ. High fidelity medical simulation as an assessment tool for pediatric residents airway management skills. Pediatr Emerg Care. 2007;23(1): Anderson JM, Murphy AA, Boyle KB, Yaeger KA, Halamek LP. Simulating extracorporeal membrane oxygenation emergencies to improve human performance. Part II: assessment of technical and behavioral skills. Simul Healthc. 2006;1(4): Halamek LP. The simulated delivery-room environment as the future modality for acquiring and maintaining skills in fetal and neonatal resuscitation. Semin Fetal Neonatal Med. 2008;13(6):