The Value of Simulation Training for Hospitals and Health Systems American College of Surgeons Surgical Simulation Meeting March 17, 2017 John R. Combes, MD
Overview Evolving Nature of Health Systems Simulation and System Optimization Inter Professional Education and Development System Design Communication and Teamwork Learning Environment Case Example : Perimortem C-section 2
ACA or Not: Needs and Trends Continue More INTEGRATION across the silos Increased coverage Delivery system reforms Payment reforms Increased transparency Adoption of health IT More AT-RISK FUNDING More PUBLIC ACCOUNTABILITY and reporting 3
CMS Framework Traditional FFS Value-Based (Link to Quality) Hospital VBP Physician VM Readmissions HACs Quality Reporting Alternative Delivery Models ACOs Medical homes Bundled payment Comprehensive Primary Care initiative Comprehensive ESRD Population Health/ At Risk Eligible Pioneer ACOs in years 3-5 Maryland hospitals Volume Value 4
5 Stages of System Development
Simulation and System Optimization Inter-professional team development Initial skill acquisition - improving performance Uncovering clinical variation Promoting efficiency in care delivery Practicing skills and maintaining competency Providing a learning environment for various levels of proficiency 6
Relationship between IPE and Healthcare Simulation 7
Interdisciplinary Simulation Table 6. Competencies Taught in an Interdisciplinary Simulation Environment Medical School Teaching Hospital Medical knowledge (40) 44% (38) 67% Patient care (53) 59% (42) 74% Interpersonal communications skills (5) 59% 3 (48) 84% Professionalism (41) 46% (37) 65% Practice-based learning/ improvement (30) 33% (31) 54% System-based practice (37) 41% (35) 61% Psychomotor tasks (32) 36% (26) 46% Leadership (44) 44% (37) 65% Team training (60) 67% (46) 81% Critical thinking/decision making (38) 42% (41) 72% Overall Usage 47% 67% 8 Source: Medical Simulation in Medical Education: Results of an AAMC Survey, 2011
AHRQ s Essential Benefits Putting Patient Safety First Optimizing Learning Conditions Providing Valuable Feedback Integrating Multiple Skills Providing a Test Bed to Identify Gaps in Technologies, Procedures, and Protocols 9
Case: Perimortem Cesarean Section (PMCS)
Cardiopulmonary Arrest in Pregnancy RARE: Prevalence 1/12,000 (U.S. data 1998-2011) May be related to conditions unique to pregnancy or etiologies found in non-pregnant state Management requires a multidisciplinary approach TWO patients at SH in 20 years No randomized trials ACLS with pregnancy modifications Early delivery by minute 4-5 is KEY to successful resuscitation 11
Professional motivation: Readiness-recognition-response In a profound obstetrical emergency minutes are crucial to the perinatal outcome (DELIVER <15 MIN) and we do this well on our unit, BUT in cardiac arrest (DELIVER <5 MIN) Typical sequential calling system was fraught with error and time consuming using precious minutes OBH first responders on unit were not ACLS providers How to get a scalpel fast 12
Elements of a Perimortem Caesarean Section? Do NOT move patient to the OR Anesthesia NOT necessary Abdominal prep NOT necessary Use incision with which you are most comfortable Close uterus while ACLS/CPR continues Consider palpating aorta to confirm pulse/effectiveness of CPR - May compress aorta to redirect CO Cephalad Stephanie Martin DO
Inter Professional Teamwork OB/Maternal Team BLS Uterine displacement Fetal viability Medical history Perimortem Cesarean Manage PPH Code Team ACLS Intubate-IVs-Medications Internal cardiac massage Neonatal Team Maternal history Gesational age of fetus Resussitation of infant ICU Team Stabilization Therapeutic hypothermia Coagulapathy/massive transfusion
2015-2016 Changes in preparation for PMCS OB Hospitalists agreed to ACLS certification and also to attend simulation courses An OB multidisciplinary rapid response team was formed called the OB STAT TEAM Scalpels were placed in locked med drawers in each L&D and antepartum room and staff aware of their purpose Simulation drills on PMCS 15
Case Presentation 29 y/o G2P1001 at 40w6d admitted for IOL Low risk patient followed by the SHMG Midwives Admit vitals: BP 138/81,P105,T98.2 Induction progressing normally all day 21:48 Fetal Heart Tone deceleration and tracing lost 21:52 Patient becomes limp and unresponsive 22:00 RRT and OB STAT called OB hospitalist and anesthesiologist immediately at bedside. Patient had agonal breaths, thready pulse. Anesthesiologist secured airway 22:09 No pulse. CODE BLUE called CPR initiated 22:13 Code team arrived and intentional handoff of leadership 22:14 Perimortem c-section in delivery suite bed.
Outcomes 17 Baby to NICU and maternal code resumed. Massive transfusion activated. Chest compressions X 25 minutes, code protocol, transfusion of blood products initiated in L&D. Uterine incision closed during code and abdominal incision covered. Transfer to ICU Mother DIC with massive transfusion of 40 units blood products/factor VIIa. Clinical course was consistent with amniotic fluid embolus as cause of arrest Mother discharged Day 9 Infant Baby: female 4200gm Apgars:1/2/3/4/5 at 1/5/10/15/20 minutes Mixed acidosis Cooled X 72 hours for hypoxemic encephalopathy EEG neg for seizure activity on Day 2. and Brain MRI neg Day 3 Baby Discharged Day 10 Team Simulation drills on cardiac arrest
Board Takeaways Simulation is a valuable tool to engender inter-professional development Can help design a system of care particularly for rare unexpected events Renewed awareness of board s role in professional development Reinforces safety as the primary motivation for the staff and organization 18
Questions/Comments John R. Combes, MD The Southport Group Chicago, IL 312-405-9459 jcombes@thesouthportgroup.com 19