They sweat. They bleed. They moan. They make great teachers.
For the members of the critical airway team at Cincinnati Children’s, everything about the trauma call felt real.
It was a nice day during an unusually mild February, a good day to get outdoors, when airway team members’ pagers started buzzing. A helicopter was on the way, carrying a child who suffered a clothesline-like injury to the neck while riding an ATV.
Within minutes, physicians, nurses and respiratory therapists assemble in the fully equipped trauma bay. As an overhead camera records their actions, the team rolls in a cart of tools and supplies specifically compiled for airway injuries. They prepare equipment, get into protective gear and update each other about the incoming case.
Only when the paramedic rolls in with a patient simulator mannequin instead of a real child does the team discover this is a training exercise. Yet they do not skip a beat.
The mannequin makes rasping, desperate breathing sounds. Monitors chirp and beep in alarm as the vital signs indicate that the child is “crashing.” With all the urgency of a real-life event, team members conduct CPR, push medications and work to open the child’s collapsed airway.
After 30 minutes of intense effort, the team successfully stabilizes the patient. Recalling the exercise, one resident says, “I felt my heart pounding in my chest.”
The staff of our emergency and critical care units come from the best medical schools, nursing schools and allied health programs. They arrive at Cincinnati Children’s with strong skills in critical care techniques and procedures. However, many soon discover they can benefit from polishing the skills required to work as a team.
“We spend hours in the debriefing room going over exercises such as the ATV case,” says Gary Geis, MD, medical director of the Center for Simulation and Research at Cincinnati Children’s. “At least half our time is spent discussing teamwork and communications in crisis situations.”
Traditionally, healthcare teaches technical skills. But non-technical skills such as teamwork and communication also are critically important to patient safety. Simulation gives healthcare providers the ability to practice these skills in a safe environment, Geis says.
Simulation training is required for certain staff at Cincinnati Children’s. All faculty in Emergency Medicine must take four hours a year; so must newly hired nurses and respiratory therapists working in emergency roles. ECMO and NICU teams also use simulators for regular skill-maintenance training.
And simulation plays a growing role in resident training.
“With work-hour restrictions affecting how much time residents spend on the floor, simulation training helps provide the repetition needed to hone skills, especially for procedures that involve rare situations,” Geis says.
Since purchasing its first pediatric mannequin in 2001, the program at Cincinnati Children’s has grown into one of the nation’s largest pediatric simulation centers.
The center includes a 13,000-square-foot space where the team runs three operating room simulation suites, six multipurpose rooms to mimic various patient care settings, three debriefing rooms with 50-inch plasma displays, and a classroom that can seat up to 50 people. The center recently developed a training center on the main hospital campus offering easier access for residents and other staff taking shorter courses.
To set up a simulation, the center can choose from more than 10 adult, child and infant-sized mannequins.
The latest versions can blink, talk, cry, convulse and sweat. They can mimic pulse, blood pressure and other vital signs. They allow vascular access in the arm, plus intraosseous access via the tibia or sternum. They include drug recognition systems that can make the simulator respond based on the types and amounts of medications administered by the trainees.
They even contain blood reservoirs to simulate bleeding gunshot wounds and limb amputations.
Preventing safety events
Simulations also help identify latent safety hazards.
“We do unannounced simulations twice a month, anywhere in the hospital, to help keep code teams at their highest level of readiness,” says Tom LeMaster, RN, MSN, MEd, program director for the simulation center. “We’ve run simulations in the cafeteria, in stairwells, even in the chapel.”
Much of the current emphasis on detecting safety threats traces back to a two-year research grant, awarded to Cincinnati Children’s in 2006 by the federal Agency for Healthcare Research and Quality (AHRQ), to evaluate how medical simulation can improve safety and quality.
The grant supported 12-hour training courses for 289 staff members in the emergency department, pediatric intensive care, cardiac intensive care, surgery and other units. In the first year (2007), the project revealed 73 latent safety threats. In the second year, teams found 134 more, Geis says.
The simulations revealed medication, equipment and supply issues, difficulties contacting key personnel, and other problems. As these issues were raised, departments responded with creative adjustments and improvements.
One fix was as simple as using stickers to highlight an important but hard-to-see button on recently purchased defibrillator devices. Another involved moving varied doses of a frequently used medication to different drawers to prevent grabbing the wrong dose in an urgent situation. Yet another resulted in training sessions after discovering that staff members were not familiar with a new brand of intraosseous needle.
“By uncovering these issues, we were able to make significant changes without a real patient having to suffer,” Geis says.
As important as these discoveries have been, he believes that simulation’s biggest impact has been in fostering better communication.
“We feel like we’ve helped change the culture of teamwork here. Staff are no longer afraid to speak up if they see something unsafe going on.”
Cincinnati Children’s is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The medical center also is an approved provider of continuing nursing education by the Ohio Nurses Association and an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.