Simulation Journal Club: In-Situ Simulation

This paper was out of Cincinnati Children’s Hospital Center, a level-1 trauma center with over 90,000 pediatric ED visits a year. The paper begins by defining “in-situ simulation” as “team-based training technique conducted in actual patient care units using equipment and resources from that unit and involving actual members of the healthcare team” or ‘crash-testing the dummy.’ The main focus of the paper was to run in-situ medical and trauma simulations to discover previously undetected, or ‘hidden’, latent safety threats (LST). LSTs are defined as “system-based threats to patient safety that can materialize at any time and are previously unrecognized by healthcare providers, unit directors, or hospital administration.” They classified identified LSTs into 4 categories using a standardized debriefing template: medication, equipment, resources, and miscellaneous categories. LSTs were identified by either the participants or the simulation facilitators. 

In-situ simulations were run over a 1-year period, as part of ‘emergency response activations’, in the resuscitation bay of the ED. In total, there were 90 simulations performed incorporating 218 healthcare providers. 

73 LSTs were identified for a rate of one per 1.2 simulations performed. This compared favourably with lab-based simulation (AKA simulation center-based) sessions that identified a latent safety threat at a rate of one per 7 simulations performed. The authors reported that the ED found solutions to all but 2 of the LSTs identified, although no explanation of the process was described. 

Our conclusion is that in-situ simulation is potentially a great tool for quality-improvement. It can identify hidden errors that are not revealed until resources are stressed such as in medical or trauma resuscitations. Of note, a post-training survey was sent immediately sent to participants after the simulation. The survey showed that staff found the simulations very valuable, but 77% reported little or no clinical impact. This seemed a bit contradictory. 73 LSTs were identified with a solution reported for 97% of them (71/73), but 77% reported little or no clinical impact? Possible explanations to this contradiction are not enough buy-in from participants, inadequate orientation as to the purpose of the simulations, non-impactful LSTs were identified, and that only ⅓ of LSTs were identified by participants (⅔ by facilitators) making the learning points for participants less effective. One of the major goals of simulation during debriefs is for team members to have self-reflection and self-realization of the educational goals, not to have them pointed out to them. Other possibilities are that participants weren’t involved with the follow-up problem-solving process or were never informed of the solutions. 

For me, the sentiment that the program had no clinical impact is a reminder that we need complete buy-in from all parties involved: hospital leadership, administration, attending physicians, nurses, PCA/PCTs, clerks, and any other interdisciplinary team or medical specialty involved. The purpose of the simulations needs to be clarified to all beforehand, debriefing needs to done in a format where LSTs and learning points are discovered by participants themselves, and participants must be part of the solution process or notified when solutions are found.