A view from the ivory tower (by M Moneypenny)

Background

On the 21st of February 2015 there was a brief Twitter exchange between Mark Forrest (@Obidoc) and others regarding the benefits of in situ "applied" simulation versus simulation centres. Although the 140 character limit on Twitter ensures thoughts are distilled, at times this can be difficult to lay out an argument. (The benefits and drawbacks listed below are by no means exhaustive.)

The benefits of in situ

The positives of in situ are manifold. By definition, the participants are in the actual environment (in the resus department, on the ward, at the roadside, under a train) which increases environmental fidelity. They are using their own equipment, guided by their own protocols. One can carry out systems testing and, if the simulation is realistic enough, performance approaches actual performance in real life.

The drawbacks of in situ

If the exercise is taking place in the actual environment there is disruption to the rest of the workplace. This can be minimised by good preparation and planning. Because of this disruption, the number of in-hospital in situ exercises is limited.

For those who extol the realism of in situ, running a simulation in a field or country lane is very different from running a simulation on a busy (and aren't they all nowadays?) hospital ward. The pre-hospital in situ equivalent would be running a simulation alongside a major motorway with a lane closed off.

When is in situ not in situ?

The Uaill Scottish Fire & Rescue Service Training Centre in Glasgow, has its own section of motorway and train track. The fire service runs multi-agency mass casualty simulations here. But the centre, and others like it across the UK, cost millions to build. Is this in situ sim?

Our home, but darn it! Why does it have to be a white tower?

The benefits of sim centres

The sim centre's sole function is as a place where simulation exercises take place. Sim centre personnel are dedicated to certain roles e.g. administrative, technical. Because the sim centre's focus is simulation the faculty are often involved in research and the development of other simulation-based medical educators.

The sim centre can be modified to replicate a "generic" ICU, ward, theatre or resus. The sim centre can accommodate hundreds of undergraduates and other trainees every year which would not be possible on a hospital ward.

The drawbacks of sim centres

Building a sim centre is expensive, although if it is built as part of a new hospital this lessens the expense. If a sim centre solely uses mannequins it is limited by what it can replicate and the "generic" ward or ICU means that it is not actually any ward or ICU. Sim centres may become silos if they don't make and sustain links with other stakeholders such as patient representatives, pre-hospital organisations and higher education institutions.

Final thoughts

A straw man(ikin)

The ivory-towered sim temple which sucks up millions of pounds and doesn't do "real simulation, which takes planning and hard work" is a straw man, which no-one would support. The reality is very different, no-one is throwing millions of pounds at us, with every penny justified and accounted for. Sim centres carry out exercises in the centre and in situ, the SCSC^HF has been in the back of ambulances, in hospital wards, in ICU and paediatric resus. We haven't (yet) been out in a field or at the side of the road, primarily because we feel that colleagues (in the fire service, ambulance service, BASICS) already occupy this niche and do a fantastic job. We use the appropriate technique based on the learning objectives of the learners, this may be high technical fidelity mannequins, part-task trainers, iPad-based sim "monitors" or a cardboard box with a 2-litre reservoir bag inside. 

In conclusion, rather than adopting an "us versus them" attitude, the poor in situ practitioners in the trenches throwing mud at the rich, work-shy inhabitants of the ivory towered temples of simulation, I would suggest an approach which involves communication and cooperation.

Sisyphus and the recurrence of errors

In their book "Managing Maintenance Error: A practical guide" Reason and Hobbs inform us that most errors are predictable:

"...more than half of the human factors incidents in maintenance are recognised as having occurred before, often many times" (p.98)

In healthcare, a similar pattern emerges. For example, a nasogastric tube is wrongly placed into a patient's lungs and the liquid feed is started. In England and Wales, from 2005-2011 twenty-one people died as result of this error. The commonest drug error in obstetric anaesthesia is mistaking thiopentone for an antibiotic and vice-versa. In the UK, there was at least one incident in 2010, two in 2011,  and one in 2012.

These are examples of error traps. In the seascape of human performance, error traps act as whirlpools, seizing the inexperienced, the tired and the distracted. James Reason tells us that the defence against error traps is organisational. In anaesthesia, the Safe Anaesthesia Liaison Group (SALG) publishes patient safety updates which detail adverse incidents and provide suggestions for avoidance and mitigation. The National Patient Safety Agency (NPSA) performed a similar role for the rest of the healthcare system, but it was disbanded in June 2012, its activity subsumed within NHS England. Many individual departments have morbidity and mortality (M&M) meetings where adverse events are discussed and defences created or adjusted. In addition, individuals will create their own personal defences, such as always having the antibiotic in a 30-ml syringe, triply-labelled.

There are problems with all of these solutions. The patient safety updates are not mandatory reading, there is no assessment of the individual or the department or the hospital to ensure that lessons have been learnt. Attendance at M&M meetings can be variable and sharing of the discussions and conclusions may be sporadic. Individual defences may be breached due to performance degradation or by another healthcare worker who is not aware of them.

Sisyphus

Sisyphus (by Titian)

Sisyphus, a deceitful king in ancient Greece, attracted the wrath of Zeus. His punishment: for all eternity he would be forced to roll a boulder up a steep hill, only for it to return to the bottom. In a similar fashion we are doomed to repeat maybe not our mistakes (because we create personal defences) but the mistakes of others. It is extremely likely that the error we were involved with today was made by someone else somewhere else last week or last month.

Solutions

A number of solutions are called for. Nationally, a system for reporting errors, such as the National Reporting and Learning System (NRLS). These error reports need to be analysed by clinicians and human factors experts to reveal error traps. Also nationally, a mandatory requirement for healthcare personnel to inform themselves of adverse events which are occurring in their field. On a local level, a robust reporting system which feeds into the national system as well as a safety culture, including M&M meetings, which encourages and rewards the reporting of adverse events and near misses. Also on a local level, defined responsibility and accountability for maintaining and modifying system defences.

The role of simulation

Simulation has a number of roles to play. First, systems testing using simulated events, such as a major haemorrhage or a fire, if performed correctly, can reveal weaknesses in the defences. Second, the errors that participants make in the simulation centre are likely to occur in the workplace. For example, in the past few years we have had 2 incidents where, in a crisis, a participant has switched off the anaesthetic machine when they meant to switch on the suction. As can be seen from the image, this is an understandable error. The same error occurred in the actual operating theatre. (It is likely that the same error has occurred a number of times across the UK, as the manufacturer has now designed a clear plastic lid for the anaesthetic machine switch, thus creating a physical barrier.) Do we, as simulation centres, have a duty to flag up common errors to the safety agencies? The third role for simulation is to raise awareness of performance limitations and error traps. Although relying on the person "at the sharp end" to defend against all errors is wrong, it is often that person who acts as the final defence when the system breaks down. Making everybody involved more aware of error traps can therefore only be a good thing.

Person-centred care: "What matters most to you today?" by Al May

What's this all about?

I read about an interesting concept via twitter the other day.  My understanding was that a hospital ward somewhere was displaying the message "What matters most to me today:" on whiteboards next to patients. The patients would be asked the question and the answer would be displayed for all to see.

It immediately struck me as a simple but potentially powerful way of putting the patient at the forefront of people’s minds.  As an anaesthetist, I don’t have a ward but I do see a lot of patients pre- and post-operatively.  What would happen if I put this question into my pre-operative conversations with patients?  Before I did it, I tried to consider the potential effects.

What were the possible effects of doing this?

On the positive side it might:

• Unearth some useful information
• Although I always ask if the patient has any questions, closing with this particular phrase is a slightly more structured way of asking and also a second chance for the patient.

• Prioritise what matters
• For example, if a patient answers that the most important thing is not feeling sick, I can then consider and explore with the patient whether a regional technique with opiate sparing would be feasible even when this wasn’t my initial plan based on risk-benefit.  Asking "What matters most to you?" could potentially add another piece of information into the risk-benefit discussion.

• Let the patient know that you're doing your best
• I am always trying to do my best for the patient.  However, following the ethos of Fred Lee, author of IfDisney Ran Your Hospital (previously a book of the month) making these aspects visible and letting the patient know can improve the overall experience.

On the negative side it might:

• Be misinterpreted
• The patient could interpret the question as restrictive in that they can only have one thing.  This is however probably dependant on the way the question is phrased and the specific situation.  For example: “Im going to look after you and do everything that I normally do, but what matters the most to you today?”  Also, there may need to be an acknowledgement of the patient's specific situation, for example in cancer surgery, “I know this is a really big day for you and we are going get you through this but what matters the most to you today?”

What happened when I tried it?

I started with trepidation but also interest in whether this would be a worthwhile addition to my usual routine.  I was worried about it coming across as an insincere service industry type “Have a nice day”  and was very careful in the delivery to try and avoid this.  I deliberately asked whether the patients had any questions before I asked them the "what matters" question.  The first patient replied that he hadn’t thought about that before and that he was “here and just wanting to get it done”.  I wondered whether I had rushed the patient and he hadn’t had a chance to think about the question and simply said what first came to mind.  I was a little disheartened initially as it didn’t seem to have utlility but I was determined to continue trying it.  

I did the same with the second patient and got a completely different repsonse, he said “Well, it’s a bit embarrassing and I’m not sure whether it matters but I’ve been reading about this thing of being awake with muscle relaxant during the surgery and it’s making me really anxious, I didn’t sleep well last night with worry”.  This led into a discussion with him about anaesthetic awareness and the fact that for the surgical procedure and anaesthetic technique he was going to have, the risk was in fact probably less than 1 in 100 000.  Bear in mind that I had already asked whether the patient had any questions and he had said no.

With such a productive conversation with the second patient, I reflected back on the discussion with the first patient to really consider in context what he had told me.  What I think he was telling me was that he had taken time off work and arranged for someone to be at home with him postoperatively and therefore simply having the procedure was the most improtant thing.  I wasn’t sure whether that would come into any of the decision making but if there was the requirement for a cancellation of one of the patients due to time for example, this could be considered along with clinical need.  

Conclusion

I think that using this closing question can potentially add to the patient experience in a positive way.  I plan to use it carefully for a few weeks and gauge the response and utility.  This concept has already spread to two other anaesthetists in my department!

ASPiH 2014 annual conference: The plus and the delta (by M Moneypenny)

The 2014 Association for Simulated Practice in Healthcare (ASPiH) annual conference took place in Nottingham between the 11th-13th November. The following is not a definitive overview of the conference and if you feel strongly that something has been missed out, then please do comment at the bottom!

The plus

The keynote lecturers were very good, with lots of food for thought and a few lightbulb moments.

ASPiH Laerdal keynote lecture by Hege Ersdal (SAFER, Norway): Low-dose high-frequency simulation: saving lives of babies on a global scale

Hege gave a moving keynote looking at work carried out in Tanzania. A 1-day course was delivered which tried to teach the importance of the "golden minute" after birth. She showed promising results of a 50% decrease in neonatal deaths in the region, however when further analysed it showed that the 50% figure hid a significant disparity between centres, some had a much greater decrease, some had none. Hege and her team found that local implementation was hampered at some sites and that frequent onsite training was the major determinant of improvement (rather than having attended a 1-day course). The team therefore implemented mandatory low-dose high-frequency training in the labour ward, supported by local leaders and the hospital management. This led on to the argument that patient outcome depends on three factors:

1. Science
2. Educational Efficiency
3. Local implementation

Hege also explained that their simulation was carried out using a technically low-fidelity mannequin (see Al May's great tweet) which makes the point that you don't need a SimNewB (or equivalent) for every labour ward.

In terms of "take home messages" for high-income countries, Hege felt that frequent in-situ simulation may be under-utilised.

Day 1 Closing keynote by Mark Gilman (Public Health England): Changing the bigger picture - the real driver to support new behaviours and lifestyles: lessons from addiction

Mark, a criminologist, talked about a smorgasbord of topics surrounding addiction. Unfortunately no amount of text can replace the experience of hearing Mark talk passionately about his work.  He discussed how PHE was managing to keep people with addictions alive, keep them out of prison, control blood-borne viruses and, at times, rehabilitate them. Mark discussed how the "big picture" has a tremendous effect on rehabilitation. If you have no friends, no job and no money then what is the incentive to stay sober or drug-free? He finished by telling us about the "5 ways to wellbeing" which applies to everybody.

Keynote lecture by Justin Moseley (National Air Traffic Services): Towing the Iceberg: Can education and training change the culture of professional practice?

Justin started his lecture with an impressive video showing the air traffic over Europe in a 24-hour period. He then told us about an equally impressive simulated training programme, with a mandatory annual component as well as on an ad-hoc basis for new equipment and procedures.

NATS has a dedicated team of expert investigators of "incidents", of which there are >2000/year in the UK. The team can release an immediate safety notice if necessary, as well interview all involved parties and creates a report (full or abbreviated) for every incident. Reporting incidents at NATS is now natural and commonplace, it used to be "I'm going to file a report on YOU!"

According to Justin, despite being a part of the "aviation" industry, TRM in air traffic control is relatively new but a TRM annual assessment will be a European Aviation Safety Agency requirement in the near future.

In terms of advice for others, Justin recommends sharing incidents, near misses and experience. He also encourages a "Safety II" approach, trying to do less "Don't do that!" and more "Do more of this!" Lastly he talked about how a "Just Culture" (which is not a "No Blame" culture) underpins Safety II and echoes Sidney Dekker by calling for "the line" (which must not be crossed) to be drawn by those who are actively involved in the job.

Day 2 Closing Keynote by Sebastian Yuen: Engaging your community: Being the change you wish to see

Sebastian talked about the rise (or arrival) of the #SocialEra with personalised healthcare and a fall in the power of big business. He talked about the power of communities and connections, and the need to engage with patients and people. He also talked about the effect of behaviour and showed a slide which  referred to a statement from Public Health England. It said:

"Our effectiveness depends on how we behave so we will:

• consistently spend our time on what we say we care about
• work together, not undermine each other
• speak well of each other, in public and in private
• behave well, especially when things go wrong
• keep our promises, small and large
• speak with candour and courage"

Which seems not a bad set of principles for simulation centres and hospitals.

The delta

Other than my lost suitcase there was very little I would change. One area of concern is the SimHeroes concept… With pre-conference heats, then semi-finals and finals it brings perhaps some excitement to the conference. However the notion of rating performance (in particular non-technical skills) makes one wonder about rater training, reliability, validity, etc. In addition, the focus on the performance in the simulation rather than the debrief perhaps emphasises the wrong aspect of simulation-based education. On the plus side, if the concept continues then we will quickly get a glimpse of what the future of gaming/beating the simulator will look like, as teams attempt to win first place.

See you next year

The next ASPiH annual conference is in Brighton, 3rd-5th November 2015. See you there?!