Stress Testing the Cardiac Catheterization Laboratory: A Novel Use of In Situ Simulation to Identify and Mitigate Latent Safety Threats During Acute Airway Management.

INTRODUCTION: Although uncommon, cardiac arrests in the cardiac catheterization laboratory (CCL) are often catastrophic and likely to increase with rising case complexity. In situ simulation (ISS) has been used to identify latent safety threats (LSTs) in inpatient units but has not yet been studied in the CCL. METHODS: Three Plan-Do-Study-Act (PDSA) cycles leveraging ISS were conducted focused on acute airway management. Data collected through debriefs focused on (1) airway management, (2) equipment availability, and (3) interdepartmental communication. The LSTs were subcategorized and plotted on the Survey Analysis for Evaluating Risk (SAFER)-Matrix. A SAFER score was calculated based on quantifying the likelihood of harm, scope, and the number of times a threat was identified during simulation. Time to definitive airway was collected as a secondary measure. Interventions were developed using cause and effect and driver diagrams between PDSA cycles. RESULTS: Eleven total simulations through 3 PDSA cycles were conducted between January and December 2021 (5 in PDSA 1, 4 in PDSA 2, and 2 in PDSA 3). One hundred one LSTs were identified with 14 total subcategories. The mean SAFER score decreased from 5.37 in PDSA 1, to 2.96 in PDSA 2, and to 1.00 in PDSA 3. Bivariate regression analysis showed a decrease in SAFER score of 2.19 for every PDSA cycle ( P = 0.011). Ordinary least squares regression had a decrease of 1.65 in airway-related threats every PDSA cycle ( P < 0.01) as well as an increase in intubation time of 35.0 seconds for every 1-unit increase in communication threat identified ( P = 0.037). CONCLUSIONS: This study successfully leveraged ISS and existing quality improvement initiatives in the CCL, resulting in a decrease in airway-related threats as measured through simulation.

In Situ Simulation as a Tool to Longitudinally Identify and Track Latent Safety Threats in a Structured Quality Improvement Initiative for SARS-CoV-2 Airway Management: A Single-Center Study.

BACKGROUND: In situ simulation has emerged as a powerful tool for identifying latent safety threats (LSTs). After the first wave of the SARS-CoV-2 pandemic, an urban community emergency department (ED) identified opportunities for improvement surrounding acute airway management and particularly focused on infection control precautions, equipment availability, and interprofessional communication during acute resuscitation. Using the Model for Improvement, a hybrid in situ/quality improvement initiative was implemented using Plan-Do-Study-Act (PDSA) cycles to enhance systems for intubating patients with SARS-CoV-2. METHODS: Three PDSA cycles consisting of 10 simulations each were conducted from June 2020 through February 2021. Latent safety threats (LST) were identified through an in situ simulation scenario involving a patient with SARS-CoV-2 in acute respiratory failure. LSTs were collected through structured debriefs focused on (1) infection control, (2) equipment availability, and (3) communication. The SAFER-Matrix was used to score LSTs according to frequency and likelihood of harm by members of the ED QI team (SAFER score). The research team worked with the same QI leaders to implement action plans based on scored threats using cause-and-effect and driver diagrams. The Donabedian model was used to conceptually evaluate the quality of interventions upon conclusion of the third PDSA cycle. RESULTS: The median SAFER score decreased from 10.94 in PDSA cycle 1 to 6.77 in PDSA cycle 2 to 4.71 in PDSA cycle 3. Across all identified LSTs, the SAFER score decreased by 3.114 for every additional PDSA cycle ( P = 0.0167). When evaluating for threats identified as being primarily structure based, there was a decrease in SAFER score of 1.28 per every additional PDSA cycle ( P = 0.001). There was a decrease in total count of LST of 0.20 per additional simulation run ( P = 0.02) after controlling for shift type, census, perceived workload, team size, and prior attendance in simulations across all PDSA cycles. CONCLUSIONS: This study presents a blueprint for the utilization of in situ simulation through multiple waves of the SARS-CoV-2 pandemic to identify LSTs and use the SAFER score as a surrogate marker to monitor the impact of interventions for a safer environment for both medical staff and patients.

A Microdebriefing Crisis Resource Management Program for Simulated Pediatric Resuscitation in a Community Hospital: A Feasibility Study.

INTRODUCTION: Crisis Resource Management (CRM) is a team training tool used in healthcare to enhance team performance and improve patient safety. Our program intends to determine the feasibility of high-fidelity simulation for teaching CRM to an interprofessional team in a community hospital and whether a microdebriefing intervention can improve performance during simulated pediatric resuscitation. METHODS: We conducted a single-center prospective interventional study with 24 teams drawn from 4 departments. The program was divided into an initial assessment simulation case (pre), a 40-minute microdebriefing intervention, and a final assessment simulation case (post). Post and pre results were analyzed for each team using t tests and Wilcoxon signed-rank tests. Primary outcome measures included (a) completion of program, (b) percent enrollment, (c) participant reaction, and (d) support of continued programs on completion. Secondary outcomes included (a) change in teamwork performance, measured by the Clinical Teamwork Scale; (b) change in time to initiation of chest compressions and defibrillation; and (c) pediatric advanced life support adherence, measured by the Clinical Performance Tool. RESULTS: We successfully completed a large-scale training program with high enrollment. Twenty-four teams with 162 participants improved in Clinical Teamwork Scale scores (42.8%-57.5%, P < 0.001), Clinical Performance Tool scores (61.7%-72.1%, P < 0.001), and time to cardiopulmonary resuscitation initiation (70.6-34.3 seconds, P < 0.001). CONCLUSIONS: Our center ran a well-attended, well-received interprofessional program in a community hospital site demonstrating that teaching CRM skills can improve simulated team performance in a diverse experienced cohort.

Use of the Donabedian Model as a Framework for COVID-19 Response at a Hospital in Suburban Westchester County, New York: A Facility-Level Case Report.

The purpose of this facility-level case report was to describe our facility's leadership process of applying the Donabedian model to structure an early response to the coronavirus disease pandemic relative to emergency care. Using the Donabedian model as a guide, both structure and process changes were implemented to maintain high-quality clinical outcomes as well as ED staff safety and engagement. Rapid changes to the model of care, both architecturally and through the expansion of universal precautions through personal protective equipment, created the foundation for what was to follow. Clinical, service quality, and staff safety outcomes were evaluated to demonstrate that the collaborative changes that follow a known process improvement model can be used to address the coronavirus disease pandemic. Further study is needed to compare the outcomes of this facility-level case study with those of others to evaluate the success of the measures outlined.