Debriefer cognitive load during Traditional Reflective Debriefing vs. Rapid Cycle Deliberate Practice interdisciplinary team training.

BACKGROUND: Cognitive load impacts performance of debriefers and learners during simulations, but limited data exists examining debriefer cognitive load. The aim of this study is to compare the cognitive load of the debriefers during simulation-based team training (SbTT) with Rapid Cycle Deliberate Practice (RCDP) debriefing and Traditional Reflective Debriefing (TRD). We hypothesize that cognitive load will be reduced during RCDP compared to TRD. METHODS: This study was part of a large-scale, interdisciplinary team training program at Children's Healthcare of Atlanta Egleston Pediatric Emergency Department, with 164 learners (physicians, nurses, medical technicians, paramedics, and respiratory therapists (RTs)). Eight debriefers (main facilitators and discipline-specific coaches) led 28 workshops, which were quasi-randomized to either RCDP or TRD. Each session began with a baseline medical resuscitation scenario and cognitive load measurement using the NASA Task Load Index (TLX), and the NASA TLX was repeated immediately following either TRD or RCDP debriefing. Raw scores of the NASA TLX before and after intervention were compared. ANOVA tests were used to compare differences in NASA TLX scores before and after intervention between the RCDP and TRD groups. RESULTS: For all debriefers, mean NASA TLX scores for physical demands and frustration significantly decreased (- 0.8, p = 0.004 and - 1.3, p = 0.002) in TRD and mean perceived performance success significantly increased (+ 2.4, p < 0.001). For RCDP, perceived performance success increased post-debriefing (+ 3.6, p < 0.001), time demands decreased (- 1.0, p = 0.04), and frustration decreased (- 2.0, p < 0.001). Comparing TRD directly to RCDP, perceived performance success was greater in RCDP than TRD (3.6 vs. 2.4, p = 0.04). Main facilitators had lower effort and mental demand in RCDP and greater perceived success (p < 0.001). CONCLUSION: RCDP had greater perceived success than TRD for debriefers. Main facilitators also report reduced effort and baseline mental demand in RCDP. For less experienced debriefers, newer simulation programs, or large team training sessions such as our study, RCDP may be a less mentally demanding debriefing methodology for facilitators.

A comparison of rapid cycle deliberate practice and traditional reflective debriefing on interprofessional team performance.

BACKGROUND: In simulation-based education, debriefing is necessary to promote knowledge acquisition and skill application. Rapid Cycle Deliberate Practice (RCDP) and Traditional Reflective Debriefing (TRD) are based in learning theories of deliberate practice and reflective learning, respectively. In this study, we compared the effectiveness of TRD versus RCDP on acquisition of conceptual knowledge and teamwork skills among interdisciplinary learners in the pediatric emergency department. METHODS: One hundred sixty-four learners including emergency department attending physicians, fellows, nurses, medical technicians, paramedics, and respiratory therapists, participated in 28 in-situ simulation workshops over 2 months. Groups were quasi-randomized to receive RCDP or TRD debriefing. Learners completed a multiple-choice test to assess teamwork knowledge. The TEAM Assessment Tool assessed team performance before and after debriefing. Primary outcomes were teamwork knowledge and team performance. RESULTS: Average pre-intervention baseline knowledge assessment scores were high in both groups (TRD mean 90.5 (SD 12.7), RCDP mean 88.7 (SD 15.5). Post-test scores showed small improvements in both groups (TRD mean 93.2 (SD 12.2), RCDP mean 89.9 (SD 13.8), as indicated by effect sizes (ES = 0.21 and 0.09, for TRD and RCDP, respectively). Assessment of team performance demonstrated a significant improvement in mean scores from pre-assessment to post-assessment for all TEAM Assessment skills in both TRD and RCDP arms, based on p-values (all p < 0.01) and effect sizes (all ES > 0.8). While pre-post improvements in TEAM scores were generally higher in the RCDP group based on effect sizes, analysis did not indicate either debriefing approach as meaningfully improved over the other. CONCLUSIONS: Our study did not demonstrate that either TRD versus RCDP was meaningfully better in teamwork knowledge acquisition or improving skill application and performance. As such, we propose Reflective Deliberate Practice as a framework for future study to allow learners to reflect on learning and practice in action.

Identifying Built Environment Risk Factors to Provider Workflow and Patient Safety Using Simulation-Based Evaluation of a Pediatric ICU Room.

OBJECTIVE: This study aimed to identify latent conditions in a pediatric intensive care unit (PICU) by analyzing characteristics of flow disruptions (FD) during a simulation of a three-phased scenario. BACKGROUND: The built environment of healthcare facilities contributes to FD that can lead to clinical errors and patient harm. In the facility design process, there is an opportunity to identify built environment features that cause FD and pose safety risks. Simulation-based evaluation of proposed designs may help in identifying and mitigating safety concerns before construction and occupancy. METHODOLOGY: During design development for a new 400-bed children's hospital, a series of simulations were conducted using physical mock-ups in a large warehouse. A three-phased scenario, (1) admission and intubation, (2) cardiac arrest, and (3) bedside surgery involving a cannulation to extracorporeal membrane oxygenation, was conducted in a PICU room mock-up. Each scenario was video recorded from four angles. The videos were systematically coded to identify FD. RESULTS: Analysis identified FDs in three ICU zones: respiratory therapists (RT) zone, nurse zone, and head of the patient. Challenges in these zones were related to spatial constraints in the RT zone and head of the bed, equipment positioning in the RT zone and nurse zone, and impeded visibility related to the location of the boom monitor in the nurse zone. CONCLUSION: Simulation-based evaluation of prototypes of patient care spaces can help identify characteristics of minor and major FD related to the built environment and can provide valuable information to inform the iterative design process.

Let us to the TWISST; Plan, Simulate, Study and Act.

Translational Work Integrating Simulation and Systems Testing (TWISST) is a novel application of simulation that augments how we discover, understand, and mitigate errors in our system. TWISST is a diagnostic and interventional tool that couples Simulation-based Clinical Systems Testing with simulation-based training (SbT). TWISST tests environments and work systems to identify latent safety threats (LSTs) and process inefficiencies. In SbT, improvements made to the work system are embedded in hard wire system improvements, ensuring optimal integration into clinical workflow. Methods: Simulation-based Clinical Systems Testing approach includes simulated scenarios, Summarize, Anchor, Facilitate, Explore, Elicit debriefing, and Failure Mode and Effect Analysis. In iterative Plan-Simulate-Study-Act cycles, frontline teams explored work system inefficiencies, identified LSTs, and tested potential solutions. As a result, system improvements were hardwired through SbT. Finally, we present a case study example of the TWISST application in the Pediatric Emergency Department. Results: TWISST identified 41 latent conditions. LSTs were related to resource/equipment/supplies (n = 18, 44%), patient safety (n = 14, 34%), and policies/procedures (n = 9, 22%). Work system improvements addressed 27 latent conditions. System changes that eliminated waste or modified the environment to support best practices mitigated 16 latent conditions. System improvements that addressed 44% of LSTs cost the department $11,000 per trauma bay. Conclusions: TWISST is an innovative and novel strategy that effectively diagnoses and remediates LSTs in a working system. This approach couples highly reliable work system improvements and training into 1 framework.

Pediatric Intensive Care Unit (PICU) Patient Room Design: Identifying Safety Risks in Mirrored Rooms Through a Graphical Systems Analysis.

OBJECTIVE: The objectives of this study are to graphically depict specific clinical challenges encountered in a mirrored pediatric intensive care unit patient room and to represent potential solutions to address these challenges using a systems approach. BACKGROUND: The intensive care unit (ICU) patient room is a highly complex patient care environment where the design of the room must support patient care delivery safely and efficiently. There is a lack of research examining how ICU design elements interact with other system components to impact patient care. METHODS: An observational case study method utilizing a systems approach was used to observe and graphically depict clinical challenges with mirrored room configurations and to identify potential solutions. Video recordings of the three clinical scenarios were analyzed in detail in conjunction with three rounds of interviews with a clinical expert. RESULTS: Equipment or task characteristics that require orienting to a specific side of a patient create challenges in a mirrored room. In order to deliver care safely and efficiently in the mirrored room, adaptations would be required including changing boom, equipment and team member locations, purchasing new equipment, staff training, and inventory management. Some procedures such as extracorporeal membrane oxygenation would be difficult to conduct safely in the mirrored room, even with significant adaptations. CONCLUSION: Solutions to the challenges presented in mirrored room configurations are multifaceted and require simultaneous and ongoing changes to multiple systems elements, while others can be addressed relatively easily, for example, purchasing new equipment.

Simulation-based User-centered Design: An Approach to Device Development during COVID-19.

INTRODUCTION: Since the onset of COVID-19, intubations have become very high risk for clinical teams. Barrier devices during endotracheal intubation protect clinicians from the aerosols generated. Simulation-based user-centered design (UCD) was an iterative design process used to develop a pediatric intubation aerosol containment system (IACS). Simulation was anchored in human factor engineering and UCD to better understand clinicians' complex interaction with the IACS device, elicit user wants and needs, identify design inefficiencies, and unveil safety concerns. METHODS: This study was a prospective observational study of a simulation-based investigation used to design a pediatric IACS rapidly. Debriefing and Failure Mode and Effect Analysis identified latent conditions related to 5 device prototypes. Design iterations made were based on feedback provided to the engineering team after each simulation. RESULTS: Simulation identified 32 latent conditions, resulting in 5 iterations of the IACS prototype. The prototypes included an (1) intubation box; (2) IACS shield; (3) IACS frame with PVC pipes; (4) IACS plexiglass frame, and finally, (5) IACS frame without a plexiglass top. CONCLUSIONS: Integration of simulation with human factor ergonomics and UCD, in partnership with mechanical engineers, facilitated a novel context to design and redesign a pediatric IACS to meet user needs and address safety concerns.

Translational Simulation Improves Compliance with the NEAR4KIDS Airway Safety Bundle in a Single-center PICU.

The National Emergency Airway Registry for Children (NEAR4KIDS) Airway Safety Quality Improvement (QI) Bundle is a QI tool to improve the safety of tracheal intubations. The ability to achieve targeted compliance with bundle adherence is a challenge for centers due to competing QI initiatives, lack of interdisciplinary involvement, and time barriers. We applied translational simulations to identify safety and performance gaps contributing to poor compliance and remediate barriers by delivering simulation-based interventions. METHODS: This was a single-center retrospective review following translational simulations to improve compliance with the NEAR4KIDS bundle . The simulation was implemented between March 2018 and December 2018. Bundle adherence was assessed 12 months before simulation and 9 months following simulation. Primary outcomes were compliance with the bundle and utilization of apneic oxygenation. The secondary outcome was the occurrence of adverse tracheal intubation-associated events. RESULTS: Preintervention bundle compliance was 66%, and the application of apneic oxygenation was 27.9%. Following the simulation intervention, bundle compliance increased to 93.7% (P < 0.001) and adherence to apneic oxygenation increased to 77.9% (P < 0.001). There was no difference in the occurrence of tracheal intubation-associated events. CONCLUSIONS: Translational simulation was a safety tool that improved NEAR4KIDS bundle compliance and elucidated factors contributing to successful implementation. Through simulation, we optimized bundle customization through process improvement, fostered a culture of safety, and effectively engaged multidisciplinary teams in this quality initiative to improve adherence to best practices surrounding tracheal intubations.

Situational Awareness Huddles in a Pediatric Cardiac Intensive Care Unit During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has created challenges for provider teams working in intensive care units, including rapidly changing patient care regulations, staffing considerations, and preservation of personal protective equipment. The need for enhanced respiratory precautions for infected patients and patients under investigation has necessitated a new process for interventions and resuscitation. LOCAL PROBLEM: Along with changing regulations and equipment, significant staff anxiety surrounded caring for infected patients and preparing for emergency situations. METHODS: A huddle process was implemented in the pediatric cardiac intensive care unit for acutely ill patients who required enhanced respiratory precautions and were at risk of imminent decompensation, or who required a bedside procedure. During a huddle, the multidisciplinary team used process maps displayed in patient rooms; the huddle process created a situational awareness of events among these teams. INTERVENTION: After implementation of huddles, a survey was distributed to cardiac intensive care unit staff in order to understand their satisfaction with the huddle process. RESULTS: A total of 36 staff responded to the survey. They thought the huddles helped them to prepare for resuscitation scenarios, helped limit the number of personnel responding to an emergency, and reduced their anxiety surrounding caring for these patients. Staff suggested generalizing this huddle process to all patients at acute risk for decompensation in the cardiac intensive care unit. CONCLUSIONS: A novel huddle process created situational awareness among staff caring for patients requiring enhanced respiratory isolation because of COVID-19. Multidisciplinary huddles allowed staff from various disciplines to apply a process map for interventions and resuscitations among critically ill children with heart disease.

SAFEE: A Debriefing Tool to Identify Latent Conditions in Simulation-based Hospital Design Testing.

In the process of hospital planning and design, the ability to mitigate risk is imperative and practical as design decisions made early can lead to unintended downstream effects that may lead to patient harm. Simulation has been applied as a strategy to identify system gaps and safety threats with the goal to mitigate risk and improve patient outcomes. Early in the pre-construction phase of design development for a new free-standing children's hospital, Simulation-based Hospital Design Testing (SbHDT) was conducted in a full-scale mock-up. This allowed healthcare teams and architects to actively witness care providing an avenue to study the interaction of humans with their environment, enabling effectively identification of latent conditions that may lay dormant in proposed design features. In order to successfully identify latent conditions in the physical environment and understand the impact of those latent conditions, a specific debriefing framework focused on the built environment was developed and implemented. This article provides a rationale for an approach to debriefing that specifically focuses on the built environment and describes SAFEE, a debriefing guide for simulationists looking to conduct SbHDT.

Designing for Patient Safety and Efficiency: Simulation-Based Hospital Design Testing.

OBJECTIVE: In the schematic design phase of a new freestanding children's hospital, Simulation-based Hospital Design Testing (SbHDT) was used to evaluate the proposed design of 11 clinical areas. The purpose of this article is to describe the SbHDT process and how it can help identify and mitigate safety concerns during the facility design process. BACKGROUND: In the design of new healthcare facilities, the ability to mitigate risk in the preconstruction period is imperative. SbHDT in a full-scale cardboard mock-up can be used to proactively test the complex interface between people and the built environment. METHOD: This study was a prospective investigation of SbHDT in the schematic design planning phase for a 400-bed freestanding children's hospital where frontline staff simulated episodes of care. Latent conditions related to design were identified through structured debriefing. Failure mode and effect analysis was used to categorize and prioritize simulation findings and was used by the architect team to inform design solutions. A second round of testing was conducted in order to validate design changes. RESULTS: A statistically significant reduction in criticality scores between Round 1 (n = 201, median = 16.14, SD = 5.8) and Round 2 (n = 201, median score of 7.68, SD = 5.26, p < .001) was identified. Bivariate analysis also demonstrated a statistically significant reduction in very high/high criticality scores between Round 1 and Round 2. CONCLUSIONS: SbHDT in the schematic phase of design planning was effective in mitigating risk related to design prototypes through effective identification of latent conditions and validation of design changes.

Can Simulation Based-Team Training Impact Bedside Teamwork in a Pediatric Intensive Care Unit?

Effective teamwork performance is essential to the delivery of high-quality and safe patient care. In this mixed methodological observational cohort study, we evaluated team performance immediately following a real medical crisis in a pediatric intensive care unit (PICU) following implementation of a simulation-based team training (SBTT) program. Comparison of teamwork skills when rated by study observers demonstrated a statistically significant improvement in 12 out of 15 composite teamwork skills during real emergency events following SBTT ( p < 0.05). Pre- and post-SBTT intervention survey data demonstrated an improvement in the perception of teamwork, most notable in the area of shared mental model and situational awareness following SBTT. Study results suggest that teamwork behaviors and skills acquired during SBTT can translate into improved bedside performance in the PICU.

Promoting Teamwork for Rapid Response Teams Through Simulation Training.

Use of teamwork skills during rapid response calls is important in the management of patient decompensation outside of the intensive care unit. The ability of a rapid response team (RRT) to influence patient outcomes depends on early team building and effective team performance. Simulation-based team training (SBTT) has been shown to be effective in teaching nontechnical teamwork skills. Rapid Cycle Deliberate Practice (RCDP) is becoming increasingly popular in simulation-based education. Emerging literature on the application of RCDP suggests this method may be superior to traditional reflective debriefing (TRD) in the acquisition of technical skills related to medical management, but fewer data exist that evaluate application of RCDP in teaching nontechnical teamwork skills. We describe a blended approach, using TRD with RCDP to hardwire teamwork behaviors including role assignment, task delegation, situational awareness, global assessment, and shared mental model to a nursing-led RRT. [J Contin Educ Nurs. 2019;50(11):523-528.].

Prevent Safety Threats in New Construction through Integration of Simulation and FMEA.

INTRODUCTION: The built environment may impact safety and decisions made during the design phases can have unintended downstream effects that lead to patient harm. These flaws within the system are latent safety threats (LSTs). Simulation-based clinical systems testing (SbCST) provides a clinical context to examine the environment for safety threats postconstruction. Integration of Failure Mode Effect Analysis (FMEA) with SbCST provides a framework to identify, categorize, and prioritize LSTs before patient exposure. METHODS: We implemented SbCST in a newly constructed pediatric subspecialty outpatient center before opening. We used in-situ simulations to evaluate both routine and high-risk clinical scenarios pertinent to each clinical area. FMEA was used as a methodology to assign risk, prioritize, and categorize LSTs identified during the simulation. RESULTS: Over 3 months, we conducted 31 simulated scenarios for 15 distinct subspecialty clinics involving 150 participants and 151 observers. We identified a total of 334 LSTs from 15 distinct clinics. LSTs were further classified into process/workflow, facility, resource, or clinical performance issues. CONCLUSIONS: Integration of SbCST and FMEA risk assessment is effective in evaluating a new space for safety threats, workflow, and process inefficiencies in the postconstruction environment, providing a framework for prioritizing issues with the greatest risk for harm.

Simulation-based clinical systems testing for healthcare spaces: from intake through implementation.

Healthcare systems are urged to build facilities that support safe and efficient delivery of care. Literature demonstrates that the built environment impacts patient safety. Design decisions made early in the planning process may introduce flaws into the system, known as latent safety threats (LSTs). Simulation-based clinical systems testing (SbCST) has successfully been incorporated in the post-construction evaluation process in order to identify LSTs prior to patient exposure and promote preparedness, easing the transition into newly built facilities. As the application of simulation in healthcare extends into the realm of process and systems testing, there is a need for a standardized approach by which to conduct SbCST in order to effectively evaluate newly built healthcare facilities. This paper describes a systemic approach by which to conduct SbCST and provides documentation and evaluation tools in order to develop, implement, and evaluate a newly built environment to identify LSTs and system inefficiencies prior to patient exposure.

Simulation-Based Team Training Improves Team Performance among Pediatric Intensive Care Unit Staff.

Simulation training fosters collaborative learning and improves communication among interdisciplinary teams. In this prospective observational cohort study, we evaluated the impact of interdisciplinary simulation-based team training (SBTT) on immediate learning of team performance behaviors. In a 3-month period, 30 simulation sessions were conducted and 165 staff members, including physicians, nurses, and respiratory therapists, were trained. Regression analysis showed a statistically significant improvement in team performance ( p < 0.0001). Study results demonstrate that SBTT is effective in immediate acquisition of optimal team performance behaviors by multidisciplinary pediatric intensive care unit staff, including physicians with higher level subspecialty training in the simulation environment.

Rapid Cycle Deliberate Practice Versus Reflective Debriefing for Pediatric Septic Shock Training.

OBJECTIVES: Rapid cycle deliberate practice is a simulation training method that cycles between deliberate practice and directed feedback to create perfect practice; in contrast to reflective debriefing where learners are asked to reflect on their performance to create change. The aim of this study is to compare the impact of rapid cycle deliberate practice versus reflective debriefing training on resident application and retention of the pediatric sepsis algorithm. DESIGN: Prospective, randomized-control study. SETTING: A tertiary care university children's hospital simulation room, featuring a high-fidelity pediatric patient simulator. SUBJECTS: Forty-six upper-level pediatric residents. INTERVENTIONS: Simulation training using rapid cycle deliberate practice or reflective debriefing. MEASUREMENTS AND MAIN RESULTS: Knowledge was assessed with a quiz on core sepsis management topics. The application of knowledge was assessed with a sepsis management checklist during the simulated scenario. The residents were assessed before and after the intervention and again at a follow-up session, 3-4 months later, to evaluate retention. Both groups had similar pre-intervention scores. Post-intervention, the rapid cycle deliberate practice group had higher checklist scores (rapid cycle deliberate practice 18 points [interquartile range, 18-19] vs reflective debriefing 17 points [interquartile range, 15-18]; p < 0.001). Both groups had improved quiz scores. At follow-up, both groups continued to have higher scores compared with the pre-intervention evaluation, with the rapid cycle deliberate practice group having a greater change in checklist score from pre-intervention to follow-up (rapid cycle deliberate practice 5 points [interquartile range, 3.5-7] vs reflective debriefing 3 points [interquartile range, 1.5-4.5]; p = 0.019). Both groups reported improved confidence in diagnosing and managing septic shock. CONCLUSIONS: Both rapid cycle deliberate practice and reflective debriefing are effective in training pediatric residents to apply the sepsis algorithm and in improving their confidence in the management of septic shock. The rapid cycle deliberate practice method was superior immediately post-training; however, it is unclear if this advantage is maintained over time. Both methods should be considered for training residents.

A Quality Initiative: A System-Wide Reduction in Serious Medication Events Through Targeted Simulation Training.

INTRODUCTION: Medication administration events (MAEs) are a great concern to the healthcare industry, because they are both common and costly. Pediatric patients pose unique challenges to healthcare systems, particularly regarding the safety of medication administration. Our objectives were to improve adherence to best practices, decrease MAEs, and decrease cost related to error reduction rates by implementing a scenario-based simulation training program for frontline nursing staff in the general care units, emergency departments, and intensive care units within our institution. METHODS: Children's simulation center in conjunction with the medication safety workgroup developed a 2-hour target-specific simulation-based training. This quality initiative focused on implementation of a MAE bundle that included the following three elements: The Five Rights, MedZone, and Independent Double Check. Adherence to the use of bundle elements was monitored via bedside auditing for 18 months after the intervention. This audit was accomplished using an institution-wide MAE reporting system. The 2012 Healthcare Cost and Utilization Project Kids' Inpatient Database and 2014 Children's Hospital Association, Pediatric Health Information System databases were used to estimate cost impact. RESULTS: A total of 1434 nurses from our intensive care units, emergency departments, and general care inpatient units participated in simulation training. Nursing adherence to the MAE bundle in the 18-month period after simulation increased by 33%, from January 2014 to June 2015. Medication administration event monitoring during the preintervention, intervention, and postintervention periods demonstrated a decrease in error rate from 2.5 events per month to 0.86 events per month This error reduction correlated to an estimated charge savings of $165,000 to $255,000 and a cost impact of $90,000 to $130,000 per year. CONCLUSIONS: Target-specific simulation-based training on a large scale has improved adherence with best practice guidelines and has led to a significant reduction in MAEs.