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15.Annual Simulation Conference 2017.pdf

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Alok Sharma

We had 22 faculty from Europe, North America, Australia, UAE, Africa, and India attend. This included speakers from NASA, The British Gymnastics team and the Resuscitation Council of the UK. We have 224 delegates and organised 12 workshops.

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[Type text] Annual Neonatal Simulation & TEL Conference “Simulating Together & Improving Outcomes’’ Organiser Dr Ranjit Gunda Consultant Neonatologist Queen Alexandra Hospital Portsmouth Founding Member MPROvE Programme Lead Wessex-Oxford Neonatal Education Programme Speakers Dr Jonathan Cusack Consultant Neonatologist, Lead Neonatal Simulation Leicester UK Dr Sarah Davidson Consultant Neonatologist, Southampton UK Dr Joe Fawke Consultant Neonatologist, Lead Neonatal Simulation Leicester UK Dr Sijo Francis Consultant Neonatologist St George’s NHS Trust Professor David Gaba Associate Dean for Immersive and Simulation- based Learning and Director of the Center for Immersive and Simulation based Learning (CISL) at Stanford University School of Medicine Professor Lou Halamek Division of Neonatal and Developmental Medicine, Department of Pediatrics Stanford University Director, Center for Advanced Pediatric and Perinatal Education Dr Hannah Shore Consultant Neonatologist, Leeds University Hospital Lead Paediatric Simulation Yorkshire United Kingdom Dr Alok Sharma Consultant Neonatologist Princess Anne Hospital Southampton Founding Member MPROvE Programme Lead Wessex-Oxford Neonatal Education Programme Jens Christian-Schwindt Consultant Neonatologist & Director Sim Characters June 8th & 9th 2017 Venue: Grand Harbor Hotel West quay Road Southampton UK
© Copyrights Reserved Dr Alok Sharma, Chair & Lead Dr Alok Sharma is a Consultant Neonatologist at Princess Anne Hospital Southampton. He is a founding member for the Wessex-Oxford Neonatal Education Programme and Lead for the Neonatal Simulation Programme at Princess Anne Hospital Southampton. He is one of the founding members of MPROvE which champions MultiPROfessional Neonatal Education through simulation and technology enhanced learning. His main areas of interest are cascading medical error and risk through in situ simulation. His current area of research is barriers to the uptake of simulation by multidisciplinary teams and latent threat identification. Work on multidisciplinary neonatal simulation done by his team, and its impact on neonatal outcomes was nominated for the National BMJ Award securing the Runner’s Up position in 2014 and was awarded the Best Research Award at ASPIH 2014. He is Course Director the ‘Neonatal Ethics and Difficult Situations Course’ and ‘Simulated Neonatal Airway’ which are run nationally in multiple centres in the UK and abroad. Dr Ranjit Gunda Co-Organiser and Treasurer Dr Ranjit Gunda is a Consultant Neonatologist at Queen Alexandra Hospital Portsmouth UK. He is current lead for the Wessex-Oxford Neonatal Education Programme and faculty on the MPROvE Neonatal Instructor Programme. Dr Gunda has trained in neonatal intensive care at Aberdeen, Southampton, Leicester and London. Ranjit is pursuing research in ‘Nutritional Influence on Surfactant Metabolism in Neonates’. He has completed a research project on the parental perception towards therapeutic hypothermia. His research interest is the use of simulation as quality improvement methodology, in patient safety and risk. His work along with Dr Sharma on ‘Multidisciplinary simulation, cost effectiveness and neonatal outcomes’ was presented at ASPIH 2014 and awarded ‘The Best Research Award’. He founded the Wessex-Oxford Neonatal Education Programme for grid neonatal training in Wessex. Dr Ranjit Gunda has also worked on ‘The OPEN concept’ and its implementation in procedural skills training in neonatology. This is currently being developed into an app for neonatal trainee’s worldwide.
© Copyrights Reserved 6th Annual Neonatal Conference Programme-Day 1 Session 1: Introduction  08.00-09.00 Registration & Meet our Sponsors  08.50-09.00 Lift Off  09.00-09.30 Simulation in neonatal care Is this an evidence based cost-effective educational tool? And does it improve outcomes? Dr Alok Sharma  09.30-10.00 The role of simulation in the objective assessment of human and system performance in health care Prof Lou Halamek Session 2: The Challenges  10.00-10.30 Introducing and sustaining simulation in your NICU What works and what doesn’t? Dr Joe Fawke Consultant Neonates Leicester  10.30-11.00 Coffee (Poster Walk) 11.00-11.45 Morning Workshops (Participants attend 1 workshop) Venue Winslow Suite Bradford Suite Standish Suite Main Hall Topic A Neonatal Toolkit for Implementing ‘Multiprofessional Neonatal Simulation’ in busy neonatal environments Moulage in Neonatal Simulation ‘Bringing realism to Neonatal Simulation Models’ Multidisciplinary Neonatal Simulation Meeting the needs of Multiprofessional Teams ‘The METE Study’ Multidisciplinary Neonatal Simulation Progressive Fidelity in Simulation Facilitators Alok Sharma Ranjit Gunda Donna Windebank-Scott Jasim Shihab Sarah Davidson Anushma Sharma Sarah McCullough
© Copyrights Reserved 12.00-1300 Lunch (Poster Walk) Session 3 Recent Advances in Neonatal Simulation 13.00-13.45 Post Lunch Workshops (Participants attend 1 workshop) Venue Winslow Suite Bradford Suite Standish Suite Main Hall Topic The OPEN Concept ‘Preterm Golden Hour Management’ Improving Your Outcomes Simulation as an Assessment Tool Assessing & measuring the performance of your neonatal resuscitation Teams Simulation to reinforce learning Simulating Developmental Care in Situ Simulation to reinforce learning Rapid Cycle Deliberate Practice in Neonatal Difficult Airway Management Facilitators Ranjit Gunda Sijo Francis Lou Halamek Sister Kim Pease Hannah Shore Alok Sharma Jennifer Diner Session 3 Plenary Session  14.00-14.30 365 days on Mars Sheyna Gifford  14.30-15.00 Psychological Impact of High Stakes Simulation Dr David Gaba 1500-15.30 Tea & Coffee (Poster Walk) Session 3 Hands On 15.30-16.30 Venue Winslow Suite Bradford Suite Standish Suite Main Hall Topic Debate: Simulating & Debriefing Neonatal Death Outcome Centred Debriefing Difficulties During Debriefing Disbelievers & Experts Thou Shalt Not Judge Thy Neighbour Facilitators Alok Sharma Hannah Shore Lou Halamek Jonathan Cusack Joe Fawke Dr Sijo Francis
© Copyrights Reserved 6th Annual Neonatal Conference Programme-Day 2 Session 1: Patient Safety  08.15-08.50 Registration & Coffee  08.50-09.00 Introduction & Catch Up Day 1  09.00-09.30 Towards a safer neonatal environment Jens Christian Schwindt  09.30-10.30 Cascading risk and improving patient safety through SIM & TEL (Abstracts 4) 10.30-11.00 Tea and Coffee (Poster Walk) Session 2: Improving Outcomes & Staff Performance  11.00-12.00 Venue Winslow Suite Bradford Suite Standish Suite Main Hall Topic More Salad Than Sandwich Learning from Mistakes Standardized Communication techniques in Neonatal Resuscitation Striving for Better Outcomes What we say and What they hear Parental Perception in Communication Reorientation of Life Sustaining Intensive Care: Improving Staff Performance Facilitators Chantelle Mann Emma Sherwood Prof Lou Halamek Dr Jonathan Hurst Session 3: Quality Improvement  12.00-12.30 Use of Technology Enhanced Learning in Delivering High Quality Neonatal Care Dr Jonathan Cusack 12.30-13.00 Hannah Shore
© Copyrights Reserved 13.00-14.00 Lunch (Poster Walk)  13.30-14.30 Quality Improvement in Neonatal Care Using TEL Abstracts (4)  14.30-15.00 Dr David Gaba 15.00-15.30 Tea & Coffee (Poster Walk) Session 5 Cross Specialty/Industry Approach 15.30-16.30 Venue Winslow Suite Bradford Suite Standish Suite Main Hall Topic The Best Way to Run a Simulation for a Low Frequency High Stakes Event Lessons from NASA Panel Discussion Mental Modelling to Address Performance Anxiety in High Stakes Events What we can learn from the GB Olympic Gymnastics Team A Pit Stop Approach to Neonatal Resuscitation Learning from F1 TBC Facilitators Dr Sheyna Gifford Kristian Thomas Lou Halamek TBC
Annual Neonatal Simulation 6 TEL Conference "Simulating Together 6 Improving Outcomes" ------September 26th and 27th 2D17----- Venue: St Mary's Stadium, Southampton , UK Distinguished Panel af Speakers Dr Margarita Burmester Consultant PICU RoyalBramptonHarefield NHSTrust Dr Sarah Davidson Consultant Neonatologist. Southampton UK Dr Sijo Francis Consultant Neonatologist. St George's NHSTrust Professor David Gaba Associate Dean 6 Otrector of the Center for lmmersive and Simulation based Learning Stanford University School of Medicine Professor Lou Halamek Division of Neonatal and Developmental Medicine. Stanford Director.Centre for Advanced Paediatric and Perinatal Education Dr Hannah Shore Consultant Neanatologist. Leeds University Hospital Lead Paediatric Simulation Yorkshire Kristian Thomas British Olympic Gymnast Dr Jonathan Cusack Consultant Neonatologist. Lead Neonatal Simulation Leicester UK Dr Joe Fawke ConsultantNeonatologist. Lead NeonatalSimulation Leicester UK Dr Sheyna Gifford Health 6Safety Officer NASA HISEAS Mars Simulation Mission Professor Colin Morley Honorary Lecturer. Department Dbs Gyn University of Cambridge UK Dr Jasim Shihab SrClinical Fellow London NTS 6 Royal London Hospital Dr Jens Christian-Schwindt Consultant Neonatologist 6 Director Sim Characters Dr Maria Tsakmakis Consultant Neonatologist Southmead Hospital Bristol Dr Donna Windebank·Scott Consultant Neonatologist Southampton Dr Alok Sharma Conference Chair & Lead University Hospitals of Southampton, Southampton, UK Dr Ranjit Kumar Gunda Conference Treasurer Rainbow Children's Hospital, Hyderabad, India
Plenary Lectures
28/09/2017 1 Using Simulation Cost- Effectively to Improve Neonatal Outcomes Dr Alok Sharma Consultant Neonatologist Southampton Dr Ranjit Gunda Consultant Neonatologist Rainbow Hospital Declaration  No conflicts of interest to declare with this presentation  All pictures & videos taken with parent and participant consent to share for educational purposes Background No equipment No Team No money Phase 1-Initial Focus  Bi monthly workshops of getting used to Simulaid Micropremmie task trainer  Focus on thermal care principles and deliberate practice  Reinforcing elements like putting the hat on, theatre temperature, maintaining incubator temperature in transport Scenario Bank  Theme based common conditions  Curriculum mapping  Task Trainers  Bank of 10 common scenarios Initial Challenges  How do we make this multidisciplinary?  How do we run simulation with our nurse colleagues?  Faculty development  Funding for manikins  A designated area
28/09/2017 2 Simulation • Neonatal transport Nurses • Grid Trainees • Senior Paediatric Trainees • Themed sessions • Every 3 months • Full Day • Multidisciplinary • Grid Trainees • Senior Paediatric Trainees • Neonatal nurses • ST1-8 • Band 5/6 Nurses Southampton Neonatal Simulation Neonatal Ethics and Difficult Situations Simulated Neonatal Airway Neonatal Transport Simulation Wessex-Oxford Neonatal Education Programme Hypothermia in Neonates<32 weeks 1 in 4 babies born hypothermic in the UK IN 2015 For neonates under 32 weeks the incidence of mild hypothermia is 28% and significant hypothermia is 9% In 2010 in PAH 33% of babies less than 32 weeks had mild hypothermia and 14% had significant hypothermia Focus on theatre temperatures and management of prematurity. We were already using plastic bags Simulating Preterm Birth
28/09/2017 3 Relation of multidisciplinary simulation to improved outcomes Temp/Yea r 2010 2011 2012 2013 2014 2015 2016 <36.5 32.8% 24.6% 16.9% 15.8% 10.4% 8% 17.5% <36 12.5% 6.1% 1.8% 1.5% 2% 0% 1.7% <35.5 3.1% 3.1% 0% 0% 0% 0% 0% Lowest 34.4C 35C 35.7C 35.9C 35.9C 36.1C 35.9C Babies 64 65 53 63 48 53 57 Simulation No Sim Pilot 2010 Medical Sim Medical Sim Multidiscip Sim Multidiscipl Sim Multidiscipl Sim Multidiscipl Sim Point of Care Simulation & Latent Threat Point of Care Simulation Neonatal Simulation Suite Cascading Risk Through Simulation Neonatal Airway Central Line Extravasation Medication Error CDH Management
28/09/2017 4 Effectiveness Cost Benefits Cost-Analysis Programme Delivery  2 consultants and 2 nurses delivered 1 whole day of simulation per month for 12 months  Participants 15 nurses each session and 5 trainees from the floor  Faculty development programme  Add on to that manikin costs and maintenance  50,000 pounds an year to run a proper neonatal simulation programme Cost vs Benefits  The NHS litigation authority for England reviews approximately 10 neonatal claims per year amounting to £127, 975 (£600 – £3,044,943) per case.  NHS lawyers have set aside £235.4m to settle 60 claims over 10 years in which babies allegedly suffered brain damage because of neonatal hypoxia-ischaemia and hypoglycaemia.  Cost of care to an extreme preterm averages out 3500-150000/episode  The total cost of preterm birth to the public sector was estimated to be 2.946 billion pounds  The largest contribution to the economic implications of preterm birth are hospital inpatient costs after birth, which are responsible for 92.0% of the incremental costs per preterm survivor.
28/09/2017 1 © 2017 D Gaba & A Calhoun Simulations that are Challenging to the Psyche of Participants (& instructors?) • David M. Gaba, M.D. –Associate Dean for Immersive and Simulation-based Learning, & Professor of Anesthesia; Stanford University –Founder & Co-Director, Patient Simulation Center, VA Palo Alto HCS –Founding EIC, Simulation in Healthcare © 2017 D Gaba & A Calhoun Disclosure Slide • Nothing to disclose of relevance to this presentation © 2017 D Gaba & A Calhoun A Reminder: Simulation is a Technique • A suite of “techniques” only sometimes using one or more “technologies” –For interactive & often powerful “immersive” activities that re-create the real-world To amplify or replace actual experiences –The power of simulation raises ethical issues © 2017 D Gaba & A Calhoun Ethical Issues IN Simulation –Simulations that challenge the psyche of the participant Death of the simulator Scenarios using deception Occurrence of clinical errors Disclosing bad news – Also… the participant is also a “user” of the system being simulated [patient or family] © 2017 D Gaba & A Calhoun Ethical Principles [tradeoffs are inevitable?] • Respect for Autonomy • Honesty & respect for individual decisions • Beneficence • Do good • Non-maleficence • Minimize risks and harms • Justice • Fairness, equality, providing what is owed © 2017 D Gaba & A Calhoun {Implicit} Sim Contract with Participants [NOTE: “Participant” vs. “learner”] • “Fiction agreement/contract” [U. Eco] –e.g. What is presented is NOT real, but participants should act as if it were {Willing} suspension of disbelief [Coleridge] Suspension of {ordinary} beliefs [R Rubio] –A "contract" because individuals explicitly agree or because they are voluntary members of a participant group [e.g. students, housestaff, clinicians]
28/09/2017 2 The Intersection of Ethics, Education, and Simulation: Exploring Difficult Issues Aaron W. Calhoun, MD, Assoc Professor, Pediatric Critical Care Medicine and Director, SPARC Program, University of Louisville School of Medicine Chair, SSIH Research Committee, Associate Editor, Simulation in Healthcare Dr. Aaron Calhoun & I share an interest in these issues, sparked in part by his paper & several editorials published by the journal Simulation in Healthcare We have now presented together on this topic & written several papers together He recently spoke at Stanford and some of his slides on our topics of joint interest were better than mine & I have his permission to use / adapt some of them! Simulated Death: A Complex Topic • Many papers about this topic; several reviews, several empirical studies. Almost all the studies are about resuscitation simulations [N.B. often "code blue" teams] • Some suggest teaching "value" to having mannequin die; others suggest none, or negative value • Many complex issues not (yet) addressed by studies at all, or else glossed over ? Different Types of "Patient Death" Within Simulations • Leighton’s Taxonomy is useful – [Collectively] Expected Death - Both facilitators and learners are aware the mannequin will die – [Participant] Unexpected Death - Facilitators plan it & know but learners do not – Death due to Action or Inaction - Completely unplanned. Facilitators decide to let mannequin die based on learner actions Leighton K: Death of a simulator. Clinical Simulation in Nursing 2009;5(2):e59-62 Simulated Death: The"Be Careful" View {Largely shared by Aaron & me} • First, Do No Harm: Using Simulated Patient Death to Enhance Learning Bruppacher HR, et al, 2011 Med Educ 45: 317-318 – Letter to Editor re: study; concerned that comments referring blame for “death” to physicians indicated erosion of collaborative environment – Simulated death often not grounded in sound ethical principles that promote non-punitive educational cultures and inter-professional collaboration, suggested simulated death should only occur as an explicit part of the learning goals {pre-disclosed or not} Death "Patient" in Simulation: Contributing Factors • Effect of stress on learning • Effect of fidelity on learning • Effect of fidelity on future expectations • Role of learner level of experience and type of practice • Role of learner's prior personal experience • Etc. Effect on Future Expectations • In practice, our actions (even when technically correct) do not always result in survival & vice versa • Does a 1:1 correlation between student actions and survival give a false impression to students? • Does a 1:1 correlation augment future psychological stress by causing learners to invariably equate death with failure? Lizotte MH. Trainee Perspectives on Manikin Death During Mock Codes. Pediatrics. 2015;136(1):e93-e98
28/09/2017 3 Effect of Experience • Experience level of participant(s) very important • Data are mixed, but many suggest that death due to action or inaction should be avoided for pre- clinical-rotation medical student participants and ? even at the rotation level • Reality is that medical students rarely have roles in actual patient care that justify the psychological baggage/risks {DG's personal opinion} Calhoun AW, Pian-Smith MC, Truog RD, Gaba DM, Meyer EC. Deception and Simulation Education: Issues, Concepts, and Commentary. Simulation in Healthcare. June 2015;10(3):163-169. Themes Gleaned FROM Our Learners 1. Learner preparation and suspension of disbelief during simulation; latter is complex 2. Differences in emotional response between real and simulated death; and between individuals 3. Effects of simulated death on future emotional engagement with learning activities 4. Learner self-perception and perception by team regarding deficits; complex & variable 5. Impact of debriefing on emotive response to the simulation – experienced & nuanced debriefer is needed 6. Impact of debriefing on learning 7. Knowledge retention and practice changes caused by mannequin death vs. other psych. sequelae Practical Implications • Many Future Questions For Empirical Research: – What level of training & type of practice IS appropriate for certain experiences? – Is our current overall educational culture too protective, or not protective enough? – What are the long-term positive and negative effects of different types of mannequin death? – What debriefings are needed with death scenarios? – {as per the King of Siam…} Etc., etc., etc. 1: Learner Preparation and Suspension of Disbelief Mannequin Death? 2: Differencesin Emotional Response between Real and Simulated Death 3: Effect of Simulated Death on Future Emotional Engagement in Learning Activities 4A: Learner Self- perception and Perception by Team Regarding Knowledge and Skill Deficits 5: Impact of Debriefingon Emotive Response to the Simulation 6: Impact of Debriefingthe Knowledge and Skills Learned Duringthe Simulation 7: Effect of Mannequin Death on Knowledge Retention and Practice Change Model of the Effect of Mannequin Death Due to Learner Action or Inaction on the Learner’s Educational Experience Learner Reaction to Subsequent Simulation Sessions Learner Experience and Knowledge from Previous Simulation Sessions 4B: Effect of ActionsUsed to Mitigate Death on Perceptions of Fidelity Yes No © 2017 D Gaba & A Calhoun Patient Death Summary • Like anything of significant meaning -- "it's complicated" • Never approach this issue with a cavalier attitude –Ensure that pedagogical goals truly justify the approach and that appropriate safeguards are in place • Empirical data may/may not come (and can't encompass all participants/issues) © 2017 D Gaba & A Calhoun Change Gears: Deception: Is it Always Wrong?
28/09/2017 4 © 2017 D Gaba & A Calhoun Simulation is a Powerful Technique • Even books & movies can be emotionally wrenching; all the more so with carefully conducted simulations • Participants bring their own psyche to simulation: –Prior experiences; sense of self-worth • They may not show/disclose discomfort or harm © 2017 D Gaba & A Calhoun Famous Extreme Examples of the Power of “Simulation” [Experiments – not healthcare] • Milgram Obedience Experiments • Stanford Prison Experiment © 2017 D Gaba & A Calhoun Stanford Prison Experiment Zimbardo et al: Performed 1971 published in 1973 • 24 university student subjects randomized to be “prisoners” or “guards” • Simulated “prison” created in Stanford psychology department • Planned 14 day expt. stopped after 6 days – Guards behaved aggressively & abusively – Prisoners became passive & depressed; 5 had to be released from study – Researchers co-opted in their roles © 2017 D Gaba & A Calhoun © 2017 D Gaba & A Calhoun Milgram Obedience Experiment Milgram et al: Performed 1960; 1st Published 1963 Milgram,: J Abnormal Soc Psych, 67, 371–378, 1963 • Volunteers from local community for experiment on learning • They were to administer memory tests to another volunteer {a “confederate” – deception} • If answers were incorrect, volunteer required to administer “electric shock” of increasing voltage  confederate © 2017 D Gaba & A Calhoun
28/09/2017 5 © 2017 D Gaba & A Calhoun Milgram Obedience ExperimentS • Many more experiments by Milgam, varying: – Location of “shockee” – Location of “investigator” – Other factors • Recent experiment with “shockee” existing only virtually (an avatar) – Many subjects still withdrew – Slater M, Antley A, Davison A, et al. A virtual reprise of the Stanley Milgram obedience experiments. PLoS One 2006;1:e39 © 2017 D Gaba & A Calhoun Are These Famous Experiments Comparable to Deception in Clinical Simulation? • These experiments DO demonstrate the power of “simulation” to affect human behavior, BUT: –The experiments were done only for research; offered no direct benefits to subjects or to society –Risk and level of harm was palpable and extreme (especially Prison Expt) –Subjects coerced to continue © 2017 D Gaba & A Calhoun To What Degree Is Simulation Inherently “Deceptive” ? • Simulations are real events meant to be “as if” they are actual clinical events –When is the “as if” inherently deceptive? –What are “expected” deceptions vs. those "beyond expectation" • Is there a tradeoff between learning & pt. safety [beneficence] vs. non- malificence? Nested Spectra of Deception… A confederate from outside the learner group joins the team during a simulation and intentionally makes inappropriate medical decisions during the case Simulation faculty intentionally place faulty equipment within the simulated environment in a way that would be unexpected to learners The outcome of the simulated case is intentionally decoupled from the actions of the learner group in a way that is inconsistent with the ground rules of the case Not Deceptive Highly Deceptive Not Deceptive Not Deceptive Highly Deceptive Highly Deceptive Distinctions in Deception • Deception “Within” vs Deception“About Deception Within Mutually Acceptable Educational Purpose Another, Undisclosed Purpose Deception About Kelman HC. Human Use of Human Subjects: The Problem of Deception in Social Psychological Experiments. Psychological Bulletin 1967;67(1):1-11. Distinctions in Deception Deception Within Mutually Acceptable Educational Purpose Another, Undisclosed Purpose Deception About Kelman HC. Human Use of Human Subjects: The Problem of Deception In Social Psychological Experiments. Psychological Bulletin 1967;67(1):1-11. • Deception “Within” vs Deception“About
28/09/2017 6 © 2017 D Gaba & A Calhoun A Sim That Launched 1,000 Debates? Example of Deception (Calhoun et al: Sim Healthcare 8:13-19, 2013) • Pediatric (6 yo) case with K+, VT, P –Learners were informed in advance that a supervising attending interested in simulation and their education might participate in the session –Attending insists on treating P with Potassium Phosphate If challenged directly would relent If KPhos given -> asystole, if K+ untreated -> death © 2017 D Gaba & A Calhoun Example of Deception (Calhoun et al: Sim Healthcare 8:13-19, 2013) • Detailed debriefing (by expert facilitator) followed –Role of attending revealed as a “confederate of the instructor” –Discussion of clinical/non- technical issues of “challenging the hierarchy” Comparison with real cases © 2017 D Gaba & A Calhoun Big Debate About Deception in Clin Sim (Truog & Meyer: Sim Healthcare 8:1-3, 2013) (Gaba: Sim Healthcare 8:1-3, 2013) • "Pro" deception: –Cases like this do occur clinically, causing serious morbidity mortality; important to teach challenging the hierarchy –Errors by superiors occur without warning; can be deadly –Simulation must replicate the likely conditions in which this would be faced –Simulation run for actual clinicians (i.e. housestaff, not students); nuanced debriefing © 2017 D Gaba & A Calhoun Big Debate About Deception in Clin Sim (Truog & Meyer: Sim Healthcare 8:1-3, 2013) (Gaba: Sim Healthcare 8:1-3, 2013) • "Anti" deception: –Deception can be harmful to the participant’s psyche; can undermine trust in teachers, clinical co-workers, simulation –Challenging the hierarchy can be taught without deception Pre-briefing that it may be needed Attending role played by a stranger © 2017 D Gaba & A Calhoun Big Debate About Deception in Clin Sim Calhoun, Pian-Smith, Truog, Gaba, Meyer: Sim Healthc; 2015 10:163-169 • Framework of elements & relationships concerning simulations that employ deception • Suggestions for future empirical research about the use of deception A Framework For Emotionally Difficult Simulations Institutional Environment Scenario Structure Session Goal Faculty Background Learner Background Educational Intent Calhoun AW, Pian-Smith MC, Truog RD, Gaba DM, Meyer EC. Deception and Simulation Education: Issues, Concepts, and Commentary. Simulation in Healthcare. June 2015;10(3):163-9.
28/09/2017 7 © 2017 D Gaba & A Calhoun General Agreement About Using Deception in Clinical Simulation –Instructors must think hard about the need for deception to accomplish goals –Deception probably inappropriate for early learners & some other populations –Pre-briefing or other techniques could eliminate or reduce level of deception –Debriefings should disclose deception(s) early; debriefers must be very experienced –Provide for routine/emergency follow-up © 2017 D Gaba & A Calhoun The Ultimate Vision To Save Lives, Brains, or Hearts & To Be Ethical Clinicians/Educators And whoever saves a life, it is as though he had saved all mankind (appearing in various forms in the Talmud, Sanhedrin 4:5 and the Quran 5:32) © 2017 D Gaba & A Calhoun
28/09/2017 1 Introducing & Sustaining Neonatal Simulation Programmes Barriers to Uptake & Faculty Development Dr. Joe Fawke Introducing & Sustaining Neonatal Simulation Programmes Barriers to Uptake & Faculty Development Dr. Joe Fawke Introducing • On unit vs. simulation centre • Programme structure – frequency • Session structure • Faculty / session • Candidates / session • Time • Session • Set up • Pack down People & Time Introducing • Advertise on your unit • Ground rules - confidentiality • Clarify expectations • Assessment? • Integration with CPD / revalidation • Performance management • Background programme maintenance & organisation • Don’t promise the world Expectations & Consistent Approach Sustainability • Sign up – volunteering vs. allocating • Who will cover the clinical work? • Contingency plans for emergencies • Contingency plans for busy days • everyday is a busy day • Rewards for participation • What happens if you don’t engage? Barriers - candidates Fear of looking silly Worried about assessment The unknown Loss of face Credibility Don’t like simulation Feel on show Don’t like the instructor Unsupportive colleagues / managers Too tired Worried about who else has signed up Unsure about the equipment
28/09/2017 2 Barriers - faculty Time, Training & Recent Experience Forgotten how the kit works Ages since I debriefed Which scenario? Loss of face Credibility Don’t like simulation Difficult candidates Availability Available space Unsupportive colleagues / managers Time Faculty Development Time, Training & Recent Experience Who? Faculty Nurses Doctors ANNPs AHPs Candidates ANNPs Nurses AHPs Doctors • Who can debrief who? • What problems do you envisage? • Are there any credibility issues? • How important is seniority? • Do they have the same faculty development needs? Relevant faculty experience Resuscitation Courses Task Training Undergraduate simulation Medical / nursing People Management Previous experience Relevant faculty experience Resuscitation Courses Task Training Undergraduate simulation Medical / nursing Faculty Training & Development Previous experience Training Course
28/09/2017 3 Initial training / faculty development Initial training / faculty development Day 1 Day 2 Simulators in Education -background education theory Running a multidisciplinary training program on your unit Practical aspects- planning a ‘Point of Care’ session Styles of debriefing for experienced staff- Advocacy Enquiry and narrative feedback Scenario design Designing a scenario in 2 groups Practice debriefing real examples ‘Keeping it real’- setting the scene Putting it all together: set up and deliver yesterdays scenario to the other team with a short debrief session Programming & getting your manikin to do what you want it to Does a simulation Instructor Course work? All scores out of 5; 1=bad, 5=good Score (content / delivery) Simulators in Education -background education theory 4.8 4.8 Practical aspects- planning a ‘Point of Care’ session 4.8 4.8 Scenario Design 4.8 4.8 Designing a scenario in 2 groups 4.8 4.8 ‘Keeping it real’- setting the scene 4.8 4.8 Programming & getting your manikin to do what you want it to 4.8 4.8 Running a multidisciplinary training program on your unit 4.8 4.8 Debriefing 4.7 4.8 Practice debriefing real examples 4.9 4.9 Set up, delivery, debriefing & candidate experience 4.8 Overall 4.9 Average sessions scores from 300 instructor course candidates “Any way as along as it is my way” • Consistency vs. variety • If you are there all the time every session is more likely to run as you want it to • You can’t be there all the time • (& you make the assumption they are better when you are there……) • Should all the faculty run & debrief sessions the same way • Pros & cons Faculty engagement • Analogous to trainee volunteering vs. allocating • Sustainability & shared workload balanced against more diverse approaches • Only those who have been on the course • ‘Wise’ colleagues Faculty engagement Previous experience Course Simulation simulation Instructor Course In house programme
28/09/2017 4 Faculty maintenance • Ongoing training / exposure • Familiarity with equipment / computers • New topics / simulations • Organisational components (shared drives for simulation) • Faculty meetings to discuss programme • Sharing of debriefing experiences – within confidential framework Updates – who & how? Previous experience Course Simulation simulation Instructor Course Instructor Update Course In house programme Update Courses – what to include? • In house / generic update course? • Practicalities of running simulations – troubleshooting • Scenario reviews • Draw on experiences • Set up issues • In simulation issues • Debriefing issues • Distilling learning points / feedback • Programme logistics Faculty Development in National Courses Previous experience NLS Course GIC NLS IP NLS NLS Instructor Potential Identified Instructor Update Days & Bulletins Regular instructing Instructor Course Certified NLS Instructor Faculty Development in National Courses Previous experien ce NLS Cours e GIC NLS IP NLS NLS Does it work? Is a national course model relevant to neonatal high fidelity simulation programmes? National Resuscitation Course High Fidelity Simulation Course Less focus on human factors More focus on human factors More didactic Less didactic Larger target audience Small, selected target audience More instructors Fewer instructors Simpler debriefs More complex debriefs Advanced Resuscitation of the Newborn Infant course ARNI Course More focus on human factors Less didactic Small, selected target audience High instructors to candidate ratio More complex debriefs
28/09/2017 5 ARNI course components Lectures Early assessment & management Human factors Skill stations Mask leak Advanced airway Workshops Communication Chest drains Simulations Cooling All scenarios 16 candidates High instructor to candidate ratio More in depth debriefing Innovative mixed mode assessment Continuous Criterion based ARNI Evaluation Pre course Post course P Technical Face mask ventilation 77 94 <0.01 Intubation 77 87 <0.05 Difficult airway management 61 89 <0.05 Chest drain insertion 67 93 <0.01 Non-technical Communication with parents regarding resuscitation 66 87 <0.05 Confidence in ability to communicatewell with team during resuscitation 75 90 <0.05 Overall confidence in ability to take a role in a resuscitation 83 93 <0.05 Confidence in ability to lead a resuscitation 81 92 <0.05 ARNI Simulation Evaluation Pre course Post course P Initial management of congenital diaphragmatic hernia 68 90 <0.001 Initial management of a preterm baby 87 92 <0.05 Initial management of a baby with suspected cyanotic heart disease 75 92 <0.001 Managing a sick postnatal ward baby 79 92 <0.01 Initial management of baby with suspected NEC 80 90 <0.01 Managing a pneumothorax 78 91 <0.05 Managing airway obstruction 69 87 <0.01 Managing post resuscitation care 77 94 <0.001 Quality Control • How do keep your simulation programme high quality? • Practicalities • Time / people pressures can lead to cut corners • What to do when the ‘quality’ is not there • “I’ve done the nurses” • Informal feedback that makes you cringe (are you right though? – sim feedback tends to be positive) Debriefing pitfalls for faculty • Judgement (Judgemental) • Do faculty understand & demonstrate the difference • Too much talking • Tall poppy • Overly negative debriefing • Power trips Assessment & Quality Control • Of trainees – changes your programme, validated tools? • Of faculty? • DASH (Harvard) - debriefing assessment of simulation in Healthcare https://harvardmedsim.org/debriefing-assessment-for-simulation-in-healthcare-dash/ • trained raters to rate instructors • students to rate their instructors • instructors to rate themselves • OSAD (Imperial) The Observational Structured Assessment of Debriefing tool https://www1.imperial.ac.uk/resources/CFE7DECB-8FE7-437C-8DAA-6AB6C5958D66/debriefingosadtool.pdf
28/09/2017 6 Application of faculty skills • Application of faculty skills to real world situation debriefing • Deferred, planned • After action debrief Summary • Introducing a simulation programme, • Candidate & Faculty barriers • Sustainability • A structured approach to faculty development may help • Initial Course • Experiential Learning • Team meetings • Programme planning with simulation faculty – increases ownership & buy in • How do you quality control your programme? Thank-you for Listening
1 © 2017 David M. Gaba The Route to Patient Safety via Simulation for Education & Training in Healthcare • David M. Gaba, M.D. - Associate Dean for Immersive and Simulation-based Learning; Professor of Anesthesiology, Stanford University - Founder & Co-Director, Patient Simulation Center at Veterans Affairs Palo Alto HCS © 2017 David M. Gaba Some "Traditional" Methods are Important but Underutilized • Story-telling • Verbal simulation • Role-playing • Standardized ACTORS (pts, families, co-workers) Simulation is a technique not a technology © 2017 David M. Gaba Current "New" Forms of Simulation Evolving Techniques • Virtual world (single vs. multi player) • "CAVE" • Interactive head-mounted display virtual reality • Star Trek Holodeck {not -- yet} © 2017 David M. Gaba 3DiTeams Jeff Taekman, et al, Duke, et al © 2017 David M. Gaba ASA's © 2017 David M. Gaba “WAVE” at USUHS
2 © 2017 David M. Gaba Mulitplayer Head-mounted Display Interactive VR (From SimX YouTube Video) © 2017 David M. Gaba Potential Impacts of Simulation on Pt. Safety – Education & Training •Improve the usable knowledge of early learners - Using full simulation for “book knowledge” is usually “overkill” - Simulation useful to practice integration & flexible USE of knowledge © 2017 David M. Gaba For SAFETY Simulation Usually is Addressed to Experienced Personnel • Advanced trainees & above • They take direct care of patients • They need the practice as individuals and teams for - Psychomotor procedural skills - Dynamic decision making - Team management / teamwork © 2017 David M. Gaba Indirect Effects of Simulation on Patient Safety • Simulation can be a lever to alter organizational cultures of safety - Clinicians - Managers - Executives - Lawmakers • Simulation can be a uniting force to trigger, focus, or host other patient safety efforts © 2017 David M. Gaba Potential Impact of Simulation on Patient Safety -- Research • Simulation-based research & development to study & improve processes of care, such as: - Clinical protocols - Human-machine interactions - Performance shaping factors (e.g. fatigue) - Cognitive aids © 2017 David M. Gaba In situ & peri situ Simulation for Systems Probing In situ: Latin for “in place” -- simulation in actual patient care areas Peri situ: "near place"-- nearby “Systems probing” – looking for what works well in the “system” and also for hidden problems If you fix a systems problem it may be fixed for EVERYONE (no training needed)
3 © 2017 David M. Gaba Simulation for "System Safety, Quality/Risk Management • Simulation can help learning by organization / personnel - Enhance event investigations; scenarios taken from events - Enhance "morbidity & mortality" conferences • Medicolegal cases - Simulation demonstrations or tests for litigation/defense © 2017 David M. Gaba Simulation-based Performance Assessment - Ensure capabilities of new graduates - "Board" certification - Continued assurance of skills & capabilities of experienced clinicians - Research on care processes - Evaluation & training of clinicians »Returning after long time out of work »After episodes of "poor performance" © 2017 David M. Gaba Assessment Needs Many Views: “Jigsaw Puzzle” or “Orthogonal Views” • Gaba, DM: Improving anesthesiologists’ performance by simulating reality (editorial). Anesthesiology 76:491-494, 1992 • McIntosh CA: Lake Wobegon for anesthesia...where everyone is above average except those who aren't: variability in the management of simulated intraoperative critical incidents. Anesth Analg 2009; 108: 6-9 © 2017 David M. Gaba Each Orthogonal View Sees Something That the Others Do Not © 2017 David M. Gaba Orthogonal Views of Clinical Performance 1. Real-cases, prospective observation + actual clinical cases & prospective - BUT… “everyday” cases & situations (boring) 2. Real-cases, by case/incident reports of challenging (problem) cases + real cases with a problem or challenge - BUT… retrospective (biased, incomplete) © 2017 David M. Gaba Orthogonal Views of Clinical Performance 3. Simulated cases, prospective observation + Challenging cases + Prospective - BUT….. simulated cases, not real A) they KNOW it’s simulated B) it’s hard to re-create the “motivational structure” of the real-world
4 © 2017 David M. Gaba Simulation’s “Window on Performance” is Unique • May be useful in many ways • Although… even when done in-situ requires serious effort ($$/€€) • Data will be “mixed-methods” (qualitiative & quantitative) with few unequivocal findings - Because clinical work is very complex! © 2017 David M. Gaba Breaking News! Study of 263 ABA Certified Anesthesiologists Weinger MB, Banerjee, A, Burden, AR, McIvor WR, Boulet J, Cooper JB, Steadman R, Slagle J, DeMaria S, Torsher L, Sinz E, Levine AI, Rask J, Davis F, Park C, Gaba DM (August, 2017) Simulation-based Assessment of the Management of Critical Events by Board-Certified Anesthesiologists © 2017 David M. Gaba T-1 Kirkpatrick level 1 (self-conf; how like?) T0 Better KNOWLEDGE (e.g. MCQ) T1 Better PERFORMANCE –in sim T2 Better PERFORMANCE – in clin work T3 Better pt. OUTCOME (T3’=cost-effective) T4 Dissemination (to others, can they do it?) T5 Adoption (will they adopt it for regular use?) T6 Better population OUTCOME (?) Sim Translational Rsch Levels (McGahie et al, SiH, S42-47, 2011; Rall, Gaba et al, Miller 8th ed, Chptr 8, p195, 2014) © 2017 David M. Gaba The Pharmaceutical Analogy for Simulation: A Policy Perspective • Who would expect a major change in outcome from a new drug when: - Using a low dose of the drug - Dosing haphazardly to only a few subjects - Not repeating treatment as necessary - Ignoring any exacerbating factors - Using only a single modality - Following subjects for only a short time (Gaba D: Sim Healthc; 2010, 5:5-7) © 2017 David M. Gaba This is What We Have [mostly] Done in Simulation Research • Simulation interventions are: • Infrequent • Often low-intensity curricula • Little reinforcement in real work • No coupling to performance assessment • In only a few disciplines/domains • Small studies & short time horizons (Gaba D: Sim Healthc; 2010, 5:5-7) © 2017 David M. Gaba Real Test of Simulation Needs a Long Time Horizon • Current studies chip away at small questions (this is good work, but….) • Current studies chip away at small questions (this is good work, but….) • The REAL question is: Does simulation improve quality if: –Long-term adoption –Comprehensive, integrated model –Career-long –Training & assessment –Evaluated over long time horizon • The REAL question is: Does simulation improve quality if: –Long-term adoption –Comprehensive, integrated model –Career-long –Training & assessment –Evaluated over long time horizon (Gaba D: Sim Healthc; 2010, 5:5-7)
5 © 2017 David M. Gaba Pharmaceutical Analogy: Who Pays for Proof? • In clinical trials, often the manufacturer - Huge research budgets, many trials but few successes is “usual” - Huge profits for successful drugs • Simulator manufacturers, centers: - Tiny margins, not used to many expensive trials with few “successes” - No “blockbusters” - Grants limited in size, scope, duration (Gaba D: Sim Healthc; 2010, 5:5-7) © 2017 David M. Gaba {Incidentally} What is the Evidence for Simulation in Commercial Aviation? • There is mandatory yearly training & checking of flying performance - Studies can be grafted onto these activities • Yet, no Level 1A evidence that it saves planes or lives – No randomized trials © 2017 David M. Gaba The Simulation Vision Is a (many) DecadeS-long Proposition • The Vision is of training that is: - Comprehensive & Integrated - Continuous – for individuals, teams, work units - Coupled with performance assessment - Over an entire career; embedded in work processes © 2017 David M. Gaba (Simulation) Training Must Be For a Lifetime (cumulative effect) • Career-long combination of modalities as individuals & teams, repeatedly cycling through: - Didactics & seminars - On-screen simulators, “virtual worlds” & virtual reality - Courses in dedicated sim center - In-situ/peri-situ simulations & drills © 2017 David M. Gaba Bottom Line Lesson If We Save Just One Life… And whoever saves a life, it is as though he had saved all mankind (appearing in various forms in the Talmud, Sanhedrin 4:5 and the Quran 5:32) © 2017 David M. Gaba
6 © 2017 David M. Gaba What is Patient Safety? • Avoiding harming people while trying to “cure” or “help” them - Prevention of errors & complications - Threat & error management - Crisis resource management Jeff Cooper, PhD © 2017 David M. Gaba Some Technological Aspects of "Simulation" Are > 25 Years Old • Part-task training • "Trigger-videos" • Mannequin-based Simulation 1986 1987 © 2017 David M. Gaba Face Validity of Simulation © 2017 David M. Gaba "Snapshot" Summary of Study • Grafted onto ABA MOCA Sim Courses at 8 well-known simulation sites; • 4 carefully standardized scenarios (@ ≈ 20 min); "hot seat" could call for help • Post-hoc video rating by 1-2 or seven highly calibrated expert raters, using multiple rubrics & scales of critical clinical actions & both med/tech & non-tech performance © 2017 David M. Gaba • Overall, ≈ 75% of critical actions were performed; majority of performances rated as average or better on scales • ≈ 25% of performances omitted several critical actions; scale ratings were in the "poor" performance range • The arrival of the second anesthesiologist generally improved overall performance (but participants said that help not always available in their clinical sites) "Snapshot" Summary of Study Results © 2017 David M. Gaba Overview of Study Conclusions • Performance on unexpected critical events is good but far from consistent • Further research needed to understand how & why performance not uniformly good • Processes of response of clinicians & teams to acute events CAN be strengthened, e.g. - Cognitive Aids (Checklists & Emergency Manuals) - Ensuring availability of help - Lifelong learning & honing of acute event skills (various approaches including simulation)
7 © 2017 David M. Gaba Simulation: Where is the Proof? • But…. Maybe we never will know the answer to many important questions about simulation…… {actually… some of Hilbert’s problems are known to be unproveable [even in principle] } David Hilbert, Famous Mathematician – Hilbert’s 23 problems (1900) © 2017 David M. Gaba So…What Should We Do About Research Concerning Healthcare Simulation? • Continue all the research we can do • But… also educate policy makers about evidence that can/cannot be had (for all practical purposes) – they must either: - Provide big funding for large, long, complex studies; or else - Not expect “definitive proof” for many issues about simulation © 2017 David M. Gaba Opportunities for Research ABOUT Simulation (examples) • Less worry about “does” it work and more about “how”, “why”, “who”, e.g. - Pedagogical approach A vs. B vs. C - WHAT are participants learning? - ???? • Outcome studies as strong as feasible • Multi-center studies/collaborations © 2017 David M. Gaba Simulation is Probably Pre-Historic • Likely a preparation or surrogate for hunting or war Photos via “Adobe Photoshop Time Machine” Full Immersion Simulation “The Real Thing” © 2017 David M. Gaba Potential Impacts of Simulation on Patient Safety • Direct Education & Training Effects • Performance Assessment • Indirect Effects – Culture change all levels • Quality & Risk Management • Research – Human factors • Equipment – regulation, approval, procurement, training © 2017 David M. Gaba Pharmacology Analogies for Simulation Weinger MB: Simulation in Healthcare 5:8-15, 2010
8 © 2017 David M. Gaba Advantages of Simulation for Performance Assessment • Can assess aspects of practice that are not readily observable in real cases - Detection, diagnosis, and management of critical situations and/or emergencies - Response to worst case situations of equipment failure, interpersonal conflict © 2017 David M. Gaba Advantages of Simulation for Performance Assessment • Can present “standard” case situations to different clinicians / crews / teams - Allows determination of actual spectrum of performance by personnel at different levels of experience © 2017 David M. Gaba Combining Modalities Hybrids • Best features of each modality can sometimes be combined, e.g.: - Mannequin = SP (voice) - SP actor + vital signs monitor - SP actor + part-task trainer (e.g. urinary catheterization model) - Virtual reality + physical simulator © 2017 David M. Gaba Measuring Intermediate Variables (T0, T1) • Fair to good measures of learning (T0) –at least ‘knows’, ‘knows how’ • Modest proof of ‘shows how’ in simulation (T1) • A few studies show improved clinical performance and very few show pt. outcome (T2 or T3) – but VERY hard to do this research © 2017 David M. Gaba T3 Outcome Measurement is Tractable When: • Simulation intervention is circumscribed; AND • Outcome is easily measured; AND • Outcome is moderately common Example: Infections & complications after CVC insertion © 2017 David M. Gaba T3 Outcome Measurement is Difficult When… • Event is rare • Outcome is subtle & hard to measure • Behavior/skill is complex • Intervention is complex (e.g. CRM sims) • Many confounds between intervention & outcome
9 © 2017 David M. Gaba What is Simulation? • A “technique” NOT a “technology” - For interactive and often “immersive” activities that re-create experiences of a real-world environment »To amplify or replace actual experiences »“Even better than the real thing” © 2017 David M. Gaba Dynamic Decision Making Team Management
28/09/2017 1 The use of technology enhanced learning to deliver high quality neonatal care Jonathan Cusack Leicester Neonatal Simulation Team Outline • Using simulation to work out what to change • Using simulation to implement change • Integrating quality improvement into your simulation program • Does it work? -measuring outcomes Quality in Healthcare • Sometimes difficult to define • Links with risk management: responding to incidents and learning from mistakes • Latent threats to patient safety: examples • Simulation is a technology to allow debriefing: should not be used in isolation Quality Improvement Cycle Plan Do Study Act Quality Improvement Cycle Plan Do Study Act Where does simulation fit in? Planning • Themes emerging from your units governance • Recurrent issues in your simulation program • Implementing best practice from research
28/09/2017 2 Using simulation to implement change • Testing what works and what doesn’t • Deliberate practice • Research example • Lessons from other industries: tools, equipment, check lists Example: intubation medication • Example: Resuscitation equipment Integrating QI with your training program • Themes for training • Other forms of technology to improve quality • Task training: mask leak difficult airway Audio prompt CPR depth Integrating simulation techniques with clinical working • After Action Review Integrating simulation techniques with clinical working • Deliberate practice EXIT procedure Complex resuscitation
28/09/2017 3 Does it work? yes Evidence • Decreased HIE rates • Decreased birth trauma /Erbs palsy • Decreased time from decision to delivery • Areas that are process driven • Integrating with large scale changes What would work in neonatal medicine? • Using simulation programs to investigate what actually works in situ • Increased use of check lists- evidence based • Using debriefing techniques after real resuscitations to identify areas to improve • Better use of deliberate practice • Mannequins and devices that reliably measure performance • Integrating with larger scale change
Abstracts for Podium Presentations
6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name H.M.Durga Herath Job Title Speciality doctor ( Paediatrics/Neonates) Institution This project was done in District General Hospital, Hambanthota, Sri Lanka Current employment - Lincoln County Hospital Email durgaherath@gmail.com Specialty ( Paediatrics/Neonates) Mobile Contact Address: 16, Greenway, Lincoln, LN22YA Submission for: Both (delete as appropriate) Title: Effective implementation of a protocol on initial stabilization of preterm neonates delivered at less than 32 weeks gestation through a simulation programme in a District General Hospital in Sri Lanka Author(s): H M D Herath, S Somarathna, D S Rajapaksha, P Dissanayaka, G W C Malkanthi, W G Ruwan Kumara Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Background: Effective initial stabilization of preterm neonates in the initial 60 minutes of life (termed neonatal golden hour) helps minimize a number of complications and lead to improved prognosis. Effective resuscitation, respiratory support, maintaining normal temperature ,blood sugar, timely parenteral nutrition, timely treatment of sepsis and a completed admission within 60 minutes of delivery are identified as key components of the golden hour. High intensity and multitude of interventions necessary and diversity of skills of staff involved make it a challenging task. A protocol specifies the essential steps of the golden hour. Simulation-based learning to practise the protocol helps to create a cohesive team. Objectives: To evaluate effective implementation of a protocol on initial stabilization of preterm neonates less than 32 weeks gestation through a simulation programme. Study design: Prospective study Method: A protocol on early stabilization preterm neonates was introduced to neonatal staff via scenario teaching comprising of a simulation followed by debriefing session for each staff member. The extent to which the key components of neonatal golden hour achieved before and after implementation of the protocol were assessed using a checklist. Results: In the post-protocol group a significant increase was seen in the number of infants resuscitated with optimal preparation (p<0.05), infants received glucose infusion and antibiotics (p<0.01), infants with blood sugar above 2.6mmol/l (p<0.05) and infants with completed admission within 1 hour (p<0.01).A significant difference in adherence to thermo-protective measures during stabilization (p<0.01) and admission temperature above 36.50C (p<0.01) were seen.Conclusions: Implementation of a protocol on golden hour through a simulation programme can significantly improve stabilization of preterm neonates.
6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Brennan Vail Job Title Current: Medical Student; At Time of Conference: Pediatric Resident Institution University of California, San Francisco Email Brennan.Vail@ucsf.edu Specialty Pediatrics Mobile Contact Address: 3474 Clay Street, San Francisco, CA 94118 Submission for: Podium and Poster Title: Simulation as a Tool for Improving the Quality of Neonatal Resuscitation Skills in Bihar, India Author(s): Brennan Vail, Melissa Morgan, Amelia Christmas, Hilary Spindler, Aritra Das, Sunil Sonthalia, Pushpalata Sharma, Megha Joshi, Dilys Walker Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Background Fourteen percent of global neonatal deaths and half of those in India occur in four Indian states, one of which is Bihar. Birth asphyxia causes one-third of neonatal deaths in Bihar. Little is known about the impact of simulation training on the quality of neonatal resuscitations (NR) in primary health centers (PHCs) in low-resource settings. Methods This analysis assessed the impact of simulation training, developed by PRONTO International and implemented within CARE India’s AMANAT program, on quality of nurse-midwives’ NR skills in simulated and live resuscitations. NR simulations were conducted and video-recorded at 160 PHCs across Bihar over 8 months. Mid- and post-training assessment videos were coded for clinical quality indicators. Trainees’ performance in live deliveries was documented by simulation facilitators using a phone application. Results In total, 226 matched simulation videos were evaluated. From mid- to post-training, proper neck extension, positive pressure ventilation (PPV) with chest rise, and assessment of heart rate increased by 14%, 19%, and 12% respectively (all p≤0.01). No significant difference was noted in stimulation, suction, proper PPV rate, or time to completion of key NR steps. In 252 live, non-vigorous deliveries, identification of asphyxia, use of suction, and use of PPV increased by 22%, 24%, and 26% respectively (all p<0.01) between weeks 1-4 and 5-8 of training. Conclusion PRONTO training, as part of the AMANAT intervention, had a positive impact on key NR skills in simulated and live resuscitations across Bihar. Simulation training is a promising tool for improving NR skills in resource-limited settings.
6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Elbaba M.A. Job Title Co-chair of pediatric simulation HGH Institution Hamad Medical Corporation Email mostafaelbaba@hotmail.com Specialty Pediatrician and simulation educator Mobile Contact Address: Title: Need makes innovation: The MPS Solutions Author(s): Elbaba M.A., Bayoumi M.A. Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Background A collaborative work amongst three simulation specialists built a mobile pediatric simulation team named MPS in 2016. We have our own equipment including many manikins of medium fidelity. We also have our SPs and few task trainers. Due to the nature of the MPS which is "mobile", we used to move from our base in Qatar to other countries overseas to conduct our pediatric simulation events. The team faced many challenges because of the mobile nature of simulation to be delivered One of the major challenges is the task trainers; we need to ship or travel with many strange pieces of equipment in the flights. Method To overcome the difficulty of transporting many task trainers required for psychomotor skills and for interventions in simulated practice, MPS has invented four commonly required task trainers in pediatric practice from very basic materials but with high fidelity. These hand-made part task trainers are: Lumbar puncture, chest tube insertion, peripheral IV cannulation and umbilical catheterization for the newborn. Outcome The learners attending our workshops used the newly created task trainers and enjoyed and engaged better during those simulation experiences. The sense of realism which reflects the high-fidelity nature of the models, was achieved as learners mentioned this in their feedback. MPS successfully demonstrated the integration of high fidelity with low technology resources. Conclusion The author will demonstrate and share the newly innovated task-trainers with the audience. MPS believes that creativity is an essential requirement for any simulation specialist or educator.
6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Kathryn Colacchio Job Title MD Institution New Hanover Regional Medical Center/Coastal Carolina Neonatology Email kathryn.colacchio@ccneo.net Specialty Neonatology Mobile Contact Address: 2131 S. 17th Street, Wilmington NC 28401 Submission for: Poster or Podium Title: Neonatal Education with Simulation Training Author(s): Dr. Kathryn Colacchio MD, Sheila Deitz NNP, Dr. Fernando Moya MD, Deborah Stokes RN, MSN Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Background: When newborns with problems are born unexpectedly in community hospitals, delivery room personnel can significantly impact morbidity and mortality as initial interventions can result in injury, developmental delays and even death. In 2014, infant mortality rates in two southeastern NC counties were more than double the state’s overall rate. We travelled to small hospitals in a mobile simulation lab to provide opportunities to practice resuscitation, stabilization and teamwork with the goal of increasing caregiver confidence during the “golden hour” (the first hour after birth). Methods: Led by a neonatologist, the multidisciplinary team facilitated common high risk scenarios (e.g. meconium aspiration, extremely premature infant) in three pilot hospitals with Level 1 nurseries. Nurses, respiratory therapists and physicians were invited to participate in situ allowing for identification and remediation of latent safety hazards. Using evidence-based recommendations from the Neonatal Resuscitation Program, S.T.A.B.L.E and TEAMSTEPPS curriculums, debriefs focused on standards of care and teamwork optimization. A pre and post survey was distributed to assess confidence levels. Results: Participants demonstrated an improvement of confidence in maintaining golden hour measures including temperature control (2.7 out of 5 vs. 4.7 out of 5) and oxygenation levels (3 out of 5 vs. 4.2 out of 5) in the extremely premature infant. Conclusions: Our goal was to improve the stabilization of the critically ill newborn by educating staff members about best practices and identifying latent safety hazards. Participants demonstrated a self-reported improvement on the confidence surveys. Anecdotally it has been a positive experience for all staff involved.
6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Name Sarah Ball Job Title Clinical Educator Institution Corniche Hospital, Abu Dhabi, UAE Email sarahl@seha.ae Specialty Neonatology Mobile Contact Address: Education & Simulation Department – Corniche Hospital – Abu Dhabi – 3788 – United Arab Emirates (UAE) Submission for: Podium / Poster / Both (delete as appropriate) Title: ‘Transforming neonatal resuscitation training to improve neonatal clinical outcome’ Author(s): Mrs Sarah Ball MSc Education, CHSE, BSc(Hons), RN(Child) Abstract: Background: • Corniche Hospital is the UAEs largest high-risk maternity facility, with 64 cots Level III Neonatal Intensive Care Unit. With 7,000 deliveries per year it is imperative that healthcare providers can deliver effective neonatal resuscitation. It is well documented that reflective multidisciplinary (MDT) simulation team training improves clinical outcome. In 2014 we commenced our journey away from traditional teaching methodologies towards an immersive simulation training model. Methodology: • RADAR, SMART, fish bone analysis, prioritization matrix, SWOT & literature review. • Faculty attended CAPE in Stanford, USA and became Certified Healthcare Simulation Educators (CHSE). • Transformed and adapted the Neonatal Resuscitation Programme (NRP). • Formed the Neonatal Foundation Life Support Programme (NFLS): Development of a community programme, accredited by the Health Authority Abu Dhabi (HAAD) utilising hybrid in-situ simulation. • Constructed the first bespoke neonatal and obstetric simulation centre under SEHA Abu Dhabi opened, 2015. Results: • Base line results from 2014 showed sub-optimum clinical outcome from neonatal resuscitation drills at 52%. With the transformation in neonatal resuscitation simulation training the clinical outcome from neonatal resuscitation drills improved to 91%. Improvements in neonatal clinical outcome have also been seen in the reduction of term admission rates to the NICU to 24.75% (below England and Wales) and reduced rates of HIE admissions to the NICU to 0.20%. Conclusions: • Transforming our neonatal resuscitation training into an immersive simulation experience has resulted in improved neonatal clinical outcome. Key messages: • Simulation can improve neonatal clinical outcome, patient safety and staff engagement.
6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Sara Phillips and Samantha Fleming Job Title Practice Educator Midwife Practice Development Midwife Institution Royal Berkshire NHS Foundation Trust Email Sara.phillips@royalberkshire.nhs.uk Specialty Midwifery Mobile Contact Address: Craven Road Maternity Unit Submission for: Podium/ Poster / Both (delete as appropriate) Title: Pre Hospital Neonatal and Obstetric Emergencies in the Home (PHONE) 999 Author(s): Samantha Fleming (Practice Development Midwife), Katherine Simpson (Clinical Skills Midwife), Darren Best (Education manager South Central Ambulance), Sara Phillips (Practice Educator Midwife), Hazel Inkster (Practice Educator Midwife), Nicola Pritchard (Neonatal Consultant) and Sunetra Sengupta (Obstetric Consultant) Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Background: The need for combined community midwife and paramedic training became apparent following a number of investigations following incidents of both obstetric and neonatal emergencies at home. Re-occurring themes were identified including poor team work and communication due to a lack of understanding of each other’s roles, responsibilities, skills and limitations. There was a lack of knowledge and confidence in both professions regarding obstetric and neonatal emergencies in the home and how to safely and effectively continue neonatal resuscitation in the ambulance. Methods: To improve team performance and neonatal outcomes South Central Ambulance Service and the practice development team at the Royal Berkshire Hospital worked together to develop the PHONE 999 study day which is multi-professional training for community midwives, paramedics, maternity and emergency support workers. The study day is a combination of lectures and low and high fidelity pre hospital simulations. Conclusion: Candidates rated their knowledge and confidence on managing obstetric and neonatal emergencies in Pre-hospital settings using a scale of 1 – 5 pre-and post courses. On average the knowledge and confidence of community midwives increased by 31.4% and paramedics by 51.7%. The feedback received has all been positive using words such as “invaluable, excellent, innovative and practical”. Results: We have reviewed notes and seen evidence of good clinical decision making, management of emergencies and effective communication between midwives and paramedics. As part of the project a training DVD was produced to demonstrate safe and effective management of on-going neonatal resuscitation in the home and during ambulance transfer to hospital.
6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Alison Michaels Job Title Education Coordinator – Simulation Institution Mater Education; Mater Misericordiae Limited Email alison.michaels@mater.org.au Specialty Neonatal Critical Care and Simulation Education Mobile Contact Address: Level 4, Duncombe Building Raymond Terrace South Brisbane, Queensland, Australia, 4101 Submission for: Both Title: Taking simulation into the NCCU and beyond: working together to innovate and improve neonatal care Author(s): Alison Michaels and Richard Mausling Abstract: Background: The Neonatal Point Of Care (POC) Simulation program adopts a multifaceted interprofessional approach to address clinical, leadership, teamwork and process issues when caring for the deteriorating neonate. This program aims to scaffold concepts learnt through simulation training offered in Mater Education Practice Improvement Centre (MEPIC) and embed these in environments where clinicians would perform neonatal resuscitation events . Method: Twenty neonatal POC simulations were held across a nine month period. Scenarios were developed to encompass the most common situations requiring neonatal resuscitation. These sessions were delivered as short announced simulation events with a structured debrief to follow. The commencement of this program involved a unique strategic team approach with both medical and nursing co-faculty. Results: Significant adaptations were applied throughout the journey of embedding this program. The interprofessional team engaged in working together to improve and innovate, with this resulting in enhanced engagement staff throughout the neonatal service. Preliminary data demonstrates increased clinician confidence across non-technical skills required to resuscitate a deteriorating neonate. Furthermore, a number of process and systems issues were identified and improved as a result of allowing the review of processes involved in POC simulations that were undertaken. Conclusions: Successfully embedding the program into the clinical area saw improved engagement in simulation- based education. This program has allowed participants to identify process and communication issues inherent in the clinical environment and has energised these participants with the ability to be innovative in improving processes and communication to ensure the provision of low variability patient care.
6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name T Pillay Job Title Consultant Neonatologist Institution Royal Wolverhampton NHS Trust Email tilly.pillay@nhs.net Specialty Neonatology Mobile Contact Address: c/o Neonatal Unit, New Cross Hospital, Wolverhampton, WV10 0QP Submission for: Podium/poster Title: Supporting Care of the Sick Neonate: Networking individuals and fostering inter-unit rapport through shared learning using mixed LNU/SCBU/NICU teams Author(s): Pillay T, Clarke L, Cookson J, Rasiah, V for the SSN Faculty Staffordshire, Shropshire & Black Country (SSBC) and Southern West Midlands (SWM) Neonatal Operational Delivery Networks (ODNs) Abstract: Introduction: A bi-network initiative aimed at optimising support for sick neonates especially where care is shared between LNU/NICU/SCBU teams was developed: its objective to facilitate engagement using small group, confidential, and shared-experience learning. This educational contract focussed on networking individuals from different neonatal units, fostering inter-unit rapport, providing consultant decision making support, and management of teams in complex clinical situations. Methods: High and low fidelity simulations, together with workshops and augmented by 20 minutes reflective time post-scenario-debrief were conducted, to promote networking, sharing of experiences, and facilitate bi-directional learning and rapport. This was supported by a multidisciplinary faculty of 24. At the end of each course an evaluation form was completed by candidates; these outcomes are reported. Results: Between October 2015-January 2017, 81 team members from 9 neonatal units participated in the course. This included 37 consultants (4 NICU, 18 LNU,15 SCBU), 17 neonatal nurses, 19 trainees, and 8 ANNPs. The course was rated as highly relevant with high quality materials supporting LNU/SCBU/NICU teams. Inter- team engagement was supported: 76% did not mind not knowing all the members of their simulation scenarios; 64% had no objections to this not being point-of-care; 18% had no opinion on this. Candidates found the course valuable and re-enforced their own leadership, communication and team building skills, strengthening inter/intra- unit rapport. They supported continued professional development in this format. Conclusion: This shared care learning, through networking individuals from different neonatal teams has proved a useful adjunct facilitating inter-unit-engagement within our SSBC and SWM Neonatal ODNs.
6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Dr Pinki Surana Job Title Neonatal Consultant Institution Birmingham Heartlands Hospital Email suranapinki@yahoo.co.uk Specialty Neonatal Medicine Mobile Contact Address: Bordesley Green East, Birmingham Heartlands Hospital, Birmingham B9 5SS Submission for: Podium/ Poster / Both (delete as appropriate) Title: Learning from in-situ Neonatal Simulation: 3 Years of Participants’ Feedback Author(s): Dr Kylee Walker, Tracey Clohessy, Janice Duckett, Dr Victoria Fradd, Dr Imogen Storey, Dr Pinki Surana Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Background: In-situ simulation in intensive care setting prepares professionals for challenging scenarios in a safe environment. Deliberate practice in a time-pressured, task-heavy clinical environment is realistic, helping with technical and cognitive skills alongside recognition of human factors. Method: A high-fidelity, in-situ simulation training was established in a tertiary neonatal unit in December 2013 with fortnightly sessions. We collected structured participants’ feedback on the quality of debriefing, their self- confidence before and after each session and whether the simulation was realistic, relevant to their training and would change their practice. Participants were also asked to provide two “learning points” and suggest areas for programme improvement. Feedback from 59 sessions covering 16 different clinical scenarios from December 2013 to October 2016 was analysed. Results: Of the 292 feedback forms reviewed, majority of the participants reported the simulation was highly relevant to their training and would change their practice. The debrief quality was rated highly. There was notable improvement in reported self-confidence after the session. 39% of the learning points related to clinical management, 38% to human factors and 24% to clinical skills. Human factors which featured highly were communication, leadership and anticipation or planning. Suggested improvements were to create a more believable environment and more frequent sessions. Conclusion: In–situ neonatal simulation training is highly valued by both doctors and nurses and improves their reported confidence – more than a third of reported learning related to human factors. Given the human factors contribution to clinical incidents, this would be expected to improve patient safety.
6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Dr Felicity Brokke Job Title Neonatal Consultant Institution Medway Maritime Hospital Email felicitybrokke@yahoo.co.uk Specialty Neonates Mobile Contact Address: Submission for: Poster Title: Quality Improvement of Peak Inspiratory and End Expiratory Pressure Settings during Infant Resuscitation at Birth. Author(s): Felicity Brokke, Amy Skinner, Victoria Lander, Alison Clark and Ghada Ramadan Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Aims: In-situ simulation training indicated the need for accurate setup of peak inspiratory pressure (PIP) and positive end expiratory pressure (PEEP) prior to newborn resuscitation. Our project aimed to improve the quality of team learning from latent inaccuracies in PIP and PEEP settings, to reduce harm and improve outcomes for newborn infants through a series of targeted interventions. Methods: During 2016, we undertook a quality improvement project to measure baseline set-up of resuscitaires in the delivery suite. The first PDSA (plan do study act) cycle was performed through a prospective daily check of all resuscitaires (n=12) PIP and PEEP settings over a one-week period. When issues were identified, an “on the spot” one to one training of midwifery staff was performed. During the second PDSA cycle we introduced “resuscitaire flashcards” to be used as an aid memoire for the daily safety checklist. Results: During the first PDSA cycle, 10% of resuscitaires PIP was high (>30 cm H2O) and PEEP was set incorrectly in 48%. Inaccuracies in PEEP were either too high flow settings (>5 cm H2O) in 22% of cases or too low flow settings (<5 cm H2O) in 26%. Following the interventions, 100% of PIP was correctly set and only 11% of PEEP was inaccurate. Overall, this quality improvement programme led to 76% improvement in performance. Conclusion: Targeted quality improvement interventions through simulation have improved PIP and PEEP resuscitaires settings. This led to a reduction in latent errors and improved care given to newborns requiring resuscitation at birth.
6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Alana Barbato, MD Job Title Neonatal-Perinatal Medicine Fellow Institution Indiana University School of Medicine Email albarbat@iupui.edu Specialty Neonatology Mobile Contact Address: 699 Riley Hospital Dr. RR 203 Indianapolis, IN 46202 Title: The Use of Simulation Education to Promote Delivery Room Euthermia in Preterm Infants Author(s): Alana Barbato, Elizabeth Wetzel, Lisa Mayer, Bobbi J. Byrne Abstract: Background: Thin skin, decreased brown fat and increased surface area to mass predispose preterm infants to heat loss in the delivery room. Hypothermia leads to cardiorespiratory compromise, hypoglycaemia, and increased long term morbidities and mortality. Preterm infants born in community hospitals versus tertiary centers also have increased morbidities and mortality. Methods: To improve admission temperatures and outcomes, the Indiana University Neonatal Outreach Simulation team provided education on preterm infant delivery room management at 25 community hospitals in the state of Indiana, USA. 471 providers completed pre and post-tests on cognitive knowledge and participated in standardized simulated scenarios with team scoring. After structured debriefing participants repeated the scenario which was also scored. 6-12 months later, the sites were revisited to evaluate knowledge and skill retention. Results: Improvements in provider knowledge was demonstrated on cognitive tests with average scores improving from 49% to 94% (p-value <0.001). Scenario scores demonstrated team deficits most notably with regards to thermoregulation methods and polyethylene bag usage (Figure 1). Repeat scenario scores showed statistically significant improvements in all aspects of the resuscitation. Preliminary data from second visits has shown some attrition in knowledge and skills though overall improvement from initial performance (Figure 2). Chart reviews demonstrating the effect of education on preterm admission temperatures are underway. Conclusions: A structured simulation education intervention on preterm infant thermoregulation improves community provider’s immediate knowledge and skills as well as performance 6-12 months after the education. Chart reviews to ultimately show the true clinical impact of the education are underway. Visit 1, Initial Scenario Visit 2, Initial Scenario Visit 1, Repeat Scenario Visit 2, Repeat Scenario Baby in bag 68/108 (63%) 72/86 (84%) 108/108 (100%) 86/86 (100%) Time (sec) 44 18 13 5 Figure 1: Percentage of polyethylene bag usage by groups along with time to place the infant in the bag after birth. *Visit 2 Data is preliminary.
Figure 2: Team scenario scoring based on total team performance and performance of thermoregulation tasks. *Visit 2 Data is preliminary. Visit 1 Total Score (out of 36) Visit 2 Total Score (out of 36) Visit 1 Thermoregulation Score (out of 8) Visit 2 Thermoregulation Score (out of 8) Initial Scenario 22.8 26.4 4.4 6.1 Repeat Scenario 32.9 34.8 7.6 7.6 0 10 20 30 Scenario Scoring Results
6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Dr Anu Sachdeva Job Title Assistant Professor Institution All India Institute of Medical Sciences, New Delhi Email dranuthukral@gmail.com Specialty Neonatology Mobile Contact Address: Department of Pediatrics, All India Institute of Medical Sciences, New Delhi Submission for: Both Title: Quality Improvement (QI) Program to improve the healthy survival of preterm neonates without severe retinopathy of prematurity (ROP) in Level-2 Neonatal Units in India Author(s): Anu Sachdeva, Deepak Chawla, Praveen Kumar, Ashok K Deorari, Sonica Raj Presenting author: Anu Sachdeva Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Background Quality improvement initiatives can improve the healthy survival of preterm neonates without ROP by adherence to evidence-based healthcare practices, Objectives • To assess current levels of knowledge, skills, attitudes and practices of health-care personnel’s, parents and administrators about clinical care pathways • To formulate, pilot test and finalize an educational package of interventions to improve the practices and the processes of care related to risk of ROP Methods A mixed-methods cross-sectional study (for objective 1) was conducted at level 2 neonatal units in India. The listed parameters were assessed in five domains i.e. good control of oxygen therapy, improving nutritional status, less exposure to blood products, less systemic infections and good developmental support. Study tools included focussed-group discussions, in-depth interviews, multiple-choice questions, objective structured clinical examinations and direct observation of care. Results A total of 4 SNCUs, 27 doctors, 46 nurses and 19 parents were enrolled for the study. Monitoring of oxygen therapy was hampered by lack of knowledge of alarm limits, practice of muting alarms and non-availability of pulse oximeters. Majority of participants knew that breast-milk is first choice for feeding of preterm neonates; however, babies invariably got other milk. Involvement of families in the care of preterm neonates was hampered by restriction of entry in the unit. Lack of knowledge of criteria of screening for ROP, non-availability of local ophthalmologist and lack of sensitization of parents about importance of ROP screening was resulting in poor screening of ROP. Educational package (will be shared with participants) is planned to be tested using debriefing in simulation labs. Delivery will be as “hub and spoke” model wherein nodal center hub being the medical college and the level 2 neonatal units in the adjoining areas as the spokes, and thus the dissemination of knowledge and competency based skills shall be imparted. Conclusions Prevalent poor healthcare practices which result in high incidence of ROP and lack of quality screening of eligible neonates indicates an urgent need to implement QI methodology in level 2 units.
QCPR Feedback trial: Comparison of different resuscitation feedback methods during randomized pediatric simulation training Michael Wagner, MD 1 , Katharina Bibl, MD 1 , Emilie Hrdliczka 1 , Maria Stiller 1 , Jutta Gamper, BSc 2 , Katharina Goeral, MD 1 , Ulrike Salzer-Muhar, MD 3 , Angelika Berger, MD, MBA 1 , Georg M. Schmölzer, MD, PhD 4,5 , Monika Olischar, MD 1 1 Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Medical University of Vienna, Vienna, Austria 2 Section for Medical Statistics, Medical University of Vienna, Vienna, Austria 3 Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Vienna, Vienna, Austria 4 Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta Health Services, Canada 5 Department of Pediatrics, University of Alberta, Edmonton, Canada Background Highest quality of pediatric resuscitation skills is required to ensure the safety of hospitalized children. Therefore, Medical Universities provide pediatric resuscitation trainings to their students. The positive effect of feedback devices has been reported previously, respective studies showed limitations due to either small numbers of trainees or their focus on adult life support only. Methods A total of 653 medical students, who participated in their mandatory pediatric basic life support (PBLS) course were included. Participants were instructed to practice at one of two different manikin models (baby and adolescent; n= 344 and 309, respectively). Participants were randomized to three different groups: Group A (n=225, instructor feedback (IF) group) received a traditional instructor-led class without additional feedback devices. Group B (n=223, device feedback (DF) group) had access to direct visual feedback during PBLS from a feedback device only. Group C (n=205, instructor and device feedback (IDF) group) received feedback from an instructor who simultaneously received feedback about the trainees’ chest compression performance from a feedback device in real-time. Results The overall Kruskal-Wallis test showed significant group differences (p<0.0001). Participants in both feedback groups (B and C) had statistically significant better chest compression scores when compared to instructor led-classes. Of all studied parameters, „enough depth” (all groups p<0.0001) and „release” (group A and C p<0.0001, group B p=0.0205) showed the highest statistically significant difference with better results in the baby compared to adolescent manikin. Conclusion and Discussion Our study compared three different feedback methods in two different manikin groups. We could show a significantly improved chest compression performance in a pediatric resuscitation simulation setting depending on feedback method. High quality chest compressions are the cornerstone of cardiopulmonary resuscitation to improve outcomes. Feedback devices should be used during pediatric resuscitation training to improve resuscitation performance.
6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Lucy Boucher Job Title ST5 Paedaitrics Institution UHCW Email lucyboucher@doctors.org.uk Specialty Neonates Mobile Contact Address: 19 the marish, warwick, Warwickshire, cv34 6bz Submission for: Both Title: Neonatal simulation, the new fat burner for paediatric trainees: Effect of in situ high fidelity neonatal simulation training on the heart rate of neonatal trainees at a single tertiary NICU. Author(s): L Boucher, S Ellis, J Daly, A Dunlop Abstract: Stress is not necessarily a negative state and cognitive literature demonstrates an inverted U relationship with performance showing an optimal level of stress for performance. Finan et al. states that within paediatrics there is a risk of trainees becoming over stressed in emergencies due to their relative infrequency and the need to perform at the highest level of competency. Methods: Prospective pilot study of Paediatric trainees at a single tertiary NICU. Heart rate was recorded for the 10 minutes prior to simulation, for the duration of the simulation and during the de- brief. Pilot study was performed over 2 months in 2016
Results: An average rise in HR of 61bpm a 96% increase from baseline. An average of 18 minutes was spent with a heart rate above baseline from the start of simulation taking 8 minutes to return to baseline. Dips In heart rate were noted when more senior help arrived whereas inter-team conflict created further rises in heart rate. Conclusions: Neonatal simulation does provoke a physiological response that can be objectively measured and there is feasiblity to upscale this project. There is scope to compare data from simulation and “real life” resuscitation as well as expanding the measures of physiological stress to include salivary cortisol levels, peripheral skin temperature and electro dermal skin activation. This data could be used to tailor simulations to target an optimum stress response to improve team performance and learning with the aim of improving outcomes in real life resuscitations potentially improving outcomes on the neonatal unit. 0 20 40 60 80 100 120 140 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 Series1 Series2 Series3
6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Chris Paton Job Title Clinical Researcher Institution University of Oxford Email Chris.paton@ndm.ox.ac.uk Specialty Health Informatics Mobile Contact Address: Peter Medawar Building, South Parks Road, Oxford Submission for: Podium Title: Feasibility and Usability of a Mobile Neonatal Simulation Training Tool Author(s): Ms. Elena Taylor, Dr Hilary Edgcombe, Dr Chris Paton, Dr Anne Geniets, Mr Jakob Rossner, Dr. Linden Baxter, Prof. Niall Winters, Prof. Mike English Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) BACKGROUND: Simulation for training health workers in neonatal resuscitation techniques is well established in both high-income and low-income settings. However, many health workers in the low-resource world have difficulty accessing up to date training at sufficient frequency to maintain their skills and knowledge. Scaling context-appropriate training remains a considerable challenge in much of the world. We have developed simulation-related training tools employing low-cost smartphone technology, based on the East African ETAT+ course content. METHOD: We conducted a mixed-methods feasibility and usability study to determine the stability, performance and acceptability of a prototype smartphone-based neonatal training application. A rapid iterative stepwise study was conducted over an 8-month period with nursing students from the UK, exploring usability and new features introduced into the tool over 8 iterations. Both “experienced” and “naïve” groups tested the app in each version, and qualitative data was retrieved using interview and focus group methods to inform the next stage. RESULTS: We describe a novel approach to the rapid development of a technology-based training tool for neonatal simulation, based on iterative testing of new versions with both experienced and naïve users. This provides a basis for further research in the LMIC setting. CONCLUSIONS: Collaboration between Kenyan and British teams including paediatricians, specialists in education and medical simulation and software developers has resulted in successful development of a basic proof-of-concept mobile app based in a simulated 3D environment.
6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Dr. Douglas Campbell, MD, FRCPC Job Title Director of NICU, Director of Allan Waters Family Simulation Centre, St. Michael’s Hospital Institution University of Toronto Email campbelld@smh.ca Specialty Neonatal-Perinatal Medicine Mobile Contact Address: 15014CC - Department of Pediatrics, St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B1W8 CANADA Submission for: Podium only please (delete as appropriate) Title: Using simulation to identify latent safety threats during neonatal MRI intramural transport Using simulation to identify latent safety threats during neonatal MRI intramural transport Author(s): Jonathan Wong1,3, Kaarthigeyan Kalaniti1,3. Michael Castaldo1,3, Kyong-Soon Lee1,3, Hilary Whyte1,3, Manohar Shroff 4, Douglas M. Campbell1,2,3 Background In-situ simulation can be used to identify latent safety, allowing for improvement of process and policy in complex health organizations. Magnetic resonance imaging (MRI) is a frequently used imaging modality but is remotely located from the neonatal intensive care unit (NICU) and can be hazardous for fragile patients. Our aim was to use simulation to identify latent safety threats (LST) during intramural transport for neonatal MRIs and to improve understanding of neonatal intramural transport processes. Methods A prospective observational study was conducted in a tertiary neonatal intensive care unit after ethics approval. Simulated ‘runs’ consisted of taking a neonate with hypoxic brain injury (MRI-compatible low-fidelity manikin: intubated or non-intubated) to the MRI suite and returning to the NICU. Data was obtained through: LST checklist, debriefing and video observation. Results Of 10 simulated runs, 4 were completed by trained transport teams, 3 by ad-hoc clinicians and 3 by scheduled intramural teams (intramural nurse & transport MD). 116 LSTs were seen (11.6 LST/sim). LSTs included: medication, equipment/environment, anticipation, communication, and systems issues. Medication-related safety hazards were self-reported in all sims. Environmental threats included: patient tubing/lines, poor knowledge of MRI room layout, and activating assistance. Differences in checklist performance were noted between dedicated transport teams and other teams. 68% of clinicians reported increased mental & physical workload during the simulations. Take home Messages In-situ simulation was able to identify a number of significant LSTs during neonatal MRI transport, with variation among different team configurations. Intramural checklists and team orientation are now being changed to improve safe practice.
6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Judith Hull Job Title ST6 Pediatrics Institution St Georges Hospital Email judithchull@doctors.org.uk Specialty Neonates Mobile Contact Address: Submission for: Both (delete as appropriate) Title: Debriefing immediately following acute events: a neonatal unit experience Author(s): J Hull, N Velauthan, N Aziz, D Duffy, C Battersby Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Background: The PEDAL (post event debrief and learning) project aims to implement routine team debriefs following actual acute events, gathering the team during or immediately after the shift. It is difficult to integrate simulation into in-house teaching. Debrief post simulation is an integral part of the learning. Adult learning theory emphasises practical, relevant, experiential learning. We hypothesise PEDAL will both enhance the learning process and reduce repeat system and communication errors by identifying areas for development within the clinical governance framework. Methods: Our multidisciplinary survey identified prior practice of debriefing, attitudes toward debriefing and perceived barriers. The PEDAL proforma was designed and implemented. A monthly bulletin was sent out summarising learning points. Educational and system issues were addressed. The Survey will be repeated post intervention. Results: Of 29 staff surveyed, only 17% felt debrief often occurred with 8% having never experienced it. Those with experience of debrief found it useful. 74% felt debrief should occur immediately. Our first monthly bulletin reflected 5 debriefs involving 20 clinicians. Common themes in learning points included communication and equipment. Learning needs identified are being addressed in ongoing departmental training. Conclusion: Feedback suggests clinicians find acute debriefs useful and they identify areas for development. It is feasible to run acute debriefs on a busy neonatal unit. Our experience suggests leadership and engagement from senior team members and a shift in culture is needed for the programme to be sustainable. We aim to embed the PEDAL process in routine clinical practice giving both training and governance benefits.
6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Dr Rachel Hayward Job Title Neonatal Grid Trainee Institution University Hospital of Wales Email rachel.hayward@doctors.org.uk Specialty Neonates Mobile Contact Address: Pentwyn Uchaf Farm, Mountain Ash, CF45 4RJ Submission for: Podium Title: Pitstop-perfect performances: lessons to be learnt from industry Author(s): Hayward R, Hayward A, Cleaton L, C Doherty Abstract: Aim To optimise practices in neonatal resuscitation using the processes used by a Formula One (F1) team. Methods Processes involved in neonatal resuscitation were identified and analysed. Three main components were selected for development: resuscitation equipment, the space available for resuscitation teams and team dynamics. Each component was analysed with a F1 team and comparisons drawn with practices conducted during a pitstop i.e. a dynamic, time critical task performed by a multi-professional team. Changes were made to each component for example, streamlining the equipment trolley, implementing a neonatal footprint in delivery theatres and developing key elements of effective team working. Results A colour coded resuscitation trolley has been developed enabling direct access to essential items during resuscitation. Checklists, a user manual and ‘on-the-spot’ tests have reinforced learning and familiarisation with the resus trolley. The implementation of a dedicated area in delivery theatres (cleared in neonatal emergencies) has enabled direct access to the patient and equipment by all members of the team. Clear allocation of roles to team members, critical appraisal of each resuscitation, fault listing and debriefing sessions will improve how team members interact and identify factors that influence their performance. Conclusions Lessons from F1 can be incorporated throughout the healthcare system. Team performance is dependent upon having a defined leader and clearly identified responsibilities for all team members. Access to essential equipment, adequate training and preparation (simulation scenarios) checklists and debriefing opportunities are essential for optimising team efficiency and providing optimal patient care.
15.Annual Simulation Conference 2017.pdf
15.Annual Simulation Conference 2017.pdf
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15.Annual Simulation Conference 2017.pdf

  • 1. [Type text] Annual Neonatal Simulation & TEL Conference “Simulating Together & Improving Outcomes’’ Organiser Dr Ranjit Gunda Consultant Neonatologist Queen Alexandra Hospital Portsmouth Founding Member MPROvE Programme Lead Wessex-Oxford Neonatal Education Programme Speakers Dr Jonathan Cusack Consultant Neonatologist, Lead Neonatal Simulation Leicester UK Dr Sarah Davidson Consultant Neonatologist, Southampton UK Dr Joe Fawke Consultant Neonatologist, Lead Neonatal Simulation Leicester UK Dr Sijo Francis Consultant Neonatologist St George’s NHS Trust Professor David Gaba Associate Dean for Immersive and Simulation- based Learning and Director of the Center for Immersive and Simulation based Learning (CISL) at Stanford University School of Medicine Professor Lou Halamek Division of Neonatal and Developmental Medicine, Department of Pediatrics Stanford University Director, Center for Advanced Pediatric and Perinatal Education Dr Hannah Shore Consultant Neonatologist, Leeds University Hospital Lead Paediatric Simulation Yorkshire United Kingdom Dr Alok Sharma Consultant Neonatologist Princess Anne Hospital Southampton Founding Member MPROvE Programme Lead Wessex-Oxford Neonatal Education Programme Jens Christian-Schwindt Consultant Neonatologist & Director Sim Characters June 8th & 9th 2017 Venue: Grand Harbor Hotel West quay Road Southampton UK
  • 2. © Copyrights Reserved Dr Alok Sharma, Chair & Lead Dr Alok Sharma is a Consultant Neonatologist at Princess Anne Hospital Southampton. He is a founding member for the Wessex-Oxford Neonatal Education Programme and Lead for the Neonatal Simulation Programme at Princess Anne Hospital Southampton. He is one of the founding members of MPROvE which champions MultiPROfessional Neonatal Education through simulation and technology enhanced learning. His main areas of interest are cascading medical error and risk through in situ simulation. His current area of research is barriers to the uptake of simulation by multidisciplinary teams and latent threat identification. Work on multidisciplinary neonatal simulation done by his team, and its impact on neonatal outcomes was nominated for the National BMJ Award securing the Runner’s Up position in 2014 and was awarded the Best Research Award at ASPIH 2014. He is Course Director the ‘Neonatal Ethics and Difficult Situations Course’ and ‘Simulated Neonatal Airway’ which are run nationally in multiple centres in the UK and abroad. Dr Ranjit Gunda Co-Organiser and Treasurer Dr Ranjit Gunda is a Consultant Neonatologist at Queen Alexandra Hospital Portsmouth UK. He is current lead for the Wessex-Oxford Neonatal Education Programme and faculty on the MPROvE Neonatal Instructor Programme. Dr Gunda has trained in neonatal intensive care at Aberdeen, Southampton, Leicester and London. Ranjit is pursuing research in ‘Nutritional Influence on Surfactant Metabolism in Neonates’. He has completed a research project on the parental perception towards therapeutic hypothermia. His research interest is the use of simulation as quality improvement methodology, in patient safety and risk. His work along with Dr Sharma on ‘Multidisciplinary simulation, cost effectiveness and neonatal outcomes’ was presented at ASPIH 2014 and awarded ‘The Best Research Award’. He founded the Wessex-Oxford Neonatal Education Programme for grid neonatal training in Wessex. Dr Ranjit Gunda has also worked on ‘The OPEN concept’ and its implementation in procedural skills training in neonatology. This is currently being developed into an app for neonatal trainee’s worldwide.
  • 3. © Copyrights Reserved 6th Annual Neonatal Conference Programme-Day 1 Session 1: Introduction  08.00-09.00 Registration & Meet our Sponsors  08.50-09.00 Lift Off  09.00-09.30 Simulation in neonatal care Is this an evidence based cost-effective educational tool? And does it improve outcomes? Dr Alok Sharma  09.30-10.00 The role of simulation in the objective assessment of human and system performance in health care Prof Lou Halamek Session 2: The Challenges  10.00-10.30 Introducing and sustaining simulation in your NICU What works and what doesn’t? Dr Joe Fawke Consultant Neonates Leicester  10.30-11.00 Coffee (Poster Walk) 11.00-11.45 Morning Workshops (Participants attend 1 workshop) Venue Winslow Suite Bradford Suite Standish Suite Main Hall Topic A Neonatal Toolkit for Implementing ‘Multiprofessional Neonatal Simulation’ in busy neonatal environments Moulage in Neonatal Simulation ‘Bringing realism to Neonatal Simulation Models’ Multidisciplinary Neonatal Simulation Meeting the needs of Multiprofessional Teams ‘The METE Study’ Multidisciplinary Neonatal Simulation Progressive Fidelity in Simulation Facilitators Alok Sharma Ranjit Gunda Donna Windebank-Scott Jasim Shihab Sarah Davidson Anushma Sharma Sarah McCullough
  • 4. © Copyrights Reserved 12.00-1300 Lunch (Poster Walk) Session 3 Recent Advances in Neonatal Simulation 13.00-13.45 Post Lunch Workshops (Participants attend 1 workshop) Venue Winslow Suite Bradford Suite Standish Suite Main Hall Topic The OPEN Concept ‘Preterm Golden Hour Management’ Improving Your Outcomes Simulation as an Assessment Tool Assessing & measuring the performance of your neonatal resuscitation Teams Simulation to reinforce learning Simulating Developmental Care in Situ Simulation to reinforce learning Rapid Cycle Deliberate Practice in Neonatal Difficult Airway Management Facilitators Ranjit Gunda Sijo Francis Lou Halamek Sister Kim Pease Hannah Shore Alok Sharma Jennifer Diner Session 3 Plenary Session  14.00-14.30 365 days on Mars Sheyna Gifford  14.30-15.00 Psychological Impact of High Stakes Simulation Dr David Gaba 1500-15.30 Tea & Coffee (Poster Walk) Session 3 Hands On 15.30-16.30 Venue Winslow Suite Bradford Suite Standish Suite Main Hall Topic Debate: Simulating & Debriefing Neonatal Death Outcome Centred Debriefing Difficulties During Debriefing Disbelievers & Experts Thou Shalt Not Judge Thy Neighbour Facilitators Alok Sharma Hannah Shore Lou Halamek Jonathan Cusack Joe Fawke Dr Sijo Francis
  • 5. © Copyrights Reserved 6th Annual Neonatal Conference Programme-Day 2 Session 1: Patient Safety  08.15-08.50 Registration & Coffee  08.50-09.00 Introduction & Catch Up Day 1  09.00-09.30 Towards a safer neonatal environment Jens Christian Schwindt  09.30-10.30 Cascading risk and improving patient safety through SIM & TEL (Abstracts 4) 10.30-11.00 Tea and Coffee (Poster Walk) Session 2: Improving Outcomes & Staff Performance  11.00-12.00 Venue Winslow Suite Bradford Suite Standish Suite Main Hall Topic More Salad Than Sandwich Learning from Mistakes Standardized Communication techniques in Neonatal Resuscitation Striving for Better Outcomes What we say and What they hear Parental Perception in Communication Reorientation of Life Sustaining Intensive Care: Improving Staff Performance Facilitators Chantelle Mann Emma Sherwood Prof Lou Halamek Dr Jonathan Hurst Session 3: Quality Improvement  12.00-12.30 Use of Technology Enhanced Learning in Delivering High Quality Neonatal Care Dr Jonathan Cusack 12.30-13.00 Hannah Shore
  • 6. © Copyrights Reserved 13.00-14.00 Lunch (Poster Walk)  13.30-14.30 Quality Improvement in Neonatal Care Using TEL Abstracts (4)  14.30-15.00 Dr David Gaba 15.00-15.30 Tea & Coffee (Poster Walk) Session 5 Cross Specialty/Industry Approach 15.30-16.30 Venue Winslow Suite Bradford Suite Standish Suite Main Hall Topic The Best Way to Run a Simulation for a Low Frequency High Stakes Event Lessons from NASA Panel Discussion Mental Modelling to Address Performance Anxiety in High Stakes Events What we can learn from the GB Olympic Gymnastics Team A Pit Stop Approach to Neonatal Resuscitation Learning from F1 TBC Facilitators Dr Sheyna Gifford Kristian Thomas Lou Halamek TBC
  • 7. Annual Neonatal Simulation 6 TEL Conference "Simulating Together 6 Improving Outcomes" ------September 26th and 27th 2D17----- Venue: St Mary's Stadium, Southampton , UK Distinguished Panel af Speakers Dr Margarita Burmester Consultant PICU RoyalBramptonHarefield NHSTrust Dr Sarah Davidson Consultant Neonatologist. Southampton UK Dr Sijo Francis Consultant Neonatologist. St George's NHSTrust Professor David Gaba Associate Dean 6 Otrector of the Center for lmmersive and Simulation based Learning Stanford University School of Medicine Professor Lou Halamek Division of Neonatal and Developmental Medicine. Stanford Director.Centre for Advanced Paediatric and Perinatal Education Dr Hannah Shore Consultant Neanatologist. Leeds University Hospital Lead Paediatric Simulation Yorkshire Kristian Thomas British Olympic Gymnast Dr Jonathan Cusack Consultant Neonatologist. Lead Neonatal Simulation Leicester UK Dr Joe Fawke ConsultantNeonatologist. Lead NeonatalSimulation Leicester UK Dr Sheyna Gifford Health 6Safety Officer NASA HISEAS Mars Simulation Mission Professor Colin Morley Honorary Lecturer. Department Dbs Gyn University of Cambridge UK Dr Jasim Shihab SrClinical Fellow London NTS 6 Royal London Hospital Dr Jens Christian-Schwindt Consultant Neonatologist 6 Director Sim Characters Dr Maria Tsakmakis Consultant Neonatologist Southmead Hospital Bristol Dr Donna Windebank·Scott Consultant Neonatologist Southampton Dr Alok Sharma Conference Chair & Lead University Hospitals of Southampton, Southampton, UK Dr Ranjit Kumar Gunda Conference Treasurer Rainbow Children's Hospital, Hyderabad, India
  • 9. 28/09/2017 1 Using Simulation Cost- Effectively to Improve Neonatal Outcomes Dr Alok Sharma Consultant Neonatologist Southampton Dr Ranjit Gunda Consultant Neonatologist Rainbow Hospital Declaration  No conflicts of interest to declare with this presentation  All pictures & videos taken with parent and participant consent to share for educational purposes Background No equipment No Team No money Phase 1-Initial Focus  Bi monthly workshops of getting used to Simulaid Micropremmie task trainer  Focus on thermal care principles and deliberate practice  Reinforcing elements like putting the hat on, theatre temperature, maintaining incubator temperature in transport Scenario Bank  Theme based common conditions  Curriculum mapping  Task Trainers  Bank of 10 common scenarios Initial Challenges  How do we make this multidisciplinary?  How do we run simulation with our nurse colleagues?  Faculty development  Funding for manikins  A designated area
  • 10. 28/09/2017 2 Simulation • Neonatal transport Nurses • Grid Trainees • Senior Paediatric Trainees • Themed sessions • Every 3 months • Full Day • Multidisciplinary • Grid Trainees • Senior Paediatric Trainees • Neonatal nurses • ST1-8 • Band 5/6 Nurses Southampton Neonatal Simulation Neonatal Ethics and Difficult Situations Simulated Neonatal Airway Neonatal Transport Simulation Wessex-Oxford Neonatal Education Programme Hypothermia in Neonates<32 weeks 1 in 4 babies born hypothermic in the UK IN 2015 For neonates under 32 weeks the incidence of mild hypothermia is 28% and significant hypothermia is 9% In 2010 in PAH 33% of babies less than 32 weeks had mild hypothermia and 14% had significant hypothermia Focus on theatre temperatures and management of prematurity. We were already using plastic bags Simulating Preterm Birth
  • 11. 28/09/2017 3 Relation of multidisciplinary simulation to improved outcomes Temp/Yea r 2010 2011 2012 2013 2014 2015 2016 <36.5 32.8% 24.6% 16.9% 15.8% 10.4% 8% 17.5% <36 12.5% 6.1% 1.8% 1.5% 2% 0% 1.7% <35.5 3.1% 3.1% 0% 0% 0% 0% 0% Lowest 34.4C 35C 35.7C 35.9C 35.9C 36.1C 35.9C Babies 64 65 53 63 48 53 57 Simulation No Sim Pilot 2010 Medical Sim Medical Sim Multidiscip Sim Multidiscipl Sim Multidiscipl Sim Multidiscipl Sim Point of Care Simulation & Latent Threat Point of Care Simulation Neonatal Simulation Suite Cascading Risk Through Simulation Neonatal Airway Central Line Extravasation Medication Error CDH Management
  • 12. 28/09/2017 4 Effectiveness Cost Benefits Cost-Analysis Programme Delivery  2 consultants and 2 nurses delivered 1 whole day of simulation per month for 12 months  Participants 15 nurses each session and 5 trainees from the floor  Faculty development programme  Add on to that manikin costs and maintenance  50,000 pounds an year to run a proper neonatal simulation programme Cost vs Benefits  The NHS litigation authority for England reviews approximately 10 neonatal claims per year amounting to £127, 975 (£600 – £3,044,943) per case.  NHS lawyers have set aside £235.4m to settle 60 claims over 10 years in which babies allegedly suffered brain damage because of neonatal hypoxia-ischaemia and hypoglycaemia.  Cost of care to an extreme preterm averages out 3500-150000/episode  The total cost of preterm birth to the public sector was estimated to be 2.946 billion pounds  The largest contribution to the economic implications of preterm birth are hospital inpatient costs after birth, which are responsible for 92.0% of the incremental costs per preterm survivor.
  • 13. 28/09/2017 1 © 2017 D Gaba & A Calhoun Simulations that are Challenging to the Psyche of Participants (& instructors?) • David M. Gaba, M.D. –Associate Dean for Immersive and Simulation-based Learning, & Professor of Anesthesia; Stanford University –Founder & Co-Director, Patient Simulation Center, VA Palo Alto HCS –Founding EIC, Simulation in Healthcare © 2017 D Gaba & A Calhoun Disclosure Slide • Nothing to disclose of relevance to this presentation © 2017 D Gaba & A Calhoun A Reminder: Simulation is a Technique • A suite of “techniques” only sometimes using one or more “technologies” –For interactive & often powerful “immersive” activities that re-create the real-world To amplify or replace actual experiences –The power of simulation raises ethical issues © 2017 D Gaba & A Calhoun Ethical Issues IN Simulation –Simulations that challenge the psyche of the participant Death of the simulator Scenarios using deception Occurrence of clinical errors Disclosing bad news – Also… the participant is also a “user” of the system being simulated [patient or family] © 2017 D Gaba & A Calhoun Ethical Principles [tradeoffs are inevitable?] • Respect for Autonomy • Honesty & respect for individual decisions • Beneficence • Do good • Non-maleficence • Minimize risks and harms • Justice • Fairness, equality, providing what is owed © 2017 D Gaba & A Calhoun {Implicit} Sim Contract with Participants [NOTE: “Participant” vs. “learner”] • “Fiction agreement/contract” [U. Eco] –e.g. What is presented is NOT real, but participants should act as if it were {Willing} suspension of disbelief [Coleridge] Suspension of {ordinary} beliefs [R Rubio] –A "contract" because individuals explicitly agree or because they are voluntary members of a participant group [e.g. students, housestaff, clinicians]
  • 14. 28/09/2017 2 The Intersection of Ethics, Education, and Simulation: Exploring Difficult Issues Aaron W. Calhoun, MD, Assoc Professor, Pediatric Critical Care Medicine and Director, SPARC Program, University of Louisville School of Medicine Chair, SSIH Research Committee, Associate Editor, Simulation in Healthcare Dr. Aaron Calhoun & I share an interest in these issues, sparked in part by his paper & several editorials published by the journal Simulation in Healthcare We have now presented together on this topic & written several papers together He recently spoke at Stanford and some of his slides on our topics of joint interest were better than mine & I have his permission to use / adapt some of them! Simulated Death: A Complex Topic • Many papers about this topic; several reviews, several empirical studies. Almost all the studies are about resuscitation simulations [N.B. often "code blue" teams] • Some suggest teaching "value" to having mannequin die; others suggest none, or negative value • Many complex issues not (yet) addressed by studies at all, or else glossed over ? Different Types of "Patient Death" Within Simulations • Leighton’s Taxonomy is useful – [Collectively] Expected Death - Both facilitators and learners are aware the mannequin will die – [Participant] Unexpected Death - Facilitators plan it & know but learners do not – Death due to Action or Inaction - Completely unplanned. Facilitators decide to let mannequin die based on learner actions Leighton K: Death of a simulator. Clinical Simulation in Nursing 2009;5(2):e59-62 Simulated Death: The"Be Careful" View {Largely shared by Aaron & me} • First, Do No Harm: Using Simulated Patient Death to Enhance Learning Bruppacher HR, et al, 2011 Med Educ 45: 317-318 – Letter to Editor re: study; concerned that comments referring blame for “death” to physicians indicated erosion of collaborative environment – Simulated death often not grounded in sound ethical principles that promote non-punitive educational cultures and inter-professional collaboration, suggested simulated death should only occur as an explicit part of the learning goals {pre-disclosed or not} Death "Patient" in Simulation: Contributing Factors • Effect of stress on learning • Effect of fidelity on learning • Effect of fidelity on future expectations • Role of learner level of experience and type of practice • Role of learner's prior personal experience • Etc. Effect on Future Expectations • In practice, our actions (even when technically correct) do not always result in survival & vice versa • Does a 1:1 correlation between student actions and survival give a false impression to students? • Does a 1:1 correlation augment future psychological stress by causing learners to invariably equate death with failure? Lizotte MH. Trainee Perspectives on Manikin Death During Mock Codes. Pediatrics. 2015;136(1):e93-e98
  • 15. 28/09/2017 3 Effect of Experience • Experience level of participant(s) very important • Data are mixed, but many suggest that death due to action or inaction should be avoided for pre- clinical-rotation medical student participants and ? even at the rotation level • Reality is that medical students rarely have roles in actual patient care that justify the psychological baggage/risks {DG's personal opinion} Calhoun AW, Pian-Smith MC, Truog RD, Gaba DM, Meyer EC. Deception and Simulation Education: Issues, Concepts, and Commentary. Simulation in Healthcare. June 2015;10(3):163-169. Themes Gleaned FROM Our Learners 1. Learner preparation and suspension of disbelief during simulation; latter is complex 2. Differences in emotional response between real and simulated death; and between individuals 3. Effects of simulated death on future emotional engagement with learning activities 4. Learner self-perception and perception by team regarding deficits; complex & variable 5. Impact of debriefing on emotive response to the simulation – experienced & nuanced debriefer is needed 6. Impact of debriefing on learning 7. Knowledge retention and practice changes caused by mannequin death vs. other psych. sequelae Practical Implications • Many Future Questions For Empirical Research: – What level of training & type of practice IS appropriate for certain experiences? – Is our current overall educational culture too protective, or not protective enough? – What are the long-term positive and negative effects of different types of mannequin death? – What debriefings are needed with death scenarios? – {as per the King of Siam…} Etc., etc., etc. 1: Learner Preparation and Suspension of Disbelief Mannequin Death? 2: Differencesin Emotional Response between Real and Simulated Death 3: Effect of Simulated Death on Future Emotional Engagement in Learning Activities 4A: Learner Self- perception and Perception by Team Regarding Knowledge and Skill Deficits 5: Impact of Debriefingon Emotive Response to the Simulation 6: Impact of Debriefingthe Knowledge and Skills Learned Duringthe Simulation 7: Effect of Mannequin Death on Knowledge Retention and Practice Change Model of the Effect of Mannequin Death Due to Learner Action or Inaction on the Learner’s Educational Experience Learner Reaction to Subsequent Simulation Sessions Learner Experience and Knowledge from Previous Simulation Sessions 4B: Effect of ActionsUsed to Mitigate Death on Perceptions of Fidelity Yes No © 2017 D Gaba & A Calhoun Patient Death Summary • Like anything of significant meaning -- "it's complicated" • Never approach this issue with a cavalier attitude –Ensure that pedagogical goals truly justify the approach and that appropriate safeguards are in place • Empirical data may/may not come (and can't encompass all participants/issues) © 2017 D Gaba & A Calhoun Change Gears: Deception: Is it Always Wrong?
  • 16. 28/09/2017 4 © 2017 D Gaba & A Calhoun Simulation is a Powerful Technique • Even books & movies can be emotionally wrenching; all the more so with carefully conducted simulations • Participants bring their own psyche to simulation: –Prior experiences; sense of self-worth • They may not show/disclose discomfort or harm © 2017 D Gaba & A Calhoun Famous Extreme Examples of the Power of “Simulation” [Experiments – not healthcare] • Milgram Obedience Experiments • Stanford Prison Experiment © 2017 D Gaba & A Calhoun Stanford Prison Experiment Zimbardo et al: Performed 1971 published in 1973 • 24 university student subjects randomized to be “prisoners” or “guards” • Simulated “prison” created in Stanford psychology department • Planned 14 day expt. stopped after 6 days – Guards behaved aggressively & abusively – Prisoners became passive & depressed; 5 had to be released from study – Researchers co-opted in their roles © 2017 D Gaba & A Calhoun © 2017 D Gaba & A Calhoun Milgram Obedience Experiment Milgram et al: Performed 1960; 1st Published 1963 Milgram,: J Abnormal Soc Psych, 67, 371–378, 1963 • Volunteers from local community for experiment on learning • They were to administer memory tests to another volunteer {a “confederate” – deception} • If answers were incorrect, volunteer required to administer “electric shock” of increasing voltage  confederate © 2017 D Gaba & A Calhoun
  • 17. 28/09/2017 5 © 2017 D Gaba & A Calhoun Milgram Obedience ExperimentS • Many more experiments by Milgam, varying: – Location of “shockee” – Location of “investigator” – Other factors • Recent experiment with “shockee” existing only virtually (an avatar) – Many subjects still withdrew – Slater M, Antley A, Davison A, et al. A virtual reprise of the Stanley Milgram obedience experiments. PLoS One 2006;1:e39 © 2017 D Gaba & A Calhoun Are These Famous Experiments Comparable to Deception in Clinical Simulation? • These experiments DO demonstrate the power of “simulation” to affect human behavior, BUT: –The experiments were done only for research; offered no direct benefits to subjects or to society –Risk and level of harm was palpable and extreme (especially Prison Expt) –Subjects coerced to continue © 2017 D Gaba & A Calhoun To What Degree Is Simulation Inherently “Deceptive” ? • Simulations are real events meant to be “as if” they are actual clinical events –When is the “as if” inherently deceptive? –What are “expected” deceptions vs. those "beyond expectation" • Is there a tradeoff between learning & pt. safety [beneficence] vs. non- malificence? Nested Spectra of Deception… A confederate from outside the learner group joins the team during a simulation and intentionally makes inappropriate medical decisions during the case Simulation faculty intentionally place faulty equipment within the simulated environment in a way that would be unexpected to learners The outcome of the simulated case is intentionally decoupled from the actions of the learner group in a way that is inconsistent with the ground rules of the case Not Deceptive Highly Deceptive Not Deceptive Not Deceptive Highly Deceptive Highly Deceptive Distinctions in Deception • Deception “Within” vs Deception“About Deception Within Mutually Acceptable Educational Purpose Another, Undisclosed Purpose Deception About Kelman HC. Human Use of Human Subjects: The Problem of Deception in Social Psychological Experiments. Psychological Bulletin 1967;67(1):1-11. Distinctions in Deception Deception Within Mutually Acceptable Educational Purpose Another, Undisclosed Purpose Deception About Kelman HC. Human Use of Human Subjects: The Problem of Deception In Social Psychological Experiments. Psychological Bulletin 1967;67(1):1-11. • Deception “Within” vs Deception“About
  • 18. 28/09/2017 6 © 2017 D Gaba & A Calhoun A Sim That Launched 1,000 Debates? Example of Deception (Calhoun et al: Sim Healthcare 8:13-19, 2013) • Pediatric (6 yo) case with K+, VT, P –Learners were informed in advance that a supervising attending interested in simulation and their education might participate in the session –Attending insists on treating P with Potassium Phosphate If challenged directly would relent If KPhos given -> asystole, if K+ untreated -> death © 2017 D Gaba & A Calhoun Example of Deception (Calhoun et al: Sim Healthcare 8:13-19, 2013) • Detailed debriefing (by expert facilitator) followed –Role of attending revealed as a “confederate of the instructor” –Discussion of clinical/non- technical issues of “challenging the hierarchy” Comparison with real cases © 2017 D Gaba & A Calhoun Big Debate About Deception in Clin Sim (Truog & Meyer: Sim Healthcare 8:1-3, 2013) (Gaba: Sim Healthcare 8:1-3, 2013) • "Pro" deception: –Cases like this do occur clinically, causing serious morbidity mortality; important to teach challenging the hierarchy –Errors by superiors occur without warning; can be deadly –Simulation must replicate the likely conditions in which this would be faced –Simulation run for actual clinicians (i.e. housestaff, not students); nuanced debriefing © 2017 D Gaba & A Calhoun Big Debate About Deception in Clin Sim (Truog & Meyer: Sim Healthcare 8:1-3, 2013) (Gaba: Sim Healthcare 8:1-3, 2013) • "Anti" deception: –Deception can be harmful to the participant’s psyche; can undermine trust in teachers, clinical co-workers, simulation –Challenging the hierarchy can be taught without deception Pre-briefing that it may be needed Attending role played by a stranger © 2017 D Gaba & A Calhoun Big Debate About Deception in Clin Sim Calhoun, Pian-Smith, Truog, Gaba, Meyer: Sim Healthc; 2015 10:163-169 • Framework of elements & relationships concerning simulations that employ deception • Suggestions for future empirical research about the use of deception A Framework For Emotionally Difficult Simulations Institutional Environment Scenario Structure Session Goal Faculty Background Learner Background Educational Intent Calhoun AW, Pian-Smith MC, Truog RD, Gaba DM, Meyer EC. Deception and Simulation Education: Issues, Concepts, and Commentary. Simulation in Healthcare. June 2015;10(3):163-9.
  • 19. 28/09/2017 7 © 2017 D Gaba & A Calhoun General Agreement About Using Deception in Clinical Simulation –Instructors must think hard about the need for deception to accomplish goals –Deception probably inappropriate for early learners & some other populations –Pre-briefing or other techniques could eliminate or reduce level of deception –Debriefings should disclose deception(s) early; debriefers must be very experienced –Provide for routine/emergency follow-up © 2017 D Gaba & A Calhoun The Ultimate Vision To Save Lives, Brains, or Hearts & To Be Ethical Clinicians/Educators And whoever saves a life, it is as though he had saved all mankind (appearing in various forms in the Talmud, Sanhedrin 4:5 and the Quran 5:32) © 2017 D Gaba & A Calhoun
  • 20. 28/09/2017 1 Introducing & Sustaining Neonatal Simulation Programmes Barriers to Uptake & Faculty Development Dr. Joe Fawke Introducing & Sustaining Neonatal Simulation Programmes Barriers to Uptake & Faculty Development Dr. Joe Fawke Introducing • On unit vs. simulation centre • Programme structure – frequency • Session structure • Faculty / session • Candidates / session • Time • Session • Set up • Pack down People & Time Introducing • Advertise on your unit • Ground rules - confidentiality • Clarify expectations • Assessment? • Integration with CPD / revalidation • Performance management • Background programme maintenance & organisation • Don’t promise the world Expectations & Consistent Approach Sustainability • Sign up – volunteering vs. allocating • Who will cover the clinical work? • Contingency plans for emergencies • Contingency plans for busy days • everyday is a busy day • Rewards for participation • What happens if you don’t engage? Barriers - candidates Fear of looking silly Worried about assessment The unknown Loss of face Credibility Don’t like simulation Feel on show Don’t like the instructor Unsupportive colleagues / managers Too tired Worried about who else has signed up Unsure about the equipment
  • 21. 28/09/2017 2 Barriers - faculty Time, Training & Recent Experience Forgotten how the kit works Ages since I debriefed Which scenario? Loss of face Credibility Don’t like simulation Difficult candidates Availability Available space Unsupportive colleagues / managers Time Faculty Development Time, Training & Recent Experience Who? Faculty Nurses Doctors ANNPs AHPs Candidates ANNPs Nurses AHPs Doctors • Who can debrief who? • What problems do you envisage? • Are there any credibility issues? • How important is seniority? • Do they have the same faculty development needs? Relevant faculty experience Resuscitation Courses Task Training Undergraduate simulation Medical / nursing People Management Previous experience Relevant faculty experience Resuscitation Courses Task Training Undergraduate simulation Medical / nursing Faculty Training & Development Previous experience Training Course
  • 22. 28/09/2017 3 Initial training / faculty development Initial training / faculty development Day 1 Day 2 Simulators in Education -background education theory Running a multidisciplinary training program on your unit Practical aspects- planning a ‘Point of Care’ session Styles of debriefing for experienced staff- Advocacy Enquiry and narrative feedback Scenario design Designing a scenario in 2 groups Practice debriefing real examples ‘Keeping it real’- setting the scene Putting it all together: set up and deliver yesterdays scenario to the other team with a short debrief session Programming & getting your manikin to do what you want it to Does a simulation Instructor Course work? All scores out of 5; 1=bad, 5=good Score (content / delivery) Simulators in Education -background education theory 4.8 4.8 Practical aspects- planning a ‘Point of Care’ session 4.8 4.8 Scenario Design 4.8 4.8 Designing a scenario in 2 groups 4.8 4.8 ‘Keeping it real’- setting the scene 4.8 4.8 Programming & getting your manikin to do what you want it to 4.8 4.8 Running a multidisciplinary training program on your unit 4.8 4.8 Debriefing 4.7 4.8 Practice debriefing real examples 4.9 4.9 Set up, delivery, debriefing & candidate experience 4.8 Overall 4.9 Average sessions scores from 300 instructor course candidates “Any way as along as it is my way” • Consistency vs. variety • If you are there all the time every session is more likely to run as you want it to • You can’t be there all the time • (& you make the assumption they are better when you are there……) • Should all the faculty run & debrief sessions the same way • Pros & cons Faculty engagement • Analogous to trainee volunteering vs. allocating • Sustainability & shared workload balanced against more diverse approaches • Only those who have been on the course • ‘Wise’ colleagues Faculty engagement Previous experience Course Simulation simulation Instructor Course In house programme
  • 23. 28/09/2017 4 Faculty maintenance • Ongoing training / exposure • Familiarity with equipment / computers • New topics / simulations • Organisational components (shared drives for simulation) • Faculty meetings to discuss programme • Sharing of debriefing experiences – within confidential framework Updates – who & how? Previous experience Course Simulation simulation Instructor Course Instructor Update Course In house programme Update Courses – what to include? • In house / generic update course? • Practicalities of running simulations – troubleshooting • Scenario reviews • Draw on experiences • Set up issues • In simulation issues • Debriefing issues • Distilling learning points / feedback • Programme logistics Faculty Development in National Courses Previous experience NLS Course GIC NLS IP NLS NLS Instructor Potential Identified Instructor Update Days & Bulletins Regular instructing Instructor Course Certified NLS Instructor Faculty Development in National Courses Previous experien ce NLS Cours e GIC NLS IP NLS NLS Does it work? Is a national course model relevant to neonatal high fidelity simulation programmes? National Resuscitation Course High Fidelity Simulation Course Less focus on human factors More focus on human factors More didactic Less didactic Larger target audience Small, selected target audience More instructors Fewer instructors Simpler debriefs More complex debriefs Advanced Resuscitation of the Newborn Infant course ARNI Course More focus on human factors Less didactic Small, selected target audience High instructors to candidate ratio More complex debriefs
  • 24. 28/09/2017 5 ARNI course components Lectures Early assessment & management Human factors Skill stations Mask leak Advanced airway Workshops Communication Chest drains Simulations Cooling All scenarios 16 candidates High instructor to candidate ratio More in depth debriefing Innovative mixed mode assessment Continuous Criterion based ARNI Evaluation Pre course Post course P Technical Face mask ventilation 77 94 <0.01 Intubation 77 87 <0.05 Difficult airway management 61 89 <0.05 Chest drain insertion 67 93 <0.01 Non-technical Communication with parents regarding resuscitation 66 87 <0.05 Confidence in ability to communicatewell with team during resuscitation 75 90 <0.05 Overall confidence in ability to take a role in a resuscitation 83 93 <0.05 Confidence in ability to lead a resuscitation 81 92 <0.05 ARNI Simulation Evaluation Pre course Post course P Initial management of congenital diaphragmatic hernia 68 90 <0.001 Initial management of a preterm baby 87 92 <0.05 Initial management of a baby with suspected cyanotic heart disease 75 92 <0.001 Managing a sick postnatal ward baby 79 92 <0.01 Initial management of baby with suspected NEC 80 90 <0.01 Managing a pneumothorax 78 91 <0.05 Managing airway obstruction 69 87 <0.01 Managing post resuscitation care 77 94 <0.001 Quality Control • How do keep your simulation programme high quality? • Practicalities • Time / people pressures can lead to cut corners • What to do when the ‘quality’ is not there • “I’ve done the nurses” • Informal feedback that makes you cringe (are you right though? – sim feedback tends to be positive) Debriefing pitfalls for faculty • Judgement (Judgemental) • Do faculty understand & demonstrate the difference • Too much talking • Tall poppy • Overly negative debriefing • Power trips Assessment & Quality Control • Of trainees – changes your programme, validated tools? • Of faculty? • DASH (Harvard) - debriefing assessment of simulation in Healthcare https://harvardmedsim.org/debriefing-assessment-for-simulation-in-healthcare-dash/ • trained raters to rate instructors • students to rate their instructors • instructors to rate themselves • OSAD (Imperial) The Observational Structured Assessment of Debriefing tool https://www1.imperial.ac.uk/resources/CFE7DECB-8FE7-437C-8DAA-6AB6C5958D66/debriefingosadtool.pdf
  • 25. 28/09/2017 6 Application of faculty skills • Application of faculty skills to real world situation debriefing • Deferred, planned • After action debrief Summary • Introducing a simulation programme, • Candidate & Faculty barriers • Sustainability • A structured approach to faculty development may help • Initial Course • Experiential Learning • Team meetings • Programme planning with simulation faculty – increases ownership & buy in • How do you quality control your programme? Thank-you for Listening
  • 26. 1 © 2017 David M. Gaba The Route to Patient Safety via Simulation for Education & Training in Healthcare • David M. Gaba, M.D. - Associate Dean for Immersive and Simulation-based Learning; Professor of Anesthesiology, Stanford University - Founder & Co-Director, Patient Simulation Center at Veterans Affairs Palo Alto HCS © 2017 David M. Gaba Some "Traditional" Methods are Important but Underutilized • Story-telling • Verbal simulation • Role-playing • Standardized ACTORS (pts, families, co-workers) Simulation is a technique not a technology © 2017 David M. Gaba Current "New" Forms of Simulation Evolving Techniques • Virtual world (single vs. multi player) • "CAVE" • Interactive head-mounted display virtual reality • Star Trek Holodeck {not -- yet} © 2017 David M. Gaba 3DiTeams Jeff Taekman, et al, Duke, et al © 2017 David M. Gaba ASA's © 2017 David M. Gaba “WAVE” at USUHS
  • 27. 2 © 2017 David M. Gaba Mulitplayer Head-mounted Display Interactive VR (From SimX YouTube Video) © 2017 David M. Gaba Potential Impacts of Simulation on Pt. Safety – Education & Training •Improve the usable knowledge of early learners - Using full simulation for “book knowledge” is usually “overkill” - Simulation useful to practice integration & flexible USE of knowledge © 2017 David M. Gaba For SAFETY Simulation Usually is Addressed to Experienced Personnel • Advanced trainees & above • They take direct care of patients • They need the practice as individuals and teams for - Psychomotor procedural skills - Dynamic decision making - Team management / teamwork © 2017 David M. Gaba Indirect Effects of Simulation on Patient Safety • Simulation can be a lever to alter organizational cultures of safety - Clinicians - Managers - Executives - Lawmakers • Simulation can be a uniting force to trigger, focus, or host other patient safety efforts © 2017 David M. Gaba Potential Impact of Simulation on Patient Safety -- Research • Simulation-based research & development to study & improve processes of care, such as: - Clinical protocols - Human-machine interactions - Performance shaping factors (e.g. fatigue) - Cognitive aids © 2017 David M. Gaba In situ & peri situ Simulation for Systems Probing In situ: Latin for “in place” -- simulation in actual patient care areas Peri situ: "near place"-- nearby “Systems probing” – looking for what works well in the “system” and also for hidden problems If you fix a systems problem it may be fixed for EVERYONE (no training needed)
  • 28. 3 © 2017 David M. Gaba Simulation for "System Safety, Quality/Risk Management • Simulation can help learning by organization / personnel - Enhance event investigations; scenarios taken from events - Enhance "morbidity & mortality" conferences • Medicolegal cases - Simulation demonstrations or tests for litigation/defense © 2017 David M. Gaba Simulation-based Performance Assessment - Ensure capabilities of new graduates - "Board" certification - Continued assurance of skills & capabilities of experienced clinicians - Research on care processes - Evaluation & training of clinicians »Returning after long time out of work »After episodes of "poor performance" © 2017 David M. Gaba Assessment Needs Many Views: “Jigsaw Puzzle” or “Orthogonal Views” • Gaba, DM: Improving anesthesiologists’ performance by simulating reality (editorial). Anesthesiology 76:491-494, 1992 • McIntosh CA: Lake Wobegon for anesthesia...where everyone is above average except those who aren't: variability in the management of simulated intraoperative critical incidents. Anesth Analg 2009; 108: 6-9 © 2017 David M. Gaba Each Orthogonal View Sees Something That the Others Do Not © 2017 David M. Gaba Orthogonal Views of Clinical Performance 1. Real-cases, prospective observation + actual clinical cases & prospective - BUT… “everyday” cases & situations (boring) 2. Real-cases, by case/incident reports of challenging (problem) cases + real cases with a problem or challenge - BUT… retrospective (biased, incomplete) © 2017 David M. Gaba Orthogonal Views of Clinical Performance 3. Simulated cases, prospective observation + Challenging cases + Prospective - BUT….. simulated cases, not real A) they KNOW it’s simulated B) it’s hard to re-create the “motivational structure” of the real-world
  • 29. 4 © 2017 David M. Gaba Simulation’s “Window on Performance” is Unique • May be useful in many ways • Although… even when done in-situ requires serious effort ($$/€€) • Data will be “mixed-methods” (qualitiative & quantitative) with few unequivocal findings - Because clinical work is very complex! © 2017 David M. Gaba Breaking News! Study of 263 ABA Certified Anesthesiologists Weinger MB, Banerjee, A, Burden, AR, McIvor WR, Boulet J, Cooper JB, Steadman R, Slagle J, DeMaria S, Torsher L, Sinz E, Levine AI, Rask J, Davis F, Park C, Gaba DM (August, 2017) Simulation-based Assessment of the Management of Critical Events by Board-Certified Anesthesiologists © 2017 David M. Gaba T-1 Kirkpatrick level 1 (self-conf; how like?) T0 Better KNOWLEDGE (e.g. MCQ) T1 Better PERFORMANCE –in sim T2 Better PERFORMANCE – in clin work T3 Better pt. OUTCOME (T3’=cost-effective) T4 Dissemination (to others, can they do it?) T5 Adoption (will they adopt it for regular use?) T6 Better population OUTCOME (?) Sim Translational Rsch Levels (McGahie et al, SiH, S42-47, 2011; Rall, Gaba et al, Miller 8th ed, Chptr 8, p195, 2014) © 2017 David M. Gaba The Pharmaceutical Analogy for Simulation: A Policy Perspective • Who would expect a major change in outcome from a new drug when: - Using a low dose of the drug - Dosing haphazardly to only a few subjects - Not repeating treatment as necessary - Ignoring any exacerbating factors - Using only a single modality - Following subjects for only a short time (Gaba D: Sim Healthc; 2010, 5:5-7) © 2017 David M. Gaba This is What We Have [mostly] Done in Simulation Research • Simulation interventions are: • Infrequent • Often low-intensity curricula • Little reinforcement in real work • No coupling to performance assessment • In only a few disciplines/domains • Small studies & short time horizons (Gaba D: Sim Healthc; 2010, 5:5-7) © 2017 David M. Gaba Real Test of Simulation Needs a Long Time Horizon • Current studies chip away at small questions (this is good work, but….) • Current studies chip away at small questions (this is good work, but….) • The REAL question is: Does simulation improve quality if: –Long-term adoption –Comprehensive, integrated model –Career-long –Training & assessment –Evaluated over long time horizon • The REAL question is: Does simulation improve quality if: –Long-term adoption –Comprehensive, integrated model –Career-long –Training & assessment –Evaluated over long time horizon (Gaba D: Sim Healthc; 2010, 5:5-7)
  • 30. 5 © 2017 David M. Gaba Pharmaceutical Analogy: Who Pays for Proof? • In clinical trials, often the manufacturer - Huge research budgets, many trials but few successes is “usual” - Huge profits for successful drugs • Simulator manufacturers, centers: - Tiny margins, not used to many expensive trials with few “successes” - No “blockbusters” - Grants limited in size, scope, duration (Gaba D: Sim Healthc; 2010, 5:5-7) © 2017 David M. Gaba {Incidentally} What is the Evidence for Simulation in Commercial Aviation? • There is mandatory yearly training & checking of flying performance - Studies can be grafted onto these activities • Yet, no Level 1A evidence that it saves planes or lives – No randomized trials © 2017 David M. Gaba The Simulation Vision Is a (many) DecadeS-long Proposition • The Vision is of training that is: - Comprehensive & Integrated - Continuous – for individuals, teams, work units - Coupled with performance assessment - Over an entire career; embedded in work processes © 2017 David M. Gaba (Simulation) Training Must Be For a Lifetime (cumulative effect) • Career-long combination of modalities as individuals & teams, repeatedly cycling through: - Didactics & seminars - On-screen simulators, “virtual worlds” & virtual reality - Courses in dedicated sim center - In-situ/peri-situ simulations & drills © 2017 David M. Gaba Bottom Line Lesson If We Save Just One Life… And whoever saves a life, it is as though he had saved all mankind (appearing in various forms in the Talmud, Sanhedrin 4:5 and the Quran 5:32) © 2017 David M. Gaba
  • 31. 6 © 2017 David M. Gaba What is Patient Safety? • Avoiding harming people while trying to “cure” or “help” them - Prevention of errors & complications - Threat & error management - Crisis resource management Jeff Cooper, PhD © 2017 David M. Gaba Some Technological Aspects of "Simulation" Are > 25 Years Old • Part-task training • "Trigger-videos" • Mannequin-based Simulation 1986 1987 © 2017 David M. Gaba Face Validity of Simulation © 2017 David M. Gaba "Snapshot" Summary of Study • Grafted onto ABA MOCA Sim Courses at 8 well-known simulation sites; • 4 carefully standardized scenarios (@ ≈ 20 min); "hot seat" could call for help • Post-hoc video rating by 1-2 or seven highly calibrated expert raters, using multiple rubrics & scales of critical clinical actions & both med/tech & non-tech performance © 2017 David M. Gaba • Overall, ≈ 75% of critical actions were performed; majority of performances rated as average or better on scales • ≈ 25% of performances omitted several critical actions; scale ratings were in the "poor" performance range • The arrival of the second anesthesiologist generally improved overall performance (but participants said that help not always available in their clinical sites) "Snapshot" Summary of Study Results © 2017 David M. Gaba Overview of Study Conclusions • Performance on unexpected critical events is good but far from consistent • Further research needed to understand how & why performance not uniformly good • Processes of response of clinicians & teams to acute events CAN be strengthened, e.g. - Cognitive Aids (Checklists & Emergency Manuals) - Ensuring availability of help - Lifelong learning & honing of acute event skills (various approaches including simulation)
  • 32. 7 © 2017 David M. Gaba Simulation: Where is the Proof? • But…. Maybe we never will know the answer to many important questions about simulation…… {actually… some of Hilbert’s problems are known to be unproveable [even in principle] } David Hilbert, Famous Mathematician – Hilbert’s 23 problems (1900) © 2017 David M. Gaba So…What Should We Do About Research Concerning Healthcare Simulation? • Continue all the research we can do • But… also educate policy makers about evidence that can/cannot be had (for all practical purposes) – they must either: - Provide big funding for large, long, complex studies; or else - Not expect “definitive proof” for many issues about simulation © 2017 David M. Gaba Opportunities for Research ABOUT Simulation (examples) • Less worry about “does” it work and more about “how”, “why”, “who”, e.g. - Pedagogical approach A vs. B vs. C - WHAT are participants learning? - ???? • Outcome studies as strong as feasible • Multi-center studies/collaborations © 2017 David M. Gaba Simulation is Probably Pre-Historic • Likely a preparation or surrogate for hunting or war Photos via “Adobe Photoshop Time Machine” Full Immersion Simulation “The Real Thing” © 2017 David M. Gaba Potential Impacts of Simulation on Patient Safety • Direct Education & Training Effects • Performance Assessment • Indirect Effects – Culture change all levels • Quality & Risk Management • Research – Human factors • Equipment – regulation, approval, procurement, training © 2017 David M. Gaba Pharmacology Analogies for Simulation Weinger MB: Simulation in Healthcare 5:8-15, 2010
  • 33. 8 © 2017 David M. Gaba Advantages of Simulation for Performance Assessment • Can assess aspects of practice that are not readily observable in real cases - Detection, diagnosis, and management of critical situations and/or emergencies - Response to worst case situations of equipment failure, interpersonal conflict © 2017 David M. Gaba Advantages of Simulation for Performance Assessment • Can present “standard” case situations to different clinicians / crews / teams - Allows determination of actual spectrum of performance by personnel at different levels of experience © 2017 David M. Gaba Combining Modalities Hybrids • Best features of each modality can sometimes be combined, e.g.: - Mannequin = SP (voice) - SP actor + vital signs monitor - SP actor + part-task trainer (e.g. urinary catheterization model) - Virtual reality + physical simulator © 2017 David M. Gaba Measuring Intermediate Variables (T0, T1) • Fair to good measures of learning (T0) –at least ‘knows’, ‘knows how’ • Modest proof of ‘shows how’ in simulation (T1) • A few studies show improved clinical performance and very few show pt. outcome (T2 or T3) – but VERY hard to do this research © 2017 David M. Gaba T3 Outcome Measurement is Tractable When: • Simulation intervention is circumscribed; AND • Outcome is easily measured; AND • Outcome is moderately common Example: Infections & complications after CVC insertion © 2017 David M. Gaba T3 Outcome Measurement is Difficult When… • Event is rare • Outcome is subtle & hard to measure • Behavior/skill is complex • Intervention is complex (e.g. CRM sims) • Many confounds between intervention & outcome
  • 34. 9 © 2017 David M. Gaba What is Simulation? • A “technique” NOT a “technology” - For interactive and often “immersive” activities that re-create experiences of a real-world environment »To amplify or replace actual experiences »“Even better than the real thing” © 2017 David M. Gaba Dynamic Decision Making Team Management
  • 35. 28/09/2017 1 The use of technology enhanced learning to deliver high quality neonatal care Jonathan Cusack Leicester Neonatal Simulation Team Outline • Using simulation to work out what to change • Using simulation to implement change • Integrating quality improvement into your simulation program • Does it work? -measuring outcomes Quality in Healthcare • Sometimes difficult to define • Links with risk management: responding to incidents and learning from mistakes • Latent threats to patient safety: examples • Simulation is a technology to allow debriefing: should not be used in isolation Quality Improvement Cycle Plan Do Study Act Quality Improvement Cycle Plan Do Study Act Where does simulation fit in? Planning • Themes emerging from your units governance • Recurrent issues in your simulation program • Implementing best practice from research
  • 36. 28/09/2017 2 Using simulation to implement change • Testing what works and what doesn’t • Deliberate practice • Research example • Lessons from other industries: tools, equipment, check lists Example: intubation medication • Example: Resuscitation equipment Integrating QI with your training program • Themes for training • Other forms of technology to improve quality • Task training: mask leak difficult airway Audio prompt CPR depth Integrating simulation techniques with clinical working • After Action Review Integrating simulation techniques with clinical working • Deliberate practice EXIT procedure Complex resuscitation
  • 37. 28/09/2017 3 Does it work? yes Evidence • Decreased HIE rates • Decreased birth trauma /Erbs palsy • Decreased time from decision to delivery • Areas that are process driven • Integrating with large scale changes What would work in neonatal medicine? • Using simulation programs to investigate what actually works in situ • Increased use of check lists- evidence based • Using debriefing techniques after real resuscitations to identify areas to improve • Better use of deliberate practice • Mannequins and devices that reliably measure performance • Integrating with larger scale change
  • 38. Abstracts for Podium Presentations
  • 39. 6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name H.M.Durga Herath Job Title Speciality doctor ( Paediatrics/Neonates) Institution This project was done in District General Hospital, Hambanthota, Sri Lanka Current employment - Lincoln County Hospital Email durgaherath@gmail.com Specialty ( Paediatrics/Neonates) Mobile Contact Address: 16, Greenway, Lincoln, LN22YA Submission for: Both (delete as appropriate) Title: Effective implementation of a protocol on initial stabilization of preterm neonates delivered at less than 32 weeks gestation through a simulation programme in a District General Hospital in Sri Lanka Author(s): H M D Herath, S Somarathna, D S Rajapaksha, P Dissanayaka, G W C Malkanthi, W G Ruwan Kumara Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Background: Effective initial stabilization of preterm neonates in the initial 60 minutes of life (termed neonatal golden hour) helps minimize a number of complications and lead to improved prognosis. Effective resuscitation, respiratory support, maintaining normal temperature ,blood sugar, timely parenteral nutrition, timely treatment of sepsis and a completed admission within 60 minutes of delivery are identified as key components of the golden hour. High intensity and multitude of interventions necessary and diversity of skills of staff involved make it a challenging task. A protocol specifies the essential steps of the golden hour. Simulation-based learning to practise the protocol helps to create a cohesive team. Objectives: To evaluate effective implementation of a protocol on initial stabilization of preterm neonates less than 32 weeks gestation through a simulation programme. Study design: Prospective study Method: A protocol on early stabilization preterm neonates was introduced to neonatal staff via scenario teaching comprising of a simulation followed by debriefing session for each staff member. The extent to which the key components of neonatal golden hour achieved before and after implementation of the protocol were assessed using a checklist. Results: In the post-protocol group a significant increase was seen in the number of infants resuscitated with optimal preparation (p<0.05), infants received glucose infusion and antibiotics (p<0.01), infants with blood sugar above 2.6mmol/l (p<0.05) and infants with completed admission within 1 hour (p<0.01).A significant difference in adherence to thermo-protective measures during stabilization (p<0.01) and admission temperature above 36.50C (p<0.01) were seen.Conclusions: Implementation of a protocol on golden hour through a simulation programme can significantly improve stabilization of preterm neonates.
  • 40. 6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Brennan Vail Job Title Current: Medical Student; At Time of Conference: Pediatric Resident Institution University of California, San Francisco Email Brennan.Vail@ucsf.edu Specialty Pediatrics Mobile Contact Address: 3474 Clay Street, San Francisco, CA 94118 Submission for: Podium and Poster Title: Simulation as a Tool for Improving the Quality of Neonatal Resuscitation Skills in Bihar, India Author(s): Brennan Vail, Melissa Morgan, Amelia Christmas, Hilary Spindler, Aritra Das, Sunil Sonthalia, Pushpalata Sharma, Megha Joshi, Dilys Walker Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Background Fourteen percent of global neonatal deaths and half of those in India occur in four Indian states, one of which is Bihar. Birth asphyxia causes one-third of neonatal deaths in Bihar. Little is known about the impact of simulation training on the quality of neonatal resuscitations (NR) in primary health centers (PHCs) in low-resource settings. Methods This analysis assessed the impact of simulation training, developed by PRONTO International and implemented within CARE India’s AMANAT program, on quality of nurse-midwives’ NR skills in simulated and live resuscitations. NR simulations were conducted and video-recorded at 160 PHCs across Bihar over 8 months. Mid- and post-training assessment videos were coded for clinical quality indicators. Trainees’ performance in live deliveries was documented by simulation facilitators using a phone application. Results In total, 226 matched simulation videos were evaluated. From mid- to post-training, proper neck extension, positive pressure ventilation (PPV) with chest rise, and assessment of heart rate increased by 14%, 19%, and 12% respectively (all p≤0.01). No significant difference was noted in stimulation, suction, proper PPV rate, or time to completion of key NR steps. In 252 live, non-vigorous deliveries, identification of asphyxia, use of suction, and use of PPV increased by 22%, 24%, and 26% respectively (all p<0.01) between weeks 1-4 and 5-8 of training. Conclusion PRONTO training, as part of the AMANAT intervention, had a positive impact on key NR skills in simulated and live resuscitations across Bihar. Simulation training is a promising tool for improving NR skills in resource-limited settings.
  • 41. 6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Elbaba M.A. Job Title Co-chair of pediatric simulation HGH Institution Hamad Medical Corporation Email mostafaelbaba@hotmail.com Specialty Pediatrician and simulation educator Mobile Contact Address: Title: Need makes innovation: The MPS Solutions Author(s): Elbaba M.A., Bayoumi M.A. Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Background A collaborative work amongst three simulation specialists built a mobile pediatric simulation team named MPS in 2016. We have our own equipment including many manikins of medium fidelity. We also have our SPs and few task trainers. Due to the nature of the MPS which is "mobile", we used to move from our base in Qatar to other countries overseas to conduct our pediatric simulation events. The team faced many challenges because of the mobile nature of simulation to be delivered One of the major challenges is the task trainers; we need to ship or travel with many strange pieces of equipment in the flights. Method To overcome the difficulty of transporting many task trainers required for psychomotor skills and for interventions in simulated practice, MPS has invented four commonly required task trainers in pediatric practice from very basic materials but with high fidelity. These hand-made part task trainers are: Lumbar puncture, chest tube insertion, peripheral IV cannulation and umbilical catheterization for the newborn. Outcome The learners attending our workshops used the newly created task trainers and enjoyed and engaged better during those simulation experiences. The sense of realism which reflects the high-fidelity nature of the models, was achieved as learners mentioned this in their feedback. MPS successfully demonstrated the integration of high fidelity with low technology resources. Conclusion The author will demonstrate and share the newly innovated task-trainers with the audience. MPS believes that creativity is an essential requirement for any simulation specialist or educator.
  • 42. 6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Kathryn Colacchio Job Title MD Institution New Hanover Regional Medical Center/Coastal Carolina Neonatology Email kathryn.colacchio@ccneo.net Specialty Neonatology Mobile Contact Address: 2131 S. 17th Street, Wilmington NC 28401 Submission for: Poster or Podium Title: Neonatal Education with Simulation Training Author(s): Dr. Kathryn Colacchio MD, Sheila Deitz NNP, Dr. Fernando Moya MD, Deborah Stokes RN, MSN Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Background: When newborns with problems are born unexpectedly in community hospitals, delivery room personnel can significantly impact morbidity and mortality as initial interventions can result in injury, developmental delays and even death. In 2014, infant mortality rates in two southeastern NC counties were more than double the state’s overall rate. We travelled to small hospitals in a mobile simulation lab to provide opportunities to practice resuscitation, stabilization and teamwork with the goal of increasing caregiver confidence during the “golden hour” (the first hour after birth). Methods: Led by a neonatologist, the multidisciplinary team facilitated common high risk scenarios (e.g. meconium aspiration, extremely premature infant) in three pilot hospitals with Level 1 nurseries. Nurses, respiratory therapists and physicians were invited to participate in situ allowing for identification and remediation of latent safety hazards. Using evidence-based recommendations from the Neonatal Resuscitation Program, S.T.A.B.L.E and TEAMSTEPPS curriculums, debriefs focused on standards of care and teamwork optimization. A pre and post survey was distributed to assess confidence levels. Results: Participants demonstrated an improvement of confidence in maintaining golden hour measures including temperature control (2.7 out of 5 vs. 4.7 out of 5) and oxygenation levels (3 out of 5 vs. 4.2 out of 5) in the extremely premature infant. Conclusions: Our goal was to improve the stabilization of the critically ill newborn by educating staff members about best practices and identifying latent safety hazards. Participants demonstrated a self-reported improvement on the confidence surveys. Anecdotally it has been a positive experience for all staff involved.
  • 43. 6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Name Sarah Ball Job Title Clinical Educator Institution Corniche Hospital, Abu Dhabi, UAE Email sarahl@seha.ae Specialty Neonatology Mobile Contact Address: Education & Simulation Department – Corniche Hospital – Abu Dhabi – 3788 – United Arab Emirates (UAE) Submission for: Podium / Poster / Both (delete as appropriate) Title: ‘Transforming neonatal resuscitation training to improve neonatal clinical outcome’ Author(s): Mrs Sarah Ball MSc Education, CHSE, BSc(Hons), RN(Child) Abstract: Background: • Corniche Hospital is the UAEs largest high-risk maternity facility, with 64 cots Level III Neonatal Intensive Care Unit. With 7,000 deliveries per year it is imperative that healthcare providers can deliver effective neonatal resuscitation. It is well documented that reflective multidisciplinary (MDT) simulation team training improves clinical outcome. In 2014 we commenced our journey away from traditional teaching methodologies towards an immersive simulation training model. Methodology: • RADAR, SMART, fish bone analysis, prioritization matrix, SWOT & literature review. • Faculty attended CAPE in Stanford, USA and became Certified Healthcare Simulation Educators (CHSE). • Transformed and adapted the Neonatal Resuscitation Programme (NRP). • Formed the Neonatal Foundation Life Support Programme (NFLS): Development of a community programme, accredited by the Health Authority Abu Dhabi (HAAD) utilising hybrid in-situ simulation. • Constructed the first bespoke neonatal and obstetric simulation centre under SEHA Abu Dhabi opened, 2015. Results: • Base line results from 2014 showed sub-optimum clinical outcome from neonatal resuscitation drills at 52%. With the transformation in neonatal resuscitation simulation training the clinical outcome from neonatal resuscitation drills improved to 91%. Improvements in neonatal clinical outcome have also been seen in the reduction of term admission rates to the NICU to 24.75% (below England and Wales) and reduced rates of HIE admissions to the NICU to 0.20%. Conclusions: • Transforming our neonatal resuscitation training into an immersive simulation experience has resulted in improved neonatal clinical outcome. Key messages: • Simulation can improve neonatal clinical outcome, patient safety and staff engagement.
  • 44. 6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Sara Phillips and Samantha Fleming Job Title Practice Educator Midwife Practice Development Midwife Institution Royal Berkshire NHS Foundation Trust Email Sara.phillips@royalberkshire.nhs.uk Specialty Midwifery Mobile Contact Address: Craven Road Maternity Unit Submission for: Podium/ Poster / Both (delete as appropriate) Title: Pre Hospital Neonatal and Obstetric Emergencies in the Home (PHONE) 999 Author(s): Samantha Fleming (Practice Development Midwife), Katherine Simpson (Clinical Skills Midwife), Darren Best (Education manager South Central Ambulance), Sara Phillips (Practice Educator Midwife), Hazel Inkster (Practice Educator Midwife), Nicola Pritchard (Neonatal Consultant) and Sunetra Sengupta (Obstetric Consultant) Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Background: The need for combined community midwife and paramedic training became apparent following a number of investigations following incidents of both obstetric and neonatal emergencies at home. Re-occurring themes were identified including poor team work and communication due to a lack of understanding of each other’s roles, responsibilities, skills and limitations. There was a lack of knowledge and confidence in both professions regarding obstetric and neonatal emergencies in the home and how to safely and effectively continue neonatal resuscitation in the ambulance. Methods: To improve team performance and neonatal outcomes South Central Ambulance Service and the practice development team at the Royal Berkshire Hospital worked together to develop the PHONE 999 study day which is multi-professional training for community midwives, paramedics, maternity and emergency support workers. The study day is a combination of lectures and low and high fidelity pre hospital simulations. Conclusion: Candidates rated their knowledge and confidence on managing obstetric and neonatal emergencies in Pre-hospital settings using a scale of 1 – 5 pre-and post courses. On average the knowledge and confidence of community midwives increased by 31.4% and paramedics by 51.7%. The feedback received has all been positive using words such as “invaluable, excellent, innovative and practical”. Results: We have reviewed notes and seen evidence of good clinical decision making, management of emergencies and effective communication between midwives and paramedics. As part of the project a training DVD was produced to demonstrate safe and effective management of on-going neonatal resuscitation in the home and during ambulance transfer to hospital.
  • 45. 6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Alison Michaels Job Title Education Coordinator – Simulation Institution Mater Education; Mater Misericordiae Limited Email alison.michaels@mater.org.au Specialty Neonatal Critical Care and Simulation Education Mobile Contact Address: Level 4, Duncombe Building Raymond Terrace South Brisbane, Queensland, Australia, 4101 Submission for: Both Title: Taking simulation into the NCCU and beyond: working together to innovate and improve neonatal care Author(s): Alison Michaels and Richard Mausling Abstract: Background: The Neonatal Point Of Care (POC) Simulation program adopts a multifaceted interprofessional approach to address clinical, leadership, teamwork and process issues when caring for the deteriorating neonate. This program aims to scaffold concepts learnt through simulation training offered in Mater Education Practice Improvement Centre (MEPIC) and embed these in environments where clinicians would perform neonatal resuscitation events . Method: Twenty neonatal POC simulations were held across a nine month period. Scenarios were developed to encompass the most common situations requiring neonatal resuscitation. These sessions were delivered as short announced simulation events with a structured debrief to follow. The commencement of this program involved a unique strategic team approach with both medical and nursing co-faculty. Results: Significant adaptations were applied throughout the journey of embedding this program. The interprofessional team engaged in working together to improve and innovate, with this resulting in enhanced engagement staff throughout the neonatal service. Preliminary data demonstrates increased clinician confidence across non-technical skills required to resuscitate a deteriorating neonate. Furthermore, a number of process and systems issues were identified and improved as a result of allowing the review of processes involved in POC simulations that were undertaken. Conclusions: Successfully embedding the program into the clinical area saw improved engagement in simulation- based education. This program has allowed participants to identify process and communication issues inherent in the clinical environment and has energised these participants with the ability to be innovative in improving processes and communication to ensure the provision of low variability patient care.
  • 46. 6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name T Pillay Job Title Consultant Neonatologist Institution Royal Wolverhampton NHS Trust Email tilly.pillay@nhs.net Specialty Neonatology Mobile Contact Address: c/o Neonatal Unit, New Cross Hospital, Wolverhampton, WV10 0QP Submission for: Podium/poster Title: Supporting Care of the Sick Neonate: Networking individuals and fostering inter-unit rapport through shared learning using mixed LNU/SCBU/NICU teams Author(s): Pillay T, Clarke L, Cookson J, Rasiah, V for the SSN Faculty Staffordshire, Shropshire & Black Country (SSBC) and Southern West Midlands (SWM) Neonatal Operational Delivery Networks (ODNs) Abstract: Introduction: A bi-network initiative aimed at optimising support for sick neonates especially where care is shared between LNU/NICU/SCBU teams was developed: its objective to facilitate engagement using small group, confidential, and shared-experience learning. This educational contract focussed on networking individuals from different neonatal units, fostering inter-unit rapport, providing consultant decision making support, and management of teams in complex clinical situations. Methods: High and low fidelity simulations, together with workshops and augmented by 20 minutes reflective time post-scenario-debrief were conducted, to promote networking, sharing of experiences, and facilitate bi-directional learning and rapport. This was supported by a multidisciplinary faculty of 24. At the end of each course an evaluation form was completed by candidates; these outcomes are reported. Results: Between October 2015-January 2017, 81 team members from 9 neonatal units participated in the course. This included 37 consultants (4 NICU, 18 LNU,15 SCBU), 17 neonatal nurses, 19 trainees, and 8 ANNPs. The course was rated as highly relevant with high quality materials supporting LNU/SCBU/NICU teams. Inter- team engagement was supported: 76% did not mind not knowing all the members of their simulation scenarios; 64% had no objections to this not being point-of-care; 18% had no opinion on this. Candidates found the course valuable and re-enforced their own leadership, communication and team building skills, strengthening inter/intra- unit rapport. They supported continued professional development in this format. Conclusion: This shared care learning, through networking individuals from different neonatal teams has proved a useful adjunct facilitating inter-unit-engagement within our SSBC and SWM Neonatal ODNs.
  • 47. 6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Dr Pinki Surana Job Title Neonatal Consultant Institution Birmingham Heartlands Hospital Email suranapinki@yahoo.co.uk Specialty Neonatal Medicine Mobile Contact Address: Bordesley Green East, Birmingham Heartlands Hospital, Birmingham B9 5SS Submission for: Podium/ Poster / Both (delete as appropriate) Title: Learning from in-situ Neonatal Simulation: 3 Years of Participants’ Feedback Author(s): Dr Kylee Walker, Tracey Clohessy, Janice Duckett, Dr Victoria Fradd, Dr Imogen Storey, Dr Pinki Surana Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Background: In-situ simulation in intensive care setting prepares professionals for challenging scenarios in a safe environment. Deliberate practice in a time-pressured, task-heavy clinical environment is realistic, helping with technical and cognitive skills alongside recognition of human factors. Method: A high-fidelity, in-situ simulation training was established in a tertiary neonatal unit in December 2013 with fortnightly sessions. We collected structured participants’ feedback on the quality of debriefing, their self- confidence before and after each session and whether the simulation was realistic, relevant to their training and would change their practice. Participants were also asked to provide two “learning points” and suggest areas for programme improvement. Feedback from 59 sessions covering 16 different clinical scenarios from December 2013 to October 2016 was analysed. Results: Of the 292 feedback forms reviewed, majority of the participants reported the simulation was highly relevant to their training and would change their practice. The debrief quality was rated highly. There was notable improvement in reported self-confidence after the session. 39% of the learning points related to clinical management, 38% to human factors and 24% to clinical skills. Human factors which featured highly were communication, leadership and anticipation or planning. Suggested improvements were to create a more believable environment and more frequent sessions. Conclusion: In–situ neonatal simulation training is highly valued by both doctors and nurses and improves their reported confidence – more than a third of reported learning related to human factors. Given the human factors contribution to clinical incidents, this would be expected to improve patient safety.
  • 48. 6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Dr Felicity Brokke Job Title Neonatal Consultant Institution Medway Maritime Hospital Email felicitybrokke@yahoo.co.uk Specialty Neonates Mobile Contact Address: Submission for: Poster Title: Quality Improvement of Peak Inspiratory and End Expiratory Pressure Settings during Infant Resuscitation at Birth. Author(s): Felicity Brokke, Amy Skinner, Victoria Lander, Alison Clark and Ghada Ramadan Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Aims: In-situ simulation training indicated the need for accurate setup of peak inspiratory pressure (PIP) and positive end expiratory pressure (PEEP) prior to newborn resuscitation. Our project aimed to improve the quality of team learning from latent inaccuracies in PIP and PEEP settings, to reduce harm and improve outcomes for newborn infants through a series of targeted interventions. Methods: During 2016, we undertook a quality improvement project to measure baseline set-up of resuscitaires in the delivery suite. The first PDSA (plan do study act) cycle was performed through a prospective daily check of all resuscitaires (n=12) PIP and PEEP settings over a one-week period. When issues were identified, an “on the spot” one to one training of midwifery staff was performed. During the second PDSA cycle we introduced “resuscitaire flashcards” to be used as an aid memoire for the daily safety checklist. Results: During the first PDSA cycle, 10% of resuscitaires PIP was high (>30 cm H2O) and PEEP was set incorrectly in 48%. Inaccuracies in PEEP were either too high flow settings (>5 cm H2O) in 22% of cases or too low flow settings (<5 cm H2O) in 26%. Following the interventions, 100% of PIP was correctly set and only 11% of PEEP was inaccurate. Overall, this quality improvement programme led to 76% improvement in performance. Conclusion: Targeted quality improvement interventions through simulation have improved PIP and PEEP resuscitaires settings. This led to a reduction in latent errors and improved care given to newborns requiring resuscitation at birth.
  • 49. 6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Alana Barbato, MD Job Title Neonatal-Perinatal Medicine Fellow Institution Indiana University School of Medicine Email albarbat@iupui.edu Specialty Neonatology Mobile Contact Address: 699 Riley Hospital Dr. RR 203 Indianapolis, IN 46202 Title: The Use of Simulation Education to Promote Delivery Room Euthermia in Preterm Infants Author(s): Alana Barbato, Elizabeth Wetzel, Lisa Mayer, Bobbi J. Byrne Abstract: Background: Thin skin, decreased brown fat and increased surface area to mass predispose preterm infants to heat loss in the delivery room. Hypothermia leads to cardiorespiratory compromise, hypoglycaemia, and increased long term morbidities and mortality. Preterm infants born in community hospitals versus tertiary centers also have increased morbidities and mortality. Methods: To improve admission temperatures and outcomes, the Indiana University Neonatal Outreach Simulation team provided education on preterm infant delivery room management at 25 community hospitals in the state of Indiana, USA. 471 providers completed pre and post-tests on cognitive knowledge and participated in standardized simulated scenarios with team scoring. After structured debriefing participants repeated the scenario which was also scored. 6-12 months later, the sites were revisited to evaluate knowledge and skill retention. Results: Improvements in provider knowledge was demonstrated on cognitive tests with average scores improving from 49% to 94% (p-value <0.001). Scenario scores demonstrated team deficits most notably with regards to thermoregulation methods and polyethylene bag usage (Figure 1). Repeat scenario scores showed statistically significant improvements in all aspects of the resuscitation. Preliminary data from second visits has shown some attrition in knowledge and skills though overall improvement from initial performance (Figure 2). Chart reviews demonstrating the effect of education on preterm admission temperatures are underway. Conclusions: A structured simulation education intervention on preterm infant thermoregulation improves community provider’s immediate knowledge and skills as well as performance 6-12 months after the education. Chart reviews to ultimately show the true clinical impact of the education are underway. Visit 1, Initial Scenario Visit 2, Initial Scenario Visit 1, Repeat Scenario Visit 2, Repeat Scenario Baby in bag 68/108 (63%) 72/86 (84%) 108/108 (100%) 86/86 (100%) Time (sec) 44 18 13 5 Figure 1: Percentage of polyethylene bag usage by groups along with time to place the infant in the bag after birth. *Visit 2 Data is preliminary.
  • 50. Figure 2: Team scenario scoring based on total team performance and performance of thermoregulation tasks. *Visit 2 Data is preliminary. Visit 1 Total Score (out of 36) Visit 2 Total Score (out of 36) Visit 1 Thermoregulation Score (out of 8) Visit 2 Thermoregulation Score (out of 8) Initial Scenario 22.8 26.4 4.4 6.1 Repeat Scenario 32.9 34.8 7.6 7.6 0 10 20 30 Scenario Scoring Results
  • 51. 6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Dr Anu Sachdeva Job Title Assistant Professor Institution All India Institute of Medical Sciences, New Delhi Email dranuthukral@gmail.com Specialty Neonatology Mobile Contact Address: Department of Pediatrics, All India Institute of Medical Sciences, New Delhi Submission for: Both Title: Quality Improvement (QI) Program to improve the healthy survival of preterm neonates without severe retinopathy of prematurity (ROP) in Level-2 Neonatal Units in India Author(s): Anu Sachdeva, Deepak Chawla, Praveen Kumar, Ashok K Deorari, Sonica Raj Presenting author: Anu Sachdeva Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Background Quality improvement initiatives can improve the healthy survival of preterm neonates without ROP by adherence to evidence-based healthcare practices, Objectives • To assess current levels of knowledge, skills, attitudes and practices of health-care personnel’s, parents and administrators about clinical care pathways • To formulate, pilot test and finalize an educational package of interventions to improve the practices and the processes of care related to risk of ROP Methods A mixed-methods cross-sectional study (for objective 1) was conducted at level 2 neonatal units in India. The listed parameters were assessed in five domains i.e. good control of oxygen therapy, improving nutritional status, less exposure to blood products, less systemic infections and good developmental support. Study tools included focussed-group discussions, in-depth interviews, multiple-choice questions, objective structured clinical examinations and direct observation of care. Results A total of 4 SNCUs, 27 doctors, 46 nurses and 19 parents were enrolled for the study. Monitoring of oxygen therapy was hampered by lack of knowledge of alarm limits, practice of muting alarms and non-availability of pulse oximeters. Majority of participants knew that breast-milk is first choice for feeding of preterm neonates; however, babies invariably got other milk. Involvement of families in the care of preterm neonates was hampered by restriction of entry in the unit. Lack of knowledge of criteria of screening for ROP, non-availability of local ophthalmologist and lack of sensitization of parents about importance of ROP screening was resulting in poor screening of ROP. Educational package (will be shared with participants) is planned to be tested using debriefing in simulation labs. Delivery will be as “hub and spoke” model wherein nodal center hub being the medical college and the level 2 neonatal units in the adjoining areas as the spokes, and thus the dissemination of knowledge and competency based skills shall be imparted. Conclusions Prevalent poor healthcare practices which result in high incidence of ROP and lack of quality screening of eligible neonates indicates an urgent need to implement QI methodology in level 2 units.
  • 52. QCPR Feedback trial: Comparison of different resuscitation feedback methods during randomized pediatric simulation training Michael Wagner, MD 1 , Katharina Bibl, MD 1 , Emilie Hrdliczka 1 , Maria Stiller 1 , Jutta Gamper, BSc 2 , Katharina Goeral, MD 1 , Ulrike Salzer-Muhar, MD 3 , Angelika Berger, MD, MBA 1 , Georg M. Schmölzer, MD, PhD 4,5 , Monika Olischar, MD 1 1 Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Medical University of Vienna, Vienna, Austria 2 Section for Medical Statistics, Medical University of Vienna, Vienna, Austria 3 Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Vienna, Vienna, Austria 4 Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta Health Services, Canada 5 Department of Pediatrics, University of Alberta, Edmonton, Canada Background Highest quality of pediatric resuscitation skills is required to ensure the safety of hospitalized children. Therefore, Medical Universities provide pediatric resuscitation trainings to their students. The positive effect of feedback devices has been reported previously, respective studies showed limitations due to either small numbers of trainees or their focus on adult life support only. Methods A total of 653 medical students, who participated in their mandatory pediatric basic life support (PBLS) course were included. Participants were instructed to practice at one of two different manikin models (baby and adolescent; n= 344 and 309, respectively). Participants were randomized to three different groups: Group A (n=225, instructor feedback (IF) group) received a traditional instructor-led class without additional feedback devices. Group B (n=223, device feedback (DF) group) had access to direct visual feedback during PBLS from a feedback device only. Group C (n=205, instructor and device feedback (IDF) group) received feedback from an instructor who simultaneously received feedback about the trainees’ chest compression performance from a feedback device in real-time. Results The overall Kruskal-Wallis test showed significant group differences (p<0.0001). Participants in both feedback groups (B and C) had statistically significant better chest compression scores when compared to instructor led-classes. Of all studied parameters, „enough depth” (all groups p<0.0001) and „release” (group A and C p<0.0001, group B p=0.0205) showed the highest statistically significant difference with better results in the baby compared to adolescent manikin. Conclusion and Discussion Our study compared three different feedback methods in two different manikin groups. We could show a significantly improved chest compression performance in a pediatric resuscitation simulation setting depending on feedback method. High quality chest compressions are the cornerstone of cardiopulmonary resuscitation to improve outcomes. Feedback devices should be used during pediatric resuscitation training to improve resuscitation performance.
  • 53. 6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Lucy Boucher Job Title ST5 Paedaitrics Institution UHCW Email lucyboucher@doctors.org.uk Specialty Neonates Mobile Contact Address: 19 the marish, warwick, Warwickshire, cv34 6bz Submission for: Both Title: Neonatal simulation, the new fat burner for paediatric trainees: Effect of in situ high fidelity neonatal simulation training on the heart rate of neonatal trainees at a single tertiary NICU. Author(s): L Boucher, S Ellis, J Daly, A Dunlop Abstract: Stress is not necessarily a negative state and cognitive literature demonstrates an inverted U relationship with performance showing an optimal level of stress for performance. Finan et al. states that within paediatrics there is a risk of trainees becoming over stressed in emergencies due to their relative infrequency and the need to perform at the highest level of competency. Methods: Prospective pilot study of Paediatric trainees at a single tertiary NICU. Heart rate was recorded for the 10 minutes prior to simulation, for the duration of the simulation and during the de- brief. Pilot study was performed over 2 months in 2016
  • 54. Results: An average rise in HR of 61bpm a 96% increase from baseline. An average of 18 minutes was spent with a heart rate above baseline from the start of simulation taking 8 minutes to return to baseline. Dips In heart rate were noted when more senior help arrived whereas inter-team conflict created further rises in heart rate. Conclusions: Neonatal simulation does provoke a physiological response that can be objectively measured and there is feasiblity to upscale this project. There is scope to compare data from simulation and “real life” resuscitation as well as expanding the measures of physiological stress to include salivary cortisol levels, peripheral skin temperature and electro dermal skin activation. This data could be used to tailor simulations to target an optimum stress response to improve team performance and learning with the aim of improving outcomes in real life resuscitations potentially improving outcomes on the neonatal unit. 0 20 40 60 80 100 120 140 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 Series1 Series2 Series3
  • 55. 6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Chris Paton Job Title Clinical Researcher Institution University of Oxford Email Chris.paton@ndm.ox.ac.uk Specialty Health Informatics Mobile Contact Address: Peter Medawar Building, South Parks Road, Oxford Submission for: Podium Title: Feasibility and Usability of a Mobile Neonatal Simulation Training Tool Author(s): Ms. Elena Taylor, Dr Hilary Edgcombe, Dr Chris Paton, Dr Anne Geniets, Mr Jakob Rossner, Dr. Linden Baxter, Prof. Niall Winters, Prof. Mike English Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) BACKGROUND: Simulation for training health workers in neonatal resuscitation techniques is well established in both high-income and low-income settings. However, many health workers in the low-resource world have difficulty accessing up to date training at sufficient frequency to maintain their skills and knowledge. Scaling context-appropriate training remains a considerable challenge in much of the world. We have developed simulation-related training tools employing low-cost smartphone technology, based on the East African ETAT+ course content. METHOD: We conducted a mixed-methods feasibility and usability study to determine the stability, performance and acceptability of a prototype smartphone-based neonatal training application. A rapid iterative stepwise study was conducted over an 8-month period with nursing students from the UK, exploring usability and new features introduced into the tool over 8 iterations. Both “experienced” and “naïve” groups tested the app in each version, and qualitative data was retrieved using interview and focus group methods to inform the next stage. RESULTS: We describe a novel approach to the rapid development of a technology-based training tool for neonatal simulation, based on iterative testing of new versions with both experienced and naïve users. This provides a basis for further research in the LMIC setting. CONCLUSIONS: Collaboration between Kenyan and British teams including paediatricians, specialists in education and medical simulation and software developers has resulted in successful development of a basic proof-of-concept mobile app based in a simulated 3D environment.
  • 56. 6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Dr. Douglas Campbell, MD, FRCPC Job Title Director of NICU, Director of Allan Waters Family Simulation Centre, St. Michael’s Hospital Institution University of Toronto Email campbelld@smh.ca Specialty Neonatal-Perinatal Medicine Mobile Contact Address: 15014CC - Department of Pediatrics, St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B1W8 CANADA Submission for: Podium only please (delete as appropriate) Title: Using simulation to identify latent safety threats during neonatal MRI intramural transport Using simulation to identify latent safety threats during neonatal MRI intramural transport Author(s): Jonathan Wong1,3, Kaarthigeyan Kalaniti1,3. Michael Castaldo1,3, Kyong-Soon Lee1,3, Hilary Whyte1,3, Manohar Shroff 4, Douglas M. Campbell1,2,3 Background In-situ simulation can be used to identify latent safety, allowing for improvement of process and policy in complex health organizations. Magnetic resonance imaging (MRI) is a frequently used imaging modality but is remotely located from the neonatal intensive care unit (NICU) and can be hazardous for fragile patients. Our aim was to use simulation to identify latent safety threats (LST) during intramural transport for neonatal MRIs and to improve understanding of neonatal intramural transport processes. Methods A prospective observational study was conducted in a tertiary neonatal intensive care unit after ethics approval. Simulated ‘runs’ consisted of taking a neonate with hypoxic brain injury (MRI-compatible low-fidelity manikin: intubated or non-intubated) to the MRI suite and returning to the NICU. Data was obtained through: LST checklist, debriefing and video observation. Results Of 10 simulated runs, 4 were completed by trained transport teams, 3 by ad-hoc clinicians and 3 by scheduled intramural teams (intramural nurse & transport MD). 116 LSTs were seen (11.6 LST/sim). LSTs included: medication, equipment/environment, anticipation, communication, and systems issues. Medication-related safety hazards were self-reported in all sims. Environmental threats included: patient tubing/lines, poor knowledge of MRI room layout, and activating assistance. Differences in checklist performance were noted between dedicated transport teams and other teams. 68% of clinicians reported increased mental & physical workload during the simulations. Take home Messages In-situ simulation was able to identify a number of significant LSTs during neonatal MRI transport, with variation among different team configurations. Intramural checklists and team orientation are now being changed to improve safe practice.
  • 57. 6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Judith Hull Job Title ST6 Pediatrics Institution St Georges Hospital Email judithchull@doctors.org.uk Specialty Neonates Mobile Contact Address: Submission for: Both (delete as appropriate) Title: Debriefing immediately following acute events: a neonatal unit experience Author(s): J Hull, N Velauthan, N Aziz, D Duffy, C Battersby Abstract: (Please consider Background/Method/Results/Conclusions/Key/Messages) Background: The PEDAL (post event debrief and learning) project aims to implement routine team debriefs following actual acute events, gathering the team during or immediately after the shift. It is difficult to integrate simulation into in-house teaching. Debrief post simulation is an integral part of the learning. Adult learning theory emphasises practical, relevant, experiential learning. We hypothesise PEDAL will both enhance the learning process and reduce repeat system and communication errors by identifying areas for development within the clinical governance framework. Methods: Our multidisciplinary survey identified prior practice of debriefing, attitudes toward debriefing and perceived barriers. The PEDAL proforma was designed and implemented. A monthly bulletin was sent out summarising learning points. Educational and system issues were addressed. The Survey will be repeated post intervention. Results: Of 29 staff surveyed, only 17% felt debrief often occurred with 8% having never experienced it. Those with experience of debrief found it useful. 74% felt debrief should occur immediately. Our first monthly bulletin reflected 5 debriefs involving 20 clinicians. Common themes in learning points included communication and equipment. Learning needs identified are being addressed in ongoing departmental training. Conclusion: Feedback suggests clinicians find acute debriefs useful and they identify areas for development. It is feasible to run acute debriefs on a busy neonatal unit. Our experience suggests leadership and engagement from senior team members and a shift in culture is needed for the programme to be sustainable. We aim to embed the PEDAL process in routine clinical practice giving both training and governance benefits.
  • 58. 6th National Neonatal Simulation Conference Abstract Submission for poster/podium presentations on Conference day 27th September 2017 Submission by: Name Dr Rachel Hayward Job Title Neonatal Grid Trainee Institution University Hospital of Wales Email rachel.hayward@doctors.org.uk Specialty Neonates Mobile Contact Address: Pentwyn Uchaf Farm, Mountain Ash, CF45 4RJ Submission for: Podium Title: Pitstop-perfect performances: lessons to be learnt from industry Author(s): Hayward R, Hayward A, Cleaton L, C Doherty Abstract: Aim To optimise practices in neonatal resuscitation using the processes used by a Formula One (F1) team. Methods Processes involved in neonatal resuscitation were identified and analysed. Three main components were selected for development: resuscitation equipment, the space available for resuscitation teams and team dynamics. Each component was analysed with a F1 team and comparisons drawn with practices conducted during a pitstop i.e. a dynamic, time critical task performed by a multi-professional team. Changes were made to each component for example, streamlining the equipment trolley, implementing a neonatal footprint in delivery theatres and developing key elements of effective team working. Results A colour coded resuscitation trolley has been developed enabling direct access to essential items during resuscitation. Checklists, a user manual and ‘on-the-spot’ tests have reinforced learning and familiarisation with the resus trolley. The implementation of a dedicated area in delivery theatres (cleared in neonatal emergencies) has enabled direct access to the patient and equipment by all members of the team. Clear allocation of roles to team members, critical appraisal of each resuscitation, fault listing and debriefing sessions will improve how team members interact and identify factors that influence their performance. Conclusions Lessons from F1 can be incorporated throughout the healthcare system. Team performance is dependent upon having a defined leader and clearly identified responsibilities for all team members. Access to essential equipment, adequate training and preparation (simulation scenarios) checklists and debriefing opportunities are essential for optimising team efficiency and providing optimal patient care.