Hospital-wide cardiac arrest in situ simulation to identify and mitigate latent safety threats

Advances in Simulation - 2022
Suzanne Bentley1, Alexander Meshel2, Lorraine Boehm1, Barbara Dilos3, Mamie McIndoe4, Rachel Carroll-Bennett5, Alfredo Astua6, L. T. K. Wong7, Colleen Smith7, Laura Iavicoli7, Julia LaMonica8, Tania López9, Jose Quitain9, Guirlene Dube10, Alex F. Manini8, Joseph L. Halbach10, Michael Meguerdichian11, Komal Bajaj12
1Simulation Center at Elmhurst, NYC Health + Hospital/Elmhurst, Elmhurst, NY, USA
2Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY, USA
3Department of Anesthesiology, NYC Health + Hospitals/Elmhurst, Elmhurst, NY, USA
4Patient Experience, NYC Health + Hospital/Elmhurst, Elmhurst, NY, USA
5Department of Obstetrics and Gynecology, NYC Health + Hospital/Elmhurst, Elmhurst, NY, USA
6Pulmonary and Critical Care, NYC Health + Hospital/Elmhurst, Elmhurst, NY, USA
7Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
8Emergency Medicine, NYC Health + Hospitals/Elmhurst, Elmhurst, NY, USA
9Pediatrics, NYC Health + Hospitals/Elmhurst, Elmhurst, NY, USA
10NYC Health + Hospitals/Elmhurst, Elmhurst, NY, USA
11Department of Emergency Medicine, NYC Health + Hospitals/Harlem, New York, NY, USA
12NYC Health + Hospital/Jacobi, Bronx, NY, USA

Tóm tắt

Abstract Background Cardiac arrest resuscitation requires well-executed teamwork to produce optimal outcomes. Frequency of cardiac arrest events differs by hospital location, which presents unique challenges in care due to variations in responding team composition and comfort levels and familiarity with obtaining and utilizing arrest equipment. The objective of this initiative is to utilize unannounced, in situ, cardiac arrest simulations hospital wide to educate, evaluate, and maximize cardiac arrest teams outside the traditional simulation lab by systematically assessing and capturing areas of opportunity for improvement, latent safety threats (LSTs), and key challenges by hospital location. Methods Unannounced in situ simulations were performed at a city hospital with multidisciplinary cardiac arrest teams responding to a presumed real cardiac arrest. Participants and facilitators identified LSTs during standardized postsimulation debriefings that were classified into equipment, medication, resource/system, or technical skill categories. A hazard matrix was used by multiplying occurrence frequency of LST in simulation and real clinical events (based on expert opinion) and severity of the LST based on agreement between two evaluators. Results Seventy-four in situ cardiac arrest simulations were conducted hospital wide. Hundreds of safety threats were identified, analyzed, and categorized yielding 106 unique latent safety threats: 21 in the equipment category, 8 in the medication category, 41 in the resource/system category, and 36 in the technical skill category. The team worked to mitigate all LSTs with priority mitigation to imminent risk level threats, then high risk threats, followed by non-imminent risk LSTs. Four LSTs were deemed imminent, requiring immediate remediation post debriefing. Fifteen LSTs had a hazard ratio greater than 8 which were deemed high risk for remediation. Depending on the category of threat, a combination of mitigating steps including the immediate fixing of an identified problem, leadership escalation, and programmatic intervention recommendations occurred resulting in mitigation of all identified threats. Conclusions Hospital-wide in situ cardiac arrest team simulation offers an effective way to both identify and mitigate LSTs. Safety during cardiac arrest care is improved through the use of a system in which LSTs are escalated urgently, mitigated, and conveyed back to participants to provide closed loop debriefing. Lastly, this hospital-wide, multidisciplinary initiative additionally served as an educational needs assessment allowing for informed, iterative education and systems improvement initiatives targeted to areas of LSTs and areas of opportunity.

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Tài liệu tham khảo

Holmberg MJ, Ross CE, Fitzmaurice GM, et al. Annual incidence of adult and pediatric in-hospital cardiac arrest in the United States. Circ Cardiovasc Qual Outcomes. 2019;12(7):e005580.

Nallamothu BK, Guetterman TC, Harrod M, et al. How do resuscitation teams at top-performing hospitals for in-hospital cardiac arrest succeed? A qualitative study. Circulation. 2018;138(2):154–63.

Petrosoniak A, Hicks CM. Beyond crisis resource management: new frontiers in human factors training for acute care medicine. Curr Opin Anaesthesiol. 2013;26(6):699–706.

Edelson DP, Litzinger B, Arora V, et al. Improving in-hospital cardiac arrest process and outcomes with performance debriefing. Arch Intern Med. 2008;168(10):1063.

Rose MR, Rose KM. Use of a surgical debriefing checklist to achieve higher value health care. Am J Med Qual. 2018;33(5):514–22.

Sullivan NJ, Duval-Arnould J, Twilley M, et al. Simulation exercise to improve retention of cardiopulmonary resuscitation priorities for in-hospital cardiac arrests: a randomized controlled trial. Resuscitation. 2015;86:6–13.

Couper K, Salman B, Soar J, Finn J, Perkins GD. Debriefing to improve outcomes from critical illness: a systematic review and meta-analysis. Intensive Care Med. 2013;39(9):1513–23.

Mullan PC, Wuestner E, Kerr TD, Christopher DP, Patel B. Implementation of an in situ qualitative debriefing tool for resuscitations. Resuscitation. 2013;84(7):946–51.

Morgan L, Hadi M, Pickering S, et al. The effect of teamwork training on team performance and clinical outcome in elective orthopaedic surgery: a controlled interrupted time series study. BMJ Open. 2015;5:e006216.

Steinemann S, Berg B, Skinner A, DiTulio A, Anzelon K, Terada K, et al. In situ, multidisciplinary, simulation-based teamwork training improves early trauma care. J Surg Educ. 2011;68(6):472–7.

Petrosoniak A, Fan M, Hicks CM, et al. Trauma resuscitation using in situ simulation team training (TRUST) study: latent safety threat evaluation using framework analysis and video review. BMJ Qual Saf. 2021;30(9):739–46.

Patterson MD, Blike GT, Nadkarni VM. In situ simulation: challenges and results. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in patient safety: new directions and alternative approaches (vol. 3: performance and tools). Rockville: Agency for Healthcare Research and Quality (US); 2008.

Lioce L, Lopreiato J, Downing D, Chang TP, Robertson JM, Anderson M, Diaz DA; Spain A.E; Terminology and Concepts Working Group. Healthcare Simulation Dictionary –Second Edition. Rockville: Agency for Healthcare Research and Quality; 2020. AHRQ Publication No. 20-0019.

Alfredsdottir H, Bjornsdottir K. Nursing and patient safety in the operating room. J Adv Nurs. 2008;61(1):29–37.

Reason J. Human error: models and management. BMJ. 2000;320(7237):768–70.

Lamberta M, Aghera A. Latent safety threat identification via medical simulation. In: StatPearls. Treasure Island: StatPearls Publishing; 2021.

Eppich W, Cheng A. Promoting excellence and reflective learning in simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simulation Healthcare. 2015;10(2):106–15.

Sawyer T, Eppich W, Brett-Fleegler M, Grant V, Cheng A. More than one way to debrief. Simul Healthc J Soc Simul Healthc. 2016;11(3):209–17.

Sawyer T, Loren D, Halamek LP. Post-event debriefings during neonatal care: why are we not doing them, and how can we start? J Perinatol. 2016;36(6):415–9.

Zinns LE, Welch-Horan TB, Moore TA, Ades A, Wolfe HA, Mullan PC. Implementation of an innovative, multiunit, postevent debriefing program in a children’s hospital. Pediatr Emerg Care. 2020;36(7):345–6.

Rose S, Cheng A. Charge nurse facilitated clinical debriefing in the emergency department. Can J Emerg Med. 2018;20(5):781–5.

Nadir N-A, Bentley S, Papanagnou D, Bajaj K, Rinnert S, Sinert R. Characteristics of real-time, non-critical incident debriefing practices in the emergency department. West J Emerg Med. 2017;18(1):146–51.

Brindle ME, Henrich N, Foster A, et al. Implementation of surgical debriefing programs in large health systems: an exploratory qualitative analysis. BMC Health Serv Res. 2018;18(1):1–14.

Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf. 2013;22(6):468–77.

Bajaj K, Minors A, Walker K, Meguerdichian M, Patterson M. “No-go considerations” for in situ simulation safety. Simul Healthc. 2018;13(3):221–4.

Bajaj K, Meguerdichian M, Thoma B, Huang S, Eppich W, Cheng A. The PEARLS Healthcare Debriefing Tool. Acad Med. 2018;93(2):336.

Dubé MM, Reid J, Kaba A, Cheng A, Eppich W, Grant V, et al. PEARLS for systems integration, simulation in healthcare. J Soc Simul Healthcare. 2019;14(5):333–42.

DeRosier J, Stalhandske E, Bagian JP, et al. Using health care failure mode and effect analysis: the Va national center for patient safety’s prospective risk analysis system. Jt Comm J Qual Improv. 2002;28:248–67.

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Advances in Simulation

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