Using Multi-D Simulation To Prepare For Pediatric Trauma Designation In The Community  - PowerPoint Presentation

Using Multi-D Simulation To Prepare For Pediatric Trauma Designation In The Community  Gemma Elegores MSN, RN,CCRN-K Simulation Education Specialist Katherine Gautreaux, MSN, RN, CEN, CPEN Trauma Education Coordinator

Introduction

Trauma SystemIncludes components required for optimal carePreventionAccessPrehospital care and transportationAcute hospital careRehabilitationResearch activities“Inclusive” trauma system Includes all members/facilities in the system, not just major trauma centersIdentifiable roles for facilities based on resources and community needsVarious levels of trauma centers need to cooperate to care for the injured patient and prevent waste American College of Surgeons, 2014

Trauma SystemNetwork required to provide spectrum of care for injured patients Trauma stratificationLevels I – IV and non designatedNOT a ranking of medical care but of resource depth American College of Surgeons, 2014

Levels I – IV StratificationLevel I Level II Level III Level IV Responsibilities & Resources Greatest amount of resources and personnel for care of the injured patient Provides regional leadership in education, research, and prevention programs Offers similar resources to a Level I facility, possibly differing only in continuous availability of certain subspecialties or sufficient prevention, education, and research activities Not required to be resident or fellow education centers Capable of assessment, resuscitation, and emergency surgery , with severely injured patients being transferred to a Level I or II facilityCapable of providing 24-hour physician coverage, resuscitation, and stabilization to injured patients before transfer to a facility that provides a higher level of trauma care.” Centers for Disease Control and Prevention, 2012

Trauma Department ResponsibilitiesAmerican College of Surgeons, 2014

Case StudyChief Complaint12 y.o. M who fell from a skateboard and hit his head Unknown LOCFather reported AMS, syncopal episodes, vomiting, and difficulty walking once patient returned home

Timeline

The Trauma Activation ProcessThe trauma activation process provides the right patient with the right resources at the right time

Trauma ActivationResources mobilized through the activation processEmergency DepartmentEquipment: airway, IV, chest tube, crash cart, warming measures, monitors etc…Team preparation: roles and responsibilities, pre-huddle, PPEHouse-wideTrauma surgery team Pharmacy Blood bank Radiology Anesthesia/OR Critical care Surgical subspecialties Chaplaincy, social work Security Etc …

Full Trauma system activation

Simulation in Healthcare

Simulation-based Clinical System Test: A Human Factor Engineering Tool Simulating in a realistic environment to evaluate a process, workflow,  environments and systems to ensure safety, effectiveness, and ease of use Focus on how systems and environments work in actual practice with REAL and error prone human beings caring for patients in a new hospital environment Goal of evaluating systems and processes that optimize safety and minimize error in complex medical environments

The Process Simulation-based Clinical System Test ( SbCST )

What is SbCSTRobust process improvement tool that can be used to proactively test the complex systems (people + physical environment + processes) involved in new patient care settings. By involving front-line personnel in clinical simulations aimed at stressing systems to find potential threats to patient/provider safety (LST – latent safety threats).

Simulation-based Clinical System Test (SbCST)A specific concern in a new patient care process is the existence of unrecognized or latent threats to safety that could affect actual patients once the facility opensSystem changes, although intended to be beneficial, may also result in negative, unanticipated outcomes

Best Practice for Simulation-based Clinical Systems Test (SbCST) Identification of Priorities What to continue What to change Needs Assessment Leaders Core Team Members Departments Stakeholders Simulation Design Scenario Location Personnel Timeline Methodologies Priority Themes Action Plans Outcomes/Metrics

Needs AssessmentFacilities and EnvironmentTechnology/Devices and equipmentProcesses of Care/Workflows Roles and ResponsibilitiesClinical Knowledge and Performance Gaps Facilities and Environment Functionality of EMS docking sheet Technology/Devices/Equipment Easy access to rapid infuser, thoracotomy tray Communication flow during activation  Processes of Care/Workflows Test paging process using *9999 to activate a trauma Activate Trauma Team Functionality of “red phone” during activation Staffing coverage  Activate MTP Roles and Responsibilities Roles of PCA/UCA PICU support- MD, RN Role of transport team Clinical Knowledge/Performance Gaps Difference between activation criteria and code levels Stakeholders

Simulation Design

The DebriefingSafety 1 and Safety 2Safety I  “Safety” is interpreted as absence of unwanted outcomes – focus is on the few things that go wrong to understand and prevent recurrence Safety II “Safety” is interpreted as consistent presence of desired outcomes - focus is on the many things that go right to enhance reliability in complex systems

Outcomes and MetricsFailure Modes and Effects Analysis (FMEA)  is an established and widely used means of proactively seeking out both latent and active weaknesses and failures in healthcare systems in order to analyze causes, assess risk, and address resolutions (The Joint Commission, 2005). 

FMEA Scoring Tool 4 - Catastrophic 3 - Major 2 - Moderate 1 - Minor Severity Categories Failure could cause death, injury Patient Outcome:     ·         Death or major permanent loss of function (sensory, motor, physiologic, or intellectual)  Visitor Outcome:     ·         A death; or hospitalization of ≥3 Staff Outcome: ·         A death; or hospitalization of ≥3 Equipment/Facility damage :  Firer beyond incipient stage; or damages ≥$250,000 Failure could cause high degree customer dissatisfaction Patient Outcome: ·         Permanent lessening of bodily functioning (sensory, motor, physiologic, or intellectual); or ·         Increased length of stay or increased level of care for ≥3 patients Visitor Outcome:   ·         Hospitalization of 1-2 visitorsStaff Outcome:·         Hospitalization of 1-2 staff; or·         ≥3 staff experiencing lost time, or restricted dutyEquipment/Facility damage: ·         Damages $100,000-$250,000Failure can be overcome, but there is minor performance lossPatient Outcome:·         Increased length of stay or increased level of care for 1-2 patientsVisitor Outcome:·         Evaluation, treatment of 1-2 visitorsStaff Outcome:·         Medical expenses, lost time, or restricted duty for 1-2 staffEquipment/Facility damage: ·         Damages $10,000-$100,000; or ·         Fire, at/smaller than incipient stageFailure not noticeable to customer, no effect on delivery of servicePatient Outcome:·         No injury, nor increased length of stay, nor increased level of careVisitor Outcome:·         Evaluated, but no treatmentStaff Outcome:·         First aid only, no lost time, or restricted dutyEquipment/Facility damage: ·         Damages <$10,000; or ·         Loss of utility without adverse patient outcomeProbabilityRatingsFrequentLikely to occur immediately or within a short period (may happen several times in 1 year)OccasionalProbably will occur (may happen several times in 1 to 2 years)Uncommon Possible to occur (may happen sometime in 2 to 5 years)RemoteUnlikely to occur (may happen sometime in 5 to 30 years)

Action Item Review

Action Item Review“Question regarding the ETA… If short time, do you even want to tell them you have ETA of 5 minutes?”“Concerns that no one’s pagers went off and concerns about Voalte connectivity”“Level 1 tubing was needed but it wasn’t yet stocked- the tubing is in-house but was not stocked yet.” “Security never responded to the call. It was unclear to the participants if they received the page/voalte call” “Unclear about a transport via air- who does this process? will this be the house supervisor or the transfer” “Participants expressed some confusion about what is meant by “stabilize and transfer” for a level 4 trauma center.”

What would you do: Unavailable EquipmentThe following equipment is either missing, started to malfunction or there is no one present competent to use it.How would you handle this?What other resources could you use?Video laryngoscope (CMAC)VentilatorChest tube Rapid infuserSufficient blood productsIO insertion deviceCT scannerBair hugger/mistral air

What would you do: Unavailable Resuscitation TeamThe following members of the resuscitation team are unavailable How would you handle this?Is anyone else capable of fulfilling their role?Emergency Medicine PhysicianEmergency Room Nurses Radiology Tech for XR or CTOR Resources: Surgeon (general or specialty); Anesthesia; OR teamSecurity Social Work and/or Chaplain

What would you do: IT IssuesYou experience problems with the primary form of communication at your facility (e.g., pagers not delivering messages, Voalte connectivity is not functioning, Spectralinks are unable to dial) What is your back up form of communication for trauma activation?

What would you do: Transport DelaysYou would like to use a rotor wing service but when you call they tell you they are grounded due to weather.What else can you do?What if you are 3 hours away from the nearest Level I or II?You would like to send the patient using your contracted transport service (e.g., Acadian, AMR etc…) but they will not be able to arrive for 2 hours.What else can you do?

ConclusionSimulation-based systems testing helps develop critical new processes (Trauma Designation)Unique multidisciplinary process that directly impacts patient safety and quality of care 

ReferencesAmerican College of Surgeons (2014, 6th ed.). Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of SurgeonsBarleycorn, Donna, and Geraldine A. Lee. "How Effective is Trauma Simulation as an Educational Process for Healthcare Providers within the Trauma Networks? A Systematic Review." International Emergency Nursing , vol. 40, 2018, pp. 37-45.Centers for Disease Control and Prevention (2012, January 12). Guidelines for Field Triage of Injured Patients. Retrieved from https://www.facs.org/~/ media/files/quality%20programs/trauma/vrc%20resources/6_guidelines%20field%20triage%202011.ashx Sullivan , Sarah, et al. "Identifying Nontechnical Skill Deficits in Trainees through Interdisciplinary Trauma Simulation." Journal of Surgical Education , vol. 75, no. 4, 2018, pp. 978-983.