Point-of-care simulation – A game changer

Delivering high-quality and safe care is a major healthcare challenge. There is no doubt that remarkable achievements have occurred in pediatric cardiac critical care over the past two decades. The specialty has become well-defined and extremely resource-intense. A great deal of focus has been laid on optimizing outcomes, particularly mortality and early morbidity. This has been achieved through a focused multidisciplinary approach to patient management with an aim to define disease pathophysiology, utilize invasive and non-invasive techniques to diagnose problems, and closely assess responses to specific treatment plans. The development of sophisticated monitoring equipment and devices to support organ function during critical illness has contributed substantially to improved outcomes.

Unfortunately, at the bedside, the daily wealth of data available beat-to-beat on every patient is generally not captured nor integrated with clinical decision making. We do not have real-time intelligence or analytics and as such, the very devices that have enabled us to provide outstanding care, also expose us to adverse events related to fundamental human and system characteristics. Errors in human judgment and decision making are well reported and are multifactorial. With the ever-increasing complexity and intensity of management, there is the real danger of information overload, and inability for all clinicians at the bedside to interpret or perceive an evolving clinical picture. In addition, there are multiple distractions and potentials for fixation within the intensive care environment related to monitoring and medical devices, as well as from other areas, such as the implementation of the electronic medical record and wireless phone communication, all of which serve to pull clinicians away from the bedside. We rely on a hierarchy of decision making and expectations, many of which are based on presumptions and past experience. Staff has different capabilities depending on years of experience and ability to integrate information. There are differences in engagement and ownership of clinical problems, problems related to conflict resolution, and ensuring optimal teamwork, along with cultural differences and expectations. All of these human-related factors contribute to the potential for error.

Medicine is possibly the only high-risk industry, which does not mandate using practice before a procedure or a surgery. One approach that is being used to train medical teams is known as crisis resource management (CRM). CRM is used broadly to train healthcare teams in aspects of teamwork during management of critical clinical events, and is generally conducted using simulation centers. However, there is a great advantage in conducting simulation at the point of care. Benefits include the ability to integrate into regular activities and schedules, enhanced realism of simulations, and opportunity to train using equipment and resources unique to each clinical environment. In addition, in situ simulation presents a unique opportunity to identify latent safety threats within a given clinical environment. This is of tremendous significance. Unlike the popular notion that simulation is only a training tool for medical students, its potential is in fact far more. It is a tool to improve patient care safety, provides opportunity for medical teams to train on human factors, and can test clinical team processes and also new equipment. Typically a debriefing process post simulation ensures that teams reflect on their actions and suitable corrective actions are taken.

At Rainbow Children’s Hospital, we are slowly moving toward using simulation at point of care as method to pre-emptively decrease medical errors to identify latent threats and improve clinical process like receiving patient to intensive care unit, timely initiation of treatment, and decreasing hospital-acquired infections, using just-in-time and in-place simulation. We have noticed that use of simulation has helped us avert dangers in patient care, which would otherwise come to light only through critical incidents or patient mortality.