Thomas Dongilli A. T. Director of Operations Peter M. Winter Institute for Simulation, Education and Research (WISER) Administrator Department of Anesthesiology University of Pittsburgh School of Medicine American Society of Anesthesiologist Endorsed Simulation Center

University of Pittsburgh University of Pittsburgh Medical Center

UPMC21 Hospitals 57,000 Employees SDS and Out Patient Clinics University of Pittsburgh School of Medicine School of Nursing School of Pharmacy Undergrad – Medical Biology Dental School

University of Pittsburgh School of Nursing ISMETT Hospital Passavant Hospital McKeesport Hospital Children’s Hospital UPMC East WISER

Medicine – Medical Students (MS 2-4) – Residents Anesthesiology Emergency Medicine ENT Internal Medicine OB/GYN (course work in development) Pediatrics Surgery Dental – Fellows Critical Care Pediatric Intensivists – Faculty Members and Community Physicians Anesthesiology Critical Care Medicine Emergency Medicine Nursing – Undergraduate Nursing Students – Practicing Nurses Med / Surg ICU OR – Nurse Anesthetists – Student Nurse Anesthetists   Pharmacy Students  Pharmacists  Occupational Therapy  Paramedics, EMTs  Respiratory Therapists  Other Simulation Centers / Educators  Many Others

– Providing a Consistent Experience – Build Base Knowledge – Repetitive Deliberate Practice to Increase Retention – Introduce Clinical Variability – Start Psychomotor Skills Development – Introduce Team Concepts

– Preparing To Begin Real Work – Standardizing the Experience Clinical Supplement – Procedural Mastery – Continue to build base knowledge – Increase Team Functions

Maintenance of Competence Base Knowledge Currency of Knowledge Therapeutic advances Skills / Procedures Base On Experience ??? Clinical Track Record (Quality Assurance)

Why can’t we shock someone within 2 minutes of a crisis but the pit crew can complete all of their tasks within 20 seconds? Are we not as educated as the pit crew? Are they better at their jobs? The answer is: They are better organized. They practice their jobs! They practice as a team!

RNs MDs PharmDs RRTs Technicians Support Staff Silos contribute to medical errors!

The IOM defines medical error as “the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim.” Approximately 1.3 Million patients are injured annually in the United States as a result of a “Preventable Medical Errors” The National Coordinating Council for Medication Error Reporting and Prevention Top 2 causes of preventable medical errors or adverse events: 1.Equipment Errors. Failure to utilize or malfunction of equipment 2.Diagnosis Errors. Failure to diagnose or recognize

1999….Between 44,000 and 98,000 Americans die each year in U.S. hospitals due to preventable medical errors (Institute Of Medicine)Institute Of Medicine 2004…. 195,000 Americans die a year due to preventable errors (HealthGrades)HealthGrades An estimated 15,000 Medicare patients die each month in part because of care they received 99,000 patients die as a result of hospital-acquired infections (HAI) each year (AHRQ, 2009).AHRQ Hospital errors rank between the fifth and eighth leading cause of death, killing more Americans than breast cancer and traffic accidents (IOM). Just one type of error—preventable adverse drug events— causes one out of five injuries or deaths per year to patients in the hospitals

Occurrences per 1000 patients admitted

“If a 747 jetliner crashed every day, killing all 500 people aboard, there would be a national uproar over aviation safety and an all-out mobilization to fix the problem. In the nation's hospitals, though, about the same number of people die on average every day from medical "adverse events," many of them preventable errors such as infections or incorrect medications.” USA Today

Psychomotor Skills Communications Skills Professionalism Skills Decision Making Base Knowledge Teamwork Skills

Assessment Individual Psychomotor Skills Monitoring and Intervention Skills Clinical Problem Solving Communication and Teamwork skills Clinical Reasoning

Crisis Team Data

Braithwaite et al. Use of medical emergency teams to detect medical errors. QUAL SAFETY HEALTH CARE, Activation of Response Teams

Patient Safety Initiatives…. Training? Risk Management? Financial? Competencies? Operational Efficiency? Clinical Preparedness?

Picked 1 topic to review…Medical Crisis  utilization of Rapid Response Team Training Emphasis on “The Team” – Utilizing highly trained personnel – Bringing critical care to the patient bed side – Promoting early intervention Mock Codes were initially used to assess the “Team” and System Responses Initial responders were unclear of role and treatment protocols Minimal to no training for the true “1 st Responders” (except BLS)

Identified Key Areas for Improvement – Recognition of Crisis Do they actually identify a crisis? – Initial treatment of patients in crisis by non ICU / Code Team members What can they do before the code team arrives?

Rationale for Course Development We want to: Enhance critical thinking and motor skills of initial providers Improve early problem recognition Eliminate inconsistent initial interventions Standardize key responses Empower decision making Improve communication Complement the MET team Assessment of current site training and policies

How many of you are instructors for students? How many clinical sites do your students rotate through? How many of you work and rotate units or at clinical sites? Are you / they prepared for an emergency at each site? – What is the correct number to dial for a code at each site? – Where is the Code Cart located? – Is there equipment in my patients room (O2, BVM, etc). – What are you expected to do in the first 5 of a crisis?

“The First 5 Minutes” Course Can be Mobile Sessions can last as little as 30 minutes Rotate through while on duty Use as preparation for clinical rotations Curriculum Discuss why participants are there Statistics about initial responders (local policies) Carry out scenario focusing on initial assessment and management Provide comprehensive debriefing session with questions and answers Provide time to practice skills

Simulated Experience – Identify a crisis is occurring – Assess ABCs – Call for appropriate help – Utilize local staff and equipment – Work together as a team – Perform key common tasks prior to MET arrival – “Package” the patient for the MET team

ABCs Calling for help Crash cart arrival HOB and Backboard Pad placement Proper use of AED O 2 and Airway management IV verification Communication Documentation

Greater than 9 minutes to shock patient (Avg.) BVM less than 10% of patients 40% of the participants did not know the correct number to dial to activate the Rapid Response Team Report was inconsistent 80% of the nurses did not set the defib to the appropriate setting (all defibs had AED functionality)

Scenario Reviewed Time to practice equipment and skills 2 nd Scenario run – 2 nd Scenario Averages: Less than 1:50 Seconds to complete key tasks 96% of top 20 tasks completed within time frame Report standardized Equipment utilized

Mandatory training for all non-ICU staff Opposite BLS recertification Part of initial BLS certification and training day Roll out program to nurses throughout health system RT and PCT are also invited to sessions SON Utilization Utilized for students prior to first clinical Include new equipment, policies

Pursue other possibilities for using the initial response structure: Trauma Patient Entering the Emergency Room When New Admission Enters Unit Crisis in Radiology ICU Application Continue to assess actual responses Create a Critical Care adaptation Include other disciplines Continue movement into outpatient areas