1. A. Trimble, E. Sleap, N. Attoe, A. Ireson, R. Thomas
The Use of Multi Modal and Hybrid Simulation in the Training of Multi Disciplinary Professionals
A. Trimble, E. Sleap, N. Attoe, A. Ireson, R. Thomas
Hampshire Hospitals Foundation Trust
In Collaboration with S. Wilding and C. Hamilton (SIMP, University Hospital Southampton Foundation Trust)
Good morning, thank you for the opportunity to present a project that we set up at Winchester hospital in collaboration with university hospitals southampton. All the photos that appear in our presentation are “stills” from the SMOTs system that we used for some of the project. Thanks to Gordon M of Scotia for his support….. ..

2. Background
Weekly simulation training established as part of protected Foundation Programme Teaching at RHCH
This project represents development of the above to include:
Multi-disciplinary involvement.
Training in communication / human factors.
Simulated patients and relatives.
The project came about in response to a recognition that there is only so far one can get with a group of doctors and a plastic mannikin.
Foundation doctors at Winchester already have weekly simulation training established as part of their protected teaching and we used this as the framework to include other healthcare professionals.
We have previously used simulated patients from UHS for communication training with foundation doctors.
In collaboration with UHS we decided to set up a project incorporating a ground breaking combination of Multi disciplinary, multi-modal and hybrid simulation training using simulated patients.

3. Is hybrid, multi modal simulation an effective tool for developing technical and non technical skills in multi disciplinary professionals?
We wanted to try out a mixture of “technical / treatment” and “non-technical / communication” simulation; using “real people” where possible and plastic mannikins when not, and putting doctors, nurses, other health professionals together in a realistic and supportive learning environment. We were careful to stress that this wasn’t a “test” as we wanted to avoid an “ALS-testing” type environment.

4. Methods 1 July 2015 – 8 Sessions Multi Disciplinary Team Three Actors
Identical structured scenario used
Acute Coronary Syndrome (ACS) → Cardiac Arrest
This project ran in july 2015 and we used the foundation doctors protected simulation teaching time on Wednesday afternoons to run 8 sessions.
Each session put together a team of at least 7; consisting of 3 FY1 doctors, a senior nurse and a mix of other trained nurses, health care support workers and students. All participants were working in an acute area within the hospital.
We used 3 Simulated patients, a patient, his wife and their daughter.
We used an identical scenario for each session; an elderly man presenting with chest pain who then suffers cardiac arrest in the emergency department.
The 2 hour sessions were timetabled into a briefing phase, a team building phase, arrival of the patient and management of him and his relatives, and then a structured debriefing for all involved.

5. Methods 2 Pre / Post Event Questionnaire Participants involved in:
Survey monkey at 2/52
Participants involved in:
Immediate “De-Briefing” including video
Verbal & written feedback from actors
Objective assessments of medical management and non technical skills
The participants completed a pre and post session questionnaire on the day and were invited to provide “on line” feedback via survey monkey 2 weeks after the experience.
The immediate post scenario debrief included review of the medical management and aspects related to communication.
The Simulated patients provided verbal feedback on the day and a written synopsis at the end of the project.
The faculty made a number of objective assessments to examine the quality of care provided.

6. The next 2 slides tell the story of what happened!
These images demonstrate what can be obtained when one uses a multi-channel AV set-up such as SMOTs. This proved very useful for immediate debriefing as well as allowing us to analyse what happened “real-time” later on.
The upper boxes show the patient, his wife, their daughter in the post arrival chest pain part of the scenario. You can see a mix of doctors, trained nurses, students and HCSWs.
The monitor screen shot shows the transistion into cardiac arrest …..

7. …. At this point the real patient is replaced with a plastic mannikin and CPR can commence. In an adjacent area the relatives are being spoken to.
The lower right box was debriefed as an example of excellent communication, the left hand side, … less so!

8. Results
We achieved an incredible amount and during the 8 sessions we managed to take 55 members of staff through the simulation process; some participated more than once.
We managed to achieve “balanced” multi-disciplinary teams for each session and this was facilitated by collaboration with the leads for workforce development at the trust.
All staff had had resuscitation training to at least BLS standard. The foundation doctors had participated regularly in simulation sessions throughout the year.

9. Medical Management ACS Management Time to start chest compressions
Inadequate in 25% of Sessions
Time to start chest compressions
5 to 38 Seconds (31 Seconds)
Time until first defibrillation
73 to 360 Seconds (176 Seconds)
Defibrillation
Unsafe in 50% of Sessions
Poorly followed ALS Algorithm
Objective assessment of the quality of the medical management demonstrated considerable room for improvement!
Examples included; drugs not given when they should have been, incorrect doses of drugs administered and failure to administer oxygen and iv fluids. There were significant delays to providing CPR and defibrillation and a general failure to follow resuscitation algorithms, despite these being prominently displayed in the “treatment area”.
Of particular concern were technical aspects of defibrillator operation. To highlight one incident; there was a delay of 6 mins to achieve first defibrillation due to all team members being unfamiliar with how to connect the patient to the defibrillator. This delay would have been longer except the faculty intervened and “sent in help” in the form of a wandering anaesthetic SpR!

10. Non Technical Skills Team Leader Assignment
FY1 as team in leader in 100% of Sessions
Examples of effective verbal and non verbal communication
All areas of concern had communication / human factors aspects
Management of Patient
Chest pain usually not treated. Lots of activity but “no action”.
Sometimes felt ignored and talked over.
Management of Relatives
Removal of relatives immediately in 7 of the 8 sessions
‘Relatives role’ delegated to untrained junior member of team in 50% of sessions; Examples of some poor communication
For our presentation today, we will condense our findings to a few “key” areas. We shall be writing this up as a full paper, but for now..
All teams elected one of the doctors as team leader. In all teams, the “senior” nurse was probably better qualified by experience and ALS certification.
The majority of team members were not previously known to each other. Bearing this in mind, communication within the teams was good.
All of the defibrillator safety and medical management concerns had “communication and team factors” related aspects; for example, it was a common theme that the team leader believed that the drug that they had ordered had been administered when in fact it had not.
The patient’s complaint of chest pain usually went untreated and unrelieved despite various staff promising to help.
Both patient and relatives felt that it took a long time for the teams to achieve anything. Although lots was going on around them this didn’t seem to translate into any useful action.
In nearly all sessions, the team tried hard to remove the relatives from the patient despite both parties wanting to remain together. When the relatives were removed their care was usually delegated to the most junior member of staff; often the student or health care support worker.
In the debriefing; participants were generally surprised that the relatives would have taken comfort and re-assurance from having been allowed to stay at the patients side.

11. Effect on Confidence
100% Agreed or Strongly Agreed that the simulation had increased their confidence for future cardiac arrests
100% felt benefit of training as a Multi Disciplinary Team
Small rise in confidence or no change in all areas (technical and non technical skills)
Recognising that there is risk associated with asking staff to participate in this sort of experience, an important part of the evaluation was to check that what we were doing wasn’t undermining staff confidence or morale.
Despite the areas of concerns that I have just highlighted in the objective assessments, it is therefore fascinating that all participants reported as positively as described on this slide.

12. Discussion
Participants enjoyed the experience and confidence levels were maintained
insight into performance lacking?
All participants had resuscitation training but some examples of poor medical management. Why?
Shortcomings of current training?
Feedback from simulated patients valuable.
Would have found it reassuring to “see things done”
Treat my pain
Uniforms
Feedback from participants would indicate that we should aim to continue with this sort of training; they enjoy it and they report increased confidence. As observers, we didn’t think that the teams had much insight in recognising that the medical management had been sub-optimal in many cases.
The question for us is why did a group of well trained, well motivated and high quality staff perform as they did? Our hypothesis is that incorporating the distractions of “real patient”, “real relatives” and working alongside new colleagues sometimes got in the way of a perfect “ALS” type performance.
… trouble is, this is how it is “in the real world” of today’s NHS.
We think we should do more of this; but beware… it does take quite some setting up, has significant funding and infrastructure consequences and needs lots of faculty to run it on the day..

13. Limitations Short Session Time (120 minutes)
Expensive; both in terms of time, faculty and fees for simulated patients.
Struggled to get (senior) nursing staff from acute areas
Later groups were ‘better prepared’ due to discussions with colleagues
In retrospect we recognise that despite our best efforts to ensure that staff were well prepared, briefed and “de-briefed” this type of training needs more time than 2 hours and does present considerable administrative challenges.
We did struggle to get enough nurses and also to get them to turn up “on time”; I’m sure this reflects that the vast majority of nurse participants were released at short notice from clinical areas in contrast to the doctors being there as part of their “protected teaching time”.

14. Developments Multi Disciplinary
ICU / theatres / ACCPs / Outreach / EMAU ANPs
Student nurses / preceptorship nurses / HCSWs
“Clinical Matrons”
Funding obtained to use simulated patients and relatives
Further sessions have longer ‘Debrief Time’ .. And “re-run”.
‘In Situ’ simulation
We have decided that as the next step we would like to develop our pilot project into a half day training experience that incorporates what we have learnt:
1. Invest in dedicated study time for nurses and other health professionals so that attendance can be guaranteed and participants well prepared and briefed in advance; the ethos being that “this is an opportunity to have some fun and practice stuff that you already know”.
2. Continue to use simulated patients, their involvement increases “realism” and adds value; although this does have funding implications. We shall incorporate their feedback into the training delivered.
3. Include human factors training and allow some time for participants to settle down and get to know each other before putting them into the simulated environment.
4. Allow more time for debriefing afterwards.
5. Eventually move away from the sim suite and into clinical areas.

15. Thank you for listening. Any Questions?

16. References
Hughes et al, Multi-Disciplinary simulation training for Anaesthetic Practitioners. Journal of perioperative practice, 2013 July; 23:7-8:
Falcone Jr et Al. Multidisciplinary Pediatric trauma team training using high fidelity trauma simulation. Journal of Pediatric Surgery, 2008 June; 43(6):
Okuda et al, The utility of simulation in medical education: what is the evidence? Mt Sinai J Med, 2009 Aug; 76(4):
Resuscitation Council UK. Advanced Life Support Manual 6th Edition
Resuscitation Council UK. Immediate Life Support Manual 3rd Edition