Simulation in the ICU

Introduction

Simulation: a situation or environment created to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions. —definition taught at the Center for Medical Simulation, Cambridge, Mass.

In the 1960s, Red Cross first aid classes taught a new cardiopulmonary resuscitation (CPR) method, having discarded the chest pressure-arm lift method, the primary resuscitation method of the 1950s and 1960s and perhaps before. So how was CPR practiced? On Resusci-Anne—a relatively new Laerdal product that was used everywhere to teach mouth-to-mouth and chest compressions following the contemporary recommendations of the American Heart Association. By today’s standards this is a relatively primitive simulator, one that is still in use.

However, perhaps the most sophisticated simulator of all had already been demonstrated in the late 1960s by Steven Abrahamson, the Dean of Education at University of Southern California. Abahamson et al. developed a high-fidelity simulator—SIM-ONE—that was more sophisticated then than some simulators that are currently available; it even fasciculated after succinylcholine injection. However, SIM-ONE required a room full of computers, each with an attendant technician in the manner of a NASA space launch. Dr. Abrahamson went on sabbatical, his simulator was dismantled, so the story goes, and it took advances in computer technology and the vision of subsequent simulation pioneers before resurrection of this technology in the 1990s. Simulation is now an exponentially growing field, driven by the patient-safety movement, changes in the educational opportunities available to trainees, and evolving computer capabilities. Medical-simulation centers that numbered in the 10s in the early 1990s now number in the 1000s worldwide. Furthermore there is accumulating evidence that simulation can be used in training of physicians and health care providers to help reduce medical errors, improve technical skills for some invasive procedures, and enhance communication skills.

Simulation in terms of a taxonomy can be characterized as follows:

▪

Task training. This entails use of simulation devices meant to teach specific psychomotor tasks with complexity that can range from simple insertion of an intravenous cannula into a simulated arm to a computerized virtual reality world that allows an operator to learn highly complex procedures such as transesophageal echocardiography, laparoscopy, or endoscopy procedures. One example of a new virtual reality simulator is that developed by Banerjee et al. to teach ventriculostomy placement ( Fig. 41.1 ).

Fig. 41.1

ImmersiveTouch.

Ventriculostomy simulation is depicted, showing the observer’s view and the operator’s view.

(From Issenberg SB, Chung HS, Devine LA. Patient safety training simulations based on competency criteria of the accreditation council for graduate medical education. Mt Sinai J Med 2011;78(6):842–53, with permission.)
▪

PC-based simulation . This entails use of PC-based programs that are installed on laptop computers. They can be set up to mimic real life scenarios such that the user has to run through all of the cognitive decision algorithms that are required in clinical practice. Moreover, in accordance with the apparent preferences of the current younger generation, the PC-based simulation also can be set up as a game.
▪

Standardized patients. What can be better than working on a real human? This notion has resulted in the development of standardized patient programs in many schools and a standardized patient society ( www.aspeducators.org ). Standardized patients are real people, individuals who are trained to display the appropriate behaviors of patients with given diseases in given situations or individuals with the relevant physical findings. Both types of standardized patients can be used to teach novices how to deal with a variety of problems.
▪

High-fidelity simulation . This uses simulators that bring together all of the physiology and pharmacologic responses of a human in a manikin, which breathes, may produce or consume a variety of different gases, and talks in an interactive manner with the students. After appropriate suspension of disbelief, this manikin becomes for all intents and purposes a real human being with a real problem that students have to diagnose and treat appropriately.

All of these elements of simulation can be further integrated to create scenarios that encompass any or all of these methods. Students can perform procedures, make decisions, and interact with a patient (manikin or standardized patient who may be attached to a task trainer). At an even higher level, students may interact with other health care providers on a team. This had led increasingly to the use of such simulation tools to train health care providers in the principles of crew/crisis resource management (CRM) (teamwork), another lesson from the aviation industry. And finally simulation can be used as an essential tool for microsystem or macrosystem simulations. Such simulations encompass handling multiple patients with management of medical, interpersonal, and system issues.

In the context of critical care, CRM is an important new vista that can be used to improve team performance.

Crisis Resource Management

In 2000, the American Heart Association established the National Registry of Cardiopulmonary Resuscitation (NRCPR) to assist participating hospitals with systematic data collection on resuscitative efforts. In so doing, the AHA provided a prospective, multisite, observational mechanism to determine the epidemiology and outcomes from in-hospital resuscitation. Initial results from the registry were reported by Peberdy et al. in 2003 from 14,720 cardiac arrests in adults at 207 hospitals, of which 86% had an organized emergency response team continuously available. The researchers reported that 44% of adult in-hospital cardiac arrest victims had a return of spontaneous circulation (ROSC), but only 17% survived to hospital discharge. Neurologic outcome was reported as good in 86% of discharged survivors. This 17% discharge survival rate is consistent with reports of others.

Various models have been proposed to prevent cardiac arrests and improve survival following cardiac arrest, such as using emergency medicine residents as responders and creating emergency response teams, but these recommendations have yet to be translated into improved survival after inpatient cardiac arrest. Several reasons can be attributed to the relatively poor results after inpatient cardiac arrest. These certainly include patients’ premorbid severity of illness such that any practice or process changes in resuscitation would not be expected to have a meaningful impact. Nonetheless, several studies emphasize the important role that various practices have on patient outcomes after resuscitation. For example, time to CPR was identified as an important factor in predicting outcome for both inpatient and out-of-hospital cardiac arrest, and organized early medical emergency response team involvement appears to positively affect outcomes. Trauma surgeons have been leaders in this aspect of resuscitation, and have demonstrated the advantage of using a team model to resuscitate victims of severe trauma. Providing further support to this concept, there is now compelling data on the advantages of CRM team training on error rates and practice process variables and, moreover, the value of attending intensivist contribution to critical care outcome. All of these observations and those of others clearly indicate process change as an area for improvement that could improve survival after in-hospital resuscitation. The notable disparity in ROSC and discharge survival rates suggest that improvements in processes of practice can reasonably be targeted as aspects of patient care that could increase the rate of meaningful survival after cardiac arrest or near arrest.

The aviation and nuclear energy industries, as well as the military, all described as high reliability organizations, have a rich and successful history of using crisis simulation to train personnel to deal with high-risk situations in complex environments. More recently, the pioneering work of anesthesiologists, critical care specialists, and others has extended the knowledge developed in these industries to acute care medicine and the operating room. These providers have collaborated with industry to develop realistic computerized manikin systems, which simulate medical crisis situations typically encountered in the operating room and intensive care unit (ICU) and that may be directed at physicians, nurses, advanced practitioners, residents, or students. The systems are being further developed and adapted to medical crisis situations outside of the operating room. For example, these units can provide both inexperienced and experienced personnel in a number of fields with exposure to common and uncommon medical crises such as myocardial ischemia, hypothermia, acute respiratory distress syndrome, septic shock, anaphylaxis, complex arrhythmias, Advanced Cardiac/Trauma Life Support protocols, pneumothorax, difficult airway situations, and many others. Moreover, the realistic setting of the simulation “theater” can be used to create realistic situations that teach important lessons about optimal team dynamics and can help improve leadership, teamwork, and self-confidence skills to manage medical emergencies. It should be remembered that effective instructor training is needed for successful implementation of simulation based CRM learning.

What Is Crisis Resource Management?

Risser et al. in their analysis of medical teamwork failures describe a core team as “a set of 3 to 10 clinically skilled caregivers who work together during a shift and have been trained to use specific teamwork behaviors to tightly coordinate and manage their clinical actions.” Risser et al. adapted knowledge from aviation CRM to the emergency department acute care setting and derived five team dimensions:

1.

Maintenance of team structure and climate. This refers initially to:
- ▪
  
  The establishment of the team leader and organization of the team
- ▪
  
  Cultivation of team climate
- ▪
  
  Constructive resolution of conflicts
Success in the subsequent four dimensions depends on this one being successfully implemented. Examples of common team failures in this area include not assigning roles properly and not holding team members accountable.

Dimensions 2, 3, and 4, described next, are the operational core of a high-quality team and are functionally intertwined, essentially occurring simultaneously. The caregivers may have to balance competing demands and must maintain a high level of situational awareness.
2.

Application of problem-solving strategies. This describes:
- ▪
  
  Conducting situational planning
- ▪
  
  Application of decision-making methods
- ▪
  
  Engaging in error correction actions
This dimension relies on adequate communication. This means that all team members are a part of decision-making, that the leader asks for and is given relevant information, and that relevant protocols are implemented.

This dimension also has caregivers being aware of the three basic types of errors: slips, lapses, and mistakes, and being assertive enough to identify and correct them. Examples of common team failures in this area include not identifying relevant established protocols, not engaging other team members in decision making, not alerting the team to potential bias and error, and not asserting the need for corrective actions.
3.

Communication with the team. This refers to:
- ▪
  
  The use of local standards for effective communication
- ▪
  
  Provision of supporting information
- ▪
  
  Requesting supporting information
The emphasis of this dimension is the assurance within the team of a common understanding of patient and operational issues that affect the performance of the team and patient outcome. There is timely information transfer and maintenance of team situational awareness. Examples of common team failures in this area include not using a check-back process to verify communication, not offering information that supports a decision, not seeking needed information, and not communicating plans to the team members.
4.

Execution of plans and management of workload. This refers to:
- ▪
  
  Plan implementation
- ▪
  
  Primary and secondary triage
- ▪
  
  Task prioritization
- ▪
  
  Management of team workload and resources
- ▪
  
  Cross-monitoring team member actions
- ▪
  
  Maintaining situational awareness
The emphasis of this dimension is to encourage willingness of team members to ask for assistance and to assist others to eliminate work overload and poor integration of everyone’s tasks. Examples of common team failures in this area include not executing the protocol or plan, not integrating team member assessments of patient needs, poor task prioritization, and inadequate cross-monitoring of team members and the team’s plan execution.
5.

Improvement of team skill. This refers to engaging in informal and formal team improvement strategies. This entails informal discussion at the time of the event and later formal review and discussion.

Baker et al., in a recent review of this topic, outline knowledge, skills, and attitudes that members of a high-quality team should possess that facilitate coordinated, adaptive performance and provide support of one’s teammates, objectives, and mission. Baker et al., in general agreement with Risser et al., indicates that each team member is able to do the following to identify when errors occur and how to recover and correct for these errors:

▪

Anticipate the needs of others
▪

Adjust to each other’s actions and to the changing environment
▪

Have a shared understanding of how a procedure should happen

Hunt et al., in a review of teamwork training, indentifies several factors listed in Table 41.1 as elements of high performing teams.

Table 41.1

Characteristics of High Performing Teams

Situation Awareness (SA)	Team performance is improved when team members continually assess their environment and update each other in a process call “shared cognition” so that they are making decisions based on current information and can have a “shared mental model” of the current state of affairs and an updated plan of action with contingencies. SA allows team to maintain “big picture” view of situation. Effective military and aviation teams have higher SA than low-performing teams.
Leadership	An effective team leader can both command the team and values input from team members. Flattening the hierarchy improves safety as information can flow both directions, while leaders who maintain an authoritarian type of leadership “reinforce large authority gradients, creating unnecessary risk.” A leader should try not to perform procedures unless the procedure is essential and no one else is capable of doing it. Stepping back and keeping a “bird’s eye view” allows the leader to take in and process more information and contributes to situational awareness.
Followership	The nonleader members of the team are called followers . Good “followership” is just as important for good team functioning as good leadership. Followers need to know their individual role on the team but also contribute to overall team functionality. They must contribute to situational awareness by verbalizing observations about changes in the environment, ideas about diagnosis, to decrease the leaders’ workload if necessary and finally to help the leader avoid mistakes; for example, “the team leader might focus on an incorrect diagnosis and apply the wrong rule (treatment) owing to a fixation error, or be incapacitated, hence everyone in the team should always be alert.” Finally, followers must not assume that the leader knows everything and should feel obligated to share observations that might impact outcome.
Closed loop communication	Closed looped communication is used to ensure that the message that was sent is heeded and understood, and involves: “(1) the sender initiating a message, (2) the receiver receiving the message, interpreting it, and acknowledging its receipt, and (3) the sender following up to ensure the intended message was received.”
Critical language and standardized practices	Critical language refers to the use of a catch phrase that means something to every member of an organization and requires specific action (standardized practices). United Airlines developed the CUS program for “I’m concerned, I’m uncomfortable, this is unsafe, or I’m scared,” which is adopted within the culture as meaning, “We have a serious problem; stop and listen to me.” Another example of a standardized approach to improve the effectiveness of communication is SBAR (situation, background, assessment, recommendation). This is a tool that gives an outline of how “awareness and education regarding the fact that nurses, physicians, and other clinicians are taught to communicate in very different styles.”
Assertive communication	Safe patient care may depend on the ability for a team member to speak up and get the attention of other team members when they believe something might be going wrong. This is more likely to happen if a team member believes speaking up will not be held against him or her. A recurrent phrase is that people can still show deference to expertise, but speak up in a “nonthreatening and respectful manner.” The idea is that all team members may have valuable input, “regardless of rank.” The “hint and hope” model has been described as a common and dangerous way of trying to indirectly communicate with other team members.
Adaptive behaviors	Teams whose members are flexible and perform as needed to optimize team functioning and demonstrate “adaptive behaviors” are those that can truly benefit from the synergy of an effective team. Examples of adaptive behavior that optimize team functionality include the following: “(1) team members ask for help when overloaded, (2) team members monitor each other’s performance to notice any performance decreases (mutual performance monitoring), or (3) team members take an active role in assisting other team members who are in need of help (backup behavior). An essential component to the above actions happening is trust among team members.”
Workload management	Workload management depends on team members demonstrating adaptive behaviors. This principle requires: (1) “proper allocation of tasks to individuals, (2) avoidance of work overloads in self and in others, (3) prioritization of tasks during periods of high workload, and (4) preventing nonessential factors from distracting attention from adherence to protocols, particularly those relating to critical tasks.”
Debriefing	Debriefing is the process of reviewing a simulation or real event after it is complete to optimize any lessons that can be learned. When using simulation as a teaching tool, simulation with no debriefing and feedback does not result in effective learning. In terms of real events, teams that debrief themselves afterwards have been shown to be higher performing.