A session blog from Day 2 of State of the Art, London December 2015. See the full list.
Blogger David Garry (@davidgarry2000)
What have we learned from human factors research?
We have known since “critical to success” (the audit commission, 1998) that there is a large variation in performance across UK critical care units. This is due to differences in working patterns, equipment availability or decision making. There are two distinct defined categories of decision making processes, “heuristics or mental models” or “deductive reasoning”. Enterprises such as the surviving sepsis campaign use a bundle approach in an attempt to change our behaviour but one must be cautious as this approach has the potential to crowd out quality at the level of the patient. Specifically, if we focus on process this could be to the detriment of outcome.
As clinicians become more senior they develop less confidence with predicting outcomes as they are more aware of uncertainty. Paradoxically they become more confident in their decision making. Dr Brett will be publishing a paper on this shortly.
As critical care clinicians we work in an environment that is full of complicated equipment and it is important that we manage this environment so that the technology is not misleading.
- Critical care is a busy environment, we should ensure that our decision making processes are fluid, transparent and focus on patient outcomes.
Pro-Con: In-situ SIM is the answer
If simulation is good enough for NASA, it’s good enough for healthcare. Although there is less evidence for in-situ simulation (it is harder to control, and is a lot newer) it is a lot cheaper as there is a significant cost associated with building and maintaining a simulation centre. In-situ sim training has the advantage that you are involving all staff simultaneously, and pertinently the people that you work with on a day-to-day basis in their usual work environment. The realism is also enhanced and people tend to become more immersed in the scenario. Dr Forrest does a lot of in-situ sim training on his ICU. The utility of this training was validated when a fire at his hospital took out both generators plunging the ICU in darkness. The staff did 27 transfers in 3 hours. The feeling among staff was that this was made possible by the staff’s prior exposure to in-situ sim training.
- In-situ sim training is cost effective, realistic and familiar, and has gained excellent feedback at Dr Forrest’s hospital.
Pro-Con: SIM centres are the answer
Dr Feely feels that in-situ sim training is essential, and indeed they do this at her hospital. However these are short episodes as it would be impractical to do this for a whole morning. Last month she booked 30 in-situ sessions on her unit but was only able to run 6. The advantage of a simulation centre is that it affords a ring-fenced environment. Creation of a sim centre does not have to be expensive and the equipment can of course be taken out for in-situ training. Maintaining safety in large scale in-situ simulation can be challenging as illustrated by the recent terrorist incident drill at a university in Kenya.
- SIM centres are essential, cost-effective and complement in-situ training.
- Does the current financial austerity limit what can currently be done? Dr Forrest felt that in-situ sim training is very cost effective.
- Is there any evidence of impact on patient outcomes? Dr Feely feels that this is very difficult if not impossible to unravel. However the timeliness and the competence of the team is enhanced, along with the positive impact on the resilience of the healthcare staff. A response from the floor pointed out that there is no evidence for any form of education.