Division of Emergency Medicine

Cincinnati Children’s Hospital

Implementation of a multidisciplinary simulation based teamwork training in a pediatric

Emergency Dept

Introduction• 1999 Institute of Medicine

(IOM) report: To Err is Human:

– Recommended: Safety programs should… establish interdisciplinary team training programs for providers that incorporate proven methods of team training such as simulation

Specific aims• Implement a multidisciplinary simulation-

based safety curriculum in a pediatric ED

• Evaluate long term clinical impact by reduction of adverse events in the ED

Specific aimsIntermediate measures

• Evaluate the effectiveness of this curriculum by assessing– Knowledge – Attitudes towards patient safety– Teamwork behaviors

• Pre and post intervention as well as at a follow up reevaluation

Implementation• Simulation based multidisciplinary teamwork,

communication and error reduction training since March 2005– Plan Simulations to Reinforce Behaviors Around Difficult

Concepts

– Equipment failures, difficult vascular access or difficult airways force teams to respond to critical scenarios in a time pressured environment

– Set up situations in which staff must use

assertive statements, challenge authority

gradient, etc

Project Results/Outcomes

• Through June 30, 2007 a total of 224 ED personnel - participated in initial teamwork training course

• 119 participants completed a re-evaluation session

• mean of 9.3 months (SD 3.3 months) after their initial training course

Results: Knowledge

• The pre and post tests for knowledge– mean pre-test score of 85.5% and a mean post

test score of 95.8%. The paired t test p <0.001.

• Retention of knowledge at the reevaluation utilizing a parallel post-test. Mean of 9.3 months post intervention – Knowledge scores averaged 94% (SD: 7.5).

Results: Attitude• Safety Attitudes Questionnaire: pre and

post intervention for demonstrated improved Z values. p < 0.001,

• Repeated SAQ at the reevaluations at a mean of 9.3 months post intervention– No continued improvement in attitude after

intervention…– But initial gain in attitude improvement

sustained over 9 mos.

Video review

• 5 video reviewers reviewed pre and post intervention simulations using Sexton’s Behavioral Markers scale

• Trend in improved score post intervention, not statistically significant at this time.

Project Results/OutcomesUnexpected Finding

• Twenty four latent safety threats and systems issues were identified during the multidisciplinary debriefings

• currently being addressed through ED operations and patient safety committees

Clinical Translation• Baseline SSE rate 2-3 per

year• Result: Knowledge is

important-but simulation (practice) reinforces the behavior we wish to see without harming patients

• Measure: ED has gone almost 18 months without a SSE

Knowledge + Practice = Behavior Change

Real World Challenges

• Initial training intervention over > 1year– Difficulty assessing contribution of simulation training

as a special cause due to other changes in the environment

• Due to mix of providers working in ED, difficult to assess the impact of the training in the clinical environment due to mixed teams

• Staff turnover and new hires ensures that some fraction of providers will not be trained at any one time