In-Situ-Simulation, a ‘how to’ guide

The following is a guide to help you set up an in-situ simulation (ISS) program in the intensive care unit. It is not an exhaustive guide but drawn from my experience of establishing a program on our unit and some of the problems and solutions along the way.

What is ISS/why do it?

ISS can be described as simulation occurring in the clinical environment within which the participants work.

There are a number of potential advantages to performing simulation within the intensive care unit as opposed to the simulation suite, which can include;

• Easier to release staff
• Individuals learning together in the teams and environment they work together in, promoting inter-professional learning and collaboration
• Reveals underlying latent safety threats

What to simulate

Firstly, decide on the purpose of the simulation. We have run both educational simulations and system/environment test simulations – these are very different and awe have found it useful to clarify what the purpose is before starting.

Our educational simulationss use a range of scenarios from high frequency routine scenarios e.g. intubation of a patient with pneumonia to infrequent high risk scenarios – e.g. displaced tracheostomy, cardiac arrest in a chair. Our focus is on familiarity with the environment, rehearsal of skills/drills, team working and human factors. Insights into team working and human factors are usually the most valued aspects of the simulations.

Before you start

Gaining buy in from the medical and nursing leaders of the department is crucial to a successful introduction. Their support will provide a ‘reflected authority’ to the program. The other key individuals for us were the nursing practice educators. We initially formed an implementation working group for the first year with a core group of enthusiasts and leaders. Consider a couple of trail runs first with interested people before starting the program; this will allow you to trouble shoot and iron out unanticipated pitfalls. This will help you to get off to a successful start once you formally commence the program.

Challenges

Introduction of a new intervention and change, particularly if people feel they are being observed/assessed by their peers, is not without difficulty. Do not give up! Once simulation is established it becomes part of the unit culture, is as normal as the daily ward round and isn’t questioned. Ensuring that people do not feel threatened by simulation and emphasising they are not being assessed helps. Highlighting the learning in the debriefs helps participants to see the role of ISS.

There are different ways of organising ISS from planned sessions with staff allocated in advance to participate, to running as a truly simulated emergency with no warning (sometimes referred to as ‘Guerrilla’ sim). We adopted for planned sessions with additional rostered nurses and Consultant cover for the trainees attending. We felt that this would result in the least disruption to patient care. Any perception that patient care is being affected is understandably likely to lead to resistance.

In general we have found little anxiety to participate from medical staff, however, some of the nursing staff have found it more challenging in the initial stages which I think is attributable to less exposure to simulation in their training/careers. We always ensure there is a nursing and medical facilitator present for the scenarios to ensure all staff groups are properly supported.

Unit capacity has infrequently (<10%) resulted in late minute cancellation. Rostering staff for the simulations has meant staff availability has not led to cancellations. The trainee bleeps are held by the 2 unit Consultants and an additional Consultant is rostered to help cover clinical work during teaching.

Equipment – what do you need?

You need an empty bed space on the unit! Check in with the nurse in charge before setting up. Usually good to warn them at the beginning of the shift what you are planning. In the absence of an ICU bed, think of alternative locations you could potentially use such as theatre recovery, Emergency Department, medical high dependency ward etc. and try to incorporate the teams there too.

There are a range of technological options with varying fidelity and complexity. We use our Resuscitation department’s Laerdal Resusci Ann Advanced Skill Trainer controlled with a SimPad controller to allow the Instructor to set and change clinical parameters. These are displayed on a simulation Patient Monitor (same in appearance as our standard monitoring and touch screen). Ideally use a wireless manikin and controller if possible (with chargers to hand!). We have elected not to video/record scenarios as that might increase staff reluctance to participating, and there are concerns about inadvertent capture of patients or relatives on the unit. I’ve taken a picture on my phone in some scenarios to highlight an issue (and then permanently deleted following the debrief); that can work well.

Depending on the scenario we will set up a central line or an iv line with iv tubing running into either an empty bag of fluid or a bucket to collect administered fluids/drugs.

Ensure you leave sufficient time for set-up, always takes longer than you think!

One of the important considerations is what equipment you will use (e.g. ETTs, larynogoscopes, syringes, drugs etc.). There are several options, use simulation only equipment or use ‘live’ patient equipment. If using simulation equipment you need to carefully consider how you will keep it separate from ‘live’ clinical supplies and prevent inadvertent use on a real patient. If using ‘live’ clinical equipment you need to plan for how you will ensure any critical equipment that is used is replaced in a timely fashion. There is also an obvious cost implication with this approach. Not restocking and leaving a bed space in a mess is a really good way to create antagonism to ISS! Our approach has been to use live equipment (with the exception of controlled drugs). This also improves latent hazard detection as we are following our normal processes and effectively systems testing our environment. In any simulation there is a risk that participants learn work arounds or adaptations of behaviour to adapt to the simulation, hopefully, using ‘live’ clinical equipment reduces some of this effect. Some effects still persist though – e.g. you cannot put pads on a manikin and have to use the studs that connect to the chest and then to the defibrillator – this is a work around for the simulation and should be highlighted as such.

At the end of the scenario and before commencing the debrief, the team restock and recheck any equipment trolleys that have been used and the bed space is returned to a state ready to receive a patient. This also builds in a 5-10min ‘cool off’ period before starting the debrief and allows participants a little time for reflection.

Running the sim

Prior to starting the simulation we inform patients and relatives in adjacent bed spaces on the unit that we are undertaking educational training. Posters can also be put up to warn visitors. We have had one complaint in four years, the overwhelming majority are very supportive and understanding.

The sim starts with a prebrief which covers;

• Learning objectives of the session
• Review of any learning objectives participants have
• Emphasis that the objective is learning and education, not assessment
• Review of where to get equipment/drugs – either simulation only or real
• Tour of the manikin – what it can do/can’t do, route for giving drugs, monitoring etc.
• The team that is available/where to get help if needed
• What will happen after the scenario – clear up and debrief

Once this has been completed, the scenario is given and usually starts with 1 or 2 nursing staff. Other participants wait in the handover room and are called as needed

Debrief & disseminating learning

The debrief is conducted with tea/coffee away from the bed space. Typically a 30-45 min scenario will have a 30min debrief. This is usually in the format of a ‘learning  conversation’. I also like the ‘Debriefing with good judgement’ approach which looks to explore decision making from the perspective of the participant and their frameworks. The debrief is co-ordinated by the medical and nursing facilitors who have received appropriate training in simulation and debriefing. Towards the end of the debrief we try and collectively come up with 3 ‘take home messages’. Each scenario will typically have 2 or 3 nursing staff and 2 or 3 medical staff. Out of a work force of 80 nurses disseminating the learning from the scenarios is challenging. One method we have chosen is to produce a quarterly simulation newsletter which highlights the simulations we have run and the learning points from each. This is emailed out to staff and left in the coffee/handover rooms. It is also available in our waiting room area for relatives to view. System/latent threats identified are forwarded to our lead for governance and included in safety reporting.

Feedback is collected from participants using a commercially available feedback tool. This is done by a web link and/or QR reader code. Certificates of participation are provided.

Useful references

1. Jenny W. Rudolph, Robert Simon, Peter Rivard, Ronald L. Dufresne, Daniel B. Raemer, Debriefing with Good Judgment: Combining Rigorous Feedback with Genuine Inquiry, Anesthesiology Clinics, Volume 25, Issue 2, 2007, Pages 361-376,
2. Patterson MD, Blike GT, Nadkarni VM. In Situ Simulation: Challenges and Results. In: Henriksen K, Battles JB, Keyes MA, et al., editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug.
3. Cook DA, Hatala R, Brydges R, et al. Technology-Enhanced Simulation for Health Professions Education: A Systematic Review and Meta-analysis. JAMA. 2011;306(9):978–988. doi:10.1001/jama.2011.1234
4.  J Contin Educ Health Prof. 2012 Fall;32(4):243-54. doi: 10.1002/chp.21152. In situ simulation in continuing education for the health care professions: a systematic review. Rosen MA¹, Hunt EA, Pronovost PJ, Federowicz MA, Weaver SJ.

FOAM and web resources

1. Life in the Fast Lane – https://litfl.com/in-situ-simulation/
2. Royal College of Emergency Medicine learning – https://www.rcemlearning.co.uk/foamed/in-situ-simulation-a-beginners-guide/
3. Jesse Spur on team sim – http://injectableorange.com/2014/01/tips-team-simulation-training/
4. Simon Carley at St Emlyn’s – http://www.stemlynsblog.org/situ-sim-st-emlyns/
5. Jon Gatward’s mobile sim site – https://mobilesim.wordpress.com/about-us-2/