BACKGROUND: Our institution recently completed an expansion of an acute care inpatient unit within a satellite hospital that does not include an on-site ICU or PICU. Because of expected increases in volume and acuity, new care models for Rapid Response Teams (RRTs) and Code Blue Teams were necessary.
OBJECTIVES: Using simulation-based training, our objectives were to define the optimal roles and responsibilities for team members (including ICU physicians via telemedicine), refine the staffing of RRTs and code Teams, and identify latent safety threats (LSTs) before opening the expanded inpatient unit.
METHODS: The laboratory-based intervention consisted of 8 scenarios anticipated to occur at the new campus, with each simulation followed by an iterative debriefing process and a 30-minute safety talk delivered within 4-hour interprofessional sessions. In situ sessions were delivered after construction and before patients were admitted.
RESULTS: A total of 175 clinicians completed a 4-hour course in 17 sessions. Over 60 clinicians participated during 2 in situ sessions before the opening of the unit. Eleven team-level knowledge deficits, 19 LSTs, and 25 system-level issues were identified, which directly informed changes and refinements in care models at the bedside and via telemedicine consultation.
CONCLUSIONS: Simulation-based training can assist in developing staffing models, refining the RRT and code processes, and identify LSTs in a new pediatric acute care unit. This training model could be used as a template for other facilities looking to expand pediatric acute care at outlying smaller, more resource-limited facilities to evaluate new teams and environments before patient exposure.
As many children’s medical centers expand into surrounding communities, there are ongoing challenges of how to maintain the quality of inpatient acute care across multiple inpatient sites. Smaller satellite facilities often have few or no in-house critical care providers, may have staff that are less experienced in providing critical care services, and may have fewer available ancillary staff. New telemedicine and communication models of care can be used to maximize quality of care at satellite or community facilities. Researchers in multiple studies have shown successful implementation of telemedicine models for resuscitations, although most frequently in the context of Code Blue resuscitations as opposed to worsening acuity on the floor as in our setting.1–3 A multidisciplinary group of leaders was tasked with developing the new care model for an expanded, satellite, 42-bed inpatient unit at our institution. They decided to implement telemedicine to allow critical care support and embed that resource into the development of a Rapid Response Team (RRT) and Code Team.
In studies, researchers have shown that when a new unit is being opened, whether it be an emergency department (ED), ICU, or adult acute care unit, simulation can improve outcomes, identify latent safety threats (LSTs), refine scope of practice, and improve team dynamics.4–8 Our institution used simulation-based training in the laboratory and in situ settings before the opening of a satellite ED, specifically to help design, implement, and assess the safety of new health care teams within a new facility.5 However, there are no previous studies in which the authors specifically discuss the use of simulation-based training and telemedicine models in preparation of opening a new pediatric acute care unit, particularly the care of the deteriorating child in non-Code Blue situations.
Our institution’s satellite campus is an example of a community satellite hospital using simulation to prepare both new campus staff and the main campus PICU telehealth responders for RRT and Code Blue situations in the new inpatient expansion. Our objectives were to define optimal staff roles for the RRT and Code Teams at the satellite inpatient unit, refine scope of practice, learn how to best use telemedicine for critical care support, and identify potential threats to patient safety (defined as LSTs) before the facility opens by using simulation and through an iterative process with each subsequent debriefing.
This was a prospective investigation leveraging high-fidelity simulation, postsimulation debriefings, and telemedicine technology within cohorts of institutional leaders and bedside providers to determine the best practice for a pediatric inpatient unit before it opened.
Setting and Subjects
The simulation and debriefing sessions took place in 2 locations. The first was a 400 sq ft simulation laboratory on the main (academic) campus, which included 2 patient rooms, 1 control room, and 1 debriefing room. One of the patient rooms and the debriefing room were outfitted with telemedicine equipment to allow for the testing of that system and the communication between providers over video. The equipment available during the simulations mirrored what would be expected on the inpatient unit. The second setting was the actual inpatient unit at the satellite campus after construction was complete but before patients were admitted (preopening). All patient rooms were outfitted with telemedicine equipment and connected to the telemedicine command center in the PICU at the main campus. This allowed for the testing of that system and the communication between providers over video. Providers were required to use only equipment and resources from the unit.
Subjects were hospital employees who were hired to work at the satellite campus. All professions (physicians, nurses, advanced practice nurses, respiratory therapists, and pharmacists) who would provide bedside care in the new unit were enrolled, and training was considered mandatory. In anticipation of higher acuity, hospital leadership planned for and hired critical care-trained nurses to work in the satellite inpatient unit. Additionally, without on-site critical care physicians, the team leadership and airway management roles during RRTs and Code Blue events would have to be different. Table 1 shows providers at RRTs and Code Blue Teams at the main, academic campus compared to what was initially proposed for the new satellite campus before training. The PICU fellow is the main physician responsible for responding to RRTs and Code Blue events at both the main (in person) and satellite (via telemedicine) campuses. At times, that role is filled by an ICU attending. Thus, both attending physicians and fellows were involved and provided telemedicine consultation in the simulation-based training sessions.
Leadership from hospital medicine, patient services (nursing), respiratory therapy, surgery, and the Center for Simulation and Research met to determine educational and system training needs. In addition to those high-level discussions, a cohort of both physician and nursing managers (leadership assessment) and bedside providers (learners’ assessment) were queried by using the center’s online intake needs assessment survey (SurveyMonkey.com). The results of these discussions and surveys were triangulated in this needs assessment to help drive course content, learning objectives, and scenario selection as part of the standard intake process at the Center for Simulation. Eight clinical scenarios likely to be encountered on the new inpatient unit were chosen, developed, and then piloted in the laboratory (phase I) for simulation training. The chosen scenarios were sepsis, status epilepticus, anaphylaxis, bronchiolitis (respiratory failure), supraventricular tachycardia, cardiopulmonary arrest, hemorrhagic shock, and peripherally inserted central catheter complication. The scenarios were developed using an event-based approach, with critical trigger points and expected responses aligned with the learning objectives for each scenario and the overall course. For feasibility, 2 4-hour laboratory courses (each involving 4 scenarios) were developed and piloted in the laboratory (phase II). Both courses were required for all new, full-time satellite nurses, whereas existing physicians, nurses, advanced practice nurses, respiratory therapists and pharmacists who would work in some capacity in the new facility were required to attend 1 course. The courses were designed to be interprofessional and included providers with differing of skill and experience levels. Each scenario was designed to simulate the new unit environment, including the participation of a critical care physician via telemedicine.
After each scenario, all providers (both participants and observers) were led through a debriefing by a group of trained facilitators. Training consisted of a standing 6-hour facilitator course offered at the Center for Simulation and Research, followed by ongoing mentoring by a center staff member until the facilitator and the staff member felt competency in debriefing was achieved. At minimum, the facilitation group included a physician, a nurse or respiratory therapist, and a staff member from the simulation center. A standardized debriefing format was used to ensure inclusion of learning objectives, learner identified topics, and facilitator identified topics in the discussion. Additionally, a standardized tool for recording outcomes was used to ensure consistency in reporting of outcomes.6
Each laboratory course consisted of a 30-minute presentation that included the relationship between teamwork and communication and how these affect patient safety, the RRT and code algorithms, responders to RRTs and codes, and the roles of the responders. The safety and communication portion included the topics of the effects of authority gradient, hierarchies, task fixation, mental modeling, the step back, clarifying questions, and closed loop communication. Because the successful avoidance or implementation of these are integral to the culture at Cincinnati Children’s Hospital Medical Center, they are believed to be an important piece of the curriculum and were encouraged to be exercised during the simulations.6 The didactic portion had a twofold pertinence to the study. It educated staff of the various responders to and roles within an RRT and code. Second, it provided permission and promoted confidence to professionally communicate feedback to team members and facilitators regarding observations noted and suggested improvements to these processes. The format of these laboratory courses was consistent with all of the simulation laboratory courses provided by the simulation center.
The simulation courses were implemented in the laboratory setting (phase III) until the actual care environment was constructed and outfitted with medical equipment. Once this space was available, a series of in situ sessions (phase IV) were performed to continue the team training and better evaluate the clinical environment before patients were admitted.
Outcomes and Measures of Outcome
Outcomes of interest were team structure issues, systems issues, LSTs, and team-level knowledge deficits. Facilitators recorded outcomes within these 4 categories on the standardized tool after each debriefing session. Recordings were based on direct observations during the simulations and debriefing discussions. Additionally, potential solutions, lessons learned, and mitigation strategies brought up during debriefings were recorded by facilitators. The debriefing data were reviewed by the simulation center, telemedicine, and facility expansion teams after each session to ensure completeness and accuracy. At interim points within the training (after phase II, after phase III, and after phase IV), formal reports were given to facility leadership to improve design and resource allocation of the new unit, improve new team communication, refine and revise team structure, and, ultimately, build effective models of care for the RRT and Code Blue Teams. The lessons learned from each session were also applied to and discussed within the following session using an iterative methodology.
The outcomes were categorized (as noted above) as a qualitative synthesis of findings. No formal statistical analysis was indicated.
A total of 175 clinicians attended 17 simulation courses offered in the laboratory setting over a 6-month period. Each simulation involved a minimum of 4 nurses (including a critical care nurse), a hospital medicine physician, a telemedicine consultant (PICU physician), 2 respiratory therapists, an advance practice nurse, and a pharmacist, if available. Participant breakdown was 72 nurses, 39 advance practice nurses, 33 physicians, 28 respiratory therapists, and 3 pharmacists.
In the month before the opening of the unit, 2 in situ courses were offered at the satellite campus. During in situs, different providers rotated through these roles to increase exposure to the training, whereas providers not participating in the simulation watched from the debriefing room. Everyone participated in large group debriefings after each simulation. Over 60 providers participated at one point during the in situ sessions.
Team-Level Knowledge Deficits
Eleven knowledge deficits (Table 2) were identified, which centered around 4 areas: equipment, resources, procedural care, and medications, paralleling the outcome areas within LSTs. For example, during an early scenario session, the team did not know how to correctly operate the defibrillator for cardioversion versus defibrillation. The confusion centered on use of the sync button, which is indicated for cardioversion. This knowledge deficit was seen in multiple simulations and was addressed in debriefing sessions. Also, in later training, the model was adjusted so the responsibility of placing defibrillator pads should fall to the ED paramedic because he or she had a high level of expertise with this machine.
Nineteen LSTs were identified across the 4 phases of training (Table 3), including multiple threats revolving around the implementation of telemedicine consultation with the ICU. A patient and family privacy concern of being constantly “live” and monitored via telemedicine was identified, which prompted the satellite unit to incorporate clarification of telemedicine use to families at time of admission.
Additionally, optimal placement of equipment and responders in the patient room in relation to the telemedicine screen was determined. For example, it was found that the defibrillator should be placed at the foot of the bed, facing the telehealth camera, allowing the ICU physician the ability to view the rhythm and assist in evaluating and managing the rhythm. The hospitalist, or team leader needs to stand toward the side of the bed rather than the foot of the bed, which is the norm for Code Blue events at the main hospital. This allows the crash cart and responders to easily enter the room and the ICU physician to optimally visualize the patient and interact with the hospitalist. Further trials led to the appreciation that the hospitalist should turn toward the camera to maximize communication. Another issue identified for the ICU physician and other personnel was noise, which both delayed answering of the telehealth calls and negatively affected the interpretation each other’s tone of voice and level of concern.
Multiple sharp-end, patient-level care and communication processes were identified as either lacking or not well defined during the simulations (Table 3). Included were concerns about how to escalate care before an RRT or Code Blue is called. Bedside providers, specifically nurses, identified the lack of clear chain of command and asked for the development of well-defined procedures on who to contact for concerns, in what order to contact them, and how to contact them. Because these bedside providers were used to working with residents at the main academic campus, they identified that those first call providers are not available in the new setting.
Systems, Team Structure, and Role Changes Based on Training
In addition to these team-level knowledge deficits and LSTs, 25 system-level issues were identified specifically surrounding the RRT and Code Blue process (Table 4). Several changes were made because of feedback from the sessions (Table 5). One example was the decision that the hospitalist led all RRTs and Code Blue events with the ICU physician in support, compared to the model at the base campus in which the ICU physician is the team leader. In addition, all communication to and from the ICU physician should run through the hospitalist. Identifying who was in charge was a key change concept because it was challenging for team members to know who to defer to when both the in-person hospitalist and telemedicine ICU physician gave orders. A second example involved medication delivery in emergent situations. Feedback indicated that the pharmacist and/or the on-site critical care nurses should be responsible for the code cart and drawing up medicines because they are the most familiar and efficient with the resuscitation medications. Having a defined role within the team in which a pharmacist or bedside nurse would remain logged into the Pyxis system was also found to be helpful. Having set positions for each role aided in easy role identification and better communication with the hospitalist and ICU physician.
Systems changes made from session feedback included pre-telemedicine huddle and RRT process modifications, clarification of code criteria, and clarification of rapid sequence intubation process. For RRTs, the concept of the pre-telemedicine huddle originated from pre-RRT hallway huddles at the main campus, which allow for the floor and RRT teams to discuss the case before entering the room, allowing optimal communication and clarification of indication for the RRT. Before calling the RRT at the satellite campus, the hospitalist, patient-flow personnel, and charge nurse now communicate via phone bridge with the base campus critical care physician. In addition, critical care nurses, the manager of patient services (the administrative nurse in charge of bed flow), and, when available, the vascular access team were added as first responders for all RRTs and codes. The last additional change was adding a shared RRT note for the manager of patient services and the hospitalist to complete documentation of parameters for either immediate or subsequent transfer after re-evaluation to the ICU at the base campus.
Likewise, the Code Blue process was revised multiple times throughout simulation training. As an example, airway management was identified as a potential high-risk, low-frequency procedure on the unit. Within an on-site ICU, physician identification of airway providers and processes was needed. Because respiratory therapists and ED attending physicians were in house and both disciplines were familiar with the ED’s rapid sequence intubation protocol, this process was selected for the new unit. This process included the use of video laryngoscopy to maintain situation awareness and assist in laryngoscopy and tube placement. Having a specific location for the airway doctor to stand and a position for the video laryngoscope aided the ICU physician in providing assistance. As another example, code criteria beyond true cardiopulmonary arrest were clarified (Table 5). These clinical deterioration scenarios included respiratory failure (as defined by the use of positive-pressure ventilation), circulatory failure (as defined as requiring infusion of >60 mL per kilogram in less than an hour or the use of inotropes), intraosseous line placement, and/or a seizure that lasted at least 10 minutes, thus requiring a second dose of a benzodiazepine.
Equipment and Resource Changes Based on Training
Key equipment and resource gaps (Table 5) were found throughout the course of the training, including knowledge and skills surrounding the code carts. Because the hospitalists and majority of nurses do not participate in codes at the base hospital, orientation to the code cart and revision of the code record sheet was needed. To support best practice guidelines for cardiopulmonary arrest, American Heart Association algorithms (Pediatric Advanced Life Support and Adult Cardiac Life Support) were added to every crash cart. Additionally, other cognitive aids for more common, yet high risk, illnesses (eg, anaphylaxis, status epilepticus) were added to the code cart.
As children’s hospitals expand to include many community settings, models to ensure quality and safe care for all children across sites and resources are needed. In previous studies, researchers have discussed the use of simulation in pediatric EDs, neonatal care in delivery rooms, and PICUs to orient teams to new facilities or improve quality and safety.4–7 However, this is the first project to use simulation as part of preparation for the opening of a pediatric acute care unit.
In training 175 providers in the laboratory setting and 60-plus providers in situ setting by using an iterative learning process, we found that simulation can be used to orient new pediatric hospital medicine teams to rapid response and Code Blue situations, to identify LSTs and team-level knowledge deficits within this environment, and to improve telemedicine-assisted code and rapid response models. Best practices gained in the satellite setting through this iterative process of simulation-based training and immediate debriefing include (1) the development of clear role definitions and scope of practice that best use team member skill sets, (2) the establishment of clear (and often lower) thresholds for which the Code Blue Team should be activated, and (3) the identification of key skill and knowledge gaps that require training to mitigate future errors in care.
Like researchers in previous studies, we demonstrate the utility of simulation-based training before and while opening a new care environment with our intervention.5,8 One theme that evolved was the use of this strategy to refine provider responsibilities and best use team skills to maximize team effectiveness before patient exposure.5 Participants suggested assigning critical care nurses to crash cart medication preparation and ED nurses to the administration of the medications because they believed these strategies would reduce medication errors and decrease time to medication delivery. Participants requested a defined team leader and a defined leadership hierarchy between the in-person team leader and the telemedicine ICU physician, which resulted in reduced team conflicts and team-level confusion as we progressed through the training. Also, having a specific location for the team leader to stand subjectively improved telemedicine-based communication with the ICU physician, reduced time to intervention and redundancies in communication, and improved the feelings of teamwork in the room. As in a previous study, the use of simulation before initiation of patient care promoted improved team dynamics for their new health care teams.9
Similar to previous studies, identifying limited access to critical care, airway support, and vascular access support is key in identifying safety threats and redefining code classification in the new facility.4 Our iterative debriefing process and reporting structure led bedside providers, unit managers, and hospital leaders to define a specific set of criteria (Table 5) for calling a Code Blue event. These criteria lowered the threshold compared with the main, academic campus, which all team members felt was appropriate given their projected resources and experience in critical situations.
Identifying key knowledge and skills gaps has been associated in previous studies with improved team member satisfaction, error reduction, and situational and environmental awareness.4,6,9 Our findings were similar in that providers identified their need for orientation to and/or practice with specific equipment (eg, defibrillator), procedural care (eg, intraosseous line placement), and cognitive aids (eg, Pediatric Advanced Life Support guidelines) (Table 5).
When trying to generalize our findings and implement our iterative simulation-based process in a community setting, 1 limitation is the major commitment a hospital or institution must make strategically and financially. However, when opening a new facility, we found in this project and in a previous one5 that institutional leadership often is more willing to provide the funding and resources for this type of training. Our main campus location has had a simulation laboratory since 2001 and has used in situ simulation since 2007. The main area of involvement initially was the ED. However, starting in 2007, all of the high-risk units (operating suites, PICU, NICU, cardiac ICU, transport medicine, and extracorporeal membrane oxygenation [ECMO] team) were trained in the laboratory setting with a similar method initially and then in situ simulations were employed throughout the hospital.4,6,10,11 Currently, there are ongoing laboratory-based courses for the ED, NICU, cardiac ICU, and ECMO providers and in situ programs in the ED, NICU, PICU, cardiac ICU, ECMO (including extracorporeal cardiopulmonary resuscitation), and operating suites. For noncritical care units, there are standing mock code (eg, clinics, inpatient units, and nonpatient care areas) and code team training programs that occur monthly. Additionally, in 2008, when this satellite hospital opened its ED and short-stay unit, the same simulation-based methodology was used,5 and, since then, the ED has maintained a laboratory-based and in situ simulation program. It is based on these programs and the published literature that hospital leadership requested the use of simulation before and after the opening of this satellite inpatient unit.
Our study has several other limitations. First, we are limited by the lack of quantitative data to further validate the qualitative iterative process used by the team to prepare providers and systems for the new facility. Future studies could collect pre-, post-, and ongoing survey-based data surrounding provider preparedness for critical illness events in a satellite setting. Blinded review of video recordings from simulations with application of validated teamwork scales could better assess for improvements in team leadership, teamwork, and communication. Second, it was unclear in this project the amount of ongoing practice that will be needed to sustain knowledge and skills gained by the providers during these sessions. The majority of providers only participated once, although some were involved in both laboratory and in situ sessions. Future studies could apply pre-, post-, and ongoing knowledge and skill assessment tools. Third, correlation of simulation-based training with improvements in patient-level outcomes and safety on the new unit was not assessed. There is likely a need for ongoing fine tuning of rapid response and code processes in situ, as has been recommended by researchers in previous studies.6 Currently, a monthly 4-hour patient safety course is provided on the satellite campus, as well as 4 in situ simulations per month. The foci of these sessions have been expanded to include the assessment and management of tracheostomy patients because 10 of the 42 beds have been dedicated to transitional care patients. Future studies investigating the use of ongoing in situ mock codes for these patients or the incorporation of just-in-time training surrounding tracheostomy emergencies are other areas of possible future study for the satellite facility.12–14
Simulation-based training can assist in developing staffing models, refine the RRT and code processes, and identify LSTs in a new pediatric acute care unit (Supplemental Figs 1–4). This training model could be used as a template for other facilities looking to expand pediatric acute care at outlying smaller, more resource-limited facilities to evaluate new teams and environments before patient exposure.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2017 by the American Academy of Pediatrics