Sustained decrease in latent safety threats through regular interprofessional in situ simulation training of neonatal emergencies
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Abstract
Simulation training at trainees’ actual workplace offers benefits over traditional simulation-based team training. We prospectively investigated whether regular in situ simulation training of neonatal emergencies in an interprofessional and interdisciplinary team could be used to identify and rectify latent safety threats (LSTs).
For this purpose, we conducted 1-day in situ simulation trainings at the Department of Gynaecology and Obstetrics, Feldbach, Austria, targeting anaesthesiologists, obstetricians, midwives, nurses and consultant paediatricians. Using published criteria for categorising LSTs, we collected LSTs, either recognised by trainers or training participants, categorised them qualitatively (medication, equipment, resource/system) and based on their potential for harm, discussed them with training participants, and reported them to hospital leadership.
We conducted 13 trainings between June 2015 and April 2023, identifying 67 LSTs, most in the category of equipment (42/67, 62.7%), followed by resource/system (14/67, 20.9%) and medication (11/67, 16.4%). Sixty-one (91.0%) of the LSTs could be rectified by the next training. We observed a significant negative correlation between the number of delivered trainings and the frequency of identified LSTs (Pearson correlation coefficient r= –0,684, p=0.01).
While we identified a higher number of LSTs in comparison to previously published studies, regular in situ simulation training of neonatal emergencies over a period of almost 8 years positively impacted patient safety, as the majority of LSTs was rectified by the next training. Even more important, the decrease in LSTs with the increasing number of delivered in situ simulation trainings underlines the sustained effect of this educational intervention.
Introduction
By addressing healthcare professionals and teams at their genuine professional workplace, in situ simulation training (ISST) offers improved immersion while enabling unbiased analysis of teamwork functions and the healthcare environment.1 2 ISST has been successfully established in many healthcare settings targeting different disciplines and professions, including medical and surgical inpatient units, emergency medicine, trauma care, paediatric emergency medicine, perinatology and neonatal intensive care.3 Despite limited high-quality studies, ISST has a positive impact on learning and organisational performance as well as the potential to improve patient outcome.3 4
Despite the growing body of evidence, studies of neonatal ISST are still scarce. Of the existing reports and investigations, the majority focus on outcomes in the simulation laboratory5 6 or on the testing of new facilities.2 7 8 Only few studies have reported patient-related outcomes, such as an association between regular ISST at a level IV neonatal intensive care unit (NICU) and a reduction in code blue events.9 Bhatia et al10 described a decrease in mortality as well as less need for life-saving interventions after birth following the introduction of an interprofessional in situ neonatal resuscitation training programme.
As identification and rectification of latent safety threats (LSTs) can help improving patient safety, we prospectively investigated whether LSTs could actually be identified and rectified through regular ISST of neonatal emergencies in an interprofessional and interdisciplinary team over a period of 95 months.
Methods
Neonatal care at the Department of Gynaecology and Obstetrics, Feldbach (2021: 1052 born infants), Austria, is being provided by practicing consultants for paediatrics and adolescent medicine. However, those paediatricians are not available on a 24/7 basis and, therefore, anaesthesiologists, obstetricians, midwives and nurses often are the first ones being confronted with sick neonates or neonatal emergencies. Hence, the trainer team of the Paediatric Simulation Group Graz (PaeSiGG), which is coordinating and delivering all simulation-based educational activities at the Division of Neonatology Graz (regional NICU level IV), has been providing regular 1-day ISST for these target groups since 2015.11 All trainers are neonatologists and paediatric intensive care specialists with additional training in paediatric simulation, performance debriefing and crisis resource management. Trainings include 45 min of theoretical instruction and 6×45 min of simulated practice in three groups of six persons each: technical skill training (3×45 min) focuses on airway management, high-quality mask ventilation, vascular access, emergency drugs and the cardiopulmonary resuscitation algorithm, while further 3×45 min are dedicated to scenario-based high-fidelity team training with consecutive, structured debriefing.12 Scenario contents reflect typical emergency situations that occur in regional hospitals including perinatal asphyxia, meconium aspiration syndrome, unexpected preterm birth, sepsis, neonatal seizure and neonates with cardiac malformations. All anaesthesiologists, obstetricians, midwives and paediatric nurses at the State Hospital Feldbach regularly participate in the ISST, with the goal of participation at least every 2 years. Newly employed healthcare professionals are prioritised and invited to attend ISST at the earliest possible time.
Evaluation
Our primary outcome measure was the number and type of LSTs, using the definition by Patterson et al13: 'system-based threats to patient safety that can materialise at any time and are previously unrecognised by healthcare providers, unit directors or hospital administration’. LSTs, either recognised by trainers or training participants during simulation trainings or debriefings, were collected, categorised qualitatively (medication, equipment, resource/system13), immediately discussed with training participants and reported to hospital leadership. As secondary outcome measure, we categorised LSTs based on their potential for harm, as defined by Dadiz et al2:
minor (LSTs of low probability of causing harm to patients, families or staff),
major (LSTs with potential to cause harm if linked with other LSTs),
serious (LSTs likely to result in harm if not resolved).
Results
Between June 2015 and April 2023, 13 trainings with a median number of 17 participants (range 14–19) were delivered. We identified a total of 67 LSTs during the 13 trainings (median of 4 per training, range 2–13), most in the category of equipment (42/67, 62.7%), followed by resource/system (14/67, 20.9%) and medication (11/67, 16.4%; figure 1). Sixty-one (91.0%) of the 67 LSTs could be rectified by the next training. There was a steady decline in the number of LSTs over the study period (June 2015 (i.e., 1st training): n=12; April 2023 (i.e., 13th training): n=2; figure 2) with a significant negative correlation between the number of delivered trainings and the frequency of identified LSTs (Pearson correlation coefficient r=–0,684, p=0.01).
Examples of identified latent safety threats: (A) Too small suction container at the resuscitation table, (B) ECG electrodes not connected to patient monitor at the resuscitation table and patient monitor not activated for immediate use, (C) outdated neonatal resuscitation algorithm from 2010 mounted in the neonatal resuscitation suite.
Number of identified latent safety threats (y-axis) for each individual in situ simulation training.
Of the 67 LSTs, 3 (4.5%) were categorised as serious, 19 (28.3%) as major and 45 (67.2%) as minor. Of the three serious LSTs, two were related to equipment and one to medication. All three serious LSTs were detected during the first five trainings and all could be quickly resolved.
Discussion
So far, only a few studies have reported identification of LSTs through neonatal and/or paediatric ISST. Yajamanyam and Sohi14 found seven LSTs during 21 in situ trainings in the paediatric emergency department and neonatal unit, four being related to equipment and medications. Zimmermann et al15 implemented a team-oriented in situ resuscitation training programme in their tertiary paediatric hospital and detected 23 different LSTs during 20 simulation sessions. During the delivery of 15 in situ trainings at their level III NICU, Eckels et al1 identified four LSTs and used them to improve system-based processes. Interestingly, we identified considerably more LSTs per training than described by previous studies. Different definitions of LSTs and variances in methods of counting and summarising most certainly contributed to this finding, but it must be kept in mind that we trained and surveyed a regional hospital without paediatric department, which may explain the relatively high rate of equipment issues that we detected. Another contributing factor could be that the external trainers from the paediatric reference centre were able to identify more LSTs than local professionals, as they are not as susceptible to system blindness.16
To our knowledge, we are first to report a negative correlation between the number of delivered ISSTs of neonatal emergencies and identified LSTs. This emphasises the lasting positive effect of our educational intervention on local patient safety. In this context, the temporary increase in LSTs in June 2021 is remarkable—during the COVID-19 pandemic, which hit Austria in March of 2020, many simulation-based team trainings were cancelled due to required social distancing and concerns about their safety.17 Unfortunately, these circumstances also affected our training programme, resulting in an undesired 22-month interval between two trainings. The temporary increase in LSTs, which we observed after resumption of our training activities, underlines the need for continuous simulation-based in situ team training in a high-acuity setting such as any delivery room.
One limitation of our study is that we did not assess the potential direct impact of ISST on clinical practice and the management of neonatal emergencies. This could be achieved either by observation and subsequent analysis of clinical performance18 or by comparing relevant patient-related parameters such as Apgar scores19 or the need for certain resuscitative measures20 between different time periods.
Conclusions
Through regular interprofessional and interdisciplinary ISST of neonatal emergencies over a period of almost 8 years, we positively impacted patient safety by identifying LSTs and rectifying most of them by the next training. The decrease in LSTs with the increasing number of delivered ISSTs emphasises the sustained effect of this educational, team-oriented intervention designed for a vulnerable patient cohort.
Contributors: Concept and design: LPM, BS, NB-S, MR, JP, WR, BU. Acquisition, analysis or interpretation of data: LPM, BS, NB-S, MR, JP, WR. Drafting of the manuscript: LPM. Statistical analysis: LPM. Critical revision of the manuscript for important intellectual content: LPM, BS, NB-S, MR, JP, WR, AR, GM, BU.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer-reviewed.
Ethics statements
Patient consent for publication:
Not applicable.
Ethics approval:
Not applicable.
Eckels M, Zeilinger T, Lee HC, et al. A neonatal intensive care unit’s experience with implementing an in-situ simulation and Debriefing patient safety program in the setting of a quality improvement collaborative. Children (Basel)2020; 7:11. doi:10.3390/children7110202•Google Scholar
Dadiz R, Riccio J, Brown K, et al. Qualitative analysis of latent safety threats uncovered by in situ simulation-based operations testing before moving into a single-family-room neonatal intensive care unit. J Perinatol2020; 40:29–35. doi:10.1038/s41372-020-0749-3•Google Scholar
Goldshtein D, Krensky C, Doshi S, et al. In situ simulation and its effects on patient outcomes: a systematic review. BMJ Simul Technol Enhanc Learn2019; 6:3–9. doi:10.1136/bmjstel-2018-000387•Google Scholar
Rosen MA, Hunt EA, Pronovost PJ, et al. In situ simulation in continuing education for the health care professions: a systematic review. J Contin Educ Health Prof2012; 32:243–54. doi:10.1002/chp.21152•Google Scholar
Rubio-Gurung S, Putet G, Touzet S, et al. In situ simulation training for neonatal resuscitation: an RCT. Pediatrics2014; 134:e790–7. doi:10.1542/peds.2013-3988•Google Scholar
Haynes J, Rettedal S, Perlman J, et al. A randomised controlled study of low-dose high-frequency in-situ simulation training to improve newborn resuscitation. Children (Basel)2021; 8:12. doi:10.3390/children8121115•Google Scholar
Bender J, Shields R, Kennally K, et al. Transportable enhanced simulation technologies for pre-implementation limited operations testing: neonatal intensive care unit. Simul Healthc2011; 6:204–12. doi:10.1097/SIH.0b013e3182183c0b•Google Scholar
Ventre KM, Barry JS, Davis D, et al. Using in situ simulation to evaluate operational readiness of a children’s hospital-based obstetrics unit. Simul Healthc2014; 9:102–11. doi:10.1097/SIH.0000000000000005•Google Scholar
Reed DJW, Hermelin RL, Kennedy CS, et al. Interdisciplinary Onsite team-based simulation training in the neonatal intensive care unit: a pilot report. J Perinatol2017; 37:461–4. doi:10.1038/jp.2016.238•Google Scholar
Bhatia M, Stewart AE, Wallace A, et al. Evaluation of an in-situ neonatal resuscitation simulation program using the new world Kirkpatrick model. Clin Simul Nurs2021; 50:27–37. doi:10.1016/j.ecns.2020.09.006•Google Scholar
Mileder L, Pansy J, Raith W, et al. Interprofessionelles in situ-Simulationstraining Neonataler Notfälle Für Geburtshilflich-Anästhesiologisches personal. Monatsschr Kinderheilkd2018; 166:S198–9. Google Scholar
Löllgen RM, Heimberg E, Wagner M, et al. Recommendations of the Netzwerk Kindersimulation for the implementation of simulation-based pediatric team trainings: a Delphi process. Children (Basel)2023; 10. doi:10.3390/children10061068•Google Scholar
Patterson MD, Geis GL, Falcone RA, et al. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf2013; 22:468–77. doi:10.1136/bmjqs-2012-000942•Google Scholar
Zimmermann K, Holzinger IB, Ganassi L, et al. Inter-professional in-situ simulated team and resuscitation training for patient safety: description and impact of a programmatic approach. BMC Med Educ2015; 15. doi:10.1186/s12909-015-0472-5•Google Scholar
McNamara M, Teeling SP. Developing a university-accredited Lean Six Sigma curriculum to overcome system blindness. Int J Qual Health Care2019; 31:3–5. doi:10.1093/intqhc/mzz074•Google Scholar
Jung P, Mileder L, Hoffmann F, et al. Simulation-based pediatric emergency team training in times of the SARS-Cov-2 pandemic. Monatsschr Kinderheilkd2020; 168:1130–1. doi:10.1007/s00112-020-01055-y•Google Scholar
Brogaard L, Hvidman L, Esberg G, et al. Teamwork and adherence to guideline on newborn resuscitation-video review of neonatal interdisciplinary teams. Front Pediatr2022; 10. doi:10.3389/fped.2022.828297•Google Scholar
Patel D, Piotrowski ZH, Nelson MR, et al. Effect of a statewide neonatal resuscitation training program on Apgar scores among high-risk neonates in Illinois. Pediatrics2001; 107:648–55. doi:10.1542/peds.107.4.648•Google Scholar
Schwindt EM, Stockenhuber R, Kainz T, et al. Neonatal simulation training decreases the incidence of chest compressions in term newborns. Resuscitation2022; 178:109–15. doi:10.1016/j.resuscitation.2022.06.006•Google Scholar