8 minute read
Improving the Quality of Care
Written by Stephanie Stemmler
The Value of Simulation Training
It started out as a routine day for Dan Hodge, MD, Krithika Kumarasan, MD, and Jordyn Huston, MD, second-year pediatric residents training at SSM Health Cardinal Glennon Children’s Hospital. Within minutes, however, that all changed. A child who had been admitted to the pediatric intensive care unit (PICU) after several days of vomiting had become unconscious. The nursing team called the young physicians to come and rapidly evaluate the situation.
Dr. Hodge stood by the bedside and leaned in to take a close look. “Hey Timmy, wake up!” he says while gently shaking the patient. No response. Within seconds, the child’s heart suddenly stops beating and Timmy is in cardiac arrest. With warning signals beeping loudly from the surrounding medical equipment, the three physicians jump into action to perform CPR while simultaneously trying to determine what caused the emergency.
“What’s going on? What do we know?” asks pediatric intensivist Brian Thompson, MD, as he watches the sometimes frenetic activity. “Let’s work the problem.”
Dr. Thompson is not watching a true emergency, however. He is facilitating a simulated emergency in SSM Health Cardinal Glennon’s new Clinical Simulation Lab as part of core training for physicians in Saint Louis University School of Medicine’s pediatric residency program. “These simulations enable medical residents to gain familiarity with all the equipment we have at Glennon and let them learn how to manage both routine procedures and emergencies in a safe learning environment,” says Dr. Thompson. “For example, in these simulated drills, they get hands-on experience in intubating patients, using defibrillators, managing emergency codes and handling needles and IVs.”
The Clinical Simulation Lab includes dedicated space for newborn, infant, child and adolescent simulations. It is equipped with advanced technology, including state-of-the-art medical equipment and realistic patient simulators, called manikins. Far different from a retail store
“There is an enormous amount of research and evidence that shows simulation-based education and training improves the overall quality of care,” says Colleen Claassen, MD, Simulation Program director. “It’s one of the most important tools for hospitals to have for training physicians, nurses and other staff on how to respond during an emergency.” mannequin, medical manikins are like a real patient in weight, breath and movement, and they have veins and airways that can be used in a wide range of simulated medical procedures.
SSM Health Cardinal Glennon, like all hospitals, has offered simulation training for years. Those training sessions were previously held in multiple locations around the Hospital, requiring regular set up and take down of all equipment.
“These simulations enable medical residents to gain familiarity with all the equipment we have at Glennon...”
Thanks to donations given to SSM Health Cardinal Glennon Children’s Foundation as well as significant funds from the Department of Pediatrics at the School of Medicine, a new dedicated space for the Clinical Simulation Lab opened earlier this year.
Beth Hankamer, MSN, BS, RN, simulation clinical educator, is the full-time coordinator for the simulation exercises developed in the lab. “Last year, we had more than 600 participants in the simulation program,” she says. “Now, with the dedicated space and more facilitators, we hope to expand not only the technology used but also the amount and types of simulations that we provide.”
Simulations have expanded from pediatric resident training to including medical student simulations as part of the curriculum at Saint Louis University School of Medicine. Training exercises range from incidents occurring at the bedside, in the emergency department and in the neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU) . Simulations for handling behavioral health situations are offered in a specialized safety room. Last year, global health simulations were added so that those who plan to participate in global medical outreach can learn how to handle medical procedures with limited supplies. And, because of the coronavirus pandemic, tele-simulation scenarios also were created.
“Thanks to our partnership with the School of Medicine and SSM Health, we have other dedicated facilities locally for comprehensive nursing and medical simulations,” says Hankamer. “But having a dedicated simulation lab for training on-site using pediatric manikins and our hospital’s own equipment enhances the training we offer and, ultimately, the care we provide to our young patients here in our own hospital.”
“Simply put, hands-on learning in a non-risk environment facilitates better reflection and retention of the skills needed whenever a real situation occurs.”
For those participating in the simulation exercises, there is no denying the adrenaline that arises when handling an emergency. At SSM Health Cardinal Glennon, new physicians in the pediatric residency program jump right into a “first night on call” exercise that deals with a rapid response scenario. The simulations become more complex throughout the three-year residency training program. “We know we are practicing when we go into a simulation, but when there is a code on a manikin in the lab and we need to have a rapid response, our own stress levels go up as we go through the steps to assess and then care for the patient,” says Dr. Kumarasan.
“Simulations draw out learning points, develop clinical reasoning and integrate theory with practice,” says Dr. Claassen, “Mistakes may be made, and learning can occur without risk to patients. Simply put, hands-on learning in a non-risk environment facilitates better reflection and retention of the skills needed whenever a real situation occurs.”
Dr. Huston agrees. “We practice these exercises to make us more comfortable so that when the time comes to handle emergencies, we do so in a calm, methodical manner,” she says.
That happened to all three pediatric residents earlier that day. In the NICU, a young child went into cardiac arrest, requiring immediate CPR, including chest compressions and a tube inserted into the airway. No longer a simulation drill, the rapid response was real, involving a full team of experienced physicians, nurses and technicians, as well as the younger physicians. “The big thing is preparedness,” notes Dr. Hodge. “We’ve all experienced these real rapid response situations since we started our pediatric residency a year ago. And we’ve also participated in other simulations since we got here to learn what to do.”
Following every simulation, facilitators review each exercise and response step-by-step, guiding the discussion on how to move through an emergency response. Then, the group is placed in a second simulation with less guidance from the facilitator. Another debrief is held to further hone critical thinking skills and responses.
Multiple research studies have shown that simulation participants are, indeed, more comfortable handling patient care because they develop the skills necessary to handle both emergencies and routine medical care. Hankamer and Dr. Claassen now are looking to expand the services and technology in the Clinical Simulation Lab. More funding would expand the equipment available to include even more advanced manikins. In addition, they want to significantly increase multidisciplinary team simulations, coordinating training of physicians, nurses and technicians together versus running separate simulations for each group. Virtual simulation courses also are in queue for development. This fall, simulation exercises will include advanced medical training for those in pediatric fellowships and residency training. As the wish list grows, a second clinical simulation educator and more trained facilitators will be needed.
Over in the Clinical Simulation Lab, “Timmy’s” heartbeat has been restored. A low potassium level has been addressed that may have caused the initial heart problems, and the group has practiced performing CPR at the bedside, using a defibrillator, intubating a patient and administering intravenous medications. They quietly discuss how to better coordinate as a team while Dr. Thompson offers his own observations on their actions during the emergency exercise. Near the bedside, Hankamer resets the software and gets ready for another training session.
Drs. Hodge, Huston and Kumarasan all agree that simulation training is critical for becoming comfortable with using equipment and providing quality patient care in the Hospital. As the number of simulations they complete continues to grow, their comfort level expands. Says Dr. Huston, “You are more likely to jump in because you’ve seen it before and practiced what to do in a simulation. That not only benefits us, but our patients, too.”
