SAFEE: A Debriefing Tool to Identify Latent Conditions in Simulation-based Hospital Design Testing

Simulation for Systems Integration: A Win-Win to Achieve Your Education, Quality, and Safety Goals

Health care education is a cornerstone of clinical excellence, ensuring the highest level of readiness to achieve high-quality and safe care. Integrating simulation into health care systems can provide a modality to address educational, quality, and safety goals. Simulation is a methodology used to immerse individuals, teams, and medical systems into clinical scenarios or environments. Through facilitation and debriefing, the immersive experience can be used to provide vital education, develop optimal health care practices, and identify prospects for improvement. Simulation provides an opportunity to blend the needs of continuing multiprofessional education while addressing quality and safety goals, and ultimately, promoting a positive safety culture. Applied comprehensively, simulation for systems integration can both promote the transformation of the health care system into a learning organization, as well as translate to improved health care outcomes. [Pediatr Ann. 2024;53(11):e408-e413.].

The Business Case for Simulation-based Hospital Design Testing; $90M Saved in Costs Avoided

Introduction

Simulation-based hospital design testing (SbHDT) applied during the design of a healthcare facility ensures that the architectural design supports safe, high-quality, and efficient care delivery beyond applicable building code compliance. This prospective investigation assesses the financial impact of SbHDT in the form of cost avoidance.

Methods

In designing a new free-standing 400+ bed children's hospital, SbHDT identified latent conditions early in the planning process to mitigate safety concerns related to the proposed design of 15 clinical areas. Architectural modifications were made to address concerns and resolve latent conditions before construction. The estimated cost of materials and labor to make an architectural change was documented for each architectural modification. Unit cost multiplied by unit count for each design element changed was summed together as total cost avoidance.

Results

The cost to conduct the simulation was $1.6M (0.01% of overall project cost). Seven hundred twenty-two latent conditions were identified, and 57% of those latent conditions were mitigated by design changes. Ninety million dollars in costs were avoided by making design modifications before construction. Twenty-eight percent of latent conditions (n = 117) would have been cost-prohibitive to modify after construction.

Conclusions

SbHDT harnessed evidence-based design to improve clinical care, optimize safety, and maximize investment. SbHDT was financially practical and had a significant impact on cost avoidance. Implementing SbHDT is associated with upfront costs, but long-term savings will accumulate over time through expenses avoided through mitigation of safety threats and operational savings.

Physical space of thirty pediatric intensive care units in the United States of America: a national survey

Introduction

The design of Pediatric Intensive Care Unit (PICU) rooms significantly impacts patient care and satisfaction. The aims were first, to describe the current physical space across PICUs in the USA, and second, to identify what proportion of PICUs are compliant with current guidelines.

Methods

A descriptive cross-sectional survey was conducted, targeting division chiefs and medical directors of PICUs nationwide. The survey collected data on unit type, construction and renovation dates, room sizes, and available amenities. According to the Guidelines for Design and Construction of Hospitals, PICU rooms are recommended to be single rooms, at least 200 sq ft, have a window and a private bathroom. Data were anonymized and reported as median and interquartile ranges or frequencies and percentages.

Results

Thirty units responded. Among the respondents, 26 had general PICUs, 9 had cardiac ICUs, and 3 had intermediate care units, with some units containing multiple types of ICUs. The median annual admissions were 1,125, with a median occupancy rate of 78%. Twenty-three percent of units had at least one double room, and 3% had triple or quadruple rooms. The median room size was 265 sq ft (IQR 230; 304), the smallest room size was 220 sq ft (IQR 179; 275), and the largest single room size was 312 sq ft (IQR 273; 330). Thirty-seven percent of units had bathrooms in every room, while 80% had windows in every room. Additionally, 46% of units had dialysis capabilities in every room, and 7% had negative pressure capabilities in every room. The median building year was 2008 (IQR 2001;2014), with 36% of units having undergone at least one renovation. Larger rooms were associated with more recent build dates (p = 0.01). Only 30% of the PICUs met the guidelines for physical space. These compliant units were built at a median of 4 years ago (IQR 1; 8).

Conclusion

This study highlights the variability in PICU room design and amenities across healthcare facilities. Many units still fall short of meeting the guidelines for room size, windows, and private bathrooms. Future research should investigate the relationship between room characteristics and patient outcomes to inform better design practices, with a goal of improving patient experiences and clinical outcomes.

Proactive patient safety: enhancing hospital readiness through simulation-based clinical systems testing and healthcare failure mode and effect analysis

BACKGROUND

Recognizing and identifying latent safety threats (LSTs) before patient care commences is crucial, aiding leaders in ensuring hospital readiness and extending its impact beyond patient safety alone. This study evaluated the effectiveness of a combination of Simulation-based Clinical Systems Testing (SbCST) with Healthcare Failure Mode and Effect Analysis (HFMEA) with regard to mitigating LSTs within a newly constructed hospital.

METHODS

Three phases of the combined SbCST and HFMEA approach were implemented across all hospital settings. The scenarios tested system functionalities, team responses, and resource availability. The threats thus identified were categorized into system-related issues, human issues, and resource issues, after which they were prioritized and addressed using mitigation strategies. Reassessment confirmed the effectiveness of these strategies before hospital commissioning.

RESULTS

More than 76% of the LSTs were mitigated through the combined approach. System-related issues, such as nonfunctional communication devices and faulty elevators, were addressed by leadership. Human issues such as miscommunication and nonadherence to hospital policy led to improvements in interprofessional communication and teamwork. Resource issues, including missing equipment and risks of oxygen explosion, were addressed through procurement, maintenance, and staff training for equipment preparation.

CONCLUSION

The SbCST and HFMEA were highly effective with regard to proactively identifying and mitigating LSTs across all aspects of hospital preparedness. This systematic and comprehensive approach offers a valuable tool for enhancing patient safety in new healthcare facilities, thereby potentially setting a new standard for proactive hazard identification and risk management in the context of healthcare construction and commissioning.

Hazard Assessment and Remediation Tool for Simulation-Based Healthcare Facility Design Testing

OBJECTIVES

To develop an objective, structured observational tool to enable identification and measurement of hazards in the built environment when applied to audiovisual recordings of simulations by trained raters.

BACKGROUND

Simulation-based facility design testing is increasingly used to optimize safety of healthcare environments, often relying on participant debriefing or direct observation by human factors experts.

METHODS

Hazard categories were defined through participant debriefing and detailed review of pediatric intensive care unit in situ simulation videos. Categories were refined and operational definitions developed through iterative coding and review. Hazard detection was optimized through the use of structured coding protocols and optimized camera angles.

RESULTS

Six hazard categories were defined: (1) slip/trip/fall/injury risk, impaired access to (2) patient or (3) equipment, (4) obstructed path, (5) poor visibility, and (6) infection risk. Analysis of paired and individual coding demonstrated strong overall reliability (0.89 and 0.85, Gwet's AC1). Reliability coefficients for each hazard category were >0.8 for all except obstructed path (0.76) for paired raters. Among individual raters, reliability coefficients were >0.8, except for slip/trip/fall/injury risk (0.68) and impaired access to equipment (0.77).

CONCLUSIONS

Hazard Assessment and Remediation Tool (HART) provides a framework to identify and quantify hazards in the built environment. The tool is highly reliable when applied to direct video review of simulations by either paired raters or trained single clinical raters. Subsequent work will (1) assess the tool's ability to discriminate between rooms with different physical attributes, (2) develop strategies to apply HART to improve facility design, and (3) assess transferability to non-ICU acute care environments.

Let us to the TWISST; Plan, Simulate, Study and Act

Translational Work Integrating Simulation and Systems Testing (TWISST) is a novel application of simulation that augments how we discover, understand, and mitigate errors in our system. TWISST is a diagnostic and interventional tool that couples Simulation-based Clinical Systems Testing with simulation-based training (SbT). TWISST tests environments and work systems to identify latent safety threats (LSTs) and process inefficiencies. In SbT, improvements made to the work system are embedded in hard wire system improvements, ensuring optimal integration into clinical workflow.

Methods

Simulation-based Clinical Systems Testing approach includes simulated scenarios, Summarize, Anchor, Facilitate, Explore, Elicit debriefing, and Failure Mode and Effect Analysis. In iterative Plan-Simulate-Study-Act cycles, frontline teams explored work system inefficiencies, identified LSTs, and tested potential solutions. As a result, system improvements were hardwired through SbT. Finally, we present a case study example of the TWISST application in the Pediatric Emergency Department.

Results

TWISST identified 41 latent conditions. LSTs were related to resource/equipment/supplies (n = 18, 44%), patient safety (n = 14, 34%), and policies/procedures (n = 9, 22%). Work system improvements addressed 27 latent conditions. System changes that eliminated waste or modified the environment to support best practices mitigated 16 latent conditions. System improvements that addressed 44% of LSTs cost the department $11,000 per trauma bay.

Conclusions

TWISST is an innovative and novel strategy that effectively diagnoses and remediates LSTs in a working system. This approach couples highly reliable work system improvements and training into 1 framework.

Video-Recorded In Situ Simulation Before Moving to the New Combined Neonatal/Pediatric Intensive Care Facility: An Observational Study

OBJECTIVES

Moving an ICU to a new location is a challenge. The objective of this study was to use in situ simulation to identify potential problems and solutions with the new environment before commencing patient care.

DESIGN

Planned, observational video-recorded simulation study using four scenarios: delivery room management of term-neonate; delivery room management of extremely low-birth-weight infant; management and transfer of an infant with respiratory syncytial virus bronchiolitis and apnea; and management and transfer of an adolescent with septic shock.

SETTING

Academic tertiary neonatal and combined neonatal ICU/PICU.

PARTICIPANTS

Sixteen volunteers (eight physicians, eight nurses).

INTERVENTIONS

Standardized briefing introduction, with before versus after survey of thoughts about each scenario, and after 8 weeks, debriefing at least 60 minutes and additional video recording.

MEASUREMENTS AND MAIN RESULTS

A total of 91 potential problem areas were identified and included issues related to technical aspects ( n = 29), infrastructure ( n = 27), administration ( n = 19), and structure ( n = 16). Fifty-three (58%) of these potential issues could be resolved before the move, including: 15 of 29 technical, 15 of 27 infrastructure, nine of 19 administration, and 14 of 16 structural. The video analysis revealed an additional 13 problem areas (six technical, three infrastructure, two administration, and two structural). Participants felt more confident 8 weeks after the simulations (χ 2 = 12.125; p < 0.002). All 16 participants confirmed the usefulness of the in situ simulation, the majority wanted further introductions to the new ward ( n = 13) and noted a positive impact of the changes on the new ward ( n = 12).

CONCLUSIONS

In situ simulation before moving into a new facility identifies numerousness potential problem areas. Survey shows that providers feel better prepared and are more confident. Video recording reveals additional difficulties not addressed in conventional verbal debriefing.

Financial and Safety Impact of Simulation-based Clinical Systems Testing on Pediatric Trauma Center Transitions

Simulation offers multiple tools that apply to medical settings, but little is known about the application of simulation to pediatric trauma workflow changes. Our institution recently underwent significant clinical changes in becoming an independent pediatric trauma center. We used a simulation-based clinical systems testing (SbCST) approach to manage change-associated risks. The purpose of this study was to describe our SbCST process, evaluate its impact on patient safety, and estimate financial costs and benefits.

Exploring health service preparation for the COVID-19 crisis utilizing simulation-based activities in a Norwegian hospital: a qualitative case study

Introduction

The first wave of the COVID-19 pandemic caused stress in healthcare organizations worldwide. Hospitals and healthcare institutions had to reorganize their services to meet the demands of the crisis. In this case study, we focus on the role of simulation as part of the pandemic preparations in a large hospital in Norway. The aim of this study is to explore hospital leaders' and simulation facilitators' expectations of, and experiences of utilizing simulation-based activities in the preparations for the COVID-19 pandemic.

Methods

This is a qualitative case study utilizing semi-structured in-depth interviews with hospital leaders and simulation facilitators in one large hospital in Norway. The data were sorted under three predefined research topics and further analyzed by inductive, thematic analysis according to Braun and Clarke within these pre-defined topics.

Results

Eleven members of the hospital leadership and simulation facilitators were included in the study. We identified four themes explaining why COVID-19 related simulation-based activities were initiated, and perceived consequences of the activities; 1) a multifaceted method like simulation fitted a multifaceted crisis, 2) a well-established culture for simulation in the hospital was crucial for scaling up simulation-based activities during the crisis, 3) potential risks were outweighed by the advantages of utilizing simulation-based activities, and finally 4) hospital leaders and simulation facilitators retrospectively assessed the use of simulation-based activities as appropriate to prepare for a pandemic crisis.

Conclusions

The hospital leadership’s decision to utilize simulation-based activities in preparing for the COVID-19 crisis may be explained by many factors. First, it seems that many years of experience with systematic use of simulation-based activities within the hospital can explain the trust in simulation as a valuable tool that were easy to reach. Second, both hospital leaders and simulation facilitators saw simulation as a unique tool for the optimization of the COVID-19 response due to the wide applicability of the method. According to hospital leaders and simulation facilitators, simulation-based activities revealed critical gaps in training and competence levels, treatment protocols, patient logistics, and environmental shortcomings that were acted upon, suggesting that institutional learning took place.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07826-5.

Pediatric Intensive Care Unit (PICU) Patient Room Design: Identifying Safety Risks in Mirrored Rooms Through a Graphical Systems Analysis

OBJECTIVE

The objectives of this study are to graphically depict specific clinical challenges encountered in a mirrored pediatric intensive care unit patient room and to represent potential solutions to address these challenges using a systems approach.

BACKGROUND

The intensive care unit (ICU) patient room is a highly complex patient care environment where the design of the room must support patient care delivery safely and efficiently. There is a lack of research examining how ICU design elements interact with other system components to impact patient care.

METHODS

An observational case study method utilizing a systems approach was used to observe and graphically depict clinical challenges with mirrored room configurations and to identify potential solutions. Video recordings of the three clinical scenarios were analyzed in detail in conjunction with three rounds of interviews with a clinical expert.

RESULTS

Equipment or task characteristics that require orienting to a specific side of a patient create challenges in a mirrored room. In order to deliver care safely and efficiently in the mirrored room, adaptations would be required including changing boom, equipment and team member locations, purchasing new equipment, staff training, and inventory management. Some procedures such as extracorporeal membrane oxygenation would be difficult to conduct safely in the mirrored room, even with significant adaptations.

CONCLUSION

Solutions to the challenges presented in mirrored room configurations are multifaceted and require simultaneous and ongoing changes to multiple systems elements, while others can be addressed relatively easily, for example, purchasing new equipment.

Simulation-based User-centered Design: An Approach to Device Development during COVID-19

Supplemental Digital Content is available in the text.

Introduction:

Since the onset of COVID-19, intubations have become very high risk for clinical teams. Barrier devices during endotracheal intubation protect clinicians from the aerosols generated. Simulation-based user-centered design (UCD) was an iterative design process used to develop a pediatric intubation aerosol containment system (IACS). Simulation was anchored in human factor engineering and UCD to better understand clinicians’ complex interaction with the IACS device, elicit user wants and needs, identify design inefficiencies, and unveil safety concerns.

Methods:

This study was a prospective observational study of a simulation-based investigation used to design a pediatric IACS rapidly. Debriefing and Failure Mode and Effect Analysis identified latent conditions related to 5 device prototypes. Design iterations made were based on feedback provided to the engineering team after each simulation.

Results:

Simulation identified 32 latent conditions, resulting in 5 iterations of the IACS prototype. The prototypes included an (1) intubation box; (2) IACS shield; (3) IACS frame with PVC pipes; (4) IACS plexiglass frame, and finally, (5) IACS frame without a plexiglass top.

Conclusions:

Integration of simulation with human factor ergonomics and UCD, in partnership with mechanical engineers, facilitated a novel context to design and redesign a pediatric IACS to meet user needs and address safety concerns.

Translational simulation: from description to action

This article describes an operational framework for implementing translational simulation in everyday practice. The framework, based on an input-process-output model, is developed from a critical review of the existing translational simulation literature and the collective experience of the authors' affiliated translational simulation services. The article describes how translational simulation may be used to explore work environments and/or people in them, improve quality through targeted interventions focused on clinical performance/patient outcomes, and be used to design and test planned infrastructure or interventions. Representative case vignettes are used to show how the framework can be applied to real world healthcare problems, including clinical space testing, process development, and culture. Finally, future directions for translational simulation are discussed. As such, the article provides a road map for practitioners who seek to address health service outcomes using translational simulation.