Up to 98 000 Americans die annually due to preventable medical errors mostly caused by deficient crisis management.1 Besides inadequate clinical competencies of individuals, 70% of these events can be attributed to miscommunication in health care teams.2 On the basis of recommendations by the Joint Commission on Accreditation of Healthcare Organizations,2 we identified multidisciplinary simulations (MuSs) as an effective tool to deliver better and safer health care in our facility. At the LAC + USC Medical Center, we treat pregnant trauma patients in one of the largest acute care hospitals in the United States. Rare and complex situations require teamwork for an efficient management. Our multidisciplinary response teams consist of physicians, nurses, respiratory therapists, and pharmacists who are practicing at different levels of training. Given these challenges, the setting is prone to result in suboptimal crisis management and unfavorable patient outcomes.
Since 2011, we have organized regular MuSs in the emergency department. Scenarios are conducted to recreate the presentation of a pregnant patient with multiple gunshot wounds or a high-velocity car accident using a high-fidelity NOELLE Birthing Simulator. In a safe and standardized setting, participants treat the patient following a predetermined clinical pathway. This usually includes the activation of a "Code OB event" that deploys obstetrics, pediatrics, and trauma surgery teams. Observing faculty evaluates interprofessional and multidisciplinary team performance using the "Performance for Communication and Teamwork" (PACT)-long form (University of Washington3). Evaluation of individual clinical knowledge and skills is based on key performance measures that are specific to each scenario and created by experts in the field. A debriefing session concludes every drill, where participants self-assess their performance and receive feedback.
Traditionally, simulations are conducted to assess individual clinical competencies or team performance.4 Hence, the series of MuSs allowed us to identify shortcoming in these areas, for example, participants performed an inadequate surgical approach, or they did not know the timelines for delivery after circulatory breakdown of the mother. Frequently, senior team members failed to take on leadership roles, assign functions, or delegate tasks, leading to delayed patient care. On the basis of these observations, we implemented a series of workshops to revisit specific teaching points and to introduce concepts of teamwork and communication, for example, team STEPPS, SBAR, or the Callout principles.5 To provide an even deeper theoretical framework, interdisciplinary grand rounds were organized. For these discussions, we used a DVD as a teaching tool that was created from recorded footage during the drill. In addition to individual and team assessments, MuSs helped us define the best practices for these types of emergencies in our facility and identify specific systems issues interfering with patient care. For example, we noted a significant delay of the "OB code" via the pager system, response teams had no preferred access to the hospital elevators postponing their arrival, and instruments and medications used for obstetrical emergencies were not readily available. On the basis of the documentation of all incidents, institutional Quality Improvement Committees initiated countermeasures and we are currently developing a new process algorithm streamlining the clinical management of pregnant trauma patients.
The benefits of MuSs are numerous. Hence, we want to advocate for the implementation of regular multidisciplinary and interprofessional drills with a 2-fold objective: to enhance the training of all health care staff and to identify the best practices for every facility. Multidisciplinary simulations provide a unique way to unite providers from many disciplines and training levels in a team that never functions together unless in a rare and severe incident. This experience cannot be taught in lectures or online modules but is crucial for patient outcomes. For academic institutions, we consider MuSs as important for resident education. Here, drills provide an educational tool to assess not only individual and team performance but also implement a culture of safety early in the formation of medical professionals. Multidisciplinary simulations should be part of every institutional quality improvement program. Besides identifying performance deficits of providers, drills expose unanticipated obstacles interfering with timely and safe patient care. In this context, MuSs can also be used in other novel ways: By recreating a situation that had led to unfavorable patient outcomes in the past, drills can leverage the understanding of sentinel events.4 Multidisciplinary simulations are frequently used either to test the safety of a new facility even before patient care begins or to perform rehearsals in difficult and rare procedures.4
On the flipside, it is important to note that the implementation of a MuS curriculum is a challenging task. It requires collaborative thinking as well as time and manpower to orchestrate the event and document and analyze the data. Financial support and institutional commitment are crucial for success. All participants have to support the overall goal and participate with the right attitude. Everyone's mind-set has to be open both for drawing conclusions in a multidisciplinary dialogue and for implementing optimized practices. However, we believe that a cultural change with the emphasis on patient safety and quality improvement will create a strong foundation to overcome these challenges. As advocates for our patients, we strongly want to encourage institutions and departments to incorporate regular drills in their culture of health care delivery-since not only our experience but also a convincing body of literature have documented that regular simulations will translate into better patient safety and outcomes in the future.4-6
-Doerthe Brueggmann, MD, PhD
-Madhu Hardasmalani, MD
-Jenny Jaque, MD
Department of Obstetrics and Gynecology, Keck School
of Medicine of USC, Los Angeles, California
([email protected])
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