Playing it safe: simulated team training in the OR

AORN Journal,  April, 2008  by Mindi Anderson,  Judy Leflore

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The Institute of Medicine (IOM) estimates that up to 98,000 patient deaths are caused annually by medical errors. (1) This statistic prompted the IOM to identify patient safety as the first of six goals in its report Crossing the Quality Chasm--A New Health System for the 21st Century. (2) The IOM identifies high-risk areas where patient safety is of the greatest concern. (1)

The OR is identified as one of the areas where serious consequences from medical errors may occur. (1) Although the vast majority of patients recover without complication from their surgeries, problems can occur when staff members do not have enough experience with rare or infrequent (ie, high-risk/low volume) events that have high morbidity and mortality rates. (3)

Perioperative leaders are faced with the challenge of ensuring that health care professionals are prepared to respond to the infrequent yet potentially lethal emergencies that may occur in the OR. Health care professionals who work in the OR are expected to make prompt, accurate decisions in life-threatening emergency situations; however, the technical performance of the OR team is dependent on human factors. (4) According to Schaefer, Helmreich, and Scheidegger, these human factors include

   effective communications, team formation
   and maintenance, leadership,
   decision making, management of
   resources, workload prioritization
   and distribution and coping with
   stress. (4)(p48)

Unfortunately, the emphasis in health care typically has been on the individual practitioner's knowledge and skills instead of team performance. (5) Quality and safety of patient care previously had been structured around the individual practitioner rather than the team as a whole. (6) Teamwork, which necessitates effective communication, has often been assumed to be part of any functioning team; therefore, training and assessment of teams and effective communication has been limited. (6) Communication failures have been reported as the leading cause of inadvertent harm to patients. (6) Additionally, human factors related to team performance (eg, effective communication) usually are not documented or evaluated. (4) The health care community has only recently begun to recognize the importance of teams and begun implementing team training interventions. (7) One vision for implementation is that eventually, all clinical teams will train, rehearse, and refine their skills together. (5)

A team of professionals is expected to perform well together in crisis situations, including those in the OR. According to Raemer, (8) there has been speculation that medical teams that practice simulated crisis scenarios together demonstrate improved team effectiveness. Simulation is one tool that may be used to increase the competency of all medical team members. (9) The IOM recommends that hospitals incorporate multidisciplinary team training using simulation in such areas as the OR. (1) Simulation is quickly becoming a topic of interest in many hospitals, and it allows participants to think while being actively involved in the clinical simulation scenario and in the learning process. (10)

SIMULATION AS A TOOL

Simulation is a broad term defined as the

   artificial replication of sufficient elements of a
   real-world domain to achieve a stated goal--and
   typically includes training individuals
   and teams to deal with the domain or testing
   the capacity of personnel to work in the
   domain. (11) (p7)

Simulation is a helpful tool for finding system flaws, training for critical events, solving problems, determining the cause of accidents by recreating events, and teaching psychomotor skills. (10) Simulation may include the use of

* high-fidelity simulators (Figures 1, 2);

* static mannequins;

* role play;

* part-task trainers (ie, an anatomically correct simulated body parts to teach a specific skill);

* computer games;

* virtual reality;

* case studies;

* haptic devices (ie, computerized task trainers) (Figure 3); and

* standardized patients/persons (ie, individuals who portray patients or assume other roles within the scenario).

According to Good, (11) high-fidelity simulators and mannequin designs are becoming more realistic. In simulation training, another term for realism is fidelity; therefore, the higher the fidelity, the more realistic the mannequin. (12,13) Some mannequins are now available as full-body mannequins in adult and pediatric sizes, as well as in both genders. (5,14)

[FIGURE 1 OMITTED]

Features of high-fidelity mannequins may include visual breathing with the rise and fall of the chest, palpable pulses, heart sounds that are both normal and abnormal, realistic airways, and visual output that displays on monitors such as electrocardiogram, blood pressure, and pulse oximetry. Many of the mannequins can respond to participant training interventions, such as ventilation/intubation, medication administration, and defibrillation. (10,12-16)

Simulation may help leaders evaluate team performance such as communication, clarity of roles, support, and utilization of resources and global assessment of the team. (8) An advanced cardiac life support team training study by DeVita et al (17) that used simulation indicated in preliminary reports that team performance and outcomes improved. Two areas of team performance that improved were communication and delineation of roles. (17)