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26 Systems-Focused Simulation andDebrieng toImprove Patient Safety, Quality Care, Environments, andProcesses
207
ulation to assess for systems issues including latent safety
threats. The simulations included over 40 individuals in
each simulation from all teams involved in trauma including the ED, operating room, site leadership, transfusion
medicine, bed placement, surgery, and more. The objectives of the simulations and debriefs were focused on the
ve process steps and included testing checklists and aids
such as the pre-brief checklist, a standardized EMS handover tool, and EXIT checklist. All tools and the overall
guideline were revised and rened based on user feedback
from the debriengs. The ndings from these simulations
were used to nalize the Level 1 Trauma Guideline.
Implementation included bi- weekly simulations for all staff
with the opportunity to apply the Guideline and share information with content leaders.
Simulation and debrieng are powerful mediators of
quality improvement, change, and implementation science.
This project included strategies to ensure a lens of continuous quality improvement using clinical event debrieng after
trauma admissions to elicit further feedback from team
members, bi-weekly trauma-focused simulations with
debrieng targeting the ve process steps, and ongoing data
analysis post implementation.
Results
Success of this approach was underpinned by the collaboration of interprofessional teams and individuals committed to
improving patient care. This was achieved by comprehensive
planning, open communication, proper risk management,
integration of system simulations, and preparation for implementation for frontline staff.
Successes enabled by standardization included the following: the reduction in the number of staff in the trauma
room with effective crowd control, improved communication techniques with the use of the pre-brief and EXIT checklists, and an observable improvement in role denition most
important with respect to having a clear trauma team leader.
Feedback from team debriefs and ongoing reports at Trauma
Quality Council Meetings reported a decrease in ambient
environmental noise during resuscitations leading to easier
team communication.
Case Study 2: Foothills Emergency Response
Activation forMulti-Trauma (FERA-Trauma)
Testing andImplementation
Our next case study builds on complexity of situations where
there are multiple incoming trauma patients simultaneously
or disaster events. System integration is often challenging in
these situations due to the many roles, teams, tasks, and vital
communications happening at the same time. These situations are often described as high-stress and time-pressured.
Level 1 Trauma activation at our large tertiary care center
(i.e., Foothills Medical Centre: FMC) is modelled around the
care of a single trauma patient. Although, there are instances
when multiple trauma patients requiring resuscitation and
operative intervention will simultaneously arrive or present
in rapid succession to the FMC ED.The Foothills Emergency
Response Activation for Trauma (FERA Trauma) protocol
was developed to help guide the FMC team in the care and
resource management for these patients. This process was
designed as a rst step in a scalable response in what may
become a Code Orange, or disaster event activation.
The criteria for activation of FERA Trauma is three or
more patients meeting Level 1 criteria within 1h. The criteria for activation were simplied to ensure the decision to
activate could be made in a timely fashion. Like Level 1
Trauma activations, it was anticipated that a certain percentage of the FERA Trauma activations would be “stood down”.
Implementation andEvaluation
An interdisciplinary project team collaborated with representation from: Trauma Services, ED, Intensive Care Unit
(ICU), Operating Room (OR), Anesthesia, General Surgery,
Site Administration, Respiratory Therapy, Bed Placement,
and Transfusion Medicine to develop a process for times
when multiple trauma patients present concurrently to the
FMC ED but fall short of activation of a code orange
(disaster).
After the process was drafted, simulations were used to
test the FERA Trauma processes and communication to
identify any latent threats to patient and staff safety and to
make system improvements before implementation in July
2020. Iterative Plan, Do, Study, Act (PDSA) testing cycles
through simulation helped to ensure a safe and quality-driven
approach and to identify the most important issues.
The simulations identied several opportunities for
improvement. The initial pager script and membership of the
page-out were rened to ensure the right teams appeared for
the huddle as soon as possible. Checklists were developed
for each team and rened through simulation to prepare for
an incoming FERA Trauma. Clear communication and
handover were key to improve patient care and a clear leader
was required. As a result of simulation and debrieng of
actual cases, it was identied that this leader should be a
physician that was not involved in direct patient care, was a
clear communicator, and must be able to work closely as a
dyad with the ED charge nurse. Through this, process gaps
were identied in the Transfusion Medicine process, and as
a result, the teams rened the process to improve timely
communication to Transfusion Medicine.
208
M. Dubé et al.
Further implementation and education of the process was
completed using the following communication strategies:
emails, grand rounds, and presentations at leadership and
staff meetings. Each of the services involved in FERA
Trauma protocol was responsible for their own internal staff
education and rollout plan.
Clinical event debrieng is another tool to ensure continuous quality improvement to review clinical events and enable
team members to share reections and ideas on improvement. These debriefs were built into the FERA Trauma process to allow for post-event evaluation. The FERA Trauma
committee decided that debriefs must occur after the FERA
Trauma had also been “stood down” to identify continuing
opportunities for improvement. It was felt that all ndings
needed to be brought to the FERA Trauma Committee to
ensure a process existed for review and further improvement.
In the rst year following implementation, several improvements were implemented including the revision of pager
scripts, an additional focus on the dyad leadership model,
improved huddle effectiveness, the use and design of cognitive aids, and standardized communication. Staff reported
improved communication with the OR, a consistent membership for the FERA Trauma activation, and identied the
importance of including the hospital administrator on call
and ED managers for both initial activation and employing
the stand-down process for FERA trauma protocol.
The extra resources mobilized by the FERA Trauma activation help to expedite patient care and transfers out of the
ED in preparation for potential increased need in capacity.
These improvements have helped to make the FERA Trauma
activation more effective and acceptable to all stakeholders
involved. This example serves to highlight the use of
simulation- based methods to design protocols, test them
with the clinical teams, take end-user feedback to make iterative renements prior to implementation, and then use multiple communication strategies and an ongoing clinical event
debrieng program to establish a culture and means of continuous quality improvement.
Case Study 3: TheUse ofSystem Simulation
withUsability Testing (Dicult Airway
Management (DAM) Algorithm, Airway
Management Pause (AMP) Checklist,
andDAM Cart)
The use of system simulation in tandem with human factors
methods such as usability testing is an effective way to
enable user-centered design.
Usability testing is best described as a “systematic way of
observing actual users trying out a product and collecting
information about the specic ways in which the product is
easy or difcult for them” [19]. Central to usability testing is
end users using the product as they normally would in clinical practice to gain an understanding of how effective, efcient, safe, and how satised they are with a specic piece of
equipment. Facilitating usability testing helps to inform purchase and design decisions, and support implementation.
Usability depends on dening the appropriate user, having a
specied goal and objectives surrounding the tasks of the
user, and ensuring alignment within the environment and
context where use of the equipment or tools will occur.
When looking at usability testing for a complex healthcare trauma team, one application may be the testing of new
carts used within the trauma bay. This serves as one example
of many other potential healthcare environments and applications [20, 21]. Simulation to create a real-to-life clinical
situation allows evaluation of where a cart would need to be
accessed, and what supplies are chosen and used in the context of caring for a traumatic or neonatal patient. Observable
behaviors and self-reported user feedback can be collected
through debrieng, and additional data around timed metrics, number and type of errors, and other measures may be
chosen to evaluate usability.
We share a case study of a wholesale revision to the
approach and management of difcult endotracheal intubation outside the OR through the development of a suite of
new difcult airway management tools and a Difcult
Airway Management (DAM) Cart. After iterative renement
and testing, the algorithm and suite of airway tools were
implemented in four adult acute care hospital sites including
an acute trauma center in the Calgary Zone of Alberta Health
Services.
Through a needs assessment, it was identied that existing DAM cart contents and layout needed to be revised to
reect evolving DAM equipment and practices and to better
marry with the development and adoption of a new algorithm
for difcult endotracheal intubation. A DAM algorithm
(Fig.26.1) was adapted from an existing DAM algorithm in
the existing literature to focus airway management teams on
a clear progression through airway management techniques
when difcult intubation is identied in order to improve
endotracheal intubation success and mitigate patient harm
[22]. This included various oxygenation methods with
prompts to progress to the next step of the algorithm (i.e.,
Plan A, Plan B, Exit) and to proceed to an Emergency strategy requiring front of neck access or surgical airway for
failed oxygenation. The Airway Management Pause (AMP),
a pre-intubation communication checklist, was also integrated in the revision as a strategy to standardize terminology and facilitate development and communication of an
airway management plan that would help to move the team
from one strategy to the next in the event of difcult or failed
endotracheal intubation.
Organization and layout of the DAM cart were congured
to mirror the DAM algorithm so that the two tools can be
on the drawer labeling
26 Systems-Focused Simulation andDebrieng toImprove Patient Safety, Quality Care, Environments, andProcesses
DAM Cart
The AMP/Algorithm is available
on the DAM Cart
PLAN A
PLAN B
EXITPLAN
EMERGENCY PLAN
Images act as visual cues
209
AMP Checklist
Adult Airway Management Pause
Exit Plan
Emergency
Plan APlan B
The plan section of the AMP
matches the language of the
algorithm
The algorithm is readily
available on the reverse of the
AMP
All tools are colour coded
EMERGENCY
DAM Algorithm
DIFFICULTAIRWAYMANAGEMENT IN AN UNCONSCIOUS PATIENT
PLAN A
Labeling on the cart matches
the algorithm plans visually
PLAN B
EXIT
Fig. 26.1 Difcult Airway Management (DAM) Algorithm, Airway Management Pause (AMP) Checklist, and Difcult Airway Management (DAM) Cart we designed to support each other
functionally
210
M. Dubé et al.
used together seamlessly when managing a difcult airway.
Specically, the cart was organized by airway plan and the
color coding and wording on the DAM algorithm and AMP
was mirrored on the cart (e.g., Plan A in text and green color
swatch on the outside drawer of the DAM cart to align with
Plan A on the DAM algorithm and AMP (Fig.26.1). In addition, images of select equipment housed within the drawers
were displayed on the outside of the cart to aid fast recognition (e.g., laryngoscope blade to indicate initial intubation
strategy equipment). Equipment needed for that step in the
algorithm was placed inside the corresponding drawer. Cart
contents were also streamlined by standardizing equipment
necessary for where it would be used (i.e., Emergency
Departments (ED) and Intensive Care Units (ICU)), and
incorporating human factors principles such as the functional
grouping principle, sequence of use principle, and clutteravoidance principle [23].
Simulation was used in usability testing where seven physicians and six respiratory therapists from multiple sites and
care areas (i.e., ED, ICU, OR) used the AMP, the DAM algorithm, and DAM cart in a simulated difcult airway management scenario in a hospital simulation lab with a patient
mannequin. This was the rst step of usability testing prior to
using it in the in situ clinical environment. A trauma scenario
of a gunshot wound to the face was used as an anticipated
difcult airway scenario where the patient’s condition worsened progressively through the scenario to increase the
urgency for decision-making and airway management
actions. Participants were told that intubation attempts were
unsuccessful to encourage movement through the DAM
algorithm and the use of specic plans and tools in the DAM
cart that mirrored the patient’s condition (e.g., Plan B, Exit,
Emergency). Following the simulation, participants were
debriefed and completed a questionnaire about the DAM
algorithm, DAM cart, and AMP which included a mix of
Likert and open-ended questions (Appendix A).
Usability testing provided the opportunity for clinicians
to try the new DAM equipment and tools in a realistic fashion and provide feedback. Through a combination of observational data and end-user feedback, small changes were
made to the DAM cart, DAM algorithm, and AMP to ensure
they would meet clinical user needs. Some examples include
more closely aligning the colors assigned to each plan
between the algorithm, the cart, and the AMP, increasing
contrast on the algorithm by using the colors as a border
around each plan. Additional changes included adding items
such as anti-fog gel for the disposable bronchoscope (Ambu
aScope), pediatric stylets, and a “call for help” sign to the
outside of the cart to mirror the algorithm.
Implementation of the revised DAM carts was supported
by the simulation team and multiple simulation labs, and
funding was obtained to upgrade existing DAM carts
throughout the Zone. This upgrading included replacement
of drawers, the addition of labelling, and the purchase of
additional equipment. Funds were also used to facilitate the
training of end users and to support ongoing interprofessional team training.
Respiratory Therapists (RT) are the primary hands-on
users of the DAM carts, with the need to locate and prepare
equipment rapidly in emergency situations. The simulation
lab carts were revamped prior to clinical implementation to
allow for RTs and clinicians from all professions to familiarize themselves with and use the tools in a safe environment
with no risk to actual patients.
Case Study 4: New Clinical Environments
andPrograms
System simulation is paramount to the safe testing and opening of new clinical environments and programs prior to use
with actual patients [24]. Guidelines suggest that for every
dollar invested in simulation-based mock-up evaluations,
somewhere between $5.06 and $26.85 can be saved through
the avoidance of future renovations [24]. In addition to cost
savings, these methods improve patient and staff safety,
afford greater efciency in operations, improve utilization of
space, and promote better overall function.
In newly developed centers and programs, the following
case study highlights the use of simulation to standardize,
test, and implement a new pediatric trauma program. In this
context, a combined focus and scaffolded approach to individual and team training, in combination with systems and
workow testing, was required to meet the needs of many
new team members coming together in a new program and
space.
Our acute level 1 and subacute level 2 team consisted of
trauma team leads (i.e., a mix of experienced emergency
physicians and pediatric trauma surgeons), clinical pharmacists, respiratory therapists, nurses, social workers, radiology
technicians, and child life specialists. Additionally,
Orthopedics and Neurosurgery consultants would be directly
called when indicated, and Transfusion Medicine and the OR
would be notied for all acute traumas.
As part of pre-opening, several trauma clinical practice
guidelines were developed, using Advanced Trauma Life
Support (ATLS) principles, key landmark studies, and other
published guidelines. These clinical practice guidelines were
approved by all stakeholders involved in the trauma program
at Sidra Medicine, and are the foundations for most of the
level 1 and 2 care for pediatric trauma patients cared for in
the ED and beyond.
This program consisted of several implementation phases
to scaffold learning and complexity during clinical commissioning. First, it was important to ensure that nursing and
physician staff were similarly qualied in baseline skills and
26 Systems-Focused Simulation andDebrieng toImprove Patient Safety, Quality Care, Environments, andProcesses
211
courses (i.e., ATLS). The second phase included site-specic
equipment training for key pieces of trauma equipment such
as intravenous hotlines/uid warmers, the Level 1 rapid
infuser, application of site-specic pelvic binders, cervical
collars, femoral splints, and backboards and scoops. It was
also important to train providers on the equipment and consumables used for a variety of trauma-related procedures
including chest tube insertion, femoral nerve blocks, intraosseous insertion, and airway management. The third phase
included a simulation curriculum than was facilitated over
12 weeks designed to incorporate increasing complexity
(i.e., individual, team, and systems complexity) and emotional intensity to align with realistic trauma scenarios.
Simulation scenarios were designed to focus on trauma
and injury proles including road collisions, ATV injuries,
falls resulting in isolated head injuries, head injuries with
pneumothorax, abdominal trauma, poly trauma, spinal
trauma, and traumatic cardiac arrest. Where appropriate,
clinical practice guidelines were used in the development of
cases with the expectation that the teams providing care
would incorporate these guidelines as part of their management. Initially, cases focused heavily on non-technical skills,
such as Crisis Resource Management (CRM), in addition to
the initial medical stabilization and management of pediatric
trauma patients. CRM skills were key as none of the teams
had worked together prior to the hospital opening. CRM topics included elements of teamwork, problem-solving, closedloop communication, and the use of other TeamSTEPPS
strategies and tools [25]. The goal was to enhance communication, leadership, and resource management. Most cases
were 15–30min long, depending on complexity and workow, and the debrief post event ran for 45min.
The curriculum then transitioned to a greater focus on
workow and systems testing. For example, one of the polytrauma cases included activation of the massive transfusion
protocol as well as testing the workow from the ED resuscitation area to the OR.For other cases, the focus was on the
workow and transfer of patients to diagnostic imaging for
computed tomography (CT) or the Pediatric Intensive Care
Unit (PICU). Scenarios that tested workows of ED trauma
bay to diagnostic imaging or to OR ran as much as 45min or
more. On average, 8–12 scenarios were facilitated per week.
Debrieng was aligned to the objectives of each scenario
using a mixed method of debrieng to elicit feedback from
the participants. Questions centered on what happened, what
was learned from the event, and what should be changed or
done differently for the next event. Feedback was collected,
and task assignments were made after each debrief to ensure
that potential changes would be prioritized and completed.
Several measures were collected to assess outcomes of
the program. Key indicators included a shortened time to
complete the primary and secondary survey; time to the OR,
CT, and PICU; and time to lab results and time to transfu-
sion. The number of missed injuries in complex cases was
recorded and reduced over time, and a noted decrease in the
number of deviations from the trauma clinical practice
guidelines was observed. Team communication also
improved dramatically.
Conclusion
The use of simulation for systems integration, including the
design and testing of new and used spaces and processes, has
been shown to reduce organizational costs, improve safety
and efciency, and lead to better implementation. This takes
a shift in mindset that moves us away from a primary focus
on the individual healthcare provider to thinking about the
healthcare system and the factors that impact our ability to
function within our role(s). These can include factors such as
the environment (e.g., noise, lighting, distractions, physical
layout and design), the physical tasks (e.g., difculty, complexity, sequence, variety), the tools and technology (e.g.,
usability, functionality, accessibility, level of automation), or
broader organization features (e.g., stafng, workloads, day
versus night differences, work culture).
This “approach” to simulation can be referred to variably
in existing literature, and can be referenced as systemfocused simulation, design thinking approach to simulation,
translational simulation, and simulation-based clinical systems testing, to name a few. As this science evolves, principles can be applied from various other disciplines such as
patient safety science and quality improvement, human factors, project and change management, design thinking, process improvement, and implementation science.
It is advantageous to think of focused systems events as
ongoing tests of change and improvement, which can help
both facilitators and participants establish a system thinking
mindset. One such idea is to consider plan-do-study-act
cycles in the context of simulation projects. This helps to
prepare teams for the work and change that most often follows the simulation and debrief. Having a project manager
role, or someone to take on related project tasks, is very helpful to manage the planning of communications, scenario codevelopment process, logistics, event planning, and follow-up
work. Some simulation programs may be armed with dedicated simulation personnel who can manage both the project
and simulation work, while others may be a collaboration
between educators, simulationists, and project managers.
Lastly, it is important to have the “sponsorship” from healthcare leadership required to enable the work to happen, implement the changes that may be required, and to support staff
to engage in the process.
Taking a “systems thinking” approach is key from the
planning stages through to the simulation, debrieng, and
improvement stages. This supports effective scenario design,
212
ensures debrieng focused on systems rather than individuals, and captures the feedback used to inform change.
Consider starting with a small project, perhaps a process
change on one unit with just a few stakeholders, and then
increase complexity to larger system-based projects over
time. These more complex projects may include multiple
user groups, complex spaces (i.e., building a new unit or hospital), and processes (i.e., complex multi-user disaster events,
protocols).
What is evident is that taking any small step to get your
system-focused simulation program operational will be a
step in the right direction to enable user-centered design and
improved safety and efciency of your healthcare system.
Key Points
• The objectives, design, and debrieng of systemsfocused simulation differs in primary purpose and
approach from traditional simulation in that it is
focused on the system elements surrounding the
healthcare team, such as the physical environment,
tasks, tools, technology, people, processes, and
organization, to enable safe and effective care.
• Simulation allows for the recreation of complex
systems and represents as close as possible how
M. Dubé et al.
work is actually happening versus how we may perceive it is happening to better assess risk, mitigate
harm, and proactively improve systems and processes of care delivery.
• System-focused simulation can reduce organizational costs, improve safety and efciency, inform
and reduce risk, as well as solve clinical challenges.
• This chapter highlights several examples of the realworld utilization and outcomes of systems simulation and human factors including protocols to
improve the initial arrival of a single trauma patient
contrasted to activation of mass casualty incident
protocols; how to incorporate human factors and system simulation to test the usability of difcult airway
management carts and airway management pause
checklists; and the commissioning of new spaces
such as emergency rooms and trauma room bays.
Acknowledgments The authors would like to recognize Dr. Andrea
Boone, Elaine Sigalet, Jason Laberge, Chris Cuthbert, and all project
sponsors for their support for this work.
Appendix A: Dam Tools Usability Testing Questionaire
This is a feedback form to provide your assessment of
the standardized Difficult Airway Management (DAM)
tools that are being developed (i.e. DAM cart configuration, DAM algorithm, Airway Management Pause). Your
participation in completing this form is valued to help
assist in determining how these tools might work in
practice and if any further changes are required before
rollout and implementation.
Thank you in advance for your feedback.
Please indicate your responses with a in the appropriate field using the following scale:
26 Systems-Focused Simulation andDebrieng toImprove Patient Safety, Quality Care, Environments, andProcesses
1= Strongly Disagree; 2= Disagree; 3= Neutral; 4= Agree; 5= Strongly Agree
–
–
213
Please continue on back of the page
Have you responded to any difcult airway manage-
ment situations in the past year? YES NO
If yes, how many? ____________________
General comments on the DAM cart conguration
(likes, dislikes, anything you would change)
_____________________________________________
_____________________________________________
General comments on the DAM algorithm (likes, dis-
likes, anything you would change)
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
214
Please indicate your responses with a in the appropriate field using the following scale:
M. Dubé et al.
1= Strongly Disagree; 2= Disagree; 3= Neutral; 4= Agree; 5= Strongly Agree
–
General comments on the AMP (likes, dislikes, any-
thing you would change)
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
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Quality Improvement andTrauma
Quality Indicators
NoriL.Bradley andSandyWidder
27
Measurement is the rst step that leads to control and eventually
to improvement. If you can’t measure something, you can’t
understand it. If you can’t understand it, you can’t control it. If
you can’t control it, you can’t improve it.—H.James Harrington
Introduction
Quality in the healthcare system is being increasingly questioned [1]. The oft-cited report “To Err Is Human” by the
Institute of Medicine indicates up to 98,000 people die annually in US hospitals because of injuries during their care [2].
This has been a strong impetus for the public to demand better quality from their healthcare system and their providers at
an affordable cost [3]. Trauma is the leading cause of death
in the rst four decades of life, the fourth leading cause of
death overall in North America, and a signicant contributor
to potential years of life lost. Overall, major trauma patients
have a 20% mortality rate, while survivors often sustain permanent disability [4]. Acute trauma care providers share the
same attitude as the public: that systems and healthcare
teams can be further improved to benet patients and population health.
It is standard for healthcare organizations to measure
quality data regularly and rigorously, but it takes more than
just measurement to determine whether targeted changes are
truly leading to improvements and prolonged success. Many
interventions are reactive to critical incidents or high-prole
issues, and sustainability may not have been factored in during the change design. This chapter will discuss healthcare
quality as it relates to trauma, current measurement systems
N. L. Bradley (*)
Department of Surgery, University of Alberta, 2D Walter
Mackenzie Centre, University of Hospital, Edmonton, AB, Canada
S. Widder
Department of Surgery, University of Alberta,
Edmonton, AB, Canada
e-mail: sandy.widder2@albertahealthservices.ca
and indicators, and the potential benets that can be derived
from contributing to a trauma data registry.
Healthcare Quality andRelevance toTrauma
A widely accepted denition states quality of care is “care
that results in desired health outcomes and is consistent with
best professional practice” [5]. In order to delineate an
abstract concept like quality into a measurable framework,
six dimensions of quality have been proposed under the
Institute of Medicine (IOM)’s “Aims for Improvement” [2]:
1. Safe: Care in healthcare facilities should be free from
harm.
2. Effective: Evidence-based practice should be the standard
of care.
3. Efcient: Care should be cost-effective with minimal
waste in the system.
4. Timely: Waits and delays to care/treatment should be
minimized.
5. Patient-centered: Care should focus on the patient,
respecting personal preferences and supporting patient
control during treatment.
6. Equitable: Disparities in care should be eradicated.
Ideally, specic performance measures that align with
these six dimensions of quality healthcare will drive improvement in patient care within each healthcare discipline.
However, a recent report highlighted a gap within trauma
care for quantiable metrics in the areas of patientcenteredness and equity. Performance measures may be categorized as those reecting structure, process, and outcomes,
relying on the Donabedian model. Briey, structure refers to
the physical environment of a healthcare facility, process
refers to clinical interventions for a given patient, and outcome refers to the patient status after completing an episode
of care. See Table27.1 for denitions and trauma-specic
examples. With respect to the IOM aims, a process measure
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L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_27
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