In situ Interprofessional Simulation in the Congenital Cardiac Intensive Care Unit using the PEARLS Framework for Systems Integration.
Event Type
Oral Presentations
TimeTuesday, April 132:00pm - 2:20pm EDT
LocationEducation and Simulation
We developed an in-situ interprofessional simulation program to study system factors to establish a congenital cardiac arrest activation tree and test it using human factors engineering principles. We used the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model to understand the structure, processes, and outcomes related to the congenital cardiac arrest activation tree (CCCAT) and discuss the Promoting Excellence and Reflective Learning in Simulation (PEARLS) for systems integration framework for our systems focused debriefing (SFD).

Healthcare organizations strive for continuous improvement in systems and processes to ensure safe, effective, and cost-conscious patient care. Simulation and debriefing, focused on identifying systems gaps, can proactively lead to safety and quality improvements. Systems-focused debriefing (SFD) requires a different approach than traditional, learner-focused debriefing. We describe PEARLS for Systems Integration (PSI), a conceptual framework, debriefing structure, and script that facilitators can use for systems-focused debriefing in establishing workflows, processes and identifying latent safety threats (LSTs) in a congenital cardiac intensive care unit.

The incidence of pediatric cardiac arrests in pediatric intensive care units (PICUs) was reported to be less than 2%; however, cardiac arrest after pediatric cardiac surgery is reported in up to 6% of patients. Post congenital cardiac surgical arrest utilizes clinical practices of pediatric advanced life support (PALS) guidelines and evidence from the management of cardiac arrest postcardiac surgery for adults. Establishing a structured, time-based flow process pathway can improve earlier recognition, distribute key responsibilities among caregivers, and reduce time to implementation of extracorporeal membrane oxygenation (ECMO) support. Practicing protocol-based arrest management has been shown to halve the time to chest reopening and to minimize complications in the performance of re-sternotomy after cardiac surgery in adults. The PEARLS for Systems Integration (PSI) framework provides a debriefing framework, and a script for systems focused debriefing (SFD). SFD in the PSI framework uses debriefing strategies to identify errors or safety threats that reflect the risks and hazards that providers and patients face in the context of poorly designed systems.

Application/ Methods
We conducted three insitu interprofessional simulation sessions with disciplines including the congenital cardiac intensivist, nursing, congenital cardiac surgeon, respiratory therapist, pharmacist, anesthesiologist, cardiac surgical/cardiology advanced practice provider, perfusionist, operating room staff, adult cardiology advanced practice providers. We conducted these simulations in the real clinical environment: CCICU with actual equipment/tools. We utilized the high-fidelity mannequin Gaumard (Florida, USA) Supertory and Gaumard Pediatric Hal. Our simulation center designed a low fidelity open chest mannequin to increase realism during the scenarios. The three simulation sessions had 8,10 and 11 participants (not learners as in regular simulation sessions), focusing on PSI. We describe the PSI framework application during interprofessional systems focused simulation in the CCICU.
In the prework phase, stakeholders: physicians (intensivist, surgeon and anesthesiologist) and nursing leadership, advance practice providers met before the simulation sessions to pre-identify primary objectives- 1) To identify leadership roles of anesthesia and intensivist when OR to ICU transfer happens, 2) To establish roles and responsibilities of primary beside and charge nurse during OR to ICU handoff, 3) To evaluate equipment (open chest cart for sternotomy), 4) To determine congenital cardiac arrest activation tree (CCCAT) order, the team member responsible for delegating calls, and team members included in the CCCAT, 5) To identify potential improvements to the equipment, test usability with a low fidelity mannequin (resternotomy capabilities), test process (emergency drug ordering for ECMO activation) and ergonomics of the room for safe and efficient personnel functioning.

The description was performed by the facilitator (versus educator in regular simulation-based team training). The facilitator's role was to uncover and explore issues, not educate participants, serve as a content expert, identify solutions, and become an operational owner of potential solutions. In our study, the facilitators were the associate director of the Congenital Cardiac ICU (CCICU) and the CCICU nurse educator. The facilitator stated: "We are going to spend the next 40 minutes debriefing the simulation. The simulation is not about your knowledge and skill. The focus is to improve the systems, establish a Congenital Cardiac Arrest Activation tree, and identify latent safety threats. This patient has a low cardiac output state (LCOS) following Bidirectional Glenn surgery and needs Extracorporeal membrane oxygenation (ECMO)."
Optional Reactions Phase: The facilitator identifies participants' emotional responses. If the number of pre-determined objectives for the specific scenario was time limiting, we skipped this phase.

Analysis: We generated a list of system issues and explored the pre-determined objectives. The Participant System Assessment focused on pre-determined stakeholder objectives. For Roles, an example of facilitator statements: "Let's talk about who would be the appropriate personnel in our clinical milieu to contact all the needed team members on CCCAT? "For technology/equipment: "What went well with the custom-designed open chest surgical tray for resternotomy?" For the environment, an example is "How were the ergonomics of the room and bed, and did all the needed equipment fit to allow all the essential duties to be performed?"
The focused facilitation phase (Advocacy Inquiry) may be included as needed if pre-determined objectives are not met with Plus Delta method. An example is, "I noticed that you had trouble getting to the open chest cart due to difficulty getting it into the room with the other OR equipment. That is concerning, as it resulted in a delay. How do you see it?". The directive feedback phase was skipped in all three simulations due to a focus on systems issues.

Summary: "We have identified the following system issues. We will attempt to classify the problems in the various categories having champions with the operational capacity to rectify issues identified and delegated them."

Results: In the first OR to CCICU transfer, we identified systems issues in the work system category (2 in technology, 1 in tool, 1 in task), 3 in processes. We applied the SEIPS 2.0 model by capturing human factors concepts of engagement (when does the bedside nurse run the blood gas, cue of the anesthesiologist, not intensivist as the former has still not handed over care).
In the emergent resternotomy at the bedside, we identified seven work system latent safety threats (LSTs)- 3 associated with room setup such as patient positioning, headlamp, appropriate bed selection. Four LST with tools regarding surgeon equipment; three in the process category regarding team member delegation to call CCCAT members, the order of calling the CCCAT, bedside RN to be first assist to the cardiac surgeon while OR staff arrives; two in the outcome (employees) category namely time to obtain emergency blood for ECMO circuit, and availability of Echocardiography technician. The concept of adaptation was captured when in an unplanned event, the clinical assistant was not available to call CCCAT and hence we had to identify alternate delegates for the task.
In the emergent resternotomy with ECMO team to bedside, we identified 4 LST in the work system category (no physical space for open chest cart, OR team does not need to bring a Bovie, pharmacy table setup for emergent medication preparation, need to expedite surgeon's specialized pack setup) and one in the process category (adding the adult cardiology advanced practice provider to the CCCAT as our program performs adult congenital heart disease operations.)
We captured, disseminated, and implemented systems changes from these SFDs. We shared individual and combined session summaries within nursing and physician staff meetings and discussed at the physician -nurse (MD-RN) collaborative, a unique opportunity at our institution. The working group created timelines and continuously communicated these "lessons learned" to promote engagement and organizational change at an interprofessional level.