Bridging the gap: Improving patient safety through targeted in-situ simulation training in a paediatric intensive care unit and Learning from Excellence (LfE)
Authors: Nayak Prabhakar , Kidd Nikki , Osborne-Ricketts Bianca , Martin Jeff , Heward Yvonne , Plunkett Adrian 
Published: December 2019

Background: Improving patient safety and reducing risk is important to a Paediatric Intensive Care Unit (PICU). Simulation-based education has generally focused on the management of clinical diagnoses, whereas the Quality and Safety Team has traditionally focused on collecting and analysing data about adverse events. There is a need to bridge the gap between the two streams - lessons learnt from adverse incidents and their impartation to staff in a targeted format during in-situ simulation training.
Methods: Birmingham Children's Hospital PICU is a 31-bedded tertiary/quaternary unit with approximately 1500 admissions per year in the UK. All adverse incidents are collated (online IR1 with specific forms for incidents involving medications, accidental extubations, buzzer pulls, and extravasations) and analysed by the PICU Safety Group and trends are monitored. The PICU Simulation Team delivers in-situ simulation training for the multidisciplinary PICU staff weekly using interactive, computer-controlled manikins. Each training scenario and debriefing lasts 1 hour. A core team of multidisciplinary simulation facilitators runs the simulation training and the AI (advocacy-inquiry) debriefing model is used for conducting the debriefings. The ‘Simulation Group’ (efferent) and the ‘Risk Group’ (afferent) regularly discuss the priorities for the unit and the lessons learnt based on actual events or near-misses in the unit. It then implements the action points during targeted scenario training sessions. This may be the utilisation of a care bundle or activation of a ‘clinical pathway’. Any practical problem with implementation of these policies is fed back to the Risk Group to close the loop. A concept of ‘Learning from Excellence’ (LfE) has been introduced successfully and both ‘adverse incidents’ and LfE are used together as approaches to improve patient safety in the unit.
Observation/Evaluation: Various simulation scenarios have been run since the start of the project. Examples include accidental extubations, delay in sepsis recognition and antibiotics prescription, ischaemic limb injury due to the indwelling arterial line, emergency chest reopening in post-operative cardiac surgical patients, child protection and safeguarding. The learning gained during each debriefing is generalised to all the participants of the simulation session and then subsequently the salient points are shared by email with the entire unit. All staff members have to undergo simulation training. Scenarios are re-run back to back if the team does not achieve the expected outcomes. The anonymous feedback forms completed by the participants of the scenarios have shown they value this targeted training and that it has helped them implement good practice. Anecdotaly, the trend of ‘incident severity’ is believed to have been on the decline over a 7-year period in our PICU but long term monitoring will continue to identify any re-emerging or fresh trends.
Conclusion: ‘Targeted’ simulation-based training is an important approach to enhance the safety culture in PICU. PICU Safety and Simulation Groups should develop a symbiotic relationship for this to succeed. Learning from Excellence can be effectively utilised to embed good practice in a clinical area.