Ep19 - In Situ and Guerrilla Sim in the ED

In Situ Simulation in Emergency Medicine: Insights from St. Emlyn's

Welcome to the St. Emlyn's blog. I'm Ian Beardsell, and I'm Simon Carley. Today, we're exploring in situ simulation, a vital method for improving patient care and team efficiency in emergency medicine. I'll be discussing this at UCEM, and we want to share our insights on implementing it effectively in your department.

What is In Situ Simulation?

In situ simulation takes place in your clinical environment, such as the resuscitation room or patient cubicles. Unlike traditional simulation centers that require significant resources, in situ simulation happens where you work every day. This method allows teams to practice and refine their skills in the actual setting, making training more relevant and practical.

Gorilla Simulation vs. In Situ Simulation

Gorilla simulation, a subset of in situ simulation, involves an element of surprise. It means conducting unplanned simulations during odd hours to test spontaneous team responses. For instance, pressing the resus buzzer at 3 AM with no prior warning and having the team manage a mock patient. While gorilla simulation is riskier and more challenging, it provides valuable insights into team dynamics and readiness.

The Importance of Simulation in Emergency Medicine

Initially, many clinicians, including myself, were skeptical about the impact of simulation training. However, extensive research and our experiences at St. Emlyn's show that simulation significantly improves clinical skills, team coordination, and patient outcomes. Studies have demonstrated its effectiveness across various departments, and we've observed marked improvements in team behavior, organization, and efficiency since implementing regular simulation sessions.

Overcoming Challenges in Simulation Training

Not everyone is comfortable with simulation, especially those who are more introverted or less familiar with the process. It's essential to acknowledge this and create a supportive environment. Normalizing simulation as part of routine training helps, as does ensuring that initial sessions are positive and constructive. We learned through trial and error to gauge participants' comfort levels and adjust the training accordingly.

Practical Tips for Conducting In Situ Simulation

1. Integration into Daily Routine: Conduct simulations around handover times, usually at 8 AM. This timing ensures double staffing, and if handover finishes early, the simulation can proceed without disrupting the department's workflow.

2. Multi-professional Participation: Involving nurses, healthcare support workers, radiographers, and other relevant staff enhances the realism and effectiveness of the simulation. For example, if a scenario involves a CT scan, we physically take the mannequin to the CT scanner.

3. Patient and Staff Engagement: Inform patients and staff beforehand to gain their support. Most patients are understanding and even find it interesting when they know a training exercise is happening.

4. Handling Distractions: Real-world distractions are an integral part of emergency medicine. Incorporating these into simulations teaches teams how to manage interruptions effectively.

Securing Buy-in from Your Department

Gaining support from senior clinicians and nursing leaders is vital. At St. Emlyn's, our clinical director and senior nurses championed the initiative. Presenting simulation as a solution to improve patient care and team coordination, backed by incident reports and data, helps persuade colleagues of its value.

Frequency and Topics for Simulation

We aim to conduct simulations three to four times a week. The focus is often on resuscitation and emergency scenarios, but we also cover other essential skills and processes, such as handover communication and teamwork. Keeping scenarios simple and relevant to daily practice ensures that training remains practical and impactful.

The Role of Debriefing

Debriefing is a critical component of simulation training. We conduct hot debriefs immediately after the simulation to capture fresh insights and feedback. This process is conversational, focusing on participants' experiences and learning points rather than a rigid critique. We also document key learning outcomes to track progress and identify areas for improvement.

Involving Other Departments

For scenarios involving multiple specialties, such as major trauma, we include relevant teams like anesthetists, surgeons, and radiologists. With high-level consent and coordination, these simulations provide comprehensive training and improve inter-departmental collaboration.

Implementing Guerrilla Simulation

While we haven't extensively practiced guerrilla simulation due to its high-risk nature, it offers significant learning opportunities. Conducting simulations in unexpected settings or times, such as a cardiac arrest in the minors area, tests the team's adaptability and response under pressure. However, it's crucial to balance this with the department's workload and stress levels to avoid overwhelming staff.

Conclusion: The Value of Simulation in Emergency Medicine

Simulation training, particularly in situ simulation, is a powerful tool for enhancing clinical skills, team dynamics, and patient care. It requires careful planning, support from leadership, and a commitment to continuous improvement. At St. Emlyn's, we've seen firsthand the positive impact of regular, practical simulation training, and we encourage other departments to adopt and adapt these practices to suit their needs.

By integrating simulation into your routine, involving multi-professional teams, and maintaining a focus on practical, relevant scenarios, you can significantly improve your department's readiness and performance. As we continue to refine our approach and share our experiences, we hope to inspire others to embrace simulation as a cornerstone of emergency medicine training.

Thank you for joining us on the St. Emlyn's blog. We look forward to sharing more insights and updates from UCEM and beyond. If you have any questions or would like to share your own experiences with simulation, please leave a comment or get in touch with us.