About the Project
When patients’ lives are in the balance, requiring quick action from Emergency Department staff and physicians, there isn’t time to step back and troubleshoot a particular procedure or protocol. Simulations provide an opportunity for this type of reflection and evaluation. Several physicians from the Emergency Department at Victoria General Hospital initiated a series of cross-departmental simulations to bring together not only the emergency department staff, but also the various specialties that interact around a patient’s bedside.
Over the last year, 1-2 simulations were held each month, involving not only Emergency Department physicians, but also Pediatric Intensive Care docs, PICU and NICU nurses, pediatricians, hematopathologists, anesthesiologists, adult intensivists, respiratory therapists, ECG and lab technicians, as well as more than 40 different emergency department nurses. Each scenario was attended by a clinical nurse educator to summarize the scenario and lessons learned to ensure any insights or actionable items were disseminated to all emergency department staff. The group also filmed each simulation so that those not able to attend on the day could still learn from the experience.
Through these exercises, the group identified a number of actionable items that have changed the way they deliver care in the emergency department. One of the most significant of these was the trialing, troubleshooting and implementation of a Massive Transfusion Protocol that had been developed by the Hematopathology department and Trauma services. Previously, if a patient was seriously injured and bleeding critically, the emergency department staff did not have a way to get blood products into the trauma bay before the patient had arrived. This could mean crucial time spent waiting for blood. As a result of the simulation work, the team, including a nurse and technician from transfusion medicine as well as Dr. Brian Berry, Hematopathologist, agreed that a protocol was needed so that blood products would be waiting for the patient upon arrival – a change that could mean the difference between life and death.
These changes also included insights into providing better care during a suspected or confirmed COVID-19 case. Previously, communication between the treatment room and the trauma bay was relatively open. However, with the need for greater precautions during COVID, the group realized that safe communication was challenging. Taking extra time to go in and out of the negative pressure room to order tests or bring in new medications or supplies negatively impacted efficient patient care. The group determined that a phone should be placed in the trauma bay, connected to the physician providing treatment. By simply speaking orders using ear bud earphones, the physician could then communicate all needs instantaneously to the group outside.
In addition to practice changes, a major benefit cited after each session was improved communication between different departments and with allied health staff. “There are specialties that we see more often, but I’ve never really spoken to hematopathology about systems of care in the emergency room, or ICU, or anesthesia, so to have these specialties, both doctors and nurses, in these simulations and available to debrief afterwards, was great”, said Dr. Matt Carere, Emergency Room Physician.
Speaking about the value of the funding, Dr. Carere underscored how critical it was to cover people’s time: “Everyone is very conscious of their time and it’s hard to get anyone to come in for two hours before or after a shift if there’s no remuneration. The buy-in has drastically changed since the funding was announced.”
The group plans to continue the simulations in the future as well as collect more specific evaluation data about how participation for emergency room staff can impact on job satisfaction and engagement with colleagues from other disciplines.
Update: ‘Heat Dome’ patients and physicians benefit from ED Simulation Initiative
For the past several years, Victoria-based Emergency Department physicians have been running in situ simulation exercises in collaboration with colleagues from other departments. Funded by the South Island Medical Staff Association through the Facility Engagement Initiative, these simulations have promoted a culture of learning, interaction and continuous improvement. Of particular interest has been simulating cases of HALO event – High Acuity, Low Occurrence. As the name suggests, these happen infrequently but require precise, time-sensitive responses when they do occur.
When the ‘heat dome’ descended recently onto British Columbia, many emergency departments were flooded with patients suffering from a dangerous condition known as hyperthermia. This rare but potentially life-threatening condition is not frequently seen in the emergency room, yet requires specialized, time-sensitive treatment. Fortunately, the ED Simulation initiative had run a hyperthermia scenario a year prior, and identified important gaps in care that could be remediated. These included having ready access to cooled-IV fluids, body bags that could be filled with ice and water to further cool patients, and fans for misting. On the eve of the surge in temperatures, these lessons learned were recirculated to Victoria Emergency Departments so that all staff could be as prepared as possible.
Over the next few days, patients flooded the Emergency Departments of both the Victoria General and Royal Jubilee hospitals. One clinician, Dr. Jacob Wilkins, working at VGH reported that “our team functioned on the brink of crisis/Code Orange due to the sheer volume of high acuity patients”. Reflecting on the previous simulation exercise, he commented “Fortunately, our team had run heatstroke and mass casualty simulations in the past. This undoubtedly saved lives”. Another physician remarked that the previous simulation was referenced a number of times by staff during the heat wave episode, and that the ED was stocked with supplies that they don’t normally carry. “Once again”, this clinician concluded, “a patient has benefitted from this program”.
This is not the first time a patient has received excellent care on the heels of a simulation exercise, and it further reinforces the value of regularly simulating HALO events with a multidisciplinary team. The benefits for clinician and staff morale, team building, and most importantly patient care, continue to emerge.
Thank you to Dr. Matt Carere, Dr. Donovan MacDonald, and their colleagues in the Emergency Department and other participating departments, for this life-saving initiative!
A list of other recent simulations run through the Victoria In Situ Simulation Program are below:
- Sympathomimetic overdose with hyperthermia (ED, Nursing, RTs, Lab techs, XRAY, unit aides)
- Beta-blocker overdose + COVID AGMP practice (ED, ICU, Nursing, RT, SIM lab support)
- Precipitous delivery, post partum hemorrhage (ED, OB/GYN, LDR nursing, ER nursing, unit aides)
- COVID sudden cardiac arrest in the department (ED, ICU, Nursing, RT, Sim lab support, Unit aide)
- Pediatric trauma, intracranial injury, hemorrhagic shock (ED, PICU, Nursing, RT, labs, Diagnostic imaging, Unit aide)
- Pregnant female with Iron overdose (ED, ICU, Nursing, RT, Unit Aide, Unit Clerks)
- 22 year old COVID positive patient with cardiomyopathy and cardiogenic shock (ED, Trauma, Nursing, RT, Unit Aide, Unit Clerks)
- Breech delivery at the Jubilee requiring NRP (ED, OB/GYN, Nursing, Unit Aide, Unit Clerks, Midwife)
- Trauma, facial burns, airway case and cyanide toxicity (ED, Intensivist, Nursing, RT, Unit Aides)