Where health care workers train matters

In-situ drills help make practice perfect

Some scenarios that cause nightmares for nurses and physicians are blessedly rare. But the problem with that is it's hard to practice so that if it does occur, you can feel confident in your actions. That's one reason why hospitals and medical and nursing schools have simulation labs and a variety of cutely named anatomically correct dummies: It's a place to practice on things that can't actually die.

The problem with this kind of training is that it isn't done in the same environment where those very physicians and nurses work. What you might reach for on the left in the lab is on your right in your own emergency room, for instance. But training on site can be difficult. It might interfere with your regular operations, and it can make patients and their families nervous. But you can make it work, says Melissa Eichelberger, MS, RNC, a patient safety nurse at Johns Hopkins Bayview Medical Center in Baltimore.

Identifying gaps

"Doing in-situ training is more natural and can help you identify system gaps that you just can't see in a simulation lab," she says. Usually, you have to wait until an event happens to identify such gaps.

Eichelberger says she started in the obstetrics unit, first coming up with scenarios that she thought might offer the opportunity to find safety issues. Then they were written out on cards, complete with objectives and schedules. Because the safety drills are held where there are patients actively being treated, staff had to let patients and family know that they were doing a drill. Otherwise, it could have been frightening for patients to see a simulated infant abduction.

Often, they had to cancel the drills — 68 were scheduled, but only 22 occurred, she says. "We wanted to do them, but not inhibit patient safety. If the unit is too busy, we can't do them."

When they did occur, they were taped, and then reviewed afterward by the participants. That allows the participants to see things from a different angle. "People don't always like that, though," she explains. "One simulation we had, a participant started crying because she couldn't get something right and thought she was going to be judged as being incompetent. But we were drilling on something I knew we had to work on. I decided to stop taping for a while after that, but when we got more comfortable, we videoed it again."

Doing the drills can help hone communication between team members, allow them to practice things that don't happen often, and also show up where some process needs to change. Or change back. One of the drills, says Eichelberger, brought to the attention of the nurses that a certain medication had been removed by pharmacists and was no longer kept on the unit. If they didn't do the drill and that same situation had occurred, it might have meant a dangerous delay in getting a necessary medication.

It's impossible to say if outcomes increase through the use of simulation drills, but she thinks they are more technically adept and provide better care because they practice. "Airlines practice all sorts of situations. Football teams practice. It makes sense that we should." She can tell from staff surveys that the safety culture has improved with the drills. That has meaning to her.

In-situ drilling doesn't have to be expensive, either. There are mannequins that cost tens of thousands of dollars that can code, cough, and even complain. But what has worked best in the OB unit at Bayview is a $700 apron simulator that is filled with fake blood and tied onto a real person. "If there is an open room and a slow day, I grab my cards and someone ties on the apron," she says. An upcoming study found that residents who used both the apron and the $30,000 dummy preferred the apron in every category measured and that it was a more effective method of testing skills.

More scenarios

While in-situ drills started on the OB unit, there are other units that have taken up simulation drills, some in situ, some in the Johns Hopkins simulation lab downtown, says Eichelberger. They do mock code drills, and when they redesigned the emergency department, they held a ramp drill. There is interest in expanding the repertoire to other units, too. With more safety nurses coming on board, it will be possible to write out more scenarios for the units that have an interest and see about scheduling in-situ drills, she says.

"This allows you to practice high-risk, low-occurrence situations in a safe environment without the possibility of harming patients and still learn," Eichelberger says. And the tapes can be saved and used as object lessons in training to improve communications or to show staff how much they have improved over time.

After she attended the International Healthcare Medical Simulation conference, Eichelberger was hooked. She has since been again, finding out key information such as how to make realistic fake blood for very little money. "You don't have to be technologically advanced to create things that will show you how your teams interact."

It doesn't take a lot of money to start a program, and there is a great deal of information and resources available from the Society for Simulation in Healthcare, http://www.ssih.org.

For more information on this topic, contact Melissa Eichelberger, MS, RNC, Patient Safety Nurse, Johns Hopkins Bayview Medical Center, Baltimore, MD. Telephone: (410) 550-9546.