Shad Deering

On the Front Lines of Patient Safety: Implementation and Evaluation of Team Training in Iraq

BACKGROUND Team training has been identified as a key strategy for reducing medical errors and building a culture of safety in health care. Communication and coordination skills can serve as barriers to potential errors, as in the modern deployed U.S. Military Healthcare System (MHS), which emphasizes rapid movement of critically injured patients to facilities capable of providing definitive care. A team training intervention--TeamSTEPPS--was implemented on a large scale during one of the most intense phases of the conflict in Iraq. This evaluation of the program constituted the first undertaken in a combat theater of operations. IMPLEMENTING TEAMSTEPPS IN IRAQ: The Baghdad combat support hospital (CSH) conducted continuous operations from a fixed facility for a 13-month deployment--between November 2007 and December 2008. The TeamSTEPPS implementation in Iraq began at this facility and spread throughout the combat theater of operations. Teamwork training was implemented in two primary training sessions, followed up with reinforcement of team behaviors on the unit by hospital leadership. RESULTS A total of 153 patient safety reports were submitted during the 13 months reviewed, 94 before TeamSTEPPS implementation and 59 afterwards. After training, there were significant decreases in the rates of communication-related errors, medication and transfusion errors, and needlestick incidents. There was a significant decrease in the rate of incidents coded communication as the primary teamwork skill that could have potentially prevented the event. CONCLUSIONS Process improvement programs such as TeamSTEPPS implementation can be conducted under the extremely austere conditions of a CSH in a combat zone. Teamwork training decreased medical errors in the CSH while deployed in the combat theater in Iraq.

Adaptation of the US Army's After-Action Review for simulation debriefing in healthcare.

Summary Statement Postsimulation debriefing is a critical component of effective learning in simulation-based health care education. Numerous formats in which to conduct the debriefing have been proposed. In this report, we describe the adaptation the US Army’s After-Action Review (AAR) debriefing format for postsimulation debriefing in health care. The Army’s AAR format is based on sound educational theory and has been used with great success in the US Army and civilian organizations for decades. Debriefing using the health care simulation AAR process requires planning, preparation, and follow-up. Conducting a postsimulation debriefing using the health care simulation AAR debriefing format includes 7 sequential steps as follows: (1) define the rules of the debriefing, (2) explain the learning objectives of the simulation, (3) benchmark performance, (4) review what was supposed to happen during the simulation, (5) identify what actually happened, (6) examine why events occurred the way they did, and (7) formalize learning by reviewing with the group what went well, what did not go well and what they would do differently if faced with a similar situation in real life. We feel that the use of the health care simulation AAR debriefing format provides a structured and supported method to conduct an effective postsimulation debriefing, with a focus on the learning objectives and reliance on preidentified performance standards.

The case for simulation as part of a comprehensive patient safety program.

Simulation in obstetrics allows us to practice in a safe environment. Simulations can improve the performance of individuals and obstetric teams. The evidence is overwhelming that, with simulated practice, obstetricians improve their technical and communication skills. Evidence is emerging that simulation ultimately may improve clinical outcomes. It stands to reason that simulation in obstetrics should be incorporated into comprehensive patient safety programs.

Obstetric simulation for medical student, resident, and fellow education

Simulation for training new providers is no longer the wave of the future, but the reality of the present. It provides significant activation and allows for both the integration of concepts with actual application and the ability to practice a wide range of procedural skills at an earlier stage of training than would otherwise be possible. It is also an optimal method to sharpen teamwork and communication skills that are critical to patient safety. These concepts are especially relevant in the field of obstetrics, where even routine deliveries may become life-threatening emergencies and the health of the mother and child are dependent on correct and timely interventions and teamwork. Almost all of the skills needed, even for advanced invasive procedures, in obstetrics can be taught with currently available simulators. In this report we will discuss the use of medical simulation for training obstetric providers from medical school through subspecialty level training.

Obstetric emergency simulation

Simulation for obstetric emergencies has progressed from being a good idea in theory to the level of an evidence-based intervention that can improve outcomes. Though not a stand-alone solution, the inclusion of simulation for training individuals and teams to react and perform correctly when obstetric emergencies occur is a critical part of a comprehensive strategy to improve outcomes for both the mother and baby. In this article, we will briefly review both the recent history of simulation for obstetric emergencies and then examine the most current evidence for specific emergencies.

Challenges affecting access to cesarean delivery and strategies to overcome them in low-income countries

Most maternal deaths occur in low‐income countries where access to appropriate medical care is restricted.

Perceived effects of deployments on surgeon and physician skills in the US Army Medical Department

BACKGROUND The military health care system is unique in that almost every physician deploys for ≥6 months to a combat or far-forward setting. The aim of this study was to determine the perceived changes in clinical skills in this deployed population. METHODS A survey was sent out to all specialty consultants to the Army Surgeon General to query active duty staff physicians in their specialty areas who have deployment experience in August 2007. Questions concerning specialty, length of deployment, perceived changes in skills, skill use while deployed, and time to get back to baseline clinically after deployment were asked. RESULTS Surveys were sent to approximately 1,500 physicians, of which 673 were usable, for a 45% response rate. More than 70% of respondents were deployed for >6 months. Fifty-nine percent reported that they were used in their specialties <40% of the time deployed. Surgeons rated surgical skills before and after deployment as 6.0 ± 1.0 and 4.0 ± 1.5, respectively (on a 7-point, Likert-type scale ranging from 1 = worst to 7 = best; P = .001). Most felt that the time needed to get back to predeployment skill levels was 1 to 6 months. CONCLUSIONS There was significant perceived degradation in both the surgical and clinical skills of those deploying for >6 months, and the degradation was correlated with the length of time deployed. Most surgical specialists felt that it took them 3 to 6 months to return to their clinical and surgical performance baseline upon returning from a deployment and that 6 months was the most amount of time they could be deployed without a significant decrement in skills.

The Central Simulation Committee (CSC): A Model for Centralization and Standardization of Simulation-Based Medical Education in the U.S. Army Healthcare System

In this report, we describe the organizational framework, operations and current status of the Central Simulation Committee (CSC). The CSC was established in 2007 with the goals of standardizing simulation-based training in Army graduate medical education programs, assisting in redeployment training of physicians returning from war, and improving patient safety within the Army Medical Department. Presently, the CSC oversees 10 Simulation Centers, controls over 21,000 sq ft of simulation center space, and provides specialty-specific training in 14 medical specialties. In the past 2 years, CSC Simulation Centers have trained over 50,000 Army medical students, residents, physician assistants, nurses, Soldiers and DoD civilian medical personnel. We hope this report provides simulation educators within the military, and our civilian simulation colleagues, with insight into the workings of our organization and provides an example of centralized support and oversight of simulation-based medical education.

Facilitating Physician Reentry to Practice: Perceived Effects of Deployments on US Army Pediatricians’ Clinical and Procedural Skills

Introduction: US Army pediatricians regularly deploy for 6 to 12 months or longer and many are deployed multiple times during their career. Prolonged breaks in pediatric clinical practice may result in skill degradation, requiring a physician reentry process to prepare pediatricians to return to clinical practice. This study sought to identify which specific pediatric clinical skills were felt to be most affected by deployment. Methods: Army pediatricians on active duty between January 2012 and March 2012 were surveyed via e‐mail to determine their comfort level and experience with clinical encounters and procedural skills prior to and after military deployment. Results: Eighty‐three pediatricians were eligible, and 75 responded (90% response rate). Of those received, 65 surveys (78%) were complete and included in the statistical analysis. Over half (54%) of the respondents were deployed longer than 6 months, and 32% were deployed for 12 months or longer. The largest changes in reported comfort were seen in neonatal, pediatric, and adolescent acute care and neonatal routine care, including neonatal and pediatric procedures. There was a significant negative correlation (r = .64; p = .003) between providers reported exposure to neonatal and pediatric clinical encounters during deployment and providers comfort with those clinical encounters after deployment. Discussion: US Army pediatricians are required to deploy for extended periods of time and have limited opportunities to practice the full range of their pediatric skills. This break in clinical practice is associated with a significant decline in perceived comfort with both routine and acute pediatric care.

Hybrid Simulation During Military Medical Student Field Training—A Novel Curriculum

OBJECTIVES Implement a new hybrid simulation curriculum into the Uniformed Services University of the Health Sciences Bushmaster Field Training Exercise for fourth-year medical students. The principal goal was to determine if high-fidelity hybrid simulation could be successfully implemented in a field environment. The secondary goals were to enhance the medical realism of training, allow students to practice crucial combat emergency medical skills and management in stressful field conditions, and develop medical team leadership. METHODS Low-, mid- and high-fidelity simulators were used in combination with standardized patients in a variety of field clinical settings. Students were given multiple opportunities to interact with the hybrid simulations. Student feedback about the simulation training was sought as part of their normal after-course critiques. RESULTS High-fidelity simulation can be successfully implemented in combat-simulated field conditions, and QA feedback indicated very positive perceptions from students. CONCLUSIONS Multiple modality hybrid simulation can be successfully implemented into large-scale military medical field exercises, and appears beneficial for multiple educational goals.