Pre-Implementation Multidisciplinary In-Situ Simulation to Refine Proposed Procedure Workflow (1090-003623) (Research Abstract Professor Rounds: Group 4)
Start time: Thursday, January 28, 2021, 1:00 PM End time: Thursday, January 28, 2021, 2:00 PM Session Type: Research Abstracts (Completed Studies)
Appropriate central line insertion practices are of paramount importance to patient safety. In 2017, our institution developed a standardized approach for the insertion of central venous catheters to create practice uniformity across our hospitals. Unfortunately, despite this effort, clinical practices remain persistently variable. Acknowledging the strong evidence base supporting the implementation of care bundles and checklists in procedural practice to improve patient safety outcomes, we developed a visual cognitive aid and formal procedure checklist to reinforce adherence to our standardized institutional central line insertion technique. We trialed our intervention using in-situ simulation to see if this novel approach to beta testing could help assess feasibility and improve staff buy-in prior to implementation.
We collected data about current central line insertion practices through a series of one-on-one interviews with physicians, advanced practice providers and nursing staff in the three intensive care units at our academic tertiary care hospital. Considering the gaps identified with this data, we proposed a new procedure checklist, a visual cognitive aid, and a multidisciplinary pre-procedure huddle, all designed to emphasize the critical elements of the procedure and prioritize teamwork and patient safety. In order to assess the feasibility of this workflow, we organized a series of in-situ simulations (ISS), bringing together pairs of nurses and either physicians or advanced practice providers from each of the intensive care units, to review, trial and provide feedback on the proposed intervention. Additionally, each pair completed a Culture of Safety survey at the beginning of their session, as well as pre- and post-simulation surveys about their experiences.
We gathered data during six ISS sessions, focusing on procedural logistics, necessary modifications, and potential communication barriers. In our sessions, we identified discrepancies in the performance of the pre-procedure time out, prompting a hard stop in our pre-procedure huddle to ensure this is performed appropriately. Review of the VCA checklist specifics identified elements warranting clarification, specifically, best practice for sterile procedure, line confirmation and dressing application. We developed a team approach for dressing placement, aimed at decreasing the number of dressing changes required to improve line sterility. After nursing staff voiced hesitancy in providing real time feedback to physicians and advanced practice providers, we incorporated tools to diffuse the perceived authority gradient and promote consideration of patient safety. All participants endorsed this workflow as likely to improve patient care and reported willingness to implement it clinically.
In-situ simulation is frequently used to identify latent safety threats, test processes and improve team dynamics in the clinical environment. We sought to use ISS as a novel approach for feasibility testing. By trialing a proposed workflow in the very environment in which it would be used, with the teams who would eventually be using it, we were able to address logistical challenges, optimize team communication and workflow design, and promote buy-in. In-situ simulation can be an integral part of process development for complex, multidisciplinary procedures, and provides an opportunity to address barriers to success without putting patients at risk.