Utilizing Simulation to its Full Potential in a Pediatric CVICU

The complexity of pediatric CVICU patients demands high-quality, tailored care, and effective team communication to prevent or reverse clinical decompensation (1). Simulation has been shown to enhance communication and team dynamics, specifically during emergency and resuscitation events (1). For example, multi-disciplinary simulation of high mortality, low occurrence events such as BTT shunt occlusion can help both provider and bedside nursing teams learn to work together, communicate effectively, and more importantly, support the patient clinically. However, simulation can be multifaceted, and I wonder if we are using it to its full potential. Beyond catastrophic events, should we implement simulation education for day-to-day, non-technical clinical skills and scenarios?

Much of the research on simulation in ICU settings focuses on high acuity, complex disease processes, and emergency response. What about using simulation to support a high-level clinical competency for our medical and nursing providers? Utilizing the benefits of simulation to offer a low-stakes environment for medical providers to practice both technical and non-technical skills (placing an arterial line vs. communicating with families) can be greatly beneficial. Simulation does not always have to focus on an emergent situation or a technical skill (3). It can include conceptual skills as well, like getting a patient with a VAD out of bed, helping a mother with skin to skin, holding of a critically ill patient, etc. Focusing on “day to day” skills of medical professionals may help increase overall clinical competence and optimize patient safety and outcomes (3).

At CHOP (The Children s Hospital of Philadelphia), we strive to include simulation exercises in most professional development opportunities. Through the recent development of a dedicated Cardiac Center simulation space, we have been able to increase the number of simulations, both high and low fidelity, and to increase the number of multidisciplinary team simulations. Simulations are co-facilitated by medical and nursing educators to ensure all content experts are present. We select participants for scenarios based on their experience and skill level. This has allowed us to challenge individuals and meet learners where they are in their practice (2). This approach has not only improved our team dynamics but has increased the confidence and skill level of our new nurses.

To optimize the onboarding of new nurses, we have changed the way we offer nursing education – we have replaced many didactic components with simulations and hands-on opportunities. For example, during our Cardiac Center Education Days, nurses learn about the pathophysiology of pulmonary hypertension through a brief didactic session followed by a low fidelity simulation and guided case study on how to identify and treat a pulmonary hypertensive crisis. During VAD training, we stress the importance of hands-on demonstration and simulation scenarios versus didactic lectures. Giving nurses the opportunity to visualize a Berlin pump in action, silence and acknowledge alarms, assess the membrane, and even hand pump in an emergency, has helped increase the comfort level of our nurses tremendously.

Like most institutions, CHOP is adjusting to the critical nursing turnover rate and national nursing shortage. As an education team, we have implemented ways to support the substantial number of new graduate nurses entering the ICU setting. A strategy most recently developed includes “the skills lab,” open simulation hours during which nurses and providers can drop in and practice with any of the on-hand equipment and a nurse educator. These learner-driven skills sessions have included preparing continuous infusion lines, assembling and using a push-pull system, drawing up emergency medications, and reviewing the code cart. Using this self-guided learning opportunity gives learners control and a safe space to practice at their current skill level.

As clinical educators, using simulation to its full potential can create a safe space to address questions or clinical practice concerns, and ultimately, to improve clinical skills and support nursing competency. I hope that that through practice, repetition, and support, medical providers will feel better prepared and gain the confidence to practice at the top of their licensure as an integral member of the multidisciplinary care team.

References:

1. Choudhury, T. A., Flyer, J. N., & McBride, M. E. (2021). Simulation as an Educational Tool in the Pediatric Cardiac Intensive Care Unit. Current pediatrics reports, 9(3), 52–59. https://doi.org/10.1007/s40124-021-00241-0
2. Moll-Khosrawi, P., Zöllner, C., Cencin, N., & Schulte-Uentrop, L. (2021). Flipped learning enhances non-technical skill performance in simulation-based education: a randomized controlled trial. BMC Medical Education, 21(1), 353. https://doi.org/10.1186/s12909-021-02766-w
3. Shariff, F., Hatala, R., & Regehr, G. (2020). The nature of learning from simulation: Now I know it, now I’ll do it, I’ll work on that. Medical Education, 54(7), 652–659. https://doi.org/10.1111/medu.14153