Key Points

Introduction

More than 12 years have elapsed since the Institute of Medicine published its report, “To Err Is Human,” which raised public awareness and called attention to the need for safer health care practice, including improving teamwork and using simulation training. Simulation mirrors or amplifies real clinical situations with guided participatory experiences. Simulation training can improve patient safety through a variety of mechanisms, including but not limited to (1) routine training for emergencies, (2) training for teamwork, (3) establishing an environment for discussing error without punishment, (4) testing new procedures for safety, (5) evaluating competence, (6) testing device usability, (7) investigating human performance, and (8) providing skills training outside of the production environment. In 2007, we reviewed existing literature and found evidence to support the premise that simulation-based training improved provider confidence, knowledge, team performance, and process of care in a simulated setting (eg, simulated settings, T ₁ ). Simulation-based training encourages errors that occur during the early learning phase of both procedural and nontechnical skills to be resolved in the laboratory rather than on real patients. Simulation-based training provides learners a psychologically safe learning environment without the fear of harming real patients. However, in 2007, there was little proof that simulation interventions actually improved real patient or population safety outcomes (eg, real patient T ₂ , or population outcomes T ₃ ). Since 2007, there has been rapid escalation of research that substantiates the concept that simulation-based deliberate practice and debriefing does improve provider knowledge, skill acquisition and retention, and patient safety in the clinical domain. Several studies in the pediatric and maternal–fetal medicine literature demonstrate beneficial clinical outcomes for clinical interventions (technical skills) or nontechnical skills such as teamwork. This article highlights recent pediatric literature that establishes the selected circumstances in which simulation-based efforts have been demonstrated to translate into improved patient outcomes and patient safety in the clinical environment.

Introduction

More than 12 years have elapsed since the Institute of Medicine published its report, “To Err Is Human,” which raised public awareness and called attention to the need for safer health care practice, including improving teamwork and using simulation training. Simulation mirrors or amplifies real clinical situations with guided participatory experiences. Simulation training can improve patient safety through a variety of mechanisms, including but not limited to (1) routine training for emergencies, (2) training for teamwork, (3) establishing an environment for discussing error without punishment, (4) testing new procedures for safety, (5) evaluating competence, (6) testing device usability, (7) investigating human performance, and (8) providing skills training outside of the production environment. In 2007, we reviewed existing literature and found evidence to support the premise that simulation-based training improved provider confidence, knowledge, team performance, and process of care in a simulated setting (eg, simulated settings, T ₁ ). Simulation-based training encourages errors that occur during the early learning phase of both procedural and nontechnical skills to be resolved in the laboratory rather than on real patients. Simulation-based training provides learners a psychologically safe learning environment without the fear of harming real patients. However, in 2007, there was little proof that simulation interventions actually improved real patient or population safety outcomes (eg, real patient T ₂ , or population outcomes T ₃ ). Since 2007, there has been rapid escalation of research that substantiates the concept that simulation-based deliberate practice and debriefing does improve provider knowledge, skill acquisition and retention, and patient safety in the clinical domain. Several studies in the pediatric and maternal–fetal medicine literature demonstrate beneficial clinical outcomes for clinical interventions (technical skills) or nontechnical skills such as teamwork. This article highlights recent pediatric literature that establishes the selected circumstances in which simulation-based efforts have been demonstrated to translate into improved patient outcomes and patient safety in the clinical environment.

Translating deliberate practice and debriefing to save lives

Park and McGaghie proposed a nomenclature for describing the translational impact of simulation studies as they progress from the simulation laboratory to patient and population outcomes ( Table 1 ). At the T ₁ research level, studies are conducted to evaluate educational outcomes assessed solely in the simulation laboratory . The goal of T ₂ simulation research is to evaluate the transfer of a skill from the laboratory to clinical performance outcomes. T ₃ studies demonstrate that practice via simulation can indeed improve clinical outcomes and patient safety . The results of T ₃ simulation research can be used to show an improvement in the overall health of a population or system and ultimately influence how safe health care is delivered. T _value simulation research demonstrates the association of simulation interventions to achieve safer and more efficient care that benefits patients, providers, and systems (eg, return on investment, T _value ). Table 2 summarizes several key pediatric simulation-based medical education studies that demonstrate the translation of simulation to achieve T _2, T _3, and T _value outcomes.

Table 2

Studies demonstrating that simulation training translates to improved patient safety and outcomes

Title, Authors	Setting and Operator	Intervention	Outcome Measures	Results	Conclusions
Maternal and neonatal health
Does training in obstetric emergencies improve neonatal outcome? Draycott et al, 2006	UK tertiary teaching hospital Obstetric medical staff and midwives	Simulation-based training for obstetric emergencies	5-min Apgar score HIE rates	Statistically significant reduction in 5-min Apgar score less than 6 and HIE	Simulation-based training improves neonatal outcomes
Improving neonatal outcome through practical shoulder dystocia training Draycott et al, 2008	UK tertiary teaching hospital Obstetric medical staff and midwives	Simulation-based training for shoulder dystocia	Retrospective, observational study pre and postintervention 1. Use of techniques to manage shoulder dystocia 2. Neonatal injury rates	A significant reduction in neonatal injury at birth after shoulder dystocia	Simulation-based training improves neonatal outcomes
Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital Riley et al, 2011	3 US community hospitals Labor and delivery staff	Compared curriculum of 3 hospitals: control, TeamSTEPPS alone, and TeamSTEPPS with simulation training	WAOS score: summary metric of adverse event score per delivery	Better WAOS score in a hospital with TeamSTEPPS with simulation training, no difference between the hospitals with TeamSTEPPS alone and control	Both didactic and simulation team training are necessary to improve perinatal patient outcomes in a community hospital
Resuscitation
Simulation-based mock codes significantly correlate with improved pediatric patient cardiopulmonary arrest survival rates Andreatta et al, 2011	US tertiary teaching hospital Mock code teams led by senior residents	Integration of simulation-based mock codes	Before and after integration 1. CPA survival rates 2. Senior resident self-perception ratings	1. Survival rate increased to ∼50% within 1 y correlating with the increased number of mock codes 2. No change in resident self-perception	Integration of simulation-based mock code improves in-hospital CPA survival rates
Regular in situ simulation training of pediatric medical emergency team improves hospital response to deteriorating patients Theilen et al, 2012	UK tertiary stand-alone children’s hospital	Implementation of pediatric medical emergency team (rapid response team) with weekly in situ simulation team training including registrars and senior nurses from the wards	Predesign and postdesign 1. Time between warning signs and first response 2. Increased frequency of nursing observations 3. Consultant review 4. Time between first response and PICU admission 5. Hospital mortality	1. Earlier first response time (median 4–1 h), Earlier PICU admission (median 11–7 h). 2. Consultant review obtained more 3. Hospital mortality improved (2.9/1000–1.3/1000 admissions)	Concurrent implementation of pediatric medical emergency team with simulation-based team training decreased response time and improved in-hospital survival rate
Invasive procedures: CVC and colonoscopy
Acquisition of competence in pediatric ileocolonoscopy with virtual endoscopy training Thomson et al, 2006	UK tertiary care teaching hospital Pediatric gastroenterology trainees from 1997 to 2004	Virtual endoscopy training	Ileocolonoscopy performance in virtual-trained vs standard-trained groups 1. Proportion of attempts of terminal ileum and cecum attainment 2. Lesion recognition rates	1. 36% higher success rate in virtual-trained group over standard-trained group 2. Significantly higher rate of lesion recognition in virtual-trained group	Virtual endoscopy training is superior to standard training to improve pediatric ileocolonoscopy
Simulation-based mastery learning improves patient outcomes in laparoscopic inguinal hernia Zendejas et al, 2011	US tertiary academic medical center	Simulation-based mastery learning curriculum for totally extraperitoneal inguinal hernia repair vs standard practice (no curriculum)	1. Operative time percentage resident participation in procedure 2. Operative performance measured by a global rating scale 3. Intraoperative and postoperative complications	1. Simulation-based mastery learning group was 6.5 min shorter at first postrandomization procedure 2. Resident participation rate was higher in simulation group Both intraoperative (5% vs 35%) and postoperative (3% vs 30%) complication lower in simulation group	Simulation-based mastery learning curriculum decreased operative time, improved trainee performance, and decreased intraoperative and postoperative complications
Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. (ADULT) Barsuk et al, 2009	US tertiary care academic hospital PGY-2 and PGY-3 internal and emergency medicine residents rotating through the medical ICU	CVC insertion in traditional vs simulation-based mastery learning program	1. Written and procedure checklist scores 2. Number of skin punctures 3. Presence of arterial puncture 4. CVC adjustment 5. CVC success 6. Pneumothorax 7. Self-confidence	1. Significantly fewer skin punctures, arterial punctures, CVC adjustments, and higher CVC success rate 2. No difference in pneumothorax rate 3. No difference in self-confidence	Simulation-based CVC insertion training with mastery learning (deliberate practice) is associated with better clinical performance
Use of simulation-based education to reduce catheter-related bloodstream infections (ADULT) Barsuk et al, 2009	US tertiary care teaching hospital PGY-2 and PGY-3 internal medicine and emergency medicine residents on medical ICU rotation	CVC insertion in traditional vs simulation-based mastery learning program (historical control and concurrent control using other ICUs within the institution)	1. CRBSI rates in medical ICU 2. CRBSI rates in comparison ICU	1. 84.5% reduction in CRBSI after program implementation 2. CRBSI rate lower than national rate after program implementation	Simulation-based CVC insertion mastery learning program decreases CRBSI
T value
Management of shoulder dystocia skill retention 6 and 12 mo after training Crofts et al, 2007	UK hospitals Junior and senior doctors and midwives	Before and delayed posttesting after simulation-based training in delivery skills in shoulder dystocia cases (3 wk, 6 and 12 mo)	1. Success or failure of delivery 2. Head-to-body delivery time 3. Performance of appropriate actions 4. Force applied 5. Communication	1. Of those who achieved delivery posttraining, 84% and 85% were able to deliver at 6 and 12 mo. 2. Simulation training resulted in sustained long-term performance	Management of shoulder dystocia skill is retained 6 and 12 mo after initial simulation training
Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical intensive care unit (ADULT) Cohen et al, 2010	US tertiary care teaching hospital PGY-2 and PGY-3 internal medicine and emergency medicine residents on medical ICU rotation	CVC insertion simulation-based mastery learning program	Annual cost for CRBSI before and after simulation-based CVC insertion education	1. 9.95 CRBSI prevented among patients in medical ICU with CVC per y (never event) 2. Net annual savings estimated to be $700,000 3. 7 to 1 return on dollar investment of simulation training	Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical ICU
Effect of just-in-time simulation training on tracheal intubation procedure safety in the pediatric intensive care unit Nishisaki et al, 2010	US tertiary care children’s hospital PGY-1 through PGY-3 pediatrics residents and PGY-3 and PGY-4 emergency medicine residents rotating through pediatric ICU	Just-in-time simulation-based pediatric intubation training for on-call residents	First attempt and overall success on simulation-trained residents vs traditional trained residents	No difference in tracheal intubation success, but more residents able to perform procedure without added complications	Just-in-time simulation-based pediatric intubation training increased resident attempts in ICU, but no change in success rate
Obstetric safety improvement and its reflection in reserved claims (ADULT) Iverson et al, 2011	US teaching hospital OB/GYN and family medicine attendings	Retrospective review of the number of cases for which money was held in reserve for claims before and after safety improvement measures	Number of reserved claims per policy year	20% decrease per year in reserved claims, which was adjusted for delivery volume, over this time period	Obstetric simulation training was associated with safety improvement and decrease in reserved claims

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