Operating room trauma simulation: The St. Luke's University Health Network experience.

INTRODUCTION

The maintenance of readiness is an important component of care optimization for the critically injured trauma patient. This applies to the individual, the team, and the system levels. Evidence shows that there may be a correlation between trauma volumes and effective trauma team readiness and that there may also exist a relationship between clinical outcomes and the number of patients treated during a specific period of time.[1] Simulated cases, especially those featuring realistic, high-fidelity scenarios, have the potential to materially enhance trauma team readiness, retention of process-specific skills, and knowledge, in addition to improving the critical thinking ability.[2345] To help enhance our trauma team's functional readiness in the emergency operative setting, we set out to design and implement an operating room (OR) trauma simulation (ORTS) exercise. The aim of this simulation exercise was to identify the key opportunities to further optimize our existing OR trauma procedures and performance.

OPERATIVE TRAUMA SIMULATION SCENARIO

Case simulation summary

Level A Alert (e.g., highest acuity) is called for a trauma patient who presents after sustaining a gunshot wound to the abdomen. He is unstable, is promptly brought to the OR, and massive transfusion protocol is called due to rapidly deteriorating patient condition. The attending trauma surgeon then decides to prepare for emergency thoracotomy, including open cardiac massage and direct application of internal defibrillation pads. In the meanwhile, the patient responds to less invasive resuscitative maneuvers, the thoracotomy is aborted, and the surgeon proceeds with the original plan to perform an exploratory laparotomy.

The setting

The simulated case scenario took place at the University Hospital OR (St. Luke's University Hospital, Bethlehem, Pennsylvania, USA).

Key components and structure of the process

The overall ORTS process is simple but requires excellent operational integration due to ongoing primary OR activities. The overall exercise takes anywhere between 30 and 50 min, depending on the completion time for each of the preplanned phases [Figure 1]. The list of exercise participants, including their respective roles, is provided in Table 1. The ORTS is designed to evaluate the skills and system-based aspects specific to emergency OR trauma cases [Table 2]. Within this framework, each learner is exposed to predefined goals, objectives, and skills [Table 3]. A deliberate preparation process [Table 4] and simulation set-up process [Table 5] takes place before the exercise commences. The simulation itself is highly structured [Table 6] and incorporates a formal skills assessment grid, complete with postexercise debrief [Table 7]. Sample photos from the simulation exercise are provided in Figure 2.

Figure 1

Allocated exercise time, including Pre-brief (5 min); Simulation (15–30 min); and Debrief (10–15 min); with an anticipated total time of 30–50 min

Table 1

Required participants of the current trauma simulation exercise

Personnel description	Personnel role
Simulation personnel	Oversight/objective observers
Trauma surgeon	Trauma team leader
Trauma residents/fellows	Trauma team participants/members
Anesthesiologist/certified registered nurse anesthetist	OR team members
Registered nurse circulator (χ2)	OR team members
Surgical technologist (χ2)	OR team members

OR: Operating room

Table 2

Summary of broadly defined categories of skills and systems-based aspects of the current trauma simulation exercise

Item category	Specific skills and system-based aspects
Systems explored	Roles of the perioperative team members during an emergency trauma surgery/MTP event
Technical skills examined	Familiarity with cell saver deployment/operation; defibrillator use, including internal pad placement
Interdisciplinary training in communication and professionalism	Participants must learn how to effectively delegate/collaborate

MTP: Massive transfusion protocol

Table 3

Summary of specific goals, objectives, and skills the learner should be exposed to and acquire as a result of this exercise

Category/item
Demonstrate competence during an MTP
Perform competently during a trauma code when the crash cart is involved
Identify the appropriate treatment and equipment needed for a patient that needs an MTP or is hemodynamically unstable in the OR
Observe/explore how to effectively delegate tasks such as having someone stay with the surgical technologist while the main circulator charts and delegates, having a second person scrub in to help at the field, and having someone help check/infuse blood. All of the above should be done in a clear, seamless, and respectful manner
Upon examining the simulated OR scenario, an objective observer should be able to readily identify who is performing each respective job/function
Demonstrate the knowledge of, and the ability to use, the equipment needed to perform thoracotomy
Demonstrate the proper use of the defibrillator device and R2 defibrillation pads

MTP: Massive transfusion protocol, OR: Operating room

Table 4

Synopsis of participant preparation for the trauma simulation exercise

Phase	Characteristics/Description
Pre-simulation	In-service training involving the following elements:
	Massive transfusion and associated documentation
	Cell saver use and instructions
	Defibrillator and crash cart instructions
	Instruments/equipment needed to perform emergency trauma thoracotomy
	Patient positioning required for a trauma patient in the OR and ergonomic assist devices/cushions needed for each position
	Main circulator, scrub, nurse to perform counts with surgical technologist and stay with them, nurse to check blood, runner, etc.
	Review the facility policy on MTP in OR
Introduction and prebrief checklist	Participants take the pre-ORTS survey and introduce themselves if needed or as consistent with their team function and/or point of entry into the scenario based on specialty, experience, and role
	The orientation of participants to the ORTS process, including: (a) Briefing; (b) Case (simulation); (c) Debriefing to discuss and review what went well and where there are opportunities for improvement; and (d) Feedback and closing remarks/discussion
	Discuss course objectives and rationale behind this exercise: (a) Simulation is a safe and confidential learning environment; (b) Acknowledge any participant anxiety; (c) Assure confidentiality of participant performance evaluation; (d) Obtain buy-in for simulation activities. Treat as a real-life situation, given the limitations of working with a mannequin, simulated medications, etc., (e) Treat the simulated patient as if it was your perioperative patient; and (f) There will be other staff or “observers” present for debriefing purposes
	Discuss expectations with participants: (a) Clinical role/realistic presence (e.g., be yourself); (b) Assure participants that “embedded observers” are there only to assist them and provide positive feedback; (c) Simulation team will be present if questions arise - but the simulation will continue just as a real-life scenario would
	Identify equipment that is necessary for the purposes of the ORTS and be aware of any potential related safety issues: (a) Mannequin; (b) Defibrillators/emergency equipment; (c) Cell saver device/circuit; (d) Monitoring devices displaying vital signs; and (e) Any pertinent/associated documentation
	Orient participants to patient situation and team member roles; the roles will be clearly explained before the simulation starts and staff will be educated on them in advance: (a) “A 35-year-old male in trauma bay with GSW to the abdomen;” (b) Staff given case cart with some preselected items and instrumentation; (c) Staff is told this simulation is supposed to mimic a “kick in the door” trauma and to be prepared for the “patient” to emergently come back to the OR
	The “float/supporting” personnel may come in and out of the room during the simulation to prompt the circulator to delegate roles to other staff
	Ask participants if there are any questions before beginning: (a) Answer any additional questions; (b) Announce that the simulation is starting

GSW: Gunshot wound, MTP: Massive transfusion protocol, OR: Operating room, ORTS: OR Trauma Simulation

Table 5

Trauma simulation setup

Phase	Characteristics/Description
Room setup	The simulation utilizes OR that is not in active use. Appropriate preparations need to take place to facilitate the ORTS without disrupting any concurrent OR case flows
Equipment and supplies	For the purpose of this simulation, an OR bed will be preferable. A mannequin representing the simulated patient will be required. Alternatively, moulage acting may be employed
	OR back table and Mayo stand basic set up is prepared, including laparotomy sponges, trauma boat and rack, and other necessary components
	Bovie electrocautery equipment will be provided to create a more realistic simulation environment
	Emergency cart (to be requested by the team) should be available, with all basic features and equipment in place
	Cell saver and tubing (to be requested by trauma attending surgeon) will also be provided for the simulation, along with Belmont (Belmont Medical Technologies, Billerica, Massachusetts, USA) rapid infuser or equivalent device setup
Simulator preparation	Mannequin/Moulage Actor configuration: (a) If mannequin, intubation by simulation instructor is performed ahead of the exercise; (b) For moulage actor, appropriate labels are placed to simulate intubation
	Electronic simulator program should be set up to provide vital signs, standardized responses, etc., in the setting of mannequin use; Analogous responses are communicated in settings that utilize a moulage actor, as appropriate
	Positioning is supine, consistent with standard trauma patient positioning
	Additional simulation features include advanced preparation for the placement of R2 pads (along with preplacement preparation)
	As the simulation begins, the stretcher is used to bring mannequin/moulage actor into the OR, followed by transfer to OR bed

OR: Operating room, ORTS: OR Trauma Simulation

Table 6

Sequence of events during simulation

Step	Comment/Description
Introduction	A 35-year-old male arrives by ambulance to an emergency department/trauma bay with a GSW to the abdomen. The patient is alert and oriented X1, and rapidly declining
Initial vital signs	Heart rate: 120 beats/minBlood pressure: 65/30 mmHgRespirations: 16 breaths/min
Adjunctive physiological indicators	Electrocardiogram: Sinus tachycardiaSpO2: 90%
Immediate actions	The patient is immediately intubated and taken directly to OR, foregoing any additional testing. This is as an emergency measure to attempt hemorrhage control: (a) Circulator and scrub assigned to trauma and prebriefed; (b) Patient arrives in the OR and vital signs continue to decline: (c) Attending trauma surgeon enters the OR and requests “cell saver and MTP” to be called immediately; (d) Anesthesiologist requests a technician to be called to help them; (e) At least two other staff members will walk into the room to ask if they can help, with the intent for the circulator to delegate tasks to them
OR events	After preparations take place in the OR for a few minutes, the attending trauma surgeon will state that he/she needs to perform an emergency thoracotomy. Around the same time, the patient’s heart rhythm degenerates into ventricular tachycardia
	Given the gravity of this rapidly evolving clinical scenario, OR staff reach for thoracotomy instruments, call for “crash cart” (if not already in the room), and rush to obtain and apply R2 pads on the patient as quickly as possible
Patient stabilizes	The attending trauma surgeon states that he/she will now defibrillate the patient, at minimum once. Staff in the room will be assessed on their ability to connect and operate the defibrillator
	Once the patient is defibrillated, the vital signs begin to stabilize. Simultaneous MTP is in progress. Thoracotomy is now aborted
	Anesthesia team announces that blood pressure has now stabilized, and the attending trauma surgeon asks if the patient is sufficiently stable to proceed with the originally planned laparotomy. Anesthesia team confirms that “we are now stable enough”
Laparotomy proceeds	The main circulator is now prompted to request any staff members who are no longer needed, given the improvement in patient condition, to leave the room
	In parallel, the OR charge nurse will call into the room asking how things are proceeding. The charge nurse will specifically ask for additional staff in other rooms if no longer required in the trauma room
Conclusion and debrief	The trauma simulation now ends, followed by a detailed debrief. The team focuses on what went well and whether there were any opportunities for improvement
	Begin debriefing by soliciting the participant’s reactions to the simulation experience. Ensure clarity by providing a brief overview of the simulated patient scenario so that everyone is on the same page: (a) Emphasize confidentiality; (b) Again clarify expectations; (c) Review learning objectives; (d) Discuss what happened during the simulation; (e) Review what went well; (f) Consider opportunities for improvement
Self/group reflection strategies	Encourage open expression and sharing of immediate reactions to the exercise. Examples of questions to ask participants: (a) “How did participating in this simulation make you feel?;” (b) “Describe your thinking when…?;” (c) “Were there performance gaps?;” (d) “What could be changed in the OR?”
	Perform a review of the participant’s roles and team expectations
	Review key principles of effective interprofessional teamwork
	Review expectations for effective communication and identify any learner issues/concerns
	Provide simulation exercise participants with postsimulation survey

SpO2: Oxygen saturation, GSW: Gunshot wound, OR: Operating room, MTP: Massive transfusion protocol

Table 7

Formal skills assessment

Action/treatment checklist	Time	Skill met	Skill not met
The lead circulator is determined and announced
Basic OR trauma setup done (surgical boat and rack)
Lead circulator delegates to other nursing team members clearly and respectfully
The team recognizes patient deterioration and calls for cell saver deployment
Learner initiates MTP when asked
Participant recognizes to get crash cart into the room and/or calls for it
Participant demonstrates how to use/set up cell saver
Learner is able to use crash cart and defibrillator
Participant shows sufficient knowledge of surgical instruments needed to open the chest
Surgical team carries out trauma in an organized fashion
Learner is able to demonstrate how to place R2 pads

Comment: The team should continue the simulation exercise until all predetermined actions and/or treatments are completed. Treatment action time points are clearly referenced, beginning with the “time of crisis” announcement. MTP: Massive transfusion protocol

Figure 2

Photos from the current operating room trauma simulation exercise. (Left) Team of participants performing a procedure on mannequin; (Right) cell saver device

DISCUSSION

Simulation is one of the most important tools to achieve and maintain readiness in trauma scenarios, especially when dealing with the less commonly encountered patient who is in extremis. Among the cornerstones of effective trauma response is the right combination of team coordination, communication, and collaboration. Without these three components, an organized trauma response is bound to have inherent inefficiencies, and patient outcomes may suffer as a result.[678]

Barriers to implementing effective simulation include low fidelity/lack of realism, inadequate logistics, insufficient time, financial consequences of “nonproductive” time, intimidating or stressful environment, and fear of being judged/critiqued.[9] Of importance, without institutional commitment to high-quality simulation, critical processes used in emergent scenarios may suffer when put to the real-life test. Previous research suggests that lower-than-usual trauma volumes, even for very busy trauma centers that experience a “temporary slow-down,” may result in worse outcomes during such slower periods.[1] Consequently, fostering some form of “mission readiness” may be beneficial to ensure that appropriate levels of critical thinking and cognitive skills, along with technical competency, are maintained [Table 7].[10111213]

Simulated scenarios, especially high-fidelity ones, promise to provide an effective platform for the maintenance of readiness, especially in the context immediately relevant to this commentary.[10111314] In addition, simulation-based training may also be beneficial in provider confidence building and patient safety promotion.[13151617] These concepts take on further significance and depth when considered in the inter-professional environment of modern trauma practice, where large and intricately interconnected teams are required to perform highly coordinated, complex task sequences in patient-centered fashion.[181920]

In conclusion, the current report of our institutional experience with ORTS provides a readily implementable framework for other, similarly structured institutions. Following exercise completion, the majority of participants identified a number of opportunities for improvement, at personal, team, and institutional levels. Consequently, we recommend other trauma centers (and institutions where similar experiences may be of value) to consider this approach to maintaining readiness, especially across “mission-critical” areas of team performance.