Presentation
PS11 - Resuscitation Ergonomics; optimizing human factors and the environment to improve CPR performance during pediatric in-hospital cardiac arrest events
DescriptionEach year in the United States there are more than 6000 pediatric in-hospital cardiac arrests (IHCA) with low survival rates. The intensive care unit, where the majority of IHCAs occur, is an inherently chaotic environment where patient acuity and stakes are high. Pediatric patients experience acute and unexpected clinical deterioration making the ICU environment dynamic, complex, and stressful. Front-line teams face daily challenges as information evolves and clinical work- flows and processes shift to address novel problems and changing needs. Front-line teams therefore must have a high level of adaptive capacity, defined as the ability to acclimate, adjust, and respond to complex, changing, and challenging conditions. Under high-stress conditions, ability to employ adaptative expertise is challenging. Strategies that involve system improvements to standardize practices and reduce variation in care minimize reliance on human behavior to augment patient safety.
In a study on CPR performance Hunt et al, recognize the impact of the physical space and ergonomics on the quality of CPR. The term ‘Resuscitation Ergonomics’ focuses on improving patient outcomes by optimizing the interaction of the environment with human factor driven behaviors during critical and emergent episodes of patient decompensation and cardiac arrest.
“Room Diagramming” is a risk mitigation strategy used to optimize the work system and environment so that effective resuscitative efforts are not solely dependent on human driven behaviors. Room diagramming improves resuscitation efforts by providing strategic mapping for personnel and equipment to optimize CPR sightlines and ergonomics so that each pivotal member of the resuscitation team has visual access to each other, patient data, and external feedback that enhance CPR quality.
Hunt et al proposed an ergonomic map that teams should adapt to improve resuscitation ergonomics. Simple adoption of an this proposed ergonomic map would have fast-tracked implementation. In our system, failure to successfully integrate new process or care models have failed due to lack of protocol clarity, staff buy-in, local practices and culture, resource availability, and heterogeneity in patient clinical condition. Imagining integration in care and assuming “face validity” would have failed to identify limitations that are unique to our ICU room design, local microwork system culture and practices.
Translational Work Integrating Simulation and Systems Testing (TWISST) is a process improvement tool that couples Simulation-based Clinical Systems Testing (SbCST) with simulation-based training (SbT). Like the quality-based method of assessing change, Plan-Simulate- Study-Act (PSSA) is a problem-solving method to identify key drivers for process improvements and specifies simulation as the iterative process improvement tool. In the ‘simulate’ phase of the PDSA cycle high-fidelity simulations of high-risk scenarios recreate and approximate the realities of complex patient care delivery to demonstrate work-as-done, unpacking the dynamic interaction of people with their work system. Debriefings and Failure Mode Effect Analysis (FMEA) is applied to identify latent conditions and mitigate safety concerns. Embedding solutions in SbT ensures optimal integration into clinical workflow before widespread implementation, hardwires system improvements, and drives change management.
TWISST methodology identified latent safety threats related to adaptation of the prescribed ergonomic map. High acuity areas including the emergency department, pediatric and cardiac intensive care unit, and cardiac step-down unit participated in TWISST simulations evaluating Resuscitation Ergonomics. Prior to simulation stakeholders created ergonomic maps for their respective unit based on the map prescribed by Hunt er al. These maps represented imagined work, where teams thought equipment and personnel would ideally be located during a cardiac arrest event. Prototype maps were then tested and validated during simulation.
Five distinct clinical areas participated in simulation (two Pediatric ICUs, one emergency department, and one cardiac ICU, and the cardiac step-down unit). Simulations for each clinical area were conducted separately with front life staff who worked in that department. High risk clinical scenarios represented an in-hospital cardiac arrest event. Teams arranged personnel and equipment in the room as directed by their ergonomic map. Debriefings identified latent conditions related to poor resuscitation ergonomics that impacted CPR quality.
Overall, 44 total latent conditions were identified across the 5 clinical areas that participated in simulation. Latent conditions included inadequate communication between team members due to their position around the patient bed. In particular, the positioning of team members that performed basic CPR was ineffective. This team included the physician, CPR coach, respiratory therapist providing bag/mask ventilation and the chest compressor. Movement of personnel and equipment during resuscitation created multiple disruptions that impeded direct communication between these team members. Additional latent conditions included ineffective access to equipment, and poor sightlines to the physiologic monitor and defibrillator. Simulations demonstrating work as done revealed unintended consequences that the teams did not image during initial ergonomic mapping.
Changes were made to the ergonomic map for each clinical area following simulation. Equipment and personnel were repositioned to improve communication to team members and sightlines to personnel and patient monitoring equipment. The impact of the built environment and in patient room design was also elucidated during simulation. The in-patient room design of each of these clinical areas is not standardized. Some units have both private rooms and open bay spaces, mirrored rooms and same handed rooms, booms, and headwalls. Due to the vast variation in physical design of each space, each clinical area required a different ergonomic map specific to that unit. Following simulation, teams realized that they in fact needed multiple variations of the map for each room layout within their unit. This work also primed the teams for a CPR quality initiative that included a CPR coach. This program utilizes real time chest compression data to provide immediate feedback to team members to ensure delivery of adequate chest compressions at the correct rate and depth. During simulations, the teams identified that often the imaged position of where the CPR coach would stand with the defibrillator was inadequate. Changes were made to the ergonomic map and the CPR coach position was relocated to optimize communication and visibility. These finalized ergonomic maps were then embedded into training during our CPR coach program role out.
Human factors are consistently in play in healthcare and the complex ways in which humans interact with their work system makes space utilization and process implementation unpredictable. Despite having a prescribed ergonomic map suggested in the literature, and teams adapting that that map for their unit specific workflow, inadequacies in team member and equipment positioning could not be imagined. Simulation offered an approach that more accurately represented work-as-done.
Through simulation videos, photos, and graphical analysis we will demonstrate how multidisciplinary care during cardiac arrest events is delivered in the highest acuity areas of a children’s hospital. We will demonstrate why was impossible for clinicians to imagine all the complexities of care delivery during cardiac arrest events. We will discuss (1) the heterogeneity in patients’ disease and (2) the nuances in care delivery that are highly dependent on clinical process, and unit-based culture that makes it challenging to create a standardize ergonomic map that works across multiple clinical areas. We will discuss how human factors and human behaviors drive space utilization, and show the workarounds that clinicians developed to overcome barriers in their environment that could potentially lead to patient harm. We will then demonstrate how we were able to mitigate risk through ergonomic mapping.
Learners will be exposed to the complexity care delivery during in-hospital cardiac arrest. Learners will understand the relationship between human factors, ergonomics, and space utilization on CPR performance and patient outcomes during cardiac arrest and why one size does not always fit all when it comes to process improvement initiatives. Learners will understand how we applied TWISST to optimize our ergonomic mapping.
In a study on CPR performance Hunt et al, recognize the impact of the physical space and ergonomics on the quality of CPR. The term ‘Resuscitation Ergonomics’ focuses on improving patient outcomes by optimizing the interaction of the environment with human factor driven behaviors during critical and emergent episodes of patient decompensation and cardiac arrest.
“Room Diagramming” is a risk mitigation strategy used to optimize the work system and environment so that effective resuscitative efforts are not solely dependent on human driven behaviors. Room diagramming improves resuscitation efforts by providing strategic mapping for personnel and equipment to optimize CPR sightlines and ergonomics so that each pivotal member of the resuscitation team has visual access to each other, patient data, and external feedback that enhance CPR quality.
Hunt et al proposed an ergonomic map that teams should adapt to improve resuscitation ergonomics. Simple adoption of an this proposed ergonomic map would have fast-tracked implementation. In our system, failure to successfully integrate new process or care models have failed due to lack of protocol clarity, staff buy-in, local practices and culture, resource availability, and heterogeneity in patient clinical condition. Imagining integration in care and assuming “face validity” would have failed to identify limitations that are unique to our ICU room design, local microwork system culture and practices.
Translational Work Integrating Simulation and Systems Testing (TWISST) is a process improvement tool that couples Simulation-based Clinical Systems Testing (SbCST) with simulation-based training (SbT). Like the quality-based method of assessing change, Plan-Simulate- Study-Act (PSSA) is a problem-solving method to identify key drivers for process improvements and specifies simulation as the iterative process improvement tool. In the ‘simulate’ phase of the PDSA cycle high-fidelity simulations of high-risk scenarios recreate and approximate the realities of complex patient care delivery to demonstrate work-as-done, unpacking the dynamic interaction of people with their work system. Debriefings and Failure Mode Effect Analysis (FMEA) is applied to identify latent conditions and mitigate safety concerns. Embedding solutions in SbT ensures optimal integration into clinical workflow before widespread implementation, hardwires system improvements, and drives change management.
TWISST methodology identified latent safety threats related to adaptation of the prescribed ergonomic map. High acuity areas including the emergency department, pediatric and cardiac intensive care unit, and cardiac step-down unit participated in TWISST simulations evaluating Resuscitation Ergonomics. Prior to simulation stakeholders created ergonomic maps for their respective unit based on the map prescribed by Hunt er al. These maps represented imagined work, where teams thought equipment and personnel would ideally be located during a cardiac arrest event. Prototype maps were then tested and validated during simulation.
Five distinct clinical areas participated in simulation (two Pediatric ICUs, one emergency department, and one cardiac ICU, and the cardiac step-down unit). Simulations for each clinical area were conducted separately with front life staff who worked in that department. High risk clinical scenarios represented an in-hospital cardiac arrest event. Teams arranged personnel and equipment in the room as directed by their ergonomic map. Debriefings identified latent conditions related to poor resuscitation ergonomics that impacted CPR quality.
Overall, 44 total latent conditions were identified across the 5 clinical areas that participated in simulation. Latent conditions included inadequate communication between team members due to their position around the patient bed. In particular, the positioning of team members that performed basic CPR was ineffective. This team included the physician, CPR coach, respiratory therapist providing bag/mask ventilation and the chest compressor. Movement of personnel and equipment during resuscitation created multiple disruptions that impeded direct communication between these team members. Additional latent conditions included ineffective access to equipment, and poor sightlines to the physiologic monitor and defibrillator. Simulations demonstrating work as done revealed unintended consequences that the teams did not image during initial ergonomic mapping.
Changes were made to the ergonomic map for each clinical area following simulation. Equipment and personnel were repositioned to improve communication to team members and sightlines to personnel and patient monitoring equipment. The impact of the built environment and in patient room design was also elucidated during simulation. The in-patient room design of each of these clinical areas is not standardized. Some units have both private rooms and open bay spaces, mirrored rooms and same handed rooms, booms, and headwalls. Due to the vast variation in physical design of each space, each clinical area required a different ergonomic map specific to that unit. Following simulation, teams realized that they in fact needed multiple variations of the map for each room layout within their unit. This work also primed the teams for a CPR quality initiative that included a CPR coach. This program utilizes real time chest compression data to provide immediate feedback to team members to ensure delivery of adequate chest compressions at the correct rate and depth. During simulations, the teams identified that often the imaged position of where the CPR coach would stand with the defibrillator was inadequate. Changes were made to the ergonomic map and the CPR coach position was relocated to optimize communication and visibility. These finalized ergonomic maps were then embedded into training during our CPR coach program role out.
Human factors are consistently in play in healthcare and the complex ways in which humans interact with their work system makes space utilization and process implementation unpredictable. Despite having a prescribed ergonomic map suggested in the literature, and teams adapting that that map for their unit specific workflow, inadequacies in team member and equipment positioning could not be imagined. Simulation offered an approach that more accurately represented work-as-done.
Through simulation videos, photos, and graphical analysis we will demonstrate how multidisciplinary care during cardiac arrest events is delivered in the highest acuity areas of a children’s hospital. We will demonstrate why was impossible for clinicians to imagine all the complexities of care delivery during cardiac arrest events. We will discuss (1) the heterogeneity in patients’ disease and (2) the nuances in care delivery that are highly dependent on clinical process, and unit-based culture that makes it challenging to create a standardize ergonomic map that works across multiple clinical areas. We will discuss how human factors and human behaviors drive space utilization, and show the workarounds that clinicians developed to overcome barriers in their environment that could potentially lead to patient harm. We will then demonstrate how we were able to mitigate risk through ergonomic mapping.
Learners will be exposed to the complexity care delivery during in-hospital cardiac arrest. Learners will understand the relationship between human factors, ergonomics, and space utilization on CPR performance and patient outcomes during cardiac arrest and why one size does not always fit all when it comes to process improvement initiatives. Learners will understand how we applied TWISST to optimize our ergonomic mapping.
Event Type
Poster Presentation
TimeMonday, March 254:45pm - 6:15pm CDT
LocationSalon C
Digital Health
Simulation and Education
Hospital Environments
Medical and Drug Delivery Devices
Patient Safety Research and Initiatives