In-situ Simulation: The 10 commandments

This past week, I had the opportunity to present to the Auckland Trauma Forum about the in-situ simulation and its value within trauma training. I believe however that it’s value extends far beyond trauma training. We’ve been using it at the helicopter base and in the ED. The pediatricians and obstetricians have recognized its utility as well especially given


the rare but high risk scenarios they may encounter.  As a result, I thought it would be appropriate to put up a post on the topic.  I’ve titled this “the 10 commandments” however, please feel free to disagree, challenge or critique my list…I just though the title sounded better that “a list of 10 things to consider while doing/planning in-situ simulation”.

Increasingly, educators are recognizing that in addition to traditional simulation (which occurs in a simulation centre), in-situ simulation provides benefits that are unattainable elsewhere. For those new to the concept, one definition of in-situ is

simulation that is physically integrated into the clinical environment

This quote is from a must-read for anyone interested in in-situ simulation. (Patterson et al. chapter on In-Situ simulation in the book “Advances in Patient Safety: New Directions and Alternative Approaches)

And now for the 10 Commandments of In-Situ Simulation (in no particular order…except maybe the first one or two).

1. Always run an in-situ simulation with well defined goals and objectives (and ensure participants have been briefed). I don’t think this needs elaboration

2. Always ensure there’s a debriefing period that’s adequate. This goes for all simulation but in-situ can easily be derailed especially if you’re using the on-call team and a sick patient arrives. Have a contingency plan for a debrief later on.

3. Use in-situ simulation to improve teamwork and coordination especially in acute care settings and high-risk situations. This will lead to improved patient outcomes (my opinion…data is promising). New data suggests the value of in-situ simulation includes improving teamwork and communication but may also lead to patient-oriented benefits.

Debriefing after a successful simulation. We have 3 different personnel here - doctor, paramedic and crewman. Truly multi-disciplinary.

Debriefing after a successful simulation. We have 3 different personnel here – doctor, paramedic and crewman. Truly multi-disciplinary.

4. Use in-situ simulation as a method of testing the ergonomics of your current clinical setting (current state analysis). We NEVER do this in medicine. I bet the next time you go into your resus room that you’ll find 10 things that are placed or designed in non-user friendly manner. Maybe the monitor isn’t easily visible. Maybe the chest-tube tray is just a big S***show everytime you open it…leading to delayed placement. Running simulations in your own work environment then evaluating it can be helpful! A study in one ED found that their response to life-threatening arrhythmias was horrible after running unannounced in-situ simulations…but it lead to improvement!

5. Separate in-situ simulation equipment from real equipment: We use identical equipment at the helicopter base for our in-situ simulation as we do in our real work. This is the benefit of in-situ simulation (we practice with the same equipment we work with). However, mixing equipment inadvertently can be dangerous. Imagine a ventilator purposefully tampered for a simulation that somehow ends up being used for a real patient. BAD. We label everything with big red tags “Defective – training gear”. Whatever you decide, just make sure everyone is aware. Sometimes you may want to use real equipment in the sim, but have someone responsible to ensure its appropriate re-integration into the clinical environment.

6. Notify others that in-situ simulation is in process: nothing worse than starting an in-situ simulation in your resus room and someone, unaware to the exercise, activates a code blue with personnel running from all ends of the hospital only to find that its just a simulation. This can be remedied by notifying others in the clinical environment via email/posters and signs.

7. Maximize learning for on-duty personnel by running an in-situ simulation: There are huge benefits of incorporating teaching for your on-call team while they’re at work anyways. Why bring people in on their day off to train when you can use down time during the day to run a sim in their own work environment! It’s efficient from a cost and time perspective. Who knows…maybe that failed airway drill run earlier in the day will prepare them for something later on!

No better way to see what its like to intubate in a helicopter then to actually the helicopter. A sim centre just isn't good enough for this objective. Notice our paramedic is in full gear too!

No better way to see what its like to intubate in a helicopter then to actually practice…in the helicopter. A sim centre just isn’t good enough for this objective. Notice our paramedic is in full gear too! Plus we can assess ergonomics of patient positioning. 

8. Multi-disciplinary is key for In-situ simulation: We work with large teams from all different specialties all the time. Engage your colleagues – not just fellow physicians but nurses, respiratory therapists, etc…

9. Seek departmental support to run in-situ simulation regularly: This doesn’t just mean one department…we rarely work in isolation during high risk/acute care situations. Often trauma or medical resuscitations require multiple teams so get support to gather teams from more than your own department.

10. Be creative! We don’t practice often enough the situations that can lead to bad outcomes. Wouldn’t it have been great if you had practiced running a resus in CT before you brought that trauma patient who crashed there? While initial decision making may have been an issue…maybe the fact the suction was missing could have been identified had an in-situ sim been run!

Bonus (#11): In-situ simulation is a fantastic way to test out new equipment/cognitive aids. We love new toys in medicine but rarely do we try them out other then when the rep comes in, gives us lunch and before we know it the new equipment is in use. This isn’t safe but despite our efforts we often escape bad outcomes. We should test run new equipment especially those used in high risk clinical settings. In addition, while I’m a huge fan of checklists or cognitive aids…I dont think these should just be implemented without some in-situ testing. Maybe the RSI checklist needs some tweaking…or maybe it doesn’t read well when it’s used in a time-sensitive manner. Get your team accustomed to using before you need it for that next failed airway.

Any feedback…I welcome hearing it!