Risk Mitigation in Sedation Systems
Reviewed by Ben Jackson, MD
Attendees at the 2017 SPS Annual Conference were treated to an insightful plenary session on the valuable role of simulation in pediatric sedation training entitled “Risk Mitigation in Sedation Systems” co-presented by Tensing Maa, MD, a Pediatric Intensivist and Medical Director of the Insitu Simulation Program at Nationwide Children’s, and Karen Kelly, MSN, RN, CHSE, a System Simulation Educator at Florida Hospital Medical Simulation and Training Center.
Citing Cravero et al’s 2006 publication in Pediatrics “Incidence and Nature of Adverse Events in Pediatric Sedation/Anesthesia for Procedures Outside the Operating Room: Report from the Pediatric Sedation Research Consortium”, Maa and Kelly noted that while ultimately serious adverse outcomes in pediatric sedation are rare, “adverse events with potential to harm and require timely rescue occurred once per 89 sedation encounters.” Simulation, they compellingly presented, offers the optimal training basis and risk mitigation strategy for pediatric sedation practitioners navigating this dichotomous reality of low-frequency, high-risk adverse event potential.
Featuring low-fidelity or high-fidelity mannequins, task trainers, human subjects acting as patients, or even virtual reality, simulation as defined by Gaba in 2004 is “a technique, not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature that evoke or replicate substantial aspects of the real world in a fully interactive fashion.” Exposures in simulated settings afford individuals and teams the opportunities to encounter high-risk events and practice navigating the challenges these events pose both to themselves and to patients. In this context, knowledge and performance gaps may be identified and closed, skill proficiency may be developed and maintained, and interprofessional teamwork may be advanced.
Vital to simulation training is the act of debriefing. Prebriefing introduces participants to goals and objectives for the case, and following the simulated clinical encounter, participants are called on to debrief, processing problems with equipment, personnel, techniques, communication and teamwork, and physical constraints, as well as identifying and discussing knowledge or skill gaps. In doing so, participants develop improved situational awareness and understanding of the perspectives of others such that subsequent runs through the case will go more smoothly with the ultimate goal of delivering enhanced care to patients in the non-simulated clinical arena.
Armed with these benefits, providers who have undergone simulation training may develop the capacity to avoid or overcome “amygdala hijacking”, which Maa and Kelly introduced. Amygdala hijacking describes the psychological neuroscience phenomenon of the incapacitation of rational thought and action governed by the brain’s prefrontal cortex when a stressful event results in the amygdala stimulating the release of stress hormones from the hypothalamic-pituitary-adrenocortical axis. Rarely occurring, life-threatening events in pediatric sedation encounters pose risk for amygdala hijacking in the sedation provider, which translates into impairment of judgment and the potential for erroneous care in the face of the stressful event. Through simulation training, sedation providers are confronted by adverse events and through deliberate, repetitive, focused practice with rigorous assessment and informative feedback develop the cognitive and psychomotor tools to navigate critical incident adverse events calmly and systematically, which translates into improved sedation care.
In terms of pragmatic application, simulation should be tailored to address one or more learning targets, which should be explicitly identified in creating scenarios: assessment, psychomotor skills, monitoring and intervention, communication, clinical problem solving, leadership and teamwork. In the pediatric sedation realm, scenarios based on upper airway obstruction, laryngospasm, apnea, or hypotension. With even the highest degree of scrutiny in patient selection, occurrence of these adverse events remain a potential during any sedation encounter. Simulation of each event scenario is warranted and offers plenty of potential for disaster and plenty of opportunity for knowledge and skill develop, while challenging participants to communicate well, to call for and handle equipment, and to employ the necessary psychomotor skills to rescue the simulated patient with an adverse event from an adverse outcome.
Finally, Maa and Kelly contrasted distinct settings in which these simulation training encounters may be run: in-situ simulation versus that in a simulation center context. In-situ simulation offers the advantages of bringing the training to the learner, allowing the participants the opportunity to navigate scenarios in the settings in which their clinical care is delivered. In the course of managing actual physical constraints, room set-up, and equipment, latent safety threats may be discovered and existing processes tested. Furthermore, in-situ simulation training may be offered “on the job” without requiring care team members to schedule additional simulation sessions or depart the care environment.
The challenges, however, involve the possibility of distraction from the simulation and of space unavailability for sedation due to concomitant patient care, which may translate into diminished participant engagement or even cancellation. Still, in-situ simulation is particularly valuable during orientation to new clinical spaces in its capacity to “crash test” the unit by ensuring oversights in planning and set-up have not occurred or discovering them prior to subjecting actual patients to the risks thereof. Simulation center training, on the other hand, may offer less physical fidelity to the patient care unit and require participants to take time away from work, but it adds a number of advantages such as freedom from the distractions of work, guaranteed simulation space availability, and ability for the simulation facilitator to operate outside of the room, a distinction which may affect the engagement of participants in the simulated scenarios.
In a dedicated simulation environment, attentiveness to the training proceeds without workplace interruption, affording participants the freedom to engage content, trial new techniques, and dialogue. With advantages and challenges to both, it is thus up to sedation services to determine which simulation modality best suits their respective needs.
In this thorough presentation, Maa and Kelly combined theoretical and practical elements to promote simulation training for pediatric sedation providers as a means of enhancing care, improving patient safety, and mitigating risk. Simulation has been demonstrated in the literature to improve patient outcomes and has been embraced by the Society for Pediatric Sedation in its robust simulation-based Provider Course with these ends in mind. Pediatric sedation providers and services are encouraged to consider these benefits and to pursue simulation training at institutions where it is not yet available.