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References Conclusions Objectives Utilizing Simulation to Identify Latent Safety Threats (LSTs) During Neonatal MRI Intramural Transport Wong J 1,2 , Kalaniti K 1 Lee KS 1 , Whyte H 1 , Shroff M 3 , Campbell DM 1,2 1 Division of Neonatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto 2 Allan Waters Family Simulation Center and Neonatal Intensive Care Unit, St. Michael’s Hospital, Li Ka Shing Knowledge Institute 3 Department of Diagnostic Imaging, The Hospital for Sick Children and Department of Medical Imaging, University of Toronto PO.ID 09-3 Background: In-situ simulation can be used to identify latent safety threats (LSTs) for patients in multiple clinical environments. Magnetic resonance imaging (MRI) is a frequently used, and costly imaging modality that is usually remotely located from most neonatal intensive care units (NICUs). Transport and MRI acquisition can put patients at risk. Our aim was to use simulation to identify LSTs during neonatal MRI transport and to improve transport processes. Methods: A prospective observational study was conducted at the Hospital for Sick Children (REB approved). Experienced transport personnel were recruited to participate in scripted simulation scenarios. Simulated ‘runs’ consisted of taking a neonate with hypoxic brain injury (MRI-compatible low-fidelity manikin) down to the MRI suite and back, in real-time. Data was obtained through self- reporting and direct observation. LST checklists and validated work load indexes were collected. Results: Ten simulated MRI transports were completed. Four were completed by dedicated transport teams, 3 by scheduled intramural teams (intramural RN & transport MD) and 3 by ad-hoc teams (RT, RN, and/or MD). 17 of 22 participants had >12 months of transport experience. 3 of 10 runs were in intubated patients.The most commonly identified LSTs included: lack of anticipation of clinical deterioration in an unfamiliar location and medication error. Medication-related hazards included: anticipation of medication need, errors in dose verification and administration. Common environmental threats included: confusion around equipment and where to resuscitate the patient once in the MRI suite. Differences in checklist performance were noted between dedicated transport teams and others. Clinicians reported increased mental & physical workload irrespective of patient acuity or years of experience. Significance: In-situ simulation was able to identify a number of significant LSTs during neonatal MRI transport, with variation amongst different team configurations. Strategies are as a result now in development for process improvement. In situ simulation of intramural transport runs detected a high amount of latent safety threats regardless of the experience of the transporting team As a result of this exercise measures include: changes to orientation of team members re: transports out of the NICU, MRI checklist implementation, medication kit review, and MRI resuscitation area are being reviewed Abstract Methods 9 th International Pediatric Simulation Symposium and Workshops 2017 1-3 June, Boston, MA, USA 1. Patterson MD, Geis GL et al. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf 2013;22:468-77. 2. Sorensen JL, Ostergaard d et al. Design of simulation-based medical education & advantages & disadvantages of in situ vs off-site simulation. BMC Medical Education 2017;17:20. 1) Identify latent safety threats (LST) during neonatal MRI intramural transport 2) Compare ability of three types of transport teams in carrying out neonatal MRI transport Results Type of LST # Details Communication 24 How to get help when in MRI suite Leadership issues within team Use of MRI tech as a resource Fixation awareness, sharing of mental model Medication 22 Anticipating need for meds (HIE patient, sedation, RSI) Team did not bring the medication(s), Drawing up medications not verified/no accountability IV fluids not brought down Equipment 12 IV equipment similar to O2 tubing, need to put IV through wall Lack of Self-inflating bags Air/oxygen/B&M setup in MRI suite Environment 26 Where to resuscitate deteriorating patient, location of MRI stethoscope unclear, difficulty with MRI IV tubing System issues General MRI suite 28 4 No teams used existing sedation guideline or intramural guideline as a checklist Only 2/10 informed front desk of leaving NICU Access to code team – code pink vs. code blue Multiple incompatible items brought into MRI (needles, syringes) TOTAL 116 11.6 LST/sim • 10 simulated neonatal MRI runs were carried out between April and December 2016 • 22 clinicians participated within 3 different type of teams: - Dedicated ACTS team: 4 runs - Intramural team (staffed RN+fellow): 3 runs - Ad hoc team: 3 runs • The median run time was 50 minutes (36-60 minutes) •All runs had multiple LSTs (self-reported and via debriefing) in multiple domains, many of a critical nature • No teams used a pre-existing protocol checklist for intramural runs (not MRI specific) or used a sedation protocol • None of the teams anticipated the need of seizure medications, RSI meds in MRI suite • 15/22 (68%) teams experienced high mental and physical workload as well as effort, but only 2/22 (9%) felt hurried or rushed • This project was a joint exercise with REB approval between the Division of Neonatology and Department of Diagnostic Imaging at the Hospital for Sick Children. •A series of 10 simulated neonatal MRI runs was carried out with existing transport teams after informed consent. • Standardized clinical scenarios involved the transport of a neonate either intubated or non- intubated full-term neonates with HIE who required MRI following re-warming, including a deterioration in the MRI suite •The MRI run included a handover, transport into the MRI scanner, and a subsequent return to the NICU Outcome measurements included: •Frequency and type of Latent safety threats (LSTs) (via questionnaire, structured debriefing and observation) •Task completion checklists scored by video-reviewers • Workload estimates (mental, physical, temporal, effort)as assessed by participants filling out a NASA Task Load Index
