He’s No Dummy

by Zach Read – zachary.read@unchealth.unc.edu
Photos by Max Englund – max.englund@unchealth.unc.edu

Before Bruce, a high-fidelity training manikin modeled after a 5-year-old boy, travels to a unit, Ashley Kellish, RN, receives clearance from the unit’s management team. The rules are simple: there must be an empty patient room to accommodate him, patient care on the unit cannot be interrupted, and staff should not be notified that Bruce is on the way.

“The staff has no idea we’re coming,” says Kellish, a clinical nurse education specialist at North Carolina Children’s Hospital and co-founder of the Children’s Hospital Simulation Committee, launched in June 2013. “We bring Bruce into the room, set him up, and get the first nurse, nursing assistant, or resident we can find. We ask them and others on the unit to come in and care for the patient. The patient is usually pulseless and not breathing—he’s coding.”

It’s not uncommon for staff on the unit to collectively sigh when they first see Bruce, admits Kellish, whose experience in educational simulation has spanned several hospitals. But once they begin caring for him, they become committed to practicing their skills and improving his condition.

Bruce, who became part of the Children’s Hospital team thanks to a gift from a generous donor, has pulses, breathes, and talks; his heart, lungs, and belly all make sounds; and he has seizures.

“Bruce can’t blink his eyes, but that’s about the only thing he doesn’t do,” says Kellish. “He’s very realistic and offers the staff a lot of abilities to practice skills and get involved in the simulation or situation.”

The committee aims to run simulations each week, taking Bruce throughout the N.C. Children’s Hospital and anywhere children are patients at UNC Hospitals. Led by Kellish, Afsaneh Pirzadeh, MD, assistant professor of pediatrics and anesthesiology, and Benny Joyner, MD, MPH, assistant professor of pediatrics and anesthesiology, the committee comprises nurses, respiratory therapists, physicians, nursing assistants, managers, and others.

The group believes that in situ simulation—conducting the simulation in the staff’s working environment rather than in a central location dedicated to simulation—is the most effective teaching and learning method for the “codes” they simulate and the goals they’ve set.


“Part of the problem is that if you go offsite to practice emergency skills, you’re with strangers, not with the team you work with,” says Kellish. “What we’re trying to do is take the manikin to your environment, with the same people you work with every day, and practice not only the skills of saving a life—the chest compressions, bagging, and so on—but how you work as a team, because these are your teammates and the people you’ll find yourself with should you have to care for a coding patient.”

In addition to focusing on improving teamwork, the committee identifies potential systems issues that, if unsolved, could prevent providers from responding most efficiently during the three to five minutes they have between the onset of a code and the arrival of a rapid response team. So far, Bruce’s visits have resulted in systems improvements as simple as relocating code carts on units and reconfiguring rooms to allow providers to move more seamlessly in and out of the room throughout the period of a code. The team plans to propose a hospital-wide systems training by calling for a code overhead and testing the response in the near future.

“There have been fewer and fewer codes because of advancements made in pediatric responses,” says Dr. Benny Joyner, interim division chief of Pediatric Critical Care and clinical co-director of the Clinical Skills and Patient Simulation Center at the UNC School of Medicine. “That means that kids aren’t having emergent situations as often, and that’s a great thing, but it also means that when it does happen, you need to be prepared. And that may involve doing better chest compressions, but it also may mean accessing equipment or getting the resources to the bed more quickly.”

The entire visit from the group lasts only 10 to 15 minutes—long enough to run the simulation and debrief, a session that provides staff with two or three teaching points. The group follows up by email with any systems issues they have identified and recommendations for improvement.

“We want people to think about how they’re communicating and how they’re working as a team and to understand the systems processes involved,” says Joyner. “Meanwhile, they’re also refreshing their training on the medical issues. Research has demonstrated that skills degrade over time if not regularly practiced, and that is the added benefit of these in situ sessions – the ability to practice on a regular basis.”

Dr. Afsaneh Pirzadeh did her fellowship at Children’s Hospital of Philadelphia, where simulation was so ingrained in the culture that some providers suffered simulation fatigue. She has been encouraged to see in situ simulations welcomed throughout UNC Hospitals. As the program expands, she hopes to strike the balance between developing a strong culture of simulation and running too many simulations.

“When we go to areas of the hospital where these are done less frequently, where a code would be rare, we’ve found that there’s a lot of interest,” says Pirzadeh.”Everyone wants to learn and get their hands on Bruce and practice, and every time we end a session, even though at the beginning people may feel they don’t have time to do the simulation, they want to do it over again. That’s a great feeling for us. We’ve gotten a lot of good feedback that way.”

Pirzadeh believes simulation is critically important for every level of care, and involving every person who cares for the patient. Even attendings in the ICU, where codes most often occur, she says, need repetition and practice. Down the road, she and her committee colleagues envision scenarios in which the PICU receives a phone call notifying them that a patient will be arriving in two hours in an emergent condition.

“We’ll be able to take our team of people who will be caring for the patient to Bruce and say, ‘This is the situation—go,’” she says. “When that patient arrives, you’ve already been through the situation, and you just did it in real time two hours earlier.”