Point-of-care simulation training to address serious untoward incidence of hypoglycaemia

Diabetes healthcare is increasing in complexity at an astounding rate. Rapid developments in practice often result in an increased depth of knowledge and skills required by healthcare professionals in caring for those with diabetes.

With ever-changing team dynamics and restructuring of healthcare organisations comes the need to provide high-quality and safe clinical practice in diabetes management. Training and education programmes are one way to address these demands, however evolving educational strategies are now required over traditional standard education.

Since the 1960s, the aviation industry has turned to simulation (SIM) training to provide such education programmes in their profession. SIM training proved to equip staff with the necessary skills and knowledge required.

The use of SIM in the aviation industry has not gone unnoticed by healthcare providers. The Chief Medical Officer, Sir Liam Donaldson (Donaldson, 2009), stated:

“Simulation training in all its forms will be a vital part in building a safer healthcare system.”

SIM training has also received significant endorsement by the Department of Health (2011) and the General Medical Council (2011). SIM training allows the recreation of real life, in an environment that is safe for the clinician and the patient, as well as being effective in developing both technical and non-technical skills (Cook et al, 2011).

Following the publication of the damming report of the failings at The Mid Staffordshire NHS Foundation Trust (Francis, 2013), the NHS in the UK is under enormous scrutiny. Our Trust has recognised the importance of cultural changes at the coalface by introducing an integrated SIM team using point-of-care (POC) SIM. POC SIM is one way to improve morale, enhance education, and tackle human factors and team working dynamics to ultimately improve upon patient care and safety.

Background
The Royal Cornwall Hospital is a district general hospital based in Truro in Cornwall, with approximately 743 beds and outpatient departments. The number of people with diabetes in Cornwall is approximately 28000 with a high inpatient prevalence of diabetes. Diabetes Inpatient Specialist Nurses (DISNs) from the Cornwall Partnership NHS Foundation Trust provide diabetes inpatient services to the acute trust.

A SIM pilot project was initially funded by the Strategic Health Authority innovation fund and the Trust’s department of post-graduate education. This enabled set up of a dedicated SIM facility with an appointment of a SIM practitioner and purchase of the SIM equipment. In collaboration with existing available resources, an anaesthetic fellow and members of the hospitals learning and development department, a SIM team was formulated. To obtain the necessary skills to deliver SIM, the team attended the Bristol Medical Simulation Centre training, which then facilitated POC training to be implemented within the hospital (Bristol Medical Simulation Centre, 2017).

Following commencement of the successful pilot, which had been received enthusiastically by all members of staff, the SIM team secured ongoing funding and requested expressions of interest from specialities and departments within the hospital. It was hoped this expansion would facilitate collaborative multi-professional SIM training throughout the Trust.

It was at this time our Trust had experienced  serious untoward incidences (SUIs) regarding hypoglycaemia management, of which one proved to be consequently fatal. This was despite an up-to-date trust-wide hypoglycaemia guideline, the introduction of hypoglycaemia boxes on all wards, regular face-to-face training and access to national e-learning modules. Therefore, these traditional educational methods alone appeared to be ineffective.

Following discussion with the SIM department, the DISNs wrote and developed a POC module for hypoglycaemia education. This enabled teaching of the Trust’s guidelines for management of hypoglycaemia on the wards at the POC. A project was then established to deliver this SIM module to the ward where the SUI had occurred over a 3-month period and evaluate its effectiveness.

The reasons for addressing hypoglycaemia management for ward staff were twofold. The primary objective relates to patient safety; in a study of more than 100000 inpatients with diabetes, those who experienced hypoglycaemic episodes were found to have had longer hospital stays, a 7% higher risk of inpatient mortality, a 39% increase in hospital costs and a 58% increased likelihood of discharge to a skilled nursing facility (Curkendell et al, 2009). The second relates to staff morale and how much this is affected by a SUI.

POC SIM training
SIM training is delivered using a human patient simulator that simulates a person experiencing hypoglycaemia. Delivered at the POC within the ward environment, the ward team have to respond in real time, using usual ward resources. It is delivered to the entire multidisciplinary team (MDT) concurrently including nurses, healthcare assistants, and junior and senior ward doctors. All members partake in their usual roles during the SIM with little instruction from the SIM team to recreate a real-life situational event (Figure 1).

Moving training into the workplace with POC SIM training provides a unique opportunity to reach staff who have limited training support and funding. Challenging human factors in the work environment allows the MDT to learn together and improve performance, with consequent delivery of safer patient care, better outcomes and improved productivity.

SIM is specifically designed to be patient-centred and service driven. Careful planning and management enables scenarios to be crafted to recreate situations in which swift, accurate management is required to achieve positive patient outcomes. Rehearsing situations increases confidence and skill such that when they are encountered in clinical practice they can be managed calmly and with the experience of detailed rehearsal. SIM improves patient care by developing not only the skill and knowledge of the individual within their particular role, but improves situational awareness required for good team working. Broussard (2008) proposes “simulators provide a safe and effective means of preparing nurses for practice”. The advantages of this style of training are outlined in Box 1.

Hypoglycaemia SIM project aims

• To transparently address failings in clinical areas following recent SUIs involving hypoglycaemia.
• Reduce the occurrence of hypoglycaemia-related SUIs.
• Improve management of hypoglycaemia within the Trust.
• Develop a knowledgeable MDT, who could identify, treat and manage hypoglycaemia effectively.

This would be achieved by:

• Prompt recognition of severe hypoglycaemia.
• Correct treatment and management of severe hypoglycaemia as per hospital guidelines.
• Identifying the possible causes for the hypoglycaemic event.
• Appropriate management of diabetes medications during hospital stay.
• Effective MDT working and communication.

Method
Quality improvement cycle
The method utilised the RAID (review, agree, implement and demonstrate) quality improvement model. This was favoured over other quality improvement models as it had successfully been used by the DISN team on a previous educational project (Bull and Veall, 2009). It was therefore a tried and tested method that instilled confidence for assisting the MDT to make quality improvements.

The review stage
This stage generates engagement of staff and stakeholders for commencement of change. The identified stakeholders were the ward managers, governance leads, DISN team and SIM team.

A review of local incident reporting and SUIs identified key failings within the process of the management of hypoglycaemia within the ward setting.

The agree stage
The DISN team met with the SIM team to gain agreement for hypoglycaemia POC training. Following agreement, the hypoglycaemia SIM module was collaboratively written based on the key learning points from one of the recent SUIs. The ward manager and governance lead on the ward where the fatal SUI had occurred agreed that the hypoglycaemia SIM could be delivered to the staff on their ward. This established engagement from all major stakeholders.

The ward manager, SIM team and DISN team agreed on dates for the training. The ward manager took responsibility for advertising the SIM training sessions, ensuring availability of staff, and allocation of bed space.

The implementation stage
The SIM and DISN team provided the POC hypoglycaemia SIM module at the agreed date and time within the ward. The ward team had to respond within real time to the event using the resources available on the ward. It was of paramount importance that the attendees worked cohesively in their usual roles, demonstrating their individual skills and knowledge, team working and communication abilities. Minimal instruction was given to staff during the scenario; the SIM teams role was that of passive observers. This enabled staff to independently make decisions and autonomous care judgments exposing any in situ system and process errors or latent safety issues.

Following the session there was an analysis of learning points with a structured team debrief and discussion, and the provision of feedback.  During the debrief a non-judgmental approach was maintained and affirmative language used to raise constructive criticism and ensuing discussion. This promoted reflection and learner transference of knowledge for application to real clinical situations. Feelings surrounding the SIM experience, performance, and skills and knowledge were explored. This limited exposure to any detrimental consequences arising from participation in the SIM. Analysis of learning points included: the team’s response to the event; team communication and working integration; appropriate and timely use of ward and hypoglycaemia resources. This promoted open and interactive discussion in a safe environment to provide feedback for development.

Any obligatory remedial measures were identified with any immediate actions to maintain patient safety implemented (Table 1). Any ongoing changes to ward culture or clinical practice required were established. Additionally, all the team members were signposted to further learning resources for consolidation of newly acquired knowledge.

The healthcare professionals involved concluded the SIM by completing anonymised evaluation forms, which incorporated both qualitative and quantitative questions (Box 2).

The implementation was challenging at times.  Effective communication was key to facilitating the process and ensuring effective learning.

The demonstration stage
This stage included measuring and discussing the improvements in staff knowledge and subsequently patient care. In general, staff who attended POC SIM training identified an improvement in their knowledge and the availability of the correct resources on their wards.

• The completed anonymised evaluation forms were reviewed and analysed demonstrating very favourable outcomes (Figure 2).
• A post-SIM report was formulated and sent to the ward manager and medical governance lead, copying in the DISN team. This was also disseminated within the organisation’s governance structure. The governance lead and SIM team liaised with the ward manager to ensure the report had been actioned and this was then formally reported back to the Trust governance board via an action grid.
• The numbers of mis-managed hypoglycaemia incidents on the ward where the SUI had occurred post-POC SIM was revisited and compared to the baseline numbers pre-POC SIM for a comparison. This had reduced by 100%.
• Anecdotal evidence of correct hypoglycaemia management obtained from DISN patient clinical reviews on the project ward, along with verbal feedback from staff verified that hypoglycaemia knowledge and confidence after attending the SIM had increased and improved.

Following the success of the initial POC project, the Trust decided to develop a rolling hypoglycaemia SIM training programme. The aim was to deliver improved quality of inpatient care for adults with diabetes in hospital trust wide.

Hypoglycaemia SIM training was then introduced into:

1. Junior doctor training
2. Degree module for nurses in care of the critically ill patient.
3. Registered nurse preceptees training programme.
4. Surgical directorate SIM rolling programme.
5. Available on request to individual wards and departments following a training needs analysis
6. DISN recommendation from identification via incident reports and through real-time incidences of severe hypoglycaemia.

Formal evaluation and success of the rolling programme was undertaken after one year.

Analysis
During the period of delivery, 60% of hypoglycaemia SIM training was delivered at POC rather than in the SIM suite. POC SIM was delivered to MDTs, the majority of which were nurses (66%); healthcare assistants, medical staff and allied healthcare professionals made up the remaining 34%.

A local audit of incidents and SUIs was undertaken to demonstrate outcomes. The recent National Diabetes Audit was also analysed. The results showed:

• 100% reduction in hypoglycaemia incidents seen on the pilot ward, and a 64% reduction in hypoglycaemia incidences and 100% reduction of SUIs throughout the Trust.
• Comparing our hospital data on hypoglycaemia to the national average in 2016, we can demonstrate below average incidents of mild hypoglycaemia at 12.3% (national average 18.5%; National Diabetes Inpatient Audit [NaDIA], 2017).
• Patients reporting they were “satisfied” or “very satisfied” with the overall care of their diabetes while in hospital was above the national average by 6% (NaDIA, 2017). Increased knowledge of staff and correct management of diabetes requirements would have been integral to this response.
• Continued analysis of feedback received post-SIM training illustrates ongoing positive learning outcomes and experiences across seven evaluation questions. Average score of 9/10 (Figure 3).

Sustainability and replication
Hypoglycaemia SIM training at our Trust has been ongoing for three consecutive years and has been embedded into a rolling programme. Working in partnership with the SIM team enabled us to up-skill and empower a readily available and funded resource. This enabled the SIM team to feel confident in their ability to deliver the hypoglycaemia module in times of a DISN absence. Working from a detailed scripted scenario, they can deliver the training and impart the key messages. Questions raised outside of their knowledge are forwarded on to the DISN team to address.

DISN attendance is not essential but advantageous. This flexibility is helpful given DISNs increasing workloads and the inpatient diabetes prevalence. The hypoglycaemia SIM is adaptable to suit each ward speciality. This customises the module, making it tangible and transferable. Additionally, POC SIM is not exclusive to hypoglycaemia training and can be applied to other diabetes-related emergencies, such as diabetic ketoacidosis. Ongoing formative and summative assessment via the aforementioned evaluation tools will evidence the sustainability of the hypoglycaemia SIM programme in the long term.

Other specialist teams in our Trust who have found current training methods to be ineffective have expressed an interest in working with the DISN team to facilitate development of their own specialist area SIM.

Ipswich Hospital NHS Trust have already replicated our hypoglycaemia SIM training following consultation with us. They have chosen to undertake a slightly different approach, with the recording of their hypoglycaemia SIM training to produce a DVD/internet teaching aid. This has since been rolled out successfully with their Trust.

Conclusion
SIM training is a certified educational method used worldwide by a variety of professions. POC SIM further develops the SIM suite training by allowing on-ward training. MDT training at the POC offers insight into how the MDT operates, as well as into the functionality of the clinical area. Crucially it allows changes to practice be made before a “real life” situation occurs.

Using state-of-the-art SIM mannequins and equipment is not crucial for this training to be successful. Role play or resuscitation mannequins with a narrator could be used in its place.

The success of POC SIM lies with its ability to tease out inherent latent safety and human factor issues via interrogation of the environment and available resources, team working and communication skills. A hypoglycaemia emergency can occur at any time and place. With bed space being at a premium, SIM training can be conducted in bathrooms, corridors and patient/staff day rooms. It is feasible that staff could encounter such a situation and adds to the realism of the scenario while allowing POC training to still be delivered in today’s pressured climate.  Other healthcare, voluntary and patient organisations could adopt this more cost effective approach.

Hypoglycaemia SIM POC training is a positive addition in the education of healthcare professionals. It is an innovative training tool and was received exceptionally well demonstrating favourable outcomes. The reduction of hypoglycaemia events following its introduction in our Trust will have a positive impact on risk of diabetes inpatient mortality and a decrease length of stay in hospital. All have obvious advantages for diabetes inpatient care and improved organisational productivity.

Acknowledgements
We would like to thank Steve Harris, Simulation Specialist Practitioner and The Simulation Team at the Royal Cornwall Hospital NHS Trust, and Karen Palmer, Scientific Advisor Diabetes at Sanofi UK for their valued assistance throughout this project.