FEB. 10, 2010

Study will enable Stanford doctors, nurses to explore simulation's power to improve patient safety

BY DIANE ROGERS

Norbert von der Groeben description of photo

Nancy Szaflarski and Clarence Braddock are spearheading the study to see how simulations might help hospitals improve patient safety.

Thanks to a $1.1 million grant from the Gordon and Betty Moore Foundation and more than $500,000 in matching support from Stanford Hospital & Clinics, physicians and nurses will be implementing an innovative quality-improvement project to evaluate whether a patient safety program can reduce the incidence and severity of hospital-acquired complications and hospital mortality.

The Palo Alto-based Gordon and Betty Moore Foundation is funding this interdisciplinary program, which will last about 2.5 years, whose primary intervention is to train nurses and physicians on a simulator to effectively respond to real-life, preventable patient problems. The project represents a collaborative effort between faculty at the Stanford University School of Medicine and nurse researchers at SHC.

Starting in July, nurses and resident physicians practicing on four hospital units will have an opportunity to improve their teamwork and clinical decision-making skills during brief simulation training exercises focused on potentially preventable hospital-acquired complications. Immediately following the exercise, the simulation faculty, composed of unit-based physicians and clinical nurse specialists, will convene debriefings where team members will reflect on their performance.

The high-fidelity simulation mannequin for example, might display a rising respiratory rate, combined with a drop in oxygen saturation — indications that the patient is experiencing what’s called acute respiratory insufficiency. That is but one of many problems that could arise at hospitals and that the simulations will evoke.

"How will the scenario unfold? What decisions will be made to stabilize the patient? How will physicians and nurses interact?’ Those are the kinds of performance measures we’ll be monitoring,” principal investigator Clarence Braddock, MD, MPH, said about its potential. “We expect to see significant improvement in recognition of the early signs of clinical deterioration, improvement in early treatment and better teamwork and communication.”

The need to implement more safeguards in hospitals was heightened by the Institute of Medicine’s landmark 1999 report, “To Err is Human: Building a Safer Health System,” which estimated that as many as 98,000 people died in hospitals each year as a result of preventable mistakes. In another report issued in 2006, the IOM looked specifically at medication errors, which harm some 1.5 million people annually and result in billions of dollars in health-care costs.

“Patient safety is a public concern that has received substantial attention, especially since the release of these two reports,” said Braddock, who is also professor of medicine and medical director for quality at the hospital. “While doctors and nurses are now well aware of these problems, our health-care system is still in need of new ways to resolve them, and we hope that our work will contribute to such advances.”

Braddock is working closely with co-investigator Nancy Szaflarski, RN, PhD, the hospital’s program director for quality outcomes, and Lynn Forsey, RN, PhD, a nurse scientist at the hospital, to implement the patient safety program and assess its effects on outcomes. The researchers plan to publish results of the study, and said the findings could help hospitals across the country to implement new guidelines to enhance treatment, improve communication and avoid complications.

What’s unique about this simulation training is that it will be conducted on actual hospital units, rather than at a training center dedicated to health-care simulation. “Our belief is that simulation conducted frequently at the bedside is a key component to advancing quality care. Research has shown that improvements in care occur most effectively when changes are implemented at the level of a hospital unit,” Szaflarski said.

Stanford has long been in the forefront of using simulation to train medical students, doctors and nurses, led by David Gaba, MD, associate dean for immersive and simulation-based learning at the medical school who is internationally known as “the father of simulation.” Simulation exercises in the new study will occur across day, evening and night shifts, and will be aimed at improving technical, teamwork, communication and critical thinking skills.

“This grant will afford the ability to probe systems ‘in place,’ and to provide training of high relevance to individual clinicians and multidisciplinary teams,” said Gaba, who is a co-investigator of the study. “Few, if any, sites around the world have attempted anything on this scale before, so we are very excited to have this unfold and see the results.”

The simulations will focus on recognizing, communicating and treating the early signs of hospital-acquired complications, such as bacterial infections and respiratory problems. One scenario might look at an elderly patient who is admitted to the hospital with pneumonia. She is put on antibiotics and oxygen, and a new intern writes an order for 100 ml of IV fluids per hour, an appropriate order for the situation. But within 24 hours she is suddenly in respiratory distress because her body couldn’t handle that much fluid and adjustments were required.

“The question is, ‘How can health-care providers utilize best practices to ensure appropriate orders for IV fluids for that elderly patient as her condition changes?’” Braddock said. “And how can we enhance physician and nurse recognition of the earliest signs that a patient might be getting into trouble?” Braddock and Szaflarski said the research study will enable them to examine the culture of safety of the involved hospital units, as well.

“New graduate nurses and first-year residents are just developing the skills needed to discern early signs of complications from routine clinical variations and they may not have the confidence to call for help early. Experienced nurses, on the other hand, have developed good clinical skills but may need more practice with communication and teamwork skills for infrequently-occurring events,” Forsey said. “It’s these nursing skills, along with vigilance, that we’ll be trying to improve in this study.”

Braddock said that the “perceived authority gradient” among nurses and physicians is another focus of the study. “One of the harsh realities that we still struggle with in modern health care is that doctors and nurses are working side by side, but some doctors write orders and expect them to be followed by nurses,” he added. “We’ll be trying to enhance collaboration among these disciplines, so the nurse will feel comfortable saying to the physician, ‘I think this patient is receiving too much fluid and we need to make an adjustment."

Other co-investigators of the study are John Morton, MD, MPH, FACS; Geoffrey Lighthall, MD; Steven Howard, MD; and Tina Hernandez-Boussard, PhD, MPH.

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Stanford Medicine integrates research, medical education and patient care at its three institutions - Stanford University School of Medicine, Stanford Hospital & Clinics and Lucile Packard Children's Hospital Stanford. For more information, please visit the Office of Communication & Public Affairs site at http://mednews.stanford.edu/.

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