“And he has just had some antibiotics…..” - epidemiology in healthcare simulations

This week I wanted to carry on with the simulation theme and consider the diseases and conditions we often simulate. 

If we start to describe our simulation scenario our participants will often second guess our scenarios - often correctly, just think of the common introductions 

The patient has just been given antibiotics [anaphylaxis] 

The patient has just returned from theatres [massive haemorrhage]……and so the list continues. 

Of course the interesting thing to realise is that in our hospitals countless patients have antibiotics each day without anaphylaxis and the majority of patients return from theatres and make uneventful recoveries. In fact the recent 6th National Audit Project of the Royal College of Anaesthetists looking at perioperative anaphylaxis (NAP 6) found out of three million patients there was a 1:10,000 occurrence of anaphylaxis compared to a probable 1:1 occurrence in simulation population following administration of antibiotics. 

So does this matter?

If the focus is just on training staff to how to respond to those rare occurrences - the procedure then maybe not but normally we also want to include some degree of clinical decision making and recognition of the condition. 

The cognitive process of identifying and recognising the myriad of signs and symptoms is clearly complicated and may include that of frequency gambling and heuristic judgement -  there is a risk here that either the participants learn that the simulation population is markedly different from the patient population, and start treating the simulations different from the patients;  or alternatively a risk that they consider the two the same and thus start seeing the conditions everywhere - our training could result in patients being treated for conditions they don’t have or other conditions being missed just because they think it is so common.  

Personally I think there are potentially two reasons why this has developed, firstly simulation used to be historically a rare or even once only event and secondly some faculty like to “borrow” scenarios for national courses like resuscitation courses. However as the frequency of simulation has increased the focus is still on the rare events - they are just presented more regularly. 

I think what brought it home for me was when we met with a national airline company who were interested to learn how we, in healthcare, used simulation and taught human factors - this led to a number of observations of each others work and to this date ongoing dialogue.  

So as a aircraft pilot is trained to fly commercial jet planes he will go from flying a real plane with one engine to developing skills in an aircraft flight simulator to enable him to work as a team, to fly a plane with multiple engines. The initial part of this training will be focussed on normal flying i.e. taking off, flying and landing. Only when competence is met in these areas then complexity will be increased. I still think in healthcare we get our “pilots” into the air for the very first time and then notice that both wings fell off! 

So what seems to be missing in healthcare is normal events - focussed more for junior staff or staff developing an understanding of a new process, procedure or role. So the opportunity for new starters to start the paperwork and get a patient monitored in an acute area rather than responding to rare events. This would allow simulation to be embedded further in induction, orientation, undergraduate learning. 

Hopefully this would have two effects, firstly in helping to align events in our simulation and real populations but also removing some of the hypervigillence and second guessing from our  candidates.