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High-Fidelity Simulation to Teach Communication Skills: Potentially Difficult Discussions Stephanie N. Sudikoff, MD Medical Director, SYN:APSE Simulation.

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Presentation on theme: "High-Fidelity Simulation to Teach Communication Skills: Potentially Difficult Discussions Stephanie N. Sudikoff, MD Medical Director, SYN:APSE Simulation."— Presentation transcript:

1 High-Fidelity Simulation to Teach Communication Skills: Potentially Difficult Discussions Stephanie N. Sudikoff, MD Medical Director, SYN:APSE Simulation Center Yale New-Haven Health System Assistant Professor of Pediatrics Pediatric Critical Care Director, Pediatric Simulation Yale University School of Medicine

2 Many types of discussions Between caregiver and patient Between caregiver and patient Between caregiver and family Between caregiver and family Among interdisciplinary care team Among interdisciplinary care team

3 Delivery of Bad News Manner of delivery has significant impact on patients and family Manner of delivery has significant impact on patients and family All caregivers (all levels) report discomfort and lack of sufficient training All caregivers (all levels) report discomfort and lack of sufficient training Many studies into best pedagogical strategy Many studies into best pedagogical strategy Lectures Lectures Small groups/role playing Small groups/role playing One on one with standardized patient One on one with standardized patient

4 Ideal strategy… Interactive Interactive Learner centered Learner centered Draws on prior experience Draws on prior experience Relevant Relevant Allows for timely application Allows for timely application Opportunity for repetitive practice Opportunity for repetitive practice Opportunity for feedback and reflection Opportunity for feedback and reflection Provides basic steps practice, discuss concerns, receive feedback

5 Delivery of Bad News: Pediatrics Frequently delivering news to parent and family, who are often present at the bedside Frequently delivering news to parent and family, who are often present at the bedside In acute care settings, news must often be delivered in the midst of complex patient care In acute care settings, news must often be delivered in the midst of complex patient care

6 Why simulation? Simulation facilitates: Simulation facilitates: Repetitive practice Repetitive practice Safe environment for practice, reflection, discussion, and feedback Safe environment for practice, reflection, discussion, and feedback Hybrid model creates realistic situation involving simultaneous patient care and family interaction Hybrid model creates realistic situation involving simultaneous patient care and family interaction Faculty teaching without competing clinical responsibilities/time pressure Faculty teaching without competing clinical responsibilities/time pressure

7 Previous Simulation Work Gaba Death Scenario Gaba Death Scenario Rosenzweig Standardized Patients Rosenzweig Standardized Patients Choose cases relevant to learners

8 Overly F, Sudikoff SN, Duffy S, Anderson A, Kobayashi L Teaching Difficult Discussions in Pediatric Emergency Medicine: 1) Sudden Infant Death 2) Child Abuse with Domestic Violence and 3) Medication Error. Simulation in Healthcare. Accepted December 2008

9 Participant Feedback Survey question Relevance to your training/duties Realism of simulation scenario Realism of simulation environment Quality of simulation debriefing Overall simulation training experience Score Average (SD) 4.9 (0.4)4.5 (0.7)4.5 (0.5)4.8 (0.4)4.9 (0.4)

10 Comments The SIDS case is very worthwhile. Traumatizing but worthwhile The SIDS case is very worthwhile. Traumatizing but worthwhile Great experience- very valuable to try out these situations first at sim center rather than on the floors. Great experience- very valuable to try out these situations first at sim center rather than on the floors. Very real, excellent learning experience Very real, excellent learning experience

11 Stages of debriefing Reactions Reactions How did that feel? How did that feel? Understanding Understanding What results were produced? What results were produced? Summary Summary How can we extrapolate this information to a larger context? How can we extrapolate this information to a larger context? Events Emotions Empathy Explanations The four Es

12 Critical characteristics of an effective debriefing Safe for the learner Safe for the learner Confidential and trusting Confidential and trusting Respectful Respectful Interactive Interactive Non-threatening Non-threatening Non-confrontational Non-confrontational Non-judgmental Non-judgmental

13 Debriefing for this case Allow sufficient time for reactions stage Allow sufficient time for reactions stage Sensitivity to powerful emotional responses Sensitivity to powerful emotional responses Supportive environment Supportive environment Allow for reflection on learner performance: use their observations to transition to teaching best practice concepts Allow for reflection on learner performance: use their observations to transition to teaching best practice concepts Consider providing gold standard for frame of reference Consider providing gold standard for frame of reference

14

15 Disclosure of Medical Errors: The Art (and Science) of Apology

16 Medical error The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim Serious error Serious error Minor error Minor error Near miss Near miss An error that could have caused harm but did not …by chance or timely intervention An error that could have caused harm but did not …by chance or timely intervention Most are due to system breakdown vs. individual failure Most are due to system breakdown vs. individual failure

17 The Importance To Err is Human To Err is Human U.S. National Institute of Medicine report, 1999 U.S. National Institute of Medicine report, 1999 Over 100,000 deaths annually in the U.S. Over 100,000 deaths annually in the U.S.

18 Hospitals 'more dangerous' than air travel (Reuters, 2005) If you feel safer in hospital than on a airplane, think again. If you feel safer in hospital than on a airplane, think again. The risk of being killed in a hospital in a developed country due to medical error is around one in 300, while the risk of dying in an air accident is one in 10 million, Britain's chief medical officer said on Monday. The risk of being killed in a hospital in a developed country due to medical error is around one in 300, while the risk of dying in an air accident is one in 10 million, Britain's chief medical officer said on Monday. "Paradoxically, people are more frightened of air travel than they are of healthcare," Liam Donaldson, who also chairs the World Health Organization's (WHO) World Alliance for Patient Safety, told a conference. "Paradoxically, people are more frightened of air travel than they are of healthcare," Liam Donaldson, who also chairs the World Health Organization's (WHO) World Alliance for Patient Safety, told a conference. He argued such a gulf in safety standards was unacceptable - even allowing for the poor condition of many patients entering hospital - and healthcare professionals needed to learn from other sectors on how to make safety a top priority. He argued such a gulf in safety standards was unacceptable - even allowing for the poor condition of many patients entering hospital - and healthcare professionals needed to learn from other sectors on how to make safety a top priority. "Other high-risk industries have systematically improved safety over a period of decades in a way that healthcare has not, the airline industry being the most high-profile example," Mr Donaldson said. "Other high-risk industries have systematically improved safety over a period of decades in a way that healthcare has not, the airline industry being the most high-profile example," Mr Donaldson said.

19 What we know Medical errors occur frequently Medical errors occur frequently Agreement exists that errors should be disclosed Agreement exists that errors should be disclosed Family Family Staff Staff Risk management Risk management Caregivers receive little training Caregivers receive little training

20 What can we do? Simulation as a tool to decrease medical errors Simulation as a tool to decrease medical errors Errors are multi-factorial Errors are multi-factorial Shed light on the problems Shed light on the problems Practice Practice Teamwork and communication Teamwork and communication

21 What can we do? Simulation as a tool to teach disclosure Simulation as a tool to teach disclosure Advantages Advantages Includes medical management Includes medical management Requires focus, multi-tasking Requires focus, multi-tasking Interaction with standardized patient or actor Interaction with standardized patient or actor Practice the words Practice the words View on video View on video Disadvantages Disadvantages Limitations of the simulator Limitations of the simulator Requires buy in Requires buy in

22 Disclosure of Medical Errors Video clip Video clip Debrief Debrief Medical error disclosure Medical error disclosure The literature The literature Attitudes Attitudes How we teach (and learn) How we teach (and learn)

23 What families want to know ??

24 What happened? What happened? Why did it happen? Why did it happen? What are the implications for their loved one? What are the implications for their loved one? How can the problem be corrected? How can the problem be corrected? How can future errors be prevented? How can future errors be prevented?

25 Apology 4 components: 4 components: Acknowledgement of the offense Acknowledgement of the offense Explanation for committing the offense Explanation for committing the offense There is no excuse for what happened There is no excuse for what happened We are still trying to find out what happened We are still trying to find out what happened Expression of shame, remorse, humility Expression of shame, remorse, humility Reparation: making amends Reparation: making amends

26 Important factors Important to choose who offers the disclosure Important to choose who offers the disclosure Timing is important Timing is important Insincere apology is worse than no apology Insincere apology is worse than no apology

27 General recommendations Listen without interrupting Listen without interrupting Relay full information Relay full information Use easy-to-understand language Use easy-to-understand language Ensure that the parents comprehend the information Ensure that the parents comprehend the information Give a sincere apology Give a sincere apology Use nonverbal communication to express concern Use nonverbal communication to express concern

28 General recommendations Communicate your commitment to the patients safety Communicate your commitment to the patients safety Convey the patients medical status and your expectations Convey the patients medical status and your expectations Solicit families opinion Solicit families opinion Use open ended questions Use open ended questions Communicate to family members that you understand their concerns Communicate to family members that you understand their concerns Communicate what you plan to do to prevent this in the future Communicate what you plan to do to prevent this in the future

29 Communication among the interdisciplinary team: The Handoff

30 High Risk One of the most common scenarios in which significant miscommunication can occur One of the most common scenarios in which significant miscommunication can occur Also high risk for patient deterioration while traveling throughout hospital Also high risk for patient deterioration while traveling throughout hospital

31 Why simulation?

32 Response to need for process improvement Multidisciplinary Multidisciplinary Vetting and refinement Vetting and refinement Implementation Implementation

33 Well received by entire team Well received by entire team Real opportunity for all members to collaborate to create multidimensional tool Real opportunity for all members to collaborate to create multidimensional tool Improved buy in Improved buy in


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