Teaching the practical management of emergencies in the community: Get simulation out of the classroom and into ‘real-life’ environments Dr EMER FORDE GENERAL PRACTITIONER GP Programme DIrector Bournemouth University Dr james Bromilow Consultant in intensive Care medicine Poole hospital nhs foundation trust Prof Clare wedderburn General practitioner Associate dean, GP training (dorset)

The problem General Practitioners in the UK have a responsibility to provide prompt and effective care in an emergency. GPs are mandated to undertake annual BLS training in the UK. Research has shown that this is an area where GPs lack confidence. (Forde, Bromilow & Wedderburn, 2017; Ramanayake, R., Ranasingha, S & Lakmini, S., 2014) UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report ‘Time to intervene’ (2012) suggested that better early assessment and intervention may have prevented deterioration to cardiorespiratory arrest.

A solution 2012 Simulation based teaching to Newly Qualified GPs Classroom based teaching Facilitated by GP and ICU Consultant Feedback good Little equipment needed It was fun “I hope this can be done regularly as it will make a huge difference to patient care” “Excellent. Life-like to make more memorable. Good practical involvement of all of us. No comments for improvement!” “Scenarios useful – commonly encountered. Interactive. Useful to do hands on practice on dose calculation. Recap of guidelines. Good reminder to keep drugs handy. VERY good session. Thoroughly enjoyed it and useful”

A better solution: ‘Real-life’ simulation based teaching

‘Real-life’ simulation based teaching Scenarios Hypoglycaemia Anaphylaxis Meningitis Seizures Severe asthma Severe croup Cardiac arrest Objectives Clinical knowledge Practical skills – turning on the oxygen, setting up a nebuliser, antibiotics Where to find doses quickly Organisation of equipment

‘Real-life’ simulation based teaching

Initial Feedback “How confident are you in the practical management of emergencies within your practice?” Before workshop : mean rating = 4.7 After workshop: mean rating = 7.5 t test, P < 0.01

Consistent learning needs Practical skills Drawing up medication (e.g.benzyl penicillin and adrenaline) Using BM machines Turning on oxygen cylinders Setting up nebulisers Using a structured ABC approach Organisation of equipment and medication

Feedback “All practices should avail themselves of this teaching- we shy away from these scenarios but we need to be as confident as possible” “incredibly useful - highlighted BNF protocols for emergencies, how to practically use oxygen and drugs” “actually using equipment kept at the practice, identifying where things are kept and practical advice e.g. giving an epipen, drawing up meds”. “fantastic set of real life emergencies which could happen in primary care” “enables us as a team to revise our knowledge and practical skills” “totally relevant. Every GPs nightmare”

Any lasting benefit? 8 week follow up “How confident are you in the practical management of emergencies within your practice?” Before workshop : mean rating = 4.7 After workshop: mean rating = 7.5 8 weeks later: mean rating = 7.0

8 week follow up 41% participants responded. 98% made changes after the workshop, either personally or within the practice. “Lots - I am more confident and feel I can remain calm and act speedily. As a practice, we now have small boxes containing the appropriate drugs for each type of emergency e.g. anaphylaxis, diabetes, chest pain” “We copied the back pages of the BNF so that we have quick access to emergency drug doses. The laminated pages are in our emergency bags and attached to our resus trolley” “Adjusted the layout of the crash trolley. Printed out algorithms for common emergencies to keep in the crash trolley along with dosing information” “Reviewed emergency drugs held at the surgery and made changes eg: hypostop gel updated partners updated glucometers”

Summary Health care simulation: Playing seriously It’s serious – because time matters. Managing time critical emergencies is an area where primary care staff need more training and opportunities to gain practical skills and confidence. Most participants knew the theory of what to do in emergencies but lacked the practical skills and confidence to quickly and efficiently manage scenarios. This included both very experienced GPs and younger GPs who had recently undertaken hospital rotations (including A&E). Participants highly valued the practical, simulation based aspect of the teaching. Simulation based education can have long term positive benefits on clinicians’ confidence and practice.

Summary Training in real-life environments highlights the organisational, equipment and system changes that need to be made within a community setting. Training works best in small groups with skilled facilitators from primary and secondary care. Our work highlights a significant patient safety issue - delays in identifying and treating time critical illnesses can have a direct impact on morbidity and mortality. We believe that there should be more of a focus on how to manage patients in the peri-arrest phase to avoid cardiac arrest rather than the current focus on BLS training alone. We propose there is a need for a national curriculum, and associated courses, to ensure clinicians are equipped to manage emergencies in community settings. Meeting with Resuscitation Council (UK) 28 November 2017.

Acknowledgements Health Education Wessex (HEW) Dorset GP Centre Dr Susie Jackson, Dr Sheona Chapman, Dr Henrik Reschreiter and Dr Chris Loew HEW Shine awards 2016: Highly commended finalist. Education and Training Innovation of the year. Publications Forde, Bromilow & Wedderburn (2017). The practical management of emergencies in primary care: Taking simulation out of the classroom and into real-life environments. BMJ STEL. Forde, Bromilow, Jackson & Wedderburn (2017). Managing emergencies in primary care: Does real world simulation based teaching have any lasting impact? BMJ STEL