Simulation demystified and reimagined-using simulation to transform clinical practices

Abstract

Simulation has traditionally been used for paedagogical purposes. More recently, simulation has been advocated for use in transformational ways – leveraging simulation to test and improve clinical systems and service delivery. This article presents a narrative account of transformational simulation in stroke care. We describe three simulation-based initiatives: a review of simulation on door-to-needle times, development of a telethrombolysis protocol and implementation of a thrombectomy pathway. This article demonstrates how simulation can be used to transform healthcare. Our examples have focussed on stroke presentations; however, the ‘seven I’s model’ outlines how simulation can be used to identify, improve and innovate across the care spectrum.

Introduction

Simulation is a widely accepted educational approach used throughout healthcare disciplines. The premise of the approach is that of constructing a psychologically safe learning environment for learners to be exposed to an authentic clinical encounter followed by a facilitated debriefing or learning conversation to identify and address perceived performance gaps. However, in recent years, the concept of moving simulation out of the classroom and pedagogical sphere and into the work setting to transform and improve quality and safety in healthcare has arisen.

One way we can put this into practice is through transformational or translational simulation. But what do we mean by these terms?

Brazil describes translational simulation as a ‘functional term for how simulation may be connected directly with health service priorities and patient outcomes, through interventional and diagnostic functions’. ¹ In essence, it is a range of activities designed to improve quality and outcomes in healthcare processes, leveraging simulation as the tool to achieve these aims which are distinct from traditional pedagogical uses of simulation. ²

Simulation can be considered a tool which mimics aspects of clinical care and can be framed as a means of studying and exploring clinical settings, environments, teams and processes.^3,4

Weldon et al. suggest a taxonomy, referred to as the seven simulation-based ‘I’s for what transformational simulation could be used for including to improve healthcare processes, as an intervention to change how things are done, to involve and include different groups or people, to identify issues, to innovate and alter how work is done and to influence people or things. ⁵

This framework offers us the opportunity to consider how we might use simulation in our areas of working to transform current practices, taking simulation away from education to the remits of quality improvement and change management as we seek to diagnose problems, test and refine different ways of doing things to embed change in practice. ⁶

To begin this journey towards transformational simulation in practice, we need to first challenge our perceptions of what simulation is. You probably have in your mind images of high-tech, mannequins that someone else must operate or of trained actors portraying clinical conditions. But this needn’t be the case. The purpose of your transformational activity will determine what resources you need to simulate the clinical process in question. It may be a member of staff representing a patient portraying a specific clinical presentation, a dialysis bag representing a patient’s circulating volume when testing delivery of a massive haemorrhage protocol, ⁷ or an empty trolley or piece of paper simulating a patient’s physical journey through the hospital. There are many descriptions within the literature of how translational simulation is used to directly improve healthcare processes and outcomes, including focussing on clinical environments, equipment, medication and physical space usage.^1,4,8

Reimagining simulation: Stroke

If we consider the common medical presentation of stroke, we will describe how we have used simulation to transform our practices and suggest how others might use the concepts of transformational simulation within their services.

Stroke remains a leading cause of death and disability across the world. Improvements in stroke outcomes over the past 20 years have been possible because of prompt diagnosis and intervention with intravenous thrombolysis to re-establish cerebral blood flow in affected brain and, more recently, mechanical thrombectomy as a treatment option for large vessel occlusive stroke.

In this article, we briefly describe two examples of how our use of transformational simulation techniques has influenced our management and internal processes in hyperacute stroke care: (1) a systematic review of the literature to assess the effect of simulation on door-to-needle times and (2) the introduction of telethrombolysis. We will then describe in detail how we used transformational simulation to development and deliver a stroke thrombectomy pathway as a spoke centre which requires patients to be transferred to a thrombectomy hub crossing health service borders.

Improvement: Door-to-needle time

In 2024, our team conducted a systematic review and meta-analysis evaluating the effects of simulation training on door-to-needle times in hyperacute stroke. ⁹ This published review identified 19 studies, totalling over 20,000 patients, which had used simulation training to improve the important clinical outcome of time to delivery of thrombolysis in patients presenting with stroke. Our review found overall that there was a mean difference of 15 min in door-to-needle times between pre- and post-simulation training in patients identified from stroke registries. It should be noted that the simulations described in this review were a very heterogenous collection, some involved training individual groups of thrombolysis decision-makers, others involved the wider clinical team, others innovated and changed their thrombolysis protocol (a new intervention) and used simulation to introduce this new protocol. ¹⁰ This review highlights the potential crossover between simulation for education and simulation for education as part of transformation with the end result being improvement in thrombolysis door-to-needle times for patients presenting with hyper-acute stroke, a condition in which multiple professions and specialities must improve by working together.

Identifying and involving: Telethrombolysis

In our second example, we look back to the beginning of the COVID-19 pandemic and the rapid transformation of healthcare processes that was required.^6,11 When hospitals were being divided into COVID-19 ‘hot’ and ‘cold’ zones, with some staff shielding and disruption of usual practices an innovative solution involving different teams in the thrombolysis process had to be created. We used the concepts of transformational simulation and change management, with a staff member acting as a patient, to test and agree a new innovation within our system of telethrombolysis (i.e. a system whereby a patient presenting with stroke is seen via a telemedicine link and a decision made on thrombolysis) identifying benefits and challenges associated with changing our way of working which is now embedded in our routine practice. ¹²

Innovating, identifying and intervening: Development of a thrombectomy pathway

In our final example, we discuss how an innovative treatment was introduced. In late 2021, a nationwide thrombectomy service for patients presenting with acute stroke in Scotland commenced. Our Emergency Department feeds into one of three thrombectomy ‘hubs’ meaning patients require prompt diagnosis, treatment and packaging prior to a transfer of around 70 miles to facilitate timely thrombectomy. Stroke outcomes are highly time-dependent and hyper-acute management requires effective multidisciplinary team working as well as sufficient knowledge and expertise. ¹³

To assess the readiness of our proposed local thrombectomy referral pathway, we designed and ran a series of translational simulations. Our simulation series was both diagnostic (seeking to identify the issues associated with onward referral to the thrombectomy centre) and influential (seeking to provide solutions in an iterative process involving all stakeholders). ⁴

The design for our simulation was guided by use of an input-process-output framework. ⁴ Each component is outlined in detail below.

Input phase

The reason for running our simulation series was to assess our preparedness for delivery of a new service (mechanical thrombectomy) and to identify barriers to this delivery. We sought to propose solutions to these barriers through repeated simulation with iterative improvements each time. Translational simulation was deemed an appropriate way of achieving these goals.

We recognised that to be successful, we needed the involvement and inclusion of the wider multidisciplinary team including stroke and emergency physicians, radiology and radiography staff, nursing and ambulance service colleagues. We were able to recruit interested parties through email and attendance at shared meetings relating to wider work ongoing around thrombectomy service delivery locally.

Process phase

Our first simulation was planned for a weekday morning in the Emergency Department. Preparation involved preparing stakeholders from stroke, radiology and paramedic teams as well as priming staff at the thrombectomy ‘hub’ (situated 70 miles away) that a simulation was going to take place. Our patient was a life-size adult mannikin brought to the department by ambulance on a trolley. Paramedics made a pre-alert call and proceeded to transport the patient to the department, arriving around 10 min later.

The Emergency Department (ED) staff on duty were informed on the morning of the simulation that a simulated patient was expected, and they were asked to act in their own role and as they would for any stroke pre-alert. On receiving the pre-alert call, staff completed the stroke pre-alert forma, identified a bed space before the stroke team and radiologist were informed of impending arrival. This is routine practice for stroke patients in our department. The clinical scenario was pre-determined of a patient presenting with a dense right-sided stroke and when calculated the National Institutes of Health Stroke Scale (NIHSS) score was >5 which prompted the team to consider thrombectomy.

The mannikin was transferred to the CT scanner and scanned in real time with a radiologist present. A CT angiogram was requested by the stroke team based on plain CT findings as per usual protocol. (The mannikin’s scan was later formally reported as dense right MCA thrombus by a neuroradiologist.)

Following this and a verbalised decision to send the patient for thrombectomy, the stroke consultant contacted the thrombectomy centre and carried out pre procedure checks via telephone as agreed with hub site. In the meantime, the patient was thrombolysed with real time drug calculation and preparation. Nursing staff performed their usual observations as per agreed thrombolysis protocol. An ambulance was booked via a designated thrombectomy transport phone number (The call handler was aware in advance that a simulation was ongoing.), and a crew was dispatched to the ED to collect the patient. The simulation ended with patient packaging and transfer into the ambulance.

We carried out a second simulation in the same manner several weeks later involving several different members of the ambulance service, stroke and radiology teams to ensure multiple team members could experience the process and be exposed to the simulated scenario.

A third, shorter simulation (not involving Scottish ambulance service) was carried out aimed at addressing specific issues that had been picked up in the previous simulations.

Output phase

Data were collated contemporaneously during the simulation by facilitators who did not take an active role in the simulation. A debrief was held immediately following the simulation allowed those involved to contribute to further data collection by way of a whiteboard debrief using aspects of the timeline debriefing tool modified for this translational simulation. ¹⁴ Pooled data were then collated and emailed to all participants for reflection and further comment. Barriers identified at debrief were debated and solutions suggested. Specific action points were detailed and those responsible for actioning identified. In September 2021, we successfully transferred our first acute stroke patient to the thrombectomy centre within the 6-h timeframe for the procedure to take place. Running a series of simulations involved multiple team members from various professional groups to experience the referral process and identify issues specific to their area of expertise. Thrombectomy is a time critical intervention so it was crucial all participants were aware of, and could mitigate for, any delays in the process.

We were able to utilise current Emergency Department processes already in place for hyperacute stroke care. There is evidence that translational simulation activities are most effective when undertaken alongside dedicated quality improvement projects. ¹ In our case, work has been ongoing in this regard with the introduction of a standardised stroke management pathway. Our departmental targets with respect to stroke care (time to CT brain, time to thrombolysis) had already shown improvement with this work and as such this was an opportunistic time to introduce our simulation series as part of our preparation for thrombectomy service delivery.

Our first simulation generated a variety of outcomes from identifying the logistical (where are the thrombolysis drugs kept) to process design (CT angiogram vetting and reporting) as well as highlighting the need for new equipment (infusion pumps and transfer bags) and the need to utilise space within the Emergency Department footprint to store these. Those present at the debrief were tasked with identifying solutions to these issues by the time of the next agreed simulation in the series.

Conclusion and challenge

In this article, we have described our approach of how we have used the concepts of transformational simulation within our emergency stroke pathways looking at thrombolysis, telethrombolysis and thrombectomy transfer as examples. We advocate for the use of transformational simulation as a tool as part of the quality improvement agenda, to explore healthcare work and environments to improve healthcare systems and teams. ¹⁵ Those wishing to get started on this transformational journey should consider Brazil and Eppich’s excellent overview of translational simulation as a conceptual model for the contribution of simulation to healthcare quality and safety ¹⁵ and Nickson et al.’s description to action paper to understand how to begin improving healthcare quality through simulation. ⁴ It is time for us to move simulation out of the classroom and into the workplace to rise to the complex challenges of transforming and improving how we deliver modern healthcare. For those interested in pursuing this opportunity it is worthwhile seeking out local simulation expertise to work alongside patient safety, human factors and quality improvement experts and expert clinicians who know and understand the clinical, cultural, political and financial healthcare landscape that itself requires to be reimagined.