A Simulation Programme for Foundation Doctors Focusing on the Management of Acutely Unwell Patients
The initial assessment and management of acutely unwell patients is an area that many foundation doctors find challenging and stressful.
The influence of human factors on a doctor’s ability to work under pressure is increasingly recognised by the medical profession. But many junior doctors have limited awareness of this.
Immersive simulation can be used to develop an understanding of the importance of human factors and focus on changing doctor’s behaviour to improve the management of acutely unwell patients.
At North Bristol NHS Trust the postgraduate centre runs a regular simulation programme for foundation doctors, which focuses on the management of acutely unwell patients in the crucial first 15 minutes. Each foundation doctor must attend two simulation sessions throughout the year. These sessions incorporate a range of acute scenarios which the junior doctors may encounter on the acute hospital wards.
During these sessions, the doctors have to rapidly assess a deteriorating patient and initiate appropriate management. The faculty has a range of medical conditions it can incorporate into the scenario to challenge the learners.
Following each scenario, there is 30 minutes of debrief. This follows a standardised framework (adapted from the frame-based feedback tool) and focuses on the clinical and non-clinical human factor aspects of the scenario.
Foundation doctors have been very receptive to this shift in focus of the simulation training towards addressing human factors and how they influence their clinical practice.
Scenarios and debrief have increased their confidence in both clinical and non-clinical areas. The majority of foundation doctors have noticed that simulation training has improved the following skills: prioritisation, situational awareness, teamwork and delegation.
A Scheme of Taster Days in Psychiatry Training for Foundation Doctors
In response to the recruitment shortage in psychiatry, the Royal College of Psychiatrists has suggested that the promotion of taster days may increase junior doctors’ exposure to psychiatry and thereby boost recruitment. This is supported by the UK Foundation Programme Office.
The taster-day scheme was set up following discussions with Severn Foundation School. Consultants and doctors in training were invited to be involved. Foundation doctors who wish to have a taster day contact the coordinator and have the opportunity to express their preference of subspecialty and geographical location.
The coordinator links them to a consultant offering their chosen subspecialty and a doctor in core training in the area. The doctor in core training then helps facilitate the taster day by offering shadowing and informal discussions about training and exams.
All taster days arranged are logged on a database. After completing the taster days, foundation doctors are asked to give online feedback.
Feedback from foundation doctors has been very positive, with doctors rating the opportunity highly as it allows them to gain an insight into psychiatry.
Consultants and doctors in higher training have been very receptive to providing taster days for foundation doctors. The doctors in training that have been involved in supervising the foundation doctors enjoy having a role in the taster days and recognise the scope for management and teaching opportunities that this brings.
Many foundation doctors who have participated have gone on to apply for core training in psychiatry – some of these have successfully applied for and commenced psychiatry core training in Severn.
An Experiential Learning Programme to Develop Quality Improvement Projects under the Guidance of Local Experts
Since 2010 foundation doctors at the Severn Foundation School have had a formalised experiential learning programme to develop quality improvement projects under the guidance of local experts. The leads for each of the acute Severn trusts work together to share good ideas. This web of experts collaborates in order to spread project outcomes across Severn and into other educational areas.
Foundation year 1 doctors are invited to undertake facilitated quality improvement projects to pursue lasting improvements in their trust. Participants choose their own projects with guidance from mentors. When they move into foundation year 2 they can then become the mentors for new entries. Doctors in training present their projects to trust boards at the end of the year, which shows the level of engagement of senior staff to this work and the importance of focusing on patient safety.
There have been many initiatives derived from the programme, including new fluid charts, new handover methods as well as new standardised equipment trolleys. This work is visible, practical and appreciated by the trust boards.
In North Bristol NHS Trust, evaluation shows that one benefit of the quality improvement projects is that junior doctors feel that they can raise issues of patient safety and that they have the power to make changes to improve patient safety.
A wider evaluation of the programme will use quantitative data, alongside interviews with participants since 2010. Current investigations show that foundation doctors are enthusiastic about the quality improvement programme and that it will continue to be implemented in years to come.
This programme can be easily adopted elsewhere. The foundation doctors undertake the projects in their own time – as do the mentors. Having a clinical education fellow as a contact point and an organiser of the evening meetings is important. To spread the programme to other more senior doctors in training and to train more senior mentors, additional funding would be needed. However, the programme can be started easily in a small way and adapted to any healthcare organisation. Within Severn, the programme has spread to acute psychiatric trusts and participating doctors also undertake projects in primary care during their rotations.
A Multi-professional Point-of-Care (POC) Simulation Programme that Enhances Confidence and Competence of Doctors in Training
University Hospitals Bristol NHS Foundation Trust has been running POC simulation teaching sessions since 2010 across the trust. Conducting simulation training with mixed nursing and medical learners is advantageous as nurses and junior doctors naturally work together to deliver care in practice.
Bringing the equipment and expertise of the simulation centres into the clinical workplace enhances the fidelity of the teaching, allows staff to attend (even during busy clinical shifts) and makes it simple to teach multi-disciplinary groups.
Simulation training offers excellent opportunities for multi-disciplinary, integrated and locally-focused teaching. The faculty and equipment previously based in the Bristol Medical Simulation Centre (BMSC) are now used to run short, simulated scenarios in clinical areas of the trust. The areas of initial focus were the emergency department, intensive care unit and the medical admissions ward.
Sessions are delivered by placing a mannequin in a clinical bed-space that is empty or is between patient occupations. Staff are recruited from the immediate clinical environment and freed for up to 20–30 minutes by cross-covering with colleagues. Doctors present on the wards are invited to join the session and are involved when the nursing staff deem that medical review is appropriate.
The scenarios remain within the bed-space, and the training does not activate the hospital cardiac arrest team or engage other participants from outside the immediate clinical area.
Scenarios have been written to target common clinical situations, where appropriate and timely intervention is critical, such as patients with a deteriorating clinical condition due to sepsis, hypoglycaemia or other similar problems. The level of teaching is varied, depending on the seniority of staff available for the session.
As well as delivering monthly teaching sessions in each area, the team have sought to identify local champions and have given them training and support to take ownership of their own branch of the POC programme.
This has allowed different areas to modify the teaching delivered, to make sure it meets the needs of their local multidisciplinary teams, for instance by incorporating critical incidents into training sessions within a few weeks of the incident occurring.
The sessions have been well received. The team’s evaluation suggests that the programme has increased the confidence and competence of medical and nursing staff to manage the various scenarios presented.
This programme can be implemented wherever there is equipment and faculty capable of running simulated medical scenarios. It is not limited to secondary or tertiary care areas and could easily be adapted to suit primary care or other care settings. The use of a mannequin is not mandatory, and patient actors can be more appropriate in certain areas.
The programme has been expanded into the delivery suite and post-natal wards, the operating theatres, the Bristol Eye Hospital and various acute medical and surgical wards in University Hospitals Bristol NHS Foundation Trust.
In areas where particular concerns had been identified, the POC programme has been integrated into a larger educational package, including targeted sessions in the BMSC and other quality-improvement interventions.
An Annual Forum where Doctors in Training can Showcase Local Initiatives
Doctors in training frequently deliver teaching in many formats during their clinical years. They often develop and deliver teaching projects that are innovative and exciting, but these projects are potentially overlooked.
The aim of the annual forum is to make sure that innovative, short-lived teaching projects are recognised and outcomes from these teaching projects are captured to avoid them being replicated multiple times by future cohorts.
The trust support a group of doctors in training to establish the annual Medical Education Forum for doctors in foundation, core and higher specialty training to showcase their ideas or completed projects. They gain vital feedback from experts in order to develop sustainable projects and meet peers interested in teaching.
A wide range of attendees from many specialties and healthcare disciplines attend the event. Keynote speakers on postgraduate qualifications and clinical teaching fellow posts punctuate the evening and an innovation award is presented.
Doctors in training are invited to submit abstracts on educational projects they have already undertaken or ideas they want to develop. An independent assessor reviews the submitted abstracts and selects four to be presented at the event.
A panel of experts in medical education attend. They give constructive criticism, suggest routes to further develop projects and names of local contacts who can help and mentor the doctors in training.
Online anonymous feedback about the forum was consistently positive. As a result of the Medical Education Forum, doctors in training get practical and useful advice for developing sustainable teaching projects.
For example, a doctor in training who presented an idea to start a foundation year 1 preparation course learnt that a local project was already running and has since become involved in it. Another doctor in training who wanted to address the understanding of medicine and anatomy through art was put in touch with a dermatologist with a similar interest who was starting a specially selected module at the university.
There are plans to expand the forum and doctors in training from all hospitals across the region can get involved. The trust will also consider whether it should invite all other healthcare professionals to submit work. Some funding is needed to host the event, but this is not prohibitive.
An Electronic Induction Programme with Integrated Assessment
It can be challenging to give doctors adequate induction and medical training. Annual August Trust induction requires many doctors to be absent for a significant period, which has implications on patient safety.
The Royal United Hospital Bath NHS Trust has therefore developed a comprehensive electronic induction (e-induction) and electronic- medical training (eMT) package. This gives doctors in training a trust induction which is fully compliant with medical training and verification of learning using multiple choice questions-style summative assessment. The e-induction and eMT are supported on the Moodle learning platform.
Many regions have successfully implemented online e-induction. But this is one of the first few to incorporate medical training with assessment of learning. 13 eMT components were integrated into a modified, interactive, multimedia, scenario-based e-induction programme. Subject matter experts defined the content and learning objectives for each topic.
The package is highly interactive and requires users to work through a series of six cases, contextualised in the setting of an emergency department during a major incident. Information from each of the 13 eMT components is integrated throughout the six cases and punctuated by assessment questions.
All new doctors in training are invited to complete the e-induction by email two weeks before their start date. They were also asked to complete the package before starting work in the trust, with the compensatory lieu day only being given to those who completed it before their first day of work.
The package was introduced in August 2013, By the end of August 2014, all doctors in training had completed it. By giving all medical training in a single format, the trust demonstrated an improvement from 0% to 100% of doctors in training completing induction and all of medical training.
By reducing the time spent on face-to-face induction and medical training, the trust can now give comprehensive induction and medical training in just 6.5 hours – 23 hours shorter than the old programme.
Overall, when comparing the number of hours that would have been spent if all doctors in training had completed the old programme versus eMT, even accounting for a lieu day for each doctor in training, there is still a saving of 15 hours. This equates to roughly two working days per doctor.
Feedback was more positive from junior doctors in training and became less positive as training level of experience increased – a few of the more senior doctors in training said that they found the package pitched at the wrong level.
It is challenging to devise a package that is concise, yet covers material in sufficient depth to meet medical training requirements. Moreover, the users completing the package ranged from F1 to ST8 level, therefore represented a vast range of experience levels, which posed a further challenge to the design.
Full Blood Tracking Project at Great Western Hospitals NHS Foundation Trust
Implementation of an electronic blood tracking system was completed in March 2008, for compliance with new legislation stating that blood for transfusion should be fully traceable from donor vein to recipient vein, for a period of no less than 30 years.
Over a thousand staff were trained and assessed against new competencies, and training of new staff and refresher training is ongoing. Wall mounted computers alongside blood fridges control access to the blood via magnetic door locks. A porter collecting blood is required to scan his or her barcoded staff ID card before using the system, and barcodes on the patient paperwork and blood packs are scanned to ensure the right blood is being collected for the right patient. At the patient bedside those administering blood must scan their own ID card, the barcoded patient wristband, and the blood itself, to back up prescribed visual checks. The handheld scanners and linked computers provide visual and audible alarms when blood may be about to be transported or put up that is for the wrong patient, has exceeded time out of prescribed temperature controls, or has expired.
Blood Transfusion processes have not only been made safer with the new system - additional benefits are now being realised in a reduction in costly blood wastage.
Electronic Discharge Summary System at Great Western Hospitals NHS Foundation Trust
The background to the implementation of the Electronic Discharge Summary System was to improve the patient discharge process ensuring a smooth transition of care for patients when they leave hospital after an inpatient admission.
An electronic solution was developed and tested and a 6 week pilot commenced in May 2007, followed by Trust-wide roll-out over the next 6 months.
The new system now delivers benefits in terms of:
- A legible discharge summary at the point of discharge;
- Methods of electronic transmission to assist with guaranteeing delivery to primary care within 48 hours of patient discharge;
- Clear documenting of discharge drugs which in the past have been difficult for both Pharmacy and GPs to read;
- Providing patients with a copy of their discharge summary as they leave the hospital
- A copy of the discharge summary is also included as part of the Trust’s electronic patient record system (EPR) and has been invaluable if a patient has been readmitted in a very short space of time following discharge to inform emergency medical staff of their medical history.
Protocol for Chlamydia Screening at Weston Area Health NHS Trust
After an audit found that very few young women with lower abdominal pain were being tested for chlamydia to rule out PID, this protocol was developed and implemented through the hospital to reduce medical errors. There has been a recent legal case where a woman presented to hospital with lower abdo pain and was not tested for chlamydia, and as a result became infertile. It is hoped that this protocol will help prevent similar cases in the future.
The authors of the poster are Kimberly Bruce (F2), Karla Blee (F2), Mr Peter Greenhouse (Consultant in Sexual Health).
Surgeons To Use Safety Checklist Before NHS Operations
Sky News have reported on an initiative started within North Bristol Trust.