Board 114 - Program Innovations Abstract Use of Simulation to Test Emergency Department System for Preparedness to Implement and Roll-Out New Electronic Medical Record Components Involving a Complex Multiple Trauma Scenario In-Situ (Submission #305)

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Introduction/Background Health care processes are complex, especially in busy Level 1 trauma units facilitating care with multidisciplinary teams. Introduction of new computerized provider order entry (CPOE) systems have the potential to create risk to patient safety if they fail to work as intended.1, 2 The use of high fidelity simulation to promote critical thinking and teamwork has been well documented in the literature as a valid mechanism for developing high efficiency healthcare teams.3 Performing In-Situ simulation was decided upon as the mechanism to "test the system" in our busy Level 1 trauma center in order to uncover latent errors before beginning the new CPOE system on actual patients. We hypothesized that it would also serve to educate our program on possible deficiencies in the workflow and function of ordering medications, lab tests and X-Ray and Computed Tomography (CT) exams while caring for complex trauma patients. Methods In anticipation of potential gaps in the function of a trauma CPOE system, we staged a complex multi-patient trauma scenario to test the readiness of this EMR module. The trauma simulation scenario included two trauma patient victims: a high fidelity adult mannequin (Laerdal ™ Medical, SimMan 3G) and a pediatric manikin (Gaumard™ Pedi-Hal). The multidisciplinary members of the trauma team were notified approximately five minutes in advance of inbound multiple trauma patients and provided with pre-arrival vital signs and conditions. Volunteer participants in the scenarios included staff consultants and residents from Trauma Surgery and Emergency Medicine, Nursing staff, Patient Registration, Emergency Department Operations specialists and a number of other allied medical staff including Pharmacy, Lab, Respiratory Therapy and Radiology. Specific objectives were planned as part of the system test, triggered by the anticipated patient care needs during the scenarios. Ordering of medications, labs, and radiology studies including CT scans would be introduced and managed with the Trauma CPOE system along with the need to modify and create new orders after the patients left the trauma bay. The simultaneous arrival of two unidentified trauma patients tested the registration process, which was an essential component of the CPOE. Immediately following the simulation exercises, the simulation volunteers were debriefed by Emergency Department team leaders. The volunteers were also provided an opportunity to complete an anonymous evaluation sent electronically. There was a 54% (28/52) response rate for this evaluation. Of those that responded to the electronic evaluation, 64% participated in the simulation exercise, whereas the rest were either confederates or observers. Conclusion Three themes emerged from this simulation exercise: 1) Role clarity across a multidisciplinary team; 2) Identification of potential threats to patient safety prior to going live in a patient care environment (i.e. registration process, medication orders); 3) System processes (i.e. location of computers, workflow changes with using a computer for orders communication across multi-departments). The day following the simulation exercise, the leaders from each of the departments participated in a final debriefing. This final debriefing discussed what each department needed to accomplish prior to the system go-live date in four days. Based on the observations made during the simulation exercise, the discussions during the debriefings and the electronic evaluation results, the simulation learning objectives were achieved by this exercise. Feedback from all participating volunteer members of the multidisciplinary trauma team led to the decision to move forward with planned implementation of the CPOE trauma order entry system for labs and radiology studies, with adjustment based on challenges identified. The simulated scenarios revealed that the CPOE medication order entry was potentially unsafe for patients. For this reason, medication ordering has not been implemented as a part of the CPOE for trauma patients.